G4 Collaboration Prize
Webinar Question and Answer
PRESENTATION 1: An electronic registry for trauma and elective operations with training of trauma care providers
Primary Applicant: Alzaeim Alazhari University
Presenter: Dr. Ahmed ElSayed
Collaborating Organizations: Primary Trauma Care Foundation (G4); Center for Global Surgery McGill University Health Center (G4) and Lifebox Foundation; Center for Innovation in Global Health, Stanford University Global Surgery
Q: Any technology requires adoption in order to be successful in aiding projects. How are you planning to address adoption by providers or those who will be offering information?
A: For the purposes of this study we will have a senior doctor in each state responsible for the local study. S/He will have three doctors responsible for collecting the data. We will entice them by providing an internet data package and free calls every month (they will need a fraction of this for the study and the rest is for them). Another incentive for them is that they will be co authors in papers to be published
Q: Love the initiative to offer context specific interventions reducing patient morbidity and mortality. Once deployed in 120 hospitals, do they have an idea of how much mortality/morbidity may be averted?
A: Our initial calculations are that improved trauma care will benefit aprox. 26000 patients/year). We calculate that decreased mortality and morbidity after surgical operations based on a 26% decrease will mean aprox. 10000 patients/year
Q: What is the telecom coverage in the remote sites? Is coverage by all 4 telecom providers necessary to get to all projected sites reliably?
A: Telecom coverage is very good overall, we will be concentrating in the 5 states in Sudan with the best coverage. We will need only one provider but initial contact will be with all 4 to see who will give us the best offer
Q: How will they measure outcomes?
A: The expected measurable outcomes are;
a) A functioning registry for trauma and elective surgical procedures.
b) At the end of the project we plan to have trained 128 primary trauma care providers out of which 32 will be trainers able to train more providers
c) At the end of the project we plan to have all participating hospitals have a sustainable WHO surgical safety checklist (total of 37 hospitals)
d) Each participating site will get an oximeter
e) We expect the project at its end to supply a database containing all the trauma and elective operations done in the study sites. This will form a base for future studies and planning the health services
f) A measurable outcome will be elective operations mortality/morbidity post WHO SS implementation
Q: How will this information be put to use? How will the family in need know where to go?
A: The data collected will be used to inform the authorities to provide a better service for trauma and elective operations. The data will also be analyzed by us to suggest solution to discovered problems. It will also hopefully form a model for countrywide implementation and hopefully implementation in other countries.
PRESENTATION 2: COSECSA Safe Surgical Checklist
Video Presentation: Dr. Abebe Bekele
Question respondents: Dr. Tom Weiser and Ms. Rosemary Mugwe
Primary Applicant: COSECSA
Collaborating Organizations: AAS (G4) and Lifebox
Q: What are the differences between the WHO and COSECSA checklist? Why modify it? What will make it more "fit for purpose?”
A: The checklist as developed by the WHO is a universal guide so that each hospital and institution has the liberty to adopt the indicators as it fits the different hospitals in the globe. In fact, the WHO clearly indicates that all hospitals need to adopt this checklist to fit their own environment. Crude copying of the checklist will not have a lasting effect and will be dropped from the service. This is also supported by literature. For instance, for a very huge hospital in the developed world where there are more than 40 operating theatres, hundreds of surgeons, scrub nurses and anaesthetists working on rotation basis everyday, introduction of the team at the beginning of each procedure is mandatory. This is not true in Africa where there is only one OR table and the staff there never change (Probably there is only one surgeon, two nurses and one anaesthetists). For the African setting, there are more important indicators such as "ïs the suction machine working today”, “Does the generator have fuel in it”, and so on.
That is what we are going to do. We are going to bring together the experts from the COSECSA region and identify what are the burning issues in their setting (which probably is similar in most COSECSA hospitals) and modify the original WHO checklist. Again, studies have also shown that adopted checklist to the local setting has a very higher chance of being implemented into routine use.
It is also not only ticking the check list, the checklist needs to be well understood by the staff to implement it. It should also be linked to a reduction of mortality and morbidity.
Q: WHO's surgery for the district surgeon already exists and is widely vetted: how will this be different?
A: As far as my knowledge goes, this is a textbook written to assist surgeons at the district level. It mainly deals with procedures, not the modification of the checklist. We are focusing on Äfricanizing the checklist” so that the African Surgical workforce understands it well and easily implements it.
PRESENTATION 3: Geospatial mapping of pediatric surgery needs
Primary Applicant: Global Paediatric Surgery Network
Presenter: Marilyn W. Butler, MD, MPH
Collaborating Organizations: WOFAPS (G4); Harvard PGSSC (G4); COSECSA (G4); McGill CGS (G4); Lancet; GICS; Stanford
Q: Dr. Butler - are you going to also map anesthesia providers who can care for your patients?
A: Initially, we had not intended to map anesthesia providers who can care for our patients, because we thought that an indirect measure of the ability to perform a colostomy in a newborn and subsequent reconstruction was the ability to provide some level of safe anesthesia. If we have the names of the pediatric anesthesiologists, however, we could map them as well. We would just need to add some data points, perhaps collaborating with another G4 Alliance member organization, such as the World Federation of Societies of Anesthesiologists.
Q: This could be a marker for access to safe, timely and effective surgery for
children. Is that partially what you are going after?
A: Yes, the purpose of the study is to assess access to safe, timely, and effective surgery for children. With the help of pediatric surgeons within each country, we will determine which level hospitals are appropriate for the safe performance of newborn colostomies, and we will then calculate the proportion of the population who can reach those hospitals within 48 hours. This will therefore serve as a proxy for access not only to surgeons or medical providers who can perform the colostomy, but also the ability to provide IV hydration and some form of anesthesia, whether it be local anesthesia or general anesthesia by a qualified provider.
Q: Is there a country where this has been done successfully so far?
A: Household surveys using the Surgeons OverSeas Assessment of Surgical Need (SOSAS) have been used to perform similar geospatial studies of access to surgery in some countries, and the Lancet Commission on Global Surgery performed similar geospatial studies of access to Bellwether procedures, none specific to children. Household surveys would be beyond the scope of this study and too labor intensive. Access to surgical care for the world’s children is disproportionally low because of the need for specialist surgical and anesthetic care. Because of these unique needs, we used imperforate anus as a proxy to assess immediate access to urgent surgery, as well as access to definitive reconstructive surgery. The former requires infrastructure including roads and hospitals, as well as a minimum of equipment and skilled manpower. The latter requires a high level of surgical and anesthetic training, as well as advanced facilities for children.
Q: Is the geospatial mapping software readily available? I understand that there is a wait-list for access to the NASA software.
A: Geospatial mapping software is available, but it is expensive and needs a fair amount of training to use. For this reason, we will collaborate with Dr. Tom Weiser at Stanford University who has experience performing geospatial studies. In the past, he has used a proprietary program through an affiliated startup company, but there are other options as well, the most popular being a program called ArcGIS. We have been working with Dr. Weiser to assure that our data points are formatted properly for analysis.
Q: This sounds fantastic, will 40K be enough to complete this or do you already have funding and this would aid successfully deploy the effort?
A: We do not already have funding, but we believe $40K is enough to complete this study. What makes this study feasible with this amount of funding is that we have strictly limited the data points for collection. In the case of colostomy, the response for each hospital identified is either “yes” or “no”; if the response is “sometimes,” that will count as “no”, since the ability to perform colostomy must always be available. In the case of definitive reconstruction, the response is “yes”, “no”, or “sometimes”, since this is an elective procedure where timing is less critical, so it could wait until skilled surgeons and anesthesiologists are available, including visiting teams.
PRESENTATION 4: Use of fingerprint identification to provide a unique patient ID with cloud interface
Primary Applicant: Healing the Children
Presenter: Dr. DAVID HOFFMAN
Collaborating Organizations: International Association of Oral & Maxillofacial Surgery (G4); WFSA (G4); IFNA (G4); SmileTrain (G4); Boston Children's Hospital; Northwell Health Care; Identazone
Q: Question on EMR proposal: How would this system interact with, and feedback into, local medical records (both paper based and electronic)?
A: Initially we will place a digital or written copy of our pertinent notes into the hospital or local health care charts. When possible we will use translator software to facilitate with foreign language issues.
Q: The question on finger print technology is for Heal The Children. I assume they are developing the system so that the local health system can use it without visiting teams.
A: This assumption is correct; any software we develop with fingerprint technology will be available to local health care workers. We plan to present our pilot project to the entire G4 Alliance for further recommendations on this issue
Q: Have fingerprints been used in previous studies successfully to prove the concept of identifying children over time?
A: A literature search on this topic has indicated that it can be used. Identazone our software partner has used this technology for the state of Michigan Medicaid system. As pointed out in the webinar the fingerprint will be used in conjunction with other demographic data but will remain unique to the patient. With regards to children and infants we plan to use parents fingerprint as a second backup an. Although there is technology that could be used such as retina or facial ID, we feel this would be price and technically prohibitive.
Q: How do you propose aligning this EMR information with MoH's and strengthening national capacity and ownership of medical records
A: I am not sure what MoH’srefers to. Access to records will be a topic to be discussed. For the moment we are concentrating on software and hardware development. Ownership of records will be a topic but for the moment we are looking at first how to procure and save data.
Q: How does it handle data protection for patients?A: Identizone will be responsible for encryption and HIPPA compliance
Q: I have looked at the possibilities (with a number of lawyers) with regards to patient data storage across countries, and it is virtually impossible to find a system that meets all requirements. S political impact is of owning such amounts of personal data for example based on a server in the US? I can list a whole range of countries that would have political issues with this.
A: This is an interesting and complex problem. I think this will be looked into after we get the initial project developed and answer some basic questions. I am not sure there is a definitive answer right now, but we are aware of such issues. I would welcome your help and input on this issue.
Q: I assume the local providers you are training will be able to use system when international teams are not there.
A: We are planning to make this program simple and intuitive so that all users will be able to use it. If it is too complex then it will be useless. One of our partners Smile Train has forms that we are using and their model appears to be working well. We will be incorporating our fingerprint and storage technology with their proven record keeping.
Q: How will the patients get smart phones? Will they be given to c
A: The smart phone concept and utilization is based on the fact that in so many countries more than half the population carries a smart phone. We have no intention of giving smart phones away.
Q: Seemingly similar initiatives have not gotten traction. How are you thinking we could succeed in getting people to join in?
A: This is a major concern of ours. Our hopes are that we can make it simple to use, and reflective of the WHO and G4 Alliance concerns. Once we get a working model, we hope to present it to the G4 Alliance to develop future plans, utilizations and funding.
Q: Will the project pay for minutes on the cell-telecom system?
A: We have not gotten to that problem yet but will now add it on our list
Q: This sounds like a >40K project, if they need to both provide hardware and develop software, as well as trial the system.
A: We have already started on the project and we are planning to run it in late May in Neiva, Colombia. Identizone is committed and is willing to work with us, the funding only makes it easier.
It is correct that the project will need more funding, but until we have a working demonstration we cannot approach other funding resources. The good news is that finger print readers are very cheap and most clinical settings have computers.
PRESENTATION 5: Primary Surgery is the Answer!
Primary Applicant: International Collaboration for Essential Surgery (ICES)
Presenter: Professor Michael Cotton
Collaborating Organizations: IFSC (G4); ASGBI Royal College of Surgeons of England
Q: Is the Collaboration Prize actually needed for this Volume 2 Trauma to be published. Will it not happen regardless?
Q: What would the grant be applied to if it supports the development of the Volume 2 textbook?
A: The Grant is being applied for because it took 15 years to re-edit the first volume on a voluntary basis. Moneys are sought for:
(1) a modest incentive to chapter editors to complete - and thereby a time-binding contract can be hung onto this activity,
(2) costs of the evaluation exercise planned in Madagascar, Tanzania and Zimbabwe.
(3) administrative costs of meetings of the editorial board (hiring venue etc)
(4) modest per diems for the Editorial board.
A huge number of hours were put into updating the first volume, and this did not just "appear”. Without funding, the new edition will not just "happen" spontaneously. The demand is there, but as the good book says, the harvest is ripe but the workers are few. They need to be remunerated.
Details of the breakdown of costs have been submitted in the application.
PRESENTATION 6: The G4 Empowerment Database - A Single Open Source Registry of Available Human and Material Resources to Efficiently Coordinate Organizational Efforts Between HICs and LMICs
Primary Applicant: International College of Surgeons
Collaborating Organizations: Americares; Intrahealth; Plasticos; Mending Kids; Cure; IFNA; PTC; Selfless (all G4) and Global ENT Outreach; Health Volunteers Overseas; Navajo Hopi Health Foundation; First Nations Limb Preservation Foundation; Scalpel
Q: Who will manage the system long-term? IntraHealth?
A: IntraHealth will both develop and apply their software as a service to satisfy their mission as the preeminent global leader in health workforce informatics within LMICs. Their open source and globally supported technological solutions have a proven track record in building human resource capacity worldwide in healthcare. IntraHealth’s analytical approach is designed to collaboratively build and logistically sustain the skills of our regional partners in healthcare.
Q: Is there a system for vetting volunteers?
A: All medical mission organizations all have their own volunteer vetting processes in place pursuant to their charters. These will be both respected and further enabled as the certifications and licensures of volunteers will be tabulated, in addition to their skill sets, experience, language diversity, and availability. The G4 Empowerment Registry will grow to account for growing member data requirements and then seamlessly incorporate those into the system’s database. Eventually, as we become more conversant with their needs and as the system matures, we could see outreach for trusted information exchange with national medical boards and the national provider CAQH credentialing database to verify clinical certifications. We see this question as one of building trust first.
Q: Our understanding is that IntraHealth International is also a contributor to this project.
A: Absolutely. It is their foundational investment into advancing the quality of global health care, specifically the healthcare worker crisis that constitutes a significant part of its core mission. This project leverages almost a decade of their software development and implementation successes with greater than ten million dollars already invested into meeting their goals. Our collaboration meaningfully builds on their mature and highly functional technologies to first create a registry of volunteers form HICs, and then scale this registry to empower local health programs to sustain ongoing academic training. They may recruit volunteers directly from this registry to assist either in person for a scheduled mission or via telemedicine. For the latter, a rotating pool of “on call” volunteers from this registry will provide a 24/7 consultation service across multiple surgical subspecialties, including obstetrics, anesthesia and trauma.
Q: Will there be some sort of dues for providers and hosts to use the database or will it be open?
A: In addition to accomplishing all of the goals set forth within our submitted budget, this grant will definitively enable the implementation of our program in several pilot locations and then scale up to demonstrate proof of purpose. This academic approach will includes both the technical adaptation of IntraHealth’s effective iHRIS Qualify software as well as developing a responsible business model to provide investors with meaningful data to justify their investments. The latter is critical to ensure the sustainability and growth of our program and will evolve as the program scales upward. IntraHealth has followed similar steps with their other technologies, for example the development and business deployment of their Health Network Programme in Tanzania where they proved the concept before it was taken to scale.
To the point: it is our goal to preemptively identify and quell all barriers to the global expansion of this program, including predictable financial obstacles. The use of this G4 Empowerment Registry by member groups, host nations, program designers, and by volunteers alike should be free. Grants to fund scaling are being written now understanding that all participating groups have fiscal constraints that must be respected.
Q: Who was on the evaluation committee?
A: The shortlist committee included Mr. Orion Henry; Ms. Sara Anderson; Ms. Mira Mehes and Mr. Brendan Allen.