La Ruche Health

In Cote d'Ivoire (25 million population), there are on average 170 new cases of cancer diagnosed in children under the age of18. With just 5 qualified pediatric oncologists working in public health and a single 17-bed pediatric oncology center available to families with limited means, the biggest challenge faced by 90% of the population who do not have adequate health cover is access. Due to geographic, financial, and knowledge limitations, the Ivorian national cancer research program (PNLCa) estimates that over 60% of cancer-related deaths in children go undetected. 

Since 2010, the PNLCa began training thousands of primary care and pediatric physicians across the nation to identify the signs of potential cancers, but there is not no digital process in place yet to refer cases to specialists for a second opinion. For the families who do not live in the commercial capital, Abidjan who make up the majority of cases, being referred to the only pediatric oncology ward in South-East Cote d'Ivoire, 'CHU de Treichville' requires long-distance journeys across a country of 322,462 km² for their very first consultation with a specialist.

Furthermore, the current workaround to this communication challenge is WhatsApp: physicians and oncologists have resorted to exchanging patient cases (names, images & observations) insecurely across the instant messaging platform for peer and specialist review.

Our solution, in partnership with the Ivorian national cancer program (PNLCa) and the public health ministry, is to address this access and communication problem in order to increase the early detection of cancers, the national survival rates, and capture true numbers for research at a national level.

Ivory Coast country profile "quick facts":

- Population: 25.07 million (2018 census)
- Poverty: 47% living below the poverty line
- Public: 1,910 primary “first contact” public medical centers, 254 secondary “referral” public medical centers, 13 third-tier “specialized” public medical centers
- Private: 2036 private medical centers
- 90% of the population do not have health insurance and therefore rely on public healthcare

We've built in a web-based Electronic Medical Records app with a built-in patient funnel to increase patient access to healthcare teams & facilitate the management and exchange of medical data. 

How it works:

• Patients engage with an AI chatbot via popular instant messaging platforms (Whatsapp or Facebook instant messaging) and are connected to healthcare teams based on need and location.
• Healthcare teams review your case on our platform & accept, reject or prompt an appointment scheduler as the AI bot generates the patient profile in the EMR app.
• Virtual or in-person consultations can be launched instantly or scheduled by the healthcare team via the EMR app and the patient is kept informed (e.g his/her place in the virtual queue or suggested date of in-person consultation)
• All relevant records such as the consultation report, historic timeline, medication, labs, prescriptions, referral letters, and billing can all be done via the app with a digital copy shared with the patient. 

Use case:

• Patients suspected of having cancer (or guardian) can connect directly to a primary care center via the chatbot.
• The primary care physician can refer the patient to a specialist via the EMR for a second opinion and/or further tests if needed.
• Once a physician tags the patient, the 5 specialists are notified and can each review and "claim" the patient profile for an in-depth review
• Internal communication between primary care physicians and specialists can be done securely and quickly using built-in templates, free-hand text input, and message subheadings/categories. 
• Specialists can order tests, update results and enter conclusions via the EMR app with the patient only needing to travel if they are diagnosed and/or the tests required can not be done locally.  

Measuring primary care performance:

• As a tool that will be deployed to thousands of primary care physicians across the Ivory Coast, key data points will be collected on demographics, reasons for visits, symptoms, tests ordered & results, payment and of course, diagnosis. 
• The ministry currently collects monthly & quarterly paper reports which are sent by all medical facilities and manually entered into DHIS2 for population health monitoring. We are working with the government's IT teams to integrate our solution to DHIS2 which will enable the above data points gathered at the point of care, making the data source more accurate and close to real-time for better data-driven decision making.

Technology:

- Web app built with HTML, CSS, JavaScript & Python
- Chatbot built using 3rd party tool (landbot)
- MongoDB is used for database and HeroKu for app hosting
- Data exchanged from bot to EMR app using web hooks

Technology stack: N-Tier Architecture (logic, presentation & data tier), logic tier being request, process presentation being the UI and data being the database

• Storage layer- mongodb database which stores all health data

• Logic layer- flask application that processes all requests and retrieves data required from the server 

• UI layer- fully responsive HTML page that presents data to the user

Comments:
- All data to be housed on government servers, in compliance with national e-health policies
- Anonymized data can be extracted from the tool for accurate offline data reporting on the number of patients, the outcome of referrals, origin (location) and demographics of the patient, details on diagnosis, etc. 
- The technology used is truly accessible by all healthcare teams, regardless of financial and IT infrastructure limitations; the tool is accessible on any browser-enabled device and will be financed by the public health ministry if the pilot meets all pre-defined KPIs. 
- Data on the solution is kept secure: user group authorization, defensive programming, 2-factor user authentication, and stored on government servers.
- User interfaces were designed based on numerous iterations of usability testing where learnability metrics were captured, and screens were designed to resemble apps users are already familiar with in their personal lives (e.g vertical scrolls and timelines like social media/e-commerce apps). 
- The solution is developed and deployed in a very cost-effective manner that makes hosting and maintenance affordable. 

The goal is to ensure that preventive health services are available to as many people as possible. The W.H.O. and the World Bank report that half of the world's population cannot access essential health services. In addition, each year many households are forced into poverty due to the high cost of health care. Approximately 800 million people spend at least 10 percent of their household budgets on health expenses for themselves, their sick children, or other family members. Around 100 million people are living in extreme poverty as a result of these expenses, surviving on under 2 dollars per day. La Ruche Health’s mission is to overcome these detrimental burdens and ensure everyone has access to effective and essential healthcare. 

It is estimated that over half of Africa's citizens lack access to healthcare, health services are of generally poor quality, and more than half of the continent's women and girls lack access to family planning.

With knowledge, history, and understanding of its community, we have decided to begin our mission in the country of Côte d’Ivoire. The health situation of the Côte d’Ivoire population is characterized by high maternal and under-5 mortality owing to poor-quality health care. Among the population, HIV prevalence is high, as are malaria and tuberculosis incidences. With few public medical centers and 47 percent of the population living below the poverty line, healthcare is hardly accessible.

Team:
Paul Lally – CTO
Rory Assandey – CEO
Ben Sasu – Back-end engineer
Andrews Antwi-Addo – UI/UX designer
Alassane Kamagate - Ivory Coast Public Health Consultant
Humphrey Nwosu – Business Developer
Cassandra Mensah - Community Manager
Tinuola Ajayi – Healthcare Subject Matter Expert

Rory was born in Cote d'Ivoire and grew up witnessing his mother, Shirley Assandey, deliver as a midwife and impact healthcare standards at a national level. To touch a bit on Rory's professional experience, aside from his 10 years as SAP Enterprise IT Consultant in SAP Labs Palo Alto, he has been doing business development for almost 2 years in Cote d'Ivoire (2021 - 2022) learning about the healthcare system and meeting with a wide cast of stakeholders (public and private practitioners and public health leaders including the minister of health)

Rory met Tinu, our Healthcare subject matter expert, in school (Cote d'Ivoire) and remained close friends. Tinu practiced primary care for 4 years in Nigeria (Navy Reference Hospital & Shepherd Medical Center) prior to taking on a role as assistant Director & Global Health Researcher, at Boston University Sch. Tinu is now a resident internal medicine doctor at the Boston Medical Center.

The rest of the team consists of 5 individuals who lived in West Africa and personally experienced similar challenges (access to modern healthcare), and therefore are united in a common, social impact purpose of making access to modern healthcare the norm for everyone. 

Paul Lally is a very talented software developer who has just completed his final year of a Computer Science degree. Paul has built websites, MVPs, and college projects using many technologies (HTML, CSS, JS/React, Flask & Django, python, and training data sets with TensorFlow libraries). Paul has been invited to interviews by several competitive graduate program managers at multi-national firms in Dublin Ireland but has politely declined all opportunities to focus on the La Ruche Health mission.

Collectively, the team has the right industry experience, cultural understanding, and motivation to execute successfully. 

As a fully bootstrapped Ivorian startup with a socially driven mission of making access to essential health services the norm, we’re applying for this grant to grow our development team (dev ops, security) and support the costs of travel and implementation overhead (hardware, project manager). This fund will enable us to transition the entire team to full-time, 80% on-site operations in order to ensure cohesion & synergies between all partnering organizations. This grant will ensure that we do not run out of financing before the end of the pilot at which point we would present the results to the government for formal approval and funding to scale nationally beyond the scope of pediatric oncology. 

Our formally confirmed partners:

• The Addis Clinic; they are a US non-profit with a presence in East Africa. Their main activity is to provide primary care and case management review through community health workers and 25+ volunteer medical specialists. They will support this project with additional remote specialists to review anonymized cases and share expert advice. 

• PNLC; this organization is responsible for national cancer research in Cote d’Ivoire and is a subsidiary of the public health ministry. They are partnering with us to deploy our solution as a case referral and internal communication tool between 1000’s of primary care physicians across the country and the CHU de Treichville public oncology department. The pilot has been tentatively approved, with the scope limited to just pediatric cases (1-17 years of age).

• University of Chicago via Metcalf program; we have a partnership with the university whereby we get access to undergrad & postgrad students. In this particular project, we post job descriptions and interview candidates for various supporting roles when we need staff augmentation. Successful candidates have been approved stipends to cover their costs where onsite travel is required. We have used over 15 students so far over the last 12 months.

Our solution is innovative for the following reasons:

1. It is the first to use social media (instant messaging) in this way, and our market test confirms that WhatsApp is an accessible and easy first touchpoint between patients of almost all ages in Cote d'Ivoire and most other healthcare networks in Africa.

2. It is accessible to users with limited IT experience and/or no access to a desktop or laptop computer. Our pilot testing with a community health worker in Kenya confirms that even low-resourced healthcare teams can overcome IT and hardware limitations and benefit from our solution e.g. using a Samsung tablet with a network sim installed to perform community screenings in remote villages in Kwale County, Kenya.

2. The user interface boasts a shallow learning curve by resembling apps the end-users are familiar with in their daily personal lives e.g vertical scroll timelines like social media. Our usability tests (documented) demonstrate these in an objective and measurable way.

3. The solution utilizes the most popular instant messaging platforms to connect communities to the healthcare network. This style of patient engagement has not been built into EMRs before, not just in the African market. 

4. Our next iteration of patient features includes a health & wellness marketplace which also is unique in how it is designed with providers and patients in mind; full control of medical records including grant & revoke controls, rewards points towards affordable 'pay as you go' health insurance in partnership with a local insurance company (agreement not yet finalized). 

Impact goals

• Increasing access to healthcare services for early detection of cancers. 
  • We are targeting an increase in the number of pediatric patients that get referred to specialists by 80% in 1 year, and 150% by year 5 (all age groups). 
  • We are targeting to diagnose 30% more pediatric cancer cases in year 1 that would otherwise go undiagnosed, and 50% in year 5 (all age groups).

• Improve health data quality for research and decision-making
  • Increase accuracy of data being passed from primary care facilities to DHIS2 via the district offices (capture accurate patient demographics, all test results, symptoms, and original reasons for visit, etc.)
  • Reduce the time taken to complete monthly reporting by primary care teams by from 2 full days to 2 hours
  • Reduce the time it takes for a monthly report to leave a primary care facility till it is visible to leadership in DHIS2 from 2 months to under 1 week. 

•  Reduce wait times for patients
  • We aim to reduce the wait times between first contact at a primary care facility to first contact with a specialist by 80% in year 1, with further improvements through process iteration by year 5.
  • ...

EMR - Electronic Medical Records web app
Whatsapp Chatbot - Patient first touch point
Wellness marketplace/patient portal (roadmap) 

The first tier is the data tier where we store all our health data in a mongo dB database. This gives us the ability to pass the data to the next tier.

The logic tier using flask we can process the data received from the data tier per user request and pass it to the final tier.

The presentation tier we have created a fully responsive user interface to display the data requested from users, this is extremely important for our application as device sizes will vary per user.

Our chatbot is built with a 3rd party tool (landbot) which we intend to swap out with Google ML API (dialog workflow) to scale beyond the pilot. Webhooks are how we parse the data from the chat history to the EMR to automatically generate the patient profile. 

Primary care physicians collect the health data in order to properly document the encounter, track the treatment plan and refer the patient to a specialist for further tests. 

Specialists process the data as contributors, to continue the treatment plan and reach a diagnosis. 

Leadership receives anonymized data through offline reporting and integrations into DHIS2 for data-driven decision-making.