GlobalStation

While there have been remarkable gains in global health, the global burden of surgical care is growing. Access to surgery may increase temporarily during programs such as short-term surgical outreach trips, however these trips cannot provide consistent, predictable presences. There are rising concerns about the impact of such trips, including the challenges with patient follow-up and the lack of quality or value reporting.

After surgical outreach trips, barriers remain to patient follow-up and safety including accessibility, availability and affordability of surgical care. Hurdles can range from patients living too far to easily access care to the lower density of providers in lower socioeconomic areas. Other indirect healthcare costs, such as time off work, cost of transportation, and childcare, only add to the out-of-pocket expenses of receiving follow-up care.

Beyond accessing surgical care during surgical outreach trips, the quality of care provided during trips, the trip impact, and the underlying hospital capacity for health quality improvement often remain unmeasured. High-quality care delivery can be a challenge to provide or measure with limited resources, imposing high costs and adverse health outcomes for the populations they serve. Quality goes beyond access to care, but includes six dimensions: safety, effectiveness, patient-centeredness, timeliness, efficiency, and equity. These dimensions have been shown to be just as important as improving access to care to promoting sustainable, safe, and accessible surgical care.

GlobalStation is designed to strengthen the quality of care provided during outreach trips and to strengthen and improve access to care for patients after surgery. Within one solution, we aim to improve individual patient outcomes while measuring the quality of care provided to patients.

This solution will be deployed in three steps. The first, which is already completed, is to design the two components of GlobalStation: the electronic health record (EHR) and the SMS-based follow-up platform. The second step includes launching GlobalStation during outreach trips to address the lack of patient follow-up after outreach trips and to introduce the system to the partnering hospitals in low- and middle-income countries (LMIC). The third step aims to include partnering hospitals and physicians in GlobalStation. 

SGS developed the EHR through a series of implementation science techniques, including interviewing local healthcare providers, working closely with an outreach organization to identify outreach trip needs, and pilot testing the SMS follow-up program in Vietnam. The goal of the EHR is to monitor patient health progress during care, and to measure system quality. This begins with initiating electronic records for each patient during patient intake, with each patient form compiling the patient’s contact information and basic demographics, previous hospital records and any films or lab results, intake health status and injury information, post-operative care and instruction, and tracks patient health outcomes following surgery over twelve weeks. The individual patient and aggregated data is accessible by any visiting care team member or by local physicians to return to during follow-up. The EHR will also measure healthcare and hospital system quality through a number of quality measures. Outreach organizations and LMICs will be able to address areas for improvement either within the outreach organization or within the partnering hospital and health system.

To address minimal outcome reporting and follow-up after surgical outreach trip, the SGS team developed an SMS-based patient follow-up program. Using patients’ given contact information in the EHR, SMS messages will be sent to the patient on their surgery day, Day 1, Week 1, Week 2, Week 4, Week 8, and Week 12 following surgery. Patients can upload images of their incision/injury site and fill out a short survey on their health and recovery progress, which can be monitored by local and visiting healthcare team members. This follow-up platform is people-centered, as SMS messages will be more accessible and affordable for those unable to attend follow-up in person. Further, the messages and health outcome measures can be adapted to meet the language, culture, and context of the area.

Our solution has three target populations: patients receiving care during outreach trips, local hospital staff and systems, and outreach organizations. Through the SMS-based follow-up, patients health and outcomes will be consistently measured without the high indirect costs of follow-up care. This is especially important for patients undergoing surgery who live far from the hospital, as it will increase their interactions with follow-up providers while removing obstacles such as transportation, child care, and others. The electronic health record will also positively impact outreach organizations and their partnering hospitals, as it will allow for record keeping, provide a communication platform to strengthen relationships, and to track health quality measures and outcomes. By identifying and monitoring health quality measures during care, outreach organizations will be held accountable for care they provide and local hospitals will be able to identify and target areas to further build capacity within their systems.

SGS was founded to increase access to sustainable, high-quality surgical care. The founding members are two orthopaedic surgeons with experience in global surgical outreach missions, giving them the background, experience, and partnerships to build tools to improve the impact of surgical outreach trips.

Our team has numerous links to global health outreach organizations and local hospitals across multiple developing countries, making our team well positioned to deliver, foster, and sustain our solution. Previous solutions have been built from these partnerships, such as Needs Assessment tools for organizations to deploy before outreach trips and identifying important quality measures for organizations to measure during outreach trips. 

1.    To connect with other individuals, teams, and organizations working within the field of global health and for many communities that SGS is serving or aims to serve in the future.

2.    To enhance skills in health design, e-health program development, and model scale-up through collaboration and support within the field.

3.    To receive financial support during the growth phase of the EHR deployment, and to improve our funding and fundraising ability.  

While the electronic health (eHealth) field is rapidly expanding and improving, the majority of solutions are aimed at developed countries or major health systems. For example, electronic health records (EHRs) are often used to measure patient outcomes in tertiary, specialty, and HIC hospitals. Their benefits within these settings are widely reported, including improved quality of care, improved documentation, and enhanced staff satisfaction and coordination.

Our solution is innovative as it adapts electronic health structures to meet the needs of global surgical outreach organizations and their partnering hospitals. GlobalStation will measure follow patients post-operatively, improve health progress recording, and provide a communication channel between local and visiting health teams. It was designed through a collaborative process involving the perspectives and feedback of local and visiting care team physicians. Its collaborative design was chosen so to ensure that all organizations and local communities can adapt and improve the platforms to best serve each community it impacts.

There are potential barriers to our solution, such as human resource challenges (e.g., IT support) and technological barriers (e.g., compatability with local systems, wifi connectivity, and user-friendliness). Additionally, implementing a new electronic record system can be disruptive and costly even when done well as its dependent on intersecting personal, organizational, environmental, and technological factors. Even with these barriers, previous EHR implementation strategies have been met with strong motivation and satisfaction from physicians in both high and low income countries. Our developing implementation plan was also created in coordination with local and visiting team members to ensure barriers are addressed while launching GlobalStation. Additionally, our plan to begin with surgical outreach organizations and integrate in local health systems will assist in overcoming barriers.

GlobalStation combines an EHR with patient follow-up in the field of surgical outreach trips. Our solution does not rely on the expansion of new hospitals or care sites to increase patient follow-up after surgery. Instead, the ability to upload photos of their incision site and to answer short questions about their daily health increases access to post-operative care at a reduced cost, time, and effort. Pairing this with measurement of health quality provided on surgical outreach trips has the potential to impact outreach organization care delivery, local hospital care, and patient outcomes.

Our impact goal for the next three years, paired with the mentorship and funding from MIT Solve, would be to grow the program to multiple outreach organizations. We hope to test the electronic health record in multiple countries and hospital locations, and to successfully implement SMS-based patient follow-up for all patients seen during outreach trips.

In the longer term, we aim to reduce health costs for local health systems and patients by working with local hospitals and health systems to integrate GlobalStation into practice for physicians and local hospitals.

Primary outcomes include:

1.    Patient outcomes for 12 weeks following surgery

2.    Quality of surgical care provided

Indicators:

1.    Percent of patients who fill out all follow-up surveys; number of messages sent; trends in patient reported impact on activities questions from day of surgery to 12 weeks post-operatively; trends in patient reported pain from day of surgery to 12 weeks post-operatively; trends in patient reported outcomes from day of surgery to 12 weeks post-operatively

2.    Percent of patients who have complications during surgery; patient mortality rate; percent of patients with a noted and shared post-operative plan; percent of caregivers instructed in home therapy and rehabilitation; percent of patients who were allocated a healthcare professional responsible for patient follow-up; average time traveled for care

Our goal is to improve patient outcome and health quality measurements and tracking for surgical outreach trips, and eventually, for partnering local hospitals and health systems. Our theory of change is through a logic framework, outlined below:

Activities: We provide two technology-based platforms: (1) an SMS-based follow-up platform for surgical patients and (2) an electronic health record for local and visiting providers to use to monitor patients and health quality performed. Our non-profit will provide technical support and educational materials on using GlobalStation to ensure easy transition to new technology. All patient-facing materials will also be translated to fit the local community, context, and language.

Outputs: (1) Outputs include indicators such as patient scores on patient-reported outcome measures, percent of patients completing follow-up at each time point. (2) Within the EHR, outputs include health quality indicators such as percent of surgeries with complications, percent

Outcomes: Outcomes include (1) ability of patients to complete follow-up after surgery on through their mobile after short-term outreach, reducing direct and indirect costs following surgery. And (2), short-term outreach trips will be held more accountable to the quality of care they are providing during trips.

Impact: In the long term, mortality and morbidity following surgery will be decreased by improving access to post-operative surgical care, strengthening local health systems, and improving the quality of care provided during surgery.

The project is powered through two technologies: OpenMRS and Memora Health. OpenMRS is a digital medical record system aiming to improve health delivery in resource-constrained environments with user-driven medical record systems. With this platform, our team has been able to design all components of the record system, including health measures collected and integration of patient-reported outcomes with their SMS-based follow-up. All visiting and local care team members will have read and write permissions within the EHR before, during, and following any outreach trips.  

Follow-up is driven through Memora Health, a digital care team specializing in integrating digital health systems such as patient education or patient-reported outcomes into health systems and health records. This platform is initiated once the patient’s contact information is entered into the EHR/OpenMRS system. Their scheduled surgical time will trigger the platform to begin sending SMS messages through Memora Health, continuing for up to 3 months post-operatively. All data entered into the Memora Health System will be uploaded into the EHR, allowing the care team to view uploaded images and observe health trends and changes over time.  

Our organization is inclusive and embraces diversity. Our team includes team members around the world, and we work closely with physicians from hospitals in high- and low-income countries who wish to expand access to and improve health quality of surgery in LMICs. We do not discriminate against any user or organization by ethnicity, social culture, religious beliefs, or sexual orientation. 

Another important component of our work is the adaption of the EHR and SMS-based follow-up to reflect the community, context, and language of the community being served. For example, the pilot program testing SMS follow-up messages were in Vietnamese but are currently being adapted to fit the language and context of Honduras and Ecuador for outreach trips there. 

At SGS, we believe everyone should have access to high quality surgery, irrespective of where they receive care. Surgical outreach trips still play a large role in ensuring access to and affordability of surgery in many LMICs, which is why we have combined the two technology-based platforms.

SGS is a non-governmental nonprofit organization, serving a global population. Our revenue comes from grants and consultation fees. As a relatively new non-profit, we aim to continue funding support through individual donations and continuing grants.

To become financially stable, we intend to begin providing the solution to different surgical outreach organizations. Our partnership and provision of the EHR and SMS-based follow-up model will be compensated through consulting fees. In the future, local health systems or NGOs will adopt and pay for these services.

Our pilot testing of SMS-based follow-up in Vietnam was funded by the Orthopaedic Research and Education Foundation Mentored Clinician Scientist Grant. Following the success of the pilot, we began adapting the EHR and SMS messages for Operation Rainbow trips to Honduras and Ecuador. 

We are continuing to establish partnerships, such as with Cure International and Piedmont Orthopedic Society. We are also working to receive grants and impact investors.