Design Approaches for Electronic
Partographs and Others Tools to Support
Intrapartum Care
Panel Presentations and Discussion
Global mHealth Forum
December 11th, 2014
Objectives
 Consider a range of design approaches for
electronic partographs and related tools
 Identify and discuss common challenges
 Advance the dialogue and share possible
solutions
Panelists
 Jonathan Payne, Merck for Mothers & UN Foundation
 Neal Lesh, Dimagi
 Heather Underwood, University of Colorado
 Shoval Dekel, Jhpiego
Session Outline
 Project Presentations
 iDeliver (Jonathan Payne)
 PartoPen (Heather Underwood)
 mLabor (Neal Lesh)
 ePartogram (Shoval Dekel)
 Facilitated Discussion
 Wrap-Up
The PartoPen:
A digital pen-based approach to address
maternal labor monitoring challenges
Heather Underwood
University of Colorado Boulder, ATLAS Institute
University of Colorado Denver | Anschutz Medical Campus
Problem & Motivation
Barriers to Correct and Effective Partograph Use
GOAL: Improve partograph completion rates
by overcoming the primary barriers to use
noted in the literature
• Form complexity and data
interpretation challenges
• Inadequate initial and ongoing training
• Limited resources
• Staff shortages
• Retroactive completion
• Lack of positive role models
• General attitude
6
LIVESCRIBE ECHO Digital Pen
the ‘magic’ is in the…
ANOTO DOT PATTERN
Open Paper vs. Fixed Print Regions
Mark
Position
X Code
Y Code
1
1
1
2
0
1
3
1
0
4
0
0
USE INSTRUCTIONS
Entire WHO manual is available in short audioprompt format by tapping on the instruction
buttons next to each partograph section.
DECISION SUPPORT
When measurements are made indicating a prolonged labor,
text and audio are emitted from the pen to alert birth attendants
of possible actions for this patient.
REMINDERS
½-Hour
4-Hour
PartoPen Reminder IDs allow
birth attendants to create short
patient-specific identifiers to link
the unique pattern encoded in the
dot pattern printed on the page to
the specific patient.
Time-based reminders are set for each patient (specific to the unique dot
pattern on the form), to remind birth attendants that one of their patients needs
another exam.
Digital Pen Benefits & Challenges
Benefits
• Low power and connectivity
requirements
• Requires little to no training on the
device
• Retains paper form without creating
double work
• Robust, durable, portable, low profile
• Fails gracefully
Challenges
• Digital Pens are not readily available
outside the US
• Printing challenges illustrated general
supply issues
• Limited third-party development support
12
High-level Design Considerations
1. digital pens are viable platform for point-of-care health solutions
and provide several benefits over other digital solutions
2. the PartoPen did address training barriers
where training was the most significant obs
3. partograph completion is affected by many factors;
partograph accuracy and completion does not
necessarily imply better clinical outcomes or highe
levels of nurse training
Acknowledgements
Dr. Ong’ech, Grace Wangombe, Sabina Wakasiaka, Grace
Omoni, and all the KNH and UoN nurses, staff, and students
Heather Underwood
h.underwood@ucdenver.edu
@hmunderwood
Landscape of Digital Tools
for Intrapartum Care
December 11, 2014
Global mHealth Forum
Jonathan Payne, MS
Project iDeliver Lead
paynejd@gmail.com
287,000
“In 2010,
women died during and
following pregnancy and childbirth. Almost all of these
deaths occurred in
,
and
most could have been
prevented.”
low-resource settings
– World Health Organization, 2012
http://goo.gl/kA73FZ
Partograph
• The partograph is widely used in the
developing world (Friedman 1954, Philpott 1972, Levin 2011)
• When used correctly, the partograph can
help prevent obstructed labor (Philpott 1972,
WHO 1994, Mathai 2009, Neilson 2003, Hofmeyr 2004)
• Birth attendant training and partograph
implementation can improve maternal
and perinatal outcomes (Levin 2011, Fahdhy 2005,
Bosse 2002, WHO 1994)
• Studies in developed countries have
shown little or no impact resulting from
partograph use (Levin 2011, Lavender 2012)
• Barriers exist to correct partograph use in
developing countries (Levin 2011, Lavender 2012)
LANDSCAPE SUMMARY
CATEGORY
FINDINGS
Clinical Guidelines
• International and country-specific clinical guidelines that are up-to-date exist for most of IP
care, though not all are validated (updated WHO IMPAC guidelines pending)
• Gap in prioritization & adaptation into formats suitable for job aid
Geographies,
Implementing
Partners
• Related implementations exist (OpenSRP, mLabor, ePartogram, CliniPAK)
• Identified implementers with sufficient interest/preparedness and viable implementation
scenarios in geographies with need
Quality Measurement
& Improvement,
Data Use
• Standardized measures & data elements exist (ICM, WHO, MEASURE Evaluation, NIPH) but
lacking minimum dataset & prioritized measures
• Successful QI during intrapartum care exists (SCC, IHI, Jacaranda)
• Examples of electronic birth logs/maternity registries replacing paper reporting (OpenSRP,
hRHR, Maternity Neighborhood)
Architecture,
Interoperability
• Alignment with OpenHIE / Motech Suite will facilitate technological integration in countries of
interest
• Terminology management solutions exist (OCL) to facilitate collaborative development of
quality measures and core dataset
Business
Requirements,
Specifications
• Many business requirements well described (based on existing projects/technologies), but
appropriateness varies based on service design, geography, technology, partner
Technology
• Digital POC tool during intrapartum is feasible and business models exist
• Related platforms exist but no one platform meets all iDeliver requirements; extending
existing platform(s) will be necessary
User Workflows,
User Support,
Adoption Strategy
• Relevant service delivery design is taking place within intrapartum care (e.g. BOLD, SCC), but
significant gaps remain on adaptation of content to digital tool at the point of care, in
particular on user acceptability and appropriate design
Clear path to success
Lower risk, but further research &
development needed
Potential risk; significant focus needed
to alleviate risk
iDeliver Vision
Project iDeliver will be a digital tool
primarily for skilled birth attendants to
improve the quality of care provided
during labor and delivery by enabling
provision of standardized care and
routine quality measurement.
22
mLabour: Reflections on
Early Design Work
Neal Lesh, Dimagi Inc
nlesh@dimagi.com
December 11th, 2014
@dimagi








Maryam Khalid
Jenny Schweers
Clayton Sims
Srishti Bishnoi
Heather Underwood
Manju Chhugani
Neal Lesh
Stella Luk
Team
Motivation to create CommCare apps for
Intrapartum Care
 Potential for high impact, e.g.,
 Improve consistency and quality of care
 Early detection of obstructed labor
 Improve referrals
 Android tablets and phones are an
attractive platform because are
 Widely available
 Good for decision support
 Operate offline and sync with a central server
Many challenges too (e.g., need for paper record,
keeping device clean, local sync)
mLabour mockups
mLabour prototype- case lists
mLabour prototype - graphs
Contractions
Design changes from user testing





Allow vaginal exam to be filled by either doctor or nurse
Support just-in-time configurability of exam reminders
Allow user to specify which key indicators will be tracked over time with
minimal key-strokes
Provide graphical representation of contraction size
Retain logs of past patients.
Design requirements and challenges





Need to do much more than partograph to provide value to workers and
reduce their burden.
Great need for flexibility as workflows and users vary greatly
Need to design for the gap between how things are supposed to work and
how they really work.
Open question if tablets will really work in busy wards
Still need to identify where greatest impact of ICT can be had
Overview of the ePartogram:
Jhpiego
Shoval Dekel
Dec. 11, 2014
Global mHealth Summit, Washington DC
Summary
 Jhpiego’s ePartogram is a tool that will be used
by health care providers in LMIC to manage
labor and guide decision-making by helping to
detect complications during labor and delivery,
which will reduce neonatal and maternal
mortality and morbidity.
Context: the Paper Partograph
 The appropriate use of the
World Health Organization’s
(WHO) paper partograph can
help decrease maternal and
perinatal mortality by reducing
prolonged or obstructed labor.
 The paper partograph along
with WHO guidelines for labor
management are the basis for
the ePartogram
ePartogram: What does it do, Why is it unique?





Stores multiple patient data
in one device
Reminds and prompts
providers to take critical
measurements
Automatic graphing
Provides alerts and alarms
for decision-making
support if complications are
predicted or occur
Telemedicine module
transmits all observations to
central level remote
supervisor for guidance and
support
34
Identifying Problems and Potential Solutions
Problem with paper partograph
How ePartogram addresses the
problem
Not user friendly: Too
cumbersome and time consuming
to fill out.
Fast data entry to allow providers to
spend more time with the women than in
filling out data.
“Post”agraph effect: When filled
out after delivery, users and
pregnant women do not benefit
from early detection of
complications.
Reminders signal when women in labor
should be examined and alarms sound
when abnormalities are found during the
exam―shows the value of the
partograph as a tool during labor.
Hard to share with others:
Maintained as a record and is
often not transferred with the
client during a referral.
Data is available at referral facilities
before the client arrives, allowing for
consultation and preparation.
Jhpiego’s Iterative Approach
Continuously returning to the Field for end user feedback an involvement in each
stage.
Review and Feedback from end users determine the next development stage for
the ePartogram
•User needs
assessment
•India, Nepal,
Tanzania
2010
2011
•Proof of concept
•Tanzania
•3 Platform
prototypes
•Review in Kenya,
assessment of
features
2012
2013
•Development of
user interface
•Focus groups with
end users in
Kenya
•Software
development
•Zanzibar, field
refinement
2014
Successes to Date
 Choosing to use a tablet interface opens the opportunity
to collaborate with other tools and make data compatible
with larger scale electronic medical records.
 Early involvement of end users, leading to heightened
interest of implementation programs in the ePartogram
 Clinical rigor and integrity- Jhpiego has spent a lot of
time and investment in the development of the clinical
rules and their validation to ensure the safety and
efficacy of the ePartogram.
Partners and Donors
What is next for the ePartogram?
 Pilot Testing in Zanzibar
 Independent Studies in Zanzibar
 Pilot Implementation in Zanzibar and
Tanzania
 Interest for Pilot Implementation in
additional Countries