Big ideas from Dominic Mutai

The following is an interview I did with my colleague Dominic Mutai
for the PATH M&E newsletter. Dominic is a disruptive thinker in Kisumu, Kenya.

Q: Before you joined PATH you developed a mobile app to predict a patient's risk of tuberculosis, and you were funded by a BMGF Grand Challenges grant. Tell us about your app and where you see these types of predictive technologies going in the future.

We developed a TB screening mobile app that predicts a person's probability of having TB.  The app's algorithm used the WHO 4-symptom rule for investigating TB suspects; (1) cough (with or without coughing blood), (2) hotness of body or sweating at night even when it is cold, (3) noticeable weight loss and, (4) night sweats to establish the probability of the person having TB. Based on the score by the app, the person was either ruled out, asked additional questions, or recommended for further evaluation.

Photo courtesy D. Mutai

mHealth technologies are turning phones into miniature labs and instant healthcare delivery systems. Mobile apps are improving care coordination, raising the level of patient engagement, and managing chronic diseases, but the technologies could be made even more effective with better use of predictive modelling. Similar predictive mHealth apps can suffice for predicting the risk lifestyle diseases like heart disease/ hypertension/stroke, or even predicting possibility of occurrence of maternal complications. Mobile apps that will put control of the user's health in their palms and give them a certain level of confidence will be very useful. Such apps will be the first point of care providing accurate information to the users, managing doubts and urging them to take control of their health


Q: You work on APHIAplus and manage a lot of data. What types of systems, tools, or processes would you like to see adopted by projects across PATH to make your work easier. In other words, what is your dream for data management in large-scale health projects?

Yes, APHIAplus is a big project that generates a lot of data. There is a constant demand by the program for better use of data in program management and decision making. This puts pressure on the M&E team. Thus we need to be armed with the best tools that are easy to use and deliver on demand analytics to the users at their convenience. Big projects like APHIAplus should have well documented systems and processes for managing vast data. First things first will be development of Data Management Plans (DMP) or an analysis plan will guides the entire data management processes- what data is to be collected, who to collect it, how to collect it, where will it be stored and how the data is be analyzed and used. Then, systems are developed that collect and store the data. Web applications and mobile apps are lately being more accepted for their ease of use and availability than the traditional desktop systems. A central and important factor in data management is where the data is stored. Good data management practices need a central database or even a data warehouse where all the project's data is stored and managed centrally than using desktop databases and spreadsheets where every person has their copy. What I would call proliferation of spreadsheets is every M&E person's nightmare because each person has their own copy of data which at many times won't be the same data. It's hard to back up and maintain all these disparate data sources. Thus it would be prudent to invest in network based relational database system fit for small enterprises; like SQL Server. After that users are then given their right analysis tools which they are comfortable with. Excel is still (and will be) a tool that many users are comfortable with thus having means where users can connect Excel to the central database works well. SQL Server being a Microsoft product integrates well with Excel and other Microsoft products. It provides Analysis Services where users can query with Excel and dice and slice the data the way they want. Bundled with SQL server are Reporting Services and Integration Services. Integration Services perhaps to be is a magical tool in data cleaning and ETL- Extracting, Transforming and Loading data from different sources while Reporting Services provides an easy to use report portal. I see that our PATH report portal makes use of it. Then there is Tableau. Tableau is just a tool beyond tools. I met Tableau when I joined PATH, and in it, I met a wonderful visualization software close to none.


Q: Since you're a Grand Challenges winner, you must have many creative ideas. Do you have any innovative ideas for how the data you manage could be better used?

Perhaps the best thing would be where the data is sourced and how to improve that process for all involved stakeholders. Our project is anchored on the Ministry of Health systems (DHIS-2). Innovation is needed to ease documentation burden on the health care worker and assist the Ministry manage entire data flow process and data use for real time disease surveillance and tracking. There is a big documentation burden on the Ministry of Health's health care workers. Paper based registers are used and there is a register for every program area - Malaria, HIV/AIDS, TB, Immunization, nutrition. Then there are monthly reports that are expected of the health care worker to manually tally and aggregate the data from the registers to the reporting tools. This is usually a big problem as the wrong data is usually tallied and entered. Another problem is the problem of patients getting lost to follow up, defaulting or transferring out. This is a common problem to all HIV care is implementing partners and the Ministry.

My idea would be a cheap point of care Electronic Health or Medical Record (EMR) that works anywhere in Africa. We have had the introduction of OpenMRS EMR but its impact has not been very successful since it requires desktop computers and electricity. Its adoption as a point of care EMR is also limited because of the typing and its ease of use. Security has also been a problem and we have had a number of computers stolen. OpenMRS also works only for the HIV care and treatment and TB areas. An alternative would be a holistic Electronic Health Record (HER) that is easy to use, using touch screens and accepts handwritten clinical notes. It should also integrate with other systems, notably DHIS 2 and at the end of the month, the health care worker just transmits the data straight to DHIS. It should give the health care workers dashboards, alerts and clinical decision support where they can track patients and diseases burden on the real time. It should provide a means of patient accessing their data and when a patient moves, the EHR and patient data can be transferred by a click of a button to the next health provider.

A Tablet based EHR would be a good idea since it will work in the remotest places in Africa without electricity (they can be charged by simple solar chargers), they are easy to use – with touch screens and they provide hand writing support; health care workers can touch and write their clinical notes instead of clicking and typing. Data will be secured using encryption while the tablets physical security is easy to implement. Patient scheduling, interactive visualizations and dashboards will be built into the system to aid in decision making. Manual report generation will be replaced by electronic report generation by a click of a button and the right data submitted straight to DHIS eliminating another point of data entry at the district level thus reducing data entry errors. We as a program, the ministry and all stakeholders would have the accurate data, instantly while the documentation burden will be relieved off the health care workers to that they can concentrate on seeing patients. Tablet prices have been dropping and we currently have tablets going for less than 100 dollars.  Hand in hand with this innovation will be creation of policies that safeguard patient's sensitive data. Many countries don't have  the US HIPAA equivalent acts and laws that safeguard patients data confidentiality, integrity and availability.  Thus a point of care Tablet based EHR would a welcome innovation.​


Short Bio​

Dominic Mutai is a Data Manager with PATH's APHIAplus western Kenya.  Prior to joining PATH, Dominic worked on vaccine and drug trials while working with KEMRI/CDC; a collaboration between Kenya Medical Research Institute and US Centers for Disease control and prevention as a Data Manager and previously, at Columbia University's International Centers for AIDS Care and treatment Programs (ICAP) as a M&E Officer. Dominic holds a Bs\Sc Degree in Computer Science and Engineering and is finalizing his MSc in IT Security and Audit. Dominic is passionate on developing tools and devices that make use of Information Technology to solve Africa's health problems. When he is not analyzing data or writing code, Dominic spends his time with his wife and two sons in their home in the lakeside town of Kisumu.​

Knowledge brokers: the bridge to somewhere

This post is based on a blog in the PATH M&E Community of Practice newsletter. 

Why do we need knowledge brokers?

We know that very little of the health data and evidence produced is systematically used to inform programs and policies. This observation has led to the creation of entire disciplines of “knowledge translation” and “evidence-based policy-making.” One of the key observations of these disciplines is that relationships matter. We can build all the databases, write all the policy briefs, or create all the data in the world, but it won’t be used unless we invest in the social element.

In her seminal article about the diffusion of innovations in healthcare organizations, Trisha Greenhalgh said, “knowledge depends for its circulation on interpersonal networks, and will only diffuse if these social features are taken into account and barriers overcome.”

Barriers exist. Even when networks exist, people are less likely to exchange information than to engage in other types of exchanges. And when we look at the direction of information exchange, people are much more likely to provide it than request it (although neither process happens very often). Look at the networks below – the same people, but three different types of relationships. On the left, the ties represent whether they reported interacting at all during policy development; in the middle the ties represent whether they provided research evidence to one another; on the left, ties represent whether they requested evidence from one another. 

Figure 1. Policy actors in Burkina Faso according to three types of relationship ties

Why are we reticent to ask for information? Wouldn't it vastly improve our work? Yes, I found in Burkina Faso that policy actors who exchanged information were more likely to use it to inform their decision-making. 

That’s where knowledge brokers come in. Knowledge brokers can be ad-hoc and informal, or a formal role in an organization. Evaluations of formalized knowledge brokering roles in high- and low-income countries have suggested that they are effective at building individual and organizational capacity to use data. So what can we do to identify, support, or be effective knowledge brokers?

1. Brokers are bridge builders

Knowledge brokers are strategically connected in their networks such that they are able to reach many otherwise unconnected actors. They build bridges between communities. They understand the context. They possess an intuitive mental map of their networks and know where to build the next bridge. We call this metric of strategic connectedness betweenness centrality, and the graph below shows the most strategically connected health systems researcher according to betweenness centrality. This person can theoretically reach the most other actors in this community to share new knowledge.

Figure 2. Co-authorship network of health systems researchers, nodes sized by betweenness centrality

2. Brokers come from the inside 

Knowledge brokers are perceived to be more credible and trustworthy if they are embedded in the organizations they target, like ministries of health or health services organizations. Detailed network mapping and qualitative interviews in Burkina Faso demonstrated that policy actors were more likely to adopt ideas from someone within the ministry than from development partners (even though the development partners had better network connectivity). This is further evidence to refute the "two communities" hypothesis prevalent in KT, which has also been challenged by others and stands in our way of designing interventions that recognize the role flexibility of actors in policy-making.  

Our team’s work on the Gavi Full Country Evaluation is also showing the importance of trust in the provision of technical assistance for vaccine decision-making. This is not the first time that approachability and patience has been identified as necessary traits of a knowledge broker.

3. Brokers are translators

The biggest skill of a knowledge broker is their ability to translate across various users’ and stakeholders’ languages, skills and perspectives. We should all keep this in mind when discussing our work. You don’t need fancy network maps to connect with a colleague and talk about research evidence, project data, or new knowledge you have. And don't forget to ask for information -- brokering goes both ways. Go forth and broker!