Integrating Patient Data Across Care Settings

Possible is integrating community-based mobile tools with its facility-based Electronic Health Record (EHR) to improve hospital-to-home care coordination.

Possible is rethinking rural healthcare to make it work for underserved populations. As an experienced healthcare provider in Nepal, we have learned that to make health systems work for the most vulnerable populations, three main shifts are necessary:

• A shift from acute, disease-based encounters to longitudinal care;

• A shift from static, unaccountable health systems to data-based, continuously improving ones; and

• A shift from care that is financially & logistically burdensome to patient-centric care.

Possible, therefore, has developed an integrated hospital-to-home healthcare model in Nepal that is designed with these three objectives in mind. It includes three critical components – improved quality of care at government-owned facilities; community-based care delivered by a trained professionalized cadre of community health workers (CHWs); and, an Electronic Health Record (EHR) that includes facility-level and community-level data.

For this Solve Challenge, Possible will develop the world’s first fully integrated Electronic Health Record (EHR) platform to enable care continuity, a holistic picture of healthcare needs, and continuous improvement of healthcare delivery. Specifically, we will complete the development of our EHR to allow seamless integration of patient data collected at the facility and community levels to ensure more efficient and coordinated care for patients.

We are integrating community-based mobile tools with a robust facility-based EHR to improve patient tracking and care coordination between the health facility and the home. Our solution would be the first truly integrated EHR system designed for rural, hard-to-reach populations that could be easily adapted to additional low and middle-income countries. By using open source tools, our innovation could be introduced, customized, and scaled in any setting where frontline CHWs are working in partnership with health facilities to improve health. Furthermore, our platform can efficiently capture data and produce aggregate data visualizations that are actionable by program managers.

Technology will play a central role in our solution to integrate our facility-based EHR with our community-based mobile application. We have a strong track record of working with technical partners and independently iterating on technology solutions as we identify specific health system design challenges to address. Our goal is to use technology to create a learning healthcare system that utilizes data continuously to inform and improve programming.

In the next 12 months, we aim to develop a fully-integrated EHR platform that tracks patients across the continuum of care to improve outcomes. First, we will develop the technological solution needed to get the two systems to communicate with each other. Once we achieve this, we will work with our facility- and community-based personnel to understand which data elements will be the most useful to incorporate into each team’s existing platform. Finally, we will develop and begin piloting new protocols to improve care coordination, referrals, and follow-up across the facility and community points of care.

Over the next several years we aim to scale our integrated solution across our health facilities and community health teams in the two districts where we currently operate. Beyond simply scaling the technology solution, we will have to train our staff on the corresponding protocols to address key drivers of morbidity and mortality in the communities we serve.

Our long-term vision is to scale our integrated EHR product in public sector facilities throughout Nepal and, eventually, shape best practices globally around deploying EHRs to improve health in underserved settings.

Possible will deploy its integrated EHR solution to its existing patient population that receive care at our facilities and the surrounding communities. Our CHWs currently visit each household in their catchment areas at regular intervals, continuously recording health data, identifying and following up on patients that need more targeted care. Given these regular touch points, our solution will immediately impact our patient population, allowing our facility-based providers and our CHWs to have a complete, real-time picture of the services each patient has received and provide care accordingly.

To date, we have provided over 600,000 patient visits at our two government hospitals, and our CHWs actively track a population of over 110,000 patients. Our CHWs follow up with certain patients treated at our facilities, including pregnant women, new mothers, and chronic disease patients. However, they are currently forced to rely on a monthly printout of patients seen at the hospital. This paper-based workaround is inefficient and can result in delays in the timely provision of care. Our solution will allow for critical two-way data flow between points of care to improve patient follow-up and outcomes.

In the next year, we anticipate serving 100,000 of our existing patients. These patients will receive fully coordinated care through the implementation of new care protocols that incorporate our solution’s ability to integrate patient data across platforms. We anticipate seeing improvements in process indicators, i.e. those related to medication adherence and follow-up rates. Over the next three years, we hope to scale up our integrated solution to our planned catchment area population of 300,000. At this stage, we anticipate seeing some initial improvements in outcomes for patients with chronic diseases and maternal and child health.

We have a dynamic team of experienced technology innovators that support our efforts to transform health systems for underserved populations. Anant Raut, Possible’s Director of Informatics, led the rollout of our EHR system at our hospital hubs and oversees our innovative digital systems design and quality improvement efforts. He leads a robust team of three developers and five implementers who have been working on these open source projects for several years. We will build on our excellent track record of innovation and iteration, as well as our Partnerships team, to attract resources to develop our solution and improve outcomes.

Possible relies primarily on support from foundations, research grants to study the impact of our model, and funding from the government of Nepal as part of our public-private partnership to operate government health facilities. We currently receive support for our EHR development efforts through a combination of unrestricted support and academic partnerships with the National Institutes of Health (NIH) and the Harvard Medical School Center for Global Health Delivery–Dubai. However, these partnerships on their own will not be sufficient to fully support our planned EHR activities for the upcoming year and beyond.

In collaboration with the German development agency, GIZ, we recently began implementing our EHR product at Trishuli District Hospital in Nuwakot District. The project will help us determine the feasibility of adapting our EHR product to public facilities without our direct management. It will also serve as a benchmark for scaling the product nationwide, which would ultimately contribute to our sustainability. Acknowledging that this could take several years, Possible is also actively adapting its systems following the passage of Nepal’s National Health Insurance Act, requiring all citizens to have health insurance. As the insurance plans roll out, Possible will be well-positioned to receive reimbursements, supporting our long-term sustainability.

Possible is eager to join a community of like-minded people using technology to make healthcare more available, affordable, and effective for marginalized communities. We are excited about the prospect of receiving additional grant funding for our work, meeting more of our peers that work in this arena to exchange ideas, and being connected to potential partners. Finally, by generating more resources for our integration solution through this challenge, we believe we will be one step closer to our goal of developing a replicable, transformational model of healthcare delivery.

We have learned to expect challenges and setbacks during the process of developing and implementing technology solutions. As such, we imagine we will face barriers while developing our solution and piloting it in our patient population. We anticipate that some of these challenges will be technical in nature while others will be related to the protocols and workflows we develop around our solution to improve care provision. Nevertheless, we are confident that with assistance from the Solve community and our own persistence, we will be able to overcome these barriers.