Community healthcare workers in developing countries often have limited education and training, and studies show they are prone to providing incorrect diagnoses and treatment—even when they have printed guidelines. Researchers at the University of Texas Health Science Center at Houston are hoping to reduce the frequency of such errors with the use of innovative smartphone-based treatment guides.
Detecting and Treating Illness in Underserved Communities
A few years ago, M. Sriram Iyengar, an expert in health information sciences, was developing a computerized guide to help NASA astronauts provide medical care to one another on long-duration space flights, where expert medical assistance is truly far away.
As he worked on the system, Iyengar became curious about how community health workers (CHWs) and other non-physician care providers in underserved communities detect and treat illness and disease. What he discovered is that CHWs—who typically have limited education and training and sometimes rely on printed guidelines—make frequent mistakes. One recent study led by the Centers for Disease Control and Prevention, for example, found that CHWs make errors in diagnosis or treatment as often as 62 percent of the time.1
This realization prompted Iyengar to begin investigating how healthcare in developing countries—where skilled doctors and other medical professionals are scarce—could be improved.
“The consequences of such mistakes can be profound, causing high mortality and morbidity,” says Iyengar, an assistant professor at the University of Texas Health Science Center at Houston. “This burden falls disproportionately on the neediest, and on infants and women.”
The Cellphone GuideView system uses smartphones to deliver medical treatment guides to community health workers. Dr. Jose Florez-Arango, a graduate research assistant, observes as a health worker in Medellin, Colombia, tries the system while “treating” injuries on a life-sized mannequin.
Adapting Computer-Based Clinical Guidelines to Mobile Phones
The idea that came to Iyengar was to adapt the computer-based clinical guidelines that he developed for the astronauts to Windows Mobile–based smartphones and other cell phones—because mobile phone usage is growing rapidly worldwide, especially in developing countries.
Iyengar’s system, called Cellphone GuideView,2 uses existing clinical guidelines created by medical experts and breaks down complex diagnostic and treatment procedures into simple steps using an authoring tool called GuideView Author. Text, pictures, audio, and video are embedded in the individual steps to help with comprehension and ease of use. Each set of steps comprising a procedure is known as a “guideview.” The guideviews are stored on a smartphone’s memory card, enabling CHWs to walk through the steps as they treat patients.
Field-Testing the GuideView System
M. Sriram Iyengar, assistant professor, University of Texas Health Science CenterBuilding on the initial work he did for NASA and the U.S. Army Telemedicine and Advanced Technology Research Center—and with software, hardware, and financial support from Microsoft External Research—Iyengar has begun field-testing the system with CHWs in Colombia. He is assisted in this project by two graduate research assistants, Jose Florez-Arango, M.D., and Carlos Garcia, M.D.
For the field tests, the research team created guideviews—containing as many as 225 steps each—in the areas of wound care, pediatric fever and musculoskeletal traumas such as contusions, dislocations and fractures. Care of wounds and musculoskeletal trauma is especially important in Colombia due to the prevalence of land mines.
Iyengar says the key to the guideviews is the use of multiple modalities—text combined with recorded verbal instructions and images or video, for example—to enhance understanding. Studies have shown that presenting information using a variety of modalities can enhance task performance, he notes.
The GuideView system also records each step the CHW takes in interacting with the patient. The records can be analyzed later by experts to provide feedback and help the CHW improve compliance with the treatment guidelines. In addition, guideviews can be programmed so that CHWs can initiate a call to a specified physician or hospital if they reach a step in the procedure that is beyond their level of expertise. The CHW can then transmit images, data, and audio to the remote expert for further advice.
Challenges so far include designing the system to work with a variety of cell phone keypads and fitting the videos and instructions—which were initially designed for use on computers—on small cell phone screens. Currently, Bluetooth earpieces are provided so the user can easily listen to voice instructions from the system. The researchers are also investigating the best way for health workers to hold the phone as they treat patients. One option is to strap the cell phone onto a lower arm, enabling hands-free use—in much the same way that people attach an MP3 player to their arm while exercising at the gym.
For the Colombian study, the researchers have recruited 50 CHWs from around the city of Medellin. Using sophisticated, life-sized mannequins that can simulate a range of medical disorders and physiological conditions, the CHWs will be asked to “treat” 30 medical conditions (10 pediatric and 20 adult) such as cardiac problems, bleeding and fractures—in some instances using printed guidelines and in other cases using the smartphone-based guides. The study will evaluate how useful the CHWs find the features and user interface of the smartphone guides, as well as the system’s impact on the cognitive and physical aspects of their performance.
Plans for the Cellphone GuideView and the Data It Collects
The data will be entered into a SQL Server database for later analysis and will comprise part of Florez-Arango’s doctoral dissertation. The researchers have used Microsoft Visual Studio 2008, Visual C# 2008 and .NET Compact Framework development tools to create the software used in writing and playing the guideviews, and they are testing the system on smartphones provided by Microsoft.
Eventually, Iyengar hopes to test Cellphone GuideView on actual patients in developing countries, probably starting in Colombia. He notes the importance of conducting thorough simulation tests before seeking approval from foreign governments for human trials.
The researchers are optimistic about the eventual impact of the system. Iyengar envisions it being used by soldiers in combat, and even helping people with chronic conditions such as diabetes and post-traumatic stress disorder administer self-care.
“I believe this could help people who are ill, help health workers provide better care and improve the general wellbeing of people,” he says. “That’s the dream.”
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1 “Effect of multiple interventions on community health workers’ adherence to clinical guidelines in Siaya district, Kenya,” Transactions of the Royal Society of Tropical Medicine and Hygiene, 2007. (Back to story)
2 The GuideView system is proprietary to the University of Texas and is currently in patent-pending status. (Back to story)
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An External Research-funded project supporting advanced technology research |
Project Principal
M. Sriram Iyengar, Ph.D., assistant professor of health information sciences, University of Texas Health Science Center at Houston; and informatics research scientist, NASA Johnson Space Center, Houston
