[Cidrz] Conference Call at Dimagi Office at 4:30 PM

[Daniel Myung]

comments interspersed below, i left some notes i was annotating down so
ignore or glean from them as you please.

On 3/16/08, Leo Anthony Celi <leoanthonyceli at yahoo.com> wrote:
>
> Hi,
>         My flight is at 6:30 PM so I was planning to get to the airport
> by 4:30 PM.  Even if I get to the airport by 4 PM, I'm probably queueing up
> for about an hour given it's an international flight.
>         Go ahead without me.  My main questions are:
> 1.  How important is real-time decision support functionality to them?  If
> they think it is key, who will provide the on-call service?  Doctors in
> Lusaka?  Doctors in the US?  How will this be possible given the time
> difference between Zambia and the US?
>

it's mixed.  It might not be a high percentage of cases.  but the dr.
reiterated that they want feedback within 30-60 minutes of an image sent to
teh central server.

text information to patient personal mobiles.
Additional QA process in addition to just comments on images?
UNAIDS on sending images internationally?


9+ countries from pepfar, will

2.  How do the doctors on-call want to be notified of the need for decision
> support?  The workflow needs to be granularized fully.  Will the doctor
> on-call just want to ring the nurse who sent the image?  A use case diagram
> will be helpful.  How do we capture and document the decision/information
> flow?  This is improtant for QA.
>

I'm thinking nothing is going to stop a doctor from calling a nurse
directly.  There's a paper from a SUNY dermatoliist who does his whole
remote derm. work from the ER vai MMS and phone calls.  So there is a
precedence for this kind of stuff.

But anyway, the scope I'd say for the initial implementation is just going
to be this, the software is only 1 way, nurse to server, server messages Doc
of info via MMS and/or SMS alert.  Doctor will call nurse for their
findings.  Doctor must then follow up on server since the server will show
that it was not updated on the server side, and the server can't know a call
was made, so a doc must go in and self acknowledge that he made a call and
put the diagnosis in.

Future implementations I'd say that the doctor will have special software on
the phone.  We can mandate this since CIDRZ is in full control of its docs,
and have the doc be able to electronically update his findings on the phone
and msg them back to the nurse.

2.  What other functionalities do they want?  How do they want to carry on
> the weekly image reviews that they have now?  Are the doctors planning to
> continue travelling to each area of the country as the programme is rolled
> out?  Or do they envision a tele-medicine type image reviews?
>

This is a tough question from this vantage point.  Once again, nothing is
going to prevent the docs or other nurses from going afield.  This will have
to be discussed as part of their institutional regimen.  However, as far as
the electronic system goes, I'd say that we should be writing the server
component as if it was the primary means of QA/QI by having docs and nurses
discuss over their images.  It's not the scope of this implementation to
look into screen sharing or whiteboards for conferences to discuss the same
image.  Assume asynchronous discussion based communication.

'q's
changes compatible w/ invasive cancer
where does the lesion go?  inside/out?
> 75% cervix area
demog
treatment history?
hiv status
cd4 count?


how do we define metrics?
evaluation of nurses.  track their progress over time.  how close they come
to the expert.

num of patients they refer

put cervical lesions as same categories as attendings.

digital pathology italian pathologists w/o borders
use as comparative for cancer accuracy for histology


3.  How are they envisioning implementation?  I presume they'll pilot the
> real-time functionality in a small area?  I've presumed from my previous
> question that it will be a roll-out implementation across the country.
>

Yeah.  As far as my experience has gone in Zambia, the rollout will probably
start local and/or trusted nurses.  In particular one nurse who's really
good is moving to the other side of the country.  She'd be an ideal
candidate for remote rollout.

4.  What other QA processes should we put in place for the pilot apart from
> a record of the exchange and transfer of information? for the actual
> implementation?
>

I think this might be part of how we build up the phone software to include
2 way communication back?  Electroncially capturing the transaction in
realtime will probably help QA/QI in the long term.

5.  We should also come up with both process and outcome metrics that
> we will track as we implement it from one area to another.  These are
> important if CIDRZ really wants to become established as the center of
> training in cervical cancer screening.  This is my area of expertise and
> would be happy to work with the CIDRZ folks.
>

Metrics as discussed in the call were discussed as thus.  For a pilot
evaluation we will document the ratio of diagnoses the nurses do.  Positive,
negative, indeterminate.  Next, we will also track the accuracy of the
diagnoses the nurses put as compared with the doctors.  Presumably maybe
there needs to be a QA/QI process that evaluates nurse/doctor findings and
assigns a score for each diagnosis after the fact?


6.  Are they going to use the same nurses as we roll out from one area of
> the country to another?  If not, how many nurses need to be trained?  I
> presume the core group of nurses will be responsible for training the nurses
> in other areas of the country?  Have they given this a thought?
>

The training and such is  CIDRZ' responsibility.  They have already a well
defined 8 week training program for nurses.  Their rollout for training and
other things are contingent on funding and other in country issues.
However, the training of practitioners and  experts in countrywide
deployments is CIDRZ' expertise in country.

7. What sort of operational and technical risks are involved in the
> project?  How can we minimize these risks?  Do we have contingency plans for
> those that are most likely to be encountered?
>

One risk/uncertainty I'm concerned about is the reliability of the
cellular/internet infrastructure.  For keeping the ministries of health
pleased (as well as general privacy concerns appeased), we may have
additional overhead on our data that may make communication difficult.  So,
finding contingency plans for this sort of thing looks to be important as
well.




         Andres, I leave the oral presentation in your hands.  Daniel Myung,
> Andres will be presenting on Tuesday in case you haven't been informed yet.
> Andres, please post a blog regarding the conference call and the
> comments/suggestions of the instructors and the rest of the class.  I'll
> make it up when I get back.
> Cheers,
> Leo
>
> *
> *
>
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