Thanks. I will be updating the document.<BR><BR><B><I>Andrés Monroy-Hernández <andresmh@media.mit.edu></I></B> wrote: <BLOCKQUOTE class=replbq style="PADDING-LEFT: 5px; MARGIN-LEFT: 5px; BORDER-LEFT: #1010ff 2px solid">Here are my notes from the meeting<BR><BR>Doctors involved in the project<BR>~~~~~~~~~~~~~~~~~~~~~<BR>dr. goresbeck parham, University of Alabama<BR>mulindi mwahamuntu, head research at ciderz<BR>(dr. moulinda, miniser of health)<BR><BR><BR>Scenarios:<BR>1. normal pic<BR>2. abnormal pic<BR>option A) can be treated by the nurse at the clinic<BR>option B) patient needs to be sent to the hospital<BR><BR>Q. what pictures should be stored?<BR>A: both A and B) and maybe even 1?<BR><BR>Q. can we handle numbers of referrals?<BR>A. the referrals will not increase at the same rate because the nurses<BR>will get better and our system will help to refer less<BR><BR>number of patients that a nurse refers now: 10/week<BR>with more experience: current referral
10/100 moves to -> 10/1000<BR><BR>Q. how often do you meet face to face?<BR>every week<BR>as the program moves to rural areas it will hard to meet that often<BR><BR>Q. are you OK in not meeting and instead provide feedback using<BR>text-based communication? (sms, email, web-based messages)<BR>yes<BR><BR>Q. opinions on papsmear as the only way to screen?<BR>citology has failed in 3rd world nations<BR>requires infrastructure, difficult to sustain,<BR>not 1 citologist in Zambia, 1-3 years to train, they usually leave, to<BR>UK, SA, Middle East<BR>pathologists, 8 yrs to train, brain drain too<BR><BR>citologist - 50% accuracy in the 1st world, accurate because patient<BR>keeps going every year<BR><BR>visual inspection, acilic acid, screeneed and treated, done by nurses...<BR><BR>* we need criteria (5 to 6 points) for doctors on call to tell the<BR>nurse, why dr feels is abnormal or normal<BR>1. changes compatible invasive cancer<BR>2. if you can see the entire abnomal
legion, inside cervical canal<BR>3. seems too large, > 75% cervix, do not treat in clinic, referr<BR>4. _<BR>5. _<BR>6. _<BR><BR>info from nurse to doctors:<BR>age, treated before? failed treatment? hiv status...<BR><BR>Q. metrics to evaluate?<BR>tracking progress of nurses.<BR>how close they come to making full diagnosis, comparable to the expert say?<BR>maybe decrease in # of patients they refer, track their ability put<BR>the cervical lesions in the same boxes, in the same categories, than<BR>the physicians...<BR>digital pathology, italian pathologist w/o borders, sending them some<BR>of the tissue removed,<BR>we can tell their nurses how accurate they are in predicting cancer<BR>based on what the pathologists see on the slide<BR><BR><BR>More tracking:<BR>patients are asked to go back 1 month after treatment to make sure<BR>they are not infected, and cervix is healing,<BR>then 6 months, 12 months...for evaluation<BR><BR>about 20-25% patients follow up<BR>track them
down is hard,<BR><BR>as of jan 2006, 2 years, screened 14K patients, 14 clinics, 1 big eval<BR>center, 15 nurses<BR><BR><BR>*someone needs to investigate, intl laws, privacy: we need to ask people!!<BR><BR>2008/3/20, Daniel Myung <DMYUNG@DIMAGI.COM>:<BR>> comments interspersed below, i left some notes i was annotating down so<BR>> ignore or glean from them as you please.<BR>><BR>> On 3/16/08, Leo Anthony Celi <LEOANTHONYCELI@YAHOO.COM>wrote:<BR>> ><BR>> > Hi,<BR>> > My flight is at 6:30 PM so I was planning to get to the airport by<BR>> 4:30 PM. Even if I get to the airport by 4 PM, I'm probably queueing up for<BR>> about an hour given it's an international flight.<BR>> > Go ahead without me. My main questions are:<BR>> > 1. How important is real-time decision support functionality to them? If<BR>> they think it is key, who will provide the on-call service? Doctors in<BR>> Lusaka? Doctors in the US? How will this be
possible given the time<BR>> difference between Zambia and the US?<BR>><BR>> it's mixed. It might not be a high percentage of cases. but the dr.<BR>> reiterated that they want feedback within 30-60 minutes of an image sent to<BR>> teh central server.<BR>><BR>> text information to patient personal mobiles.<BR>> Additional QA process in addition to just comments on images?<BR>> UNAIDS on sending images internationally?<BR>><BR>><BR>> 9+ countries from pepfar, will<BR>><BR>> ><BR>> > 2. How do the doctors on-call want to be notified of the need for<BR>> decision support? The workflow needs to be granularized fully. Will the<BR>> doctor on-call just want to ring the nurse who sent the image? A use case<BR>> diagram will be helpful. How do we capture and document the<BR>> decision/information flow? This is improtant for QA.<BR>><BR>> I'm thinking nothing is going to stop a doctor from calling a nurse<BR>>
directly. There's a paper from a SUNY dermatoliist who does his whole<BR>> remote derm. work from the ER vai MMS and phone calls. So there is a<BR>> precedence for this kind of stuff.<BR>><BR>> But anyway, the scope I'd say for the initial implementation is just going<BR>> to be this, the software is only 1 way, nurse to server, server messages Doc<BR>> of info via MMS and/or SMS alert. Doctor will call nurse for their<BR>> findings. Doctor must then follow up on server since the server will show<BR>> that it was not updated on the server side, and the server can't know a call<BR>> was made, so a doc must go in and self acknowledge that he made a call and<BR>> put the diagnosis in.<BR>><BR>> Future implementations I'd say that the doctor will have special software on<BR>> the phone. We can mandate this since CIDRZ is in full control of its docs,<BR>> and have the doc be able to electronically update his findings on the
phone<BR>> and msg them back to the nurse.<BR>><BR>> ><BR>> > 2. What other functionalities do they want? How do they want to carry on<BR>> the weekly image reviews that they have now? Are the doctors planning to<BR>> continue travelling to each area of the country as the programme is rolled<BR>> out? Or do they envision a tele-medicine type image reviews?<BR>><BR>> This is a tough question from this vantage point. Once again, nothing is<BR>> going to prevent the docs or other nurses from going afield. This will have<BR>> to be discussed as part of their institutional regimen. However, as far as<BR>> the electronic system goes, I'd say that we should be writing the server<BR>> component as if it was the primary means of QA/QI by having docs and nurses<BR>> discuss over their images. It's not the scope of this implementation to<BR>> look into screen sharing or whiteboards for conferences to discuss the same<BR>> image.
Assume asynchronous discussion based communication.<BR>> 'q's<BR>> changes compatible w/ invasive cancer<BR>> where does the lesion go? inside/out?<BR>> > 75% cervix area<BR>> demog<BR>> treatment history?<BR>> hiv status<BR>> cd4 count?<BR>><BR>><BR>> how do we define metrics?<BR>> evaluation of nurses. track their progress over time. how close they come<BR>> to the expert.<BR>><BR>> num of patients they refer<BR>><BR>> put cervical lesions as same categories as attendings.<BR>><BR>> digital pathology italian pathologists w/o borders<BR>> use as comparative for cancer accuracy for histology<BR>><BR>><BR>> ><BR>> > 3. How are they envisioning implementation? I presume they'll pilot the<BR>> real-time functionality in a small area? I've presumed from my previous<BR>> question that it will be a roll-out implementation across the country.<BR>><BR>> Yeah. As far as my experience has
gone in Zambia, the rollout will probably<BR>> start local and/or trusted nurses. In particular one nurse who's really<BR>> good is moving to the other side of the country. She'd be an ideal<BR>> candidate for remote rollout.<BR>><BR>> ><BR>> > 4. What other QA processes should we put in place for the pilot apart<BR>> from a record of the exchange and transfer of information? for the actual<BR>> implementation?<BR>><BR>> I think this might be part of how we build up the phone software to include<BR>> 2 way communication back? Electroncially capturing the transaction in<BR>> realtime will probably help QA/QI in the long term.<BR>><BR>> ><BR>> > 5. We should also come up with both process and outcome metrics that we<BR>> will track as we implement it from one area to another. These are important<BR>> if CIDRZ really wants to become established as the center of training in<BR>> cervical cancer screening. This
is my area of expertise and would be happy<BR>> to work with the CIDRZ folks.<BR>><BR>> Metrics as discussed in the call were discussed as thus. For a pilot<BR>> evaluation we will document the ratio of diagnoses the nurses do. Positive,<BR>> negative, indeterminate. Next, we will also track the accuracy of the<BR>> diagnoses the nurses put as compared with the doctors. Presumably maybe<BR>> there needs to be a QA/QI process that evaluates nurse/doctor findings and<BR>> assigns a score for each diagnosis after the fact?<BR>><BR>> ><BR>> > 6. Are they going to use the same nurses as we roll out from one area of<BR>> the country to another? If not, how many nurses need to be trained? I<BR>> presume the core group of nurses will be responsible for training the nurses<BR>> in other areas of the country? Have they given this a thought?<BR>><BR>> The training and such is CIDRZ' responsibility. They have already a well<BR>>
defined 8 week training program for nurses. Their rollout for training and<BR>> other things are contingent on funding and other in country issues.<BR>> However, the training of practitioners and experts in countrywide<BR>> deployments is CIDRZ' expertise in country.<BR>><BR>> ><BR>> > 7. What sort of operational and technical risks are involved in the<BR>> project? How can we minimize these risks? Do we have contingency plans for<BR>> those that are most likely to be encountered?<BR>><BR>> One risk/uncertainty I'm concerned about is the reliability of the<BR>> cellular/internet infrastructure. For keeping the ministries of health<BR>> pleased (as well as general privacy concerns appeased), we may have<BR>> additional overhead on our data that may make communication difficult. So,<BR>> finding contingency plans for this sort of thing looks to be important as<BR>> well.<BR>><BR>><BR>><BR>> ><BR>> >
Andres, I leave the oral presentation in your hands. Daniel<BR>> Myung, Andres will be presenting on Tuesday in case you haven't been<BR>> informed yet. Andres, please post a blog regarding the conference call and<BR>> the comments/suggestions of the instructors and the rest of the class. I'll<BR>> make it up when I get back.<BR>> > Cheers,<BR>> > Leo<BR>> ><BR>> ><BR>> ><BR>><BR>> _______________________________________________<BR>> Cidrz mailing list<BR>> Cidrz@mit.edu<BR>> http://mailman.mit.edu/mailman/listinfo/cidrz<BR>><BR>><BR><BR><BR>-- <BR>Andrés<BR><BR>_______________________________________________<BR>Cidrz mailing list<BR>Cidrz@mit.edu<BR>http://mailman.mit.edu/mailman/listinfo/cidrz<BR></BLOCKQUOTE><BR>