[Health] Ebola, MERS, Zika, N.N. and GNU Health

[Christoph H. Larsen]

Dear All,

Apologies for cross-posting, but unusual circumstances demand unusual 
actions.

The ongoing outbreak of the Zika virus has been declared an emergency by 
WHO, and this certainly highlights yet another time the importance given 
to disease surveillance as an integral part to health information 
gathering, processing, reporting and related decision-making.

To date, we have a number of hospital health information systems, GNU 
Health, of course, included, that do their job with various strengths 
and weaknesses. GNU Health boasts the existing integration with Tryton 
as ERP system, which is simply great. Plus, is integrated with an 
evolving LIMS, which is of exponentially increasing importance, because 
surveillance is nothing without laboratory confirmation.

There is DHIS2 (http://www.dhis2.org) as USAID-funded and endorsed data 
warehouse for health data aggregation, analysis and presentation at the 
national level, with aim to further informed, evidence-based 
decision-making. DHIS2 has come a long way, but it is still pretty 
clunky, well, IMHO. Modifications may not always be easy to implement, 
depending on the running version.

Back to GNU Health: Given Tryton's scrupulously clean, lean and mean 
data models and structure, there is no reason, why a further push 
towards business intelligence (a.k.a. data aggregation, analysis and 
presentation, with data mining thrown in) should not be possible. This 
could be achieved as a Tryton or GNU Health module, or via linking to 
external facilities. Solr uses Java, Lucene has been ported to Python... 
As long as this heavy stuff runs at the central level (Ministry of 
Health), this does not matter *that* much, and even less, if feedback of 
the aggregate data and analysis can be done via lightweight 
communication channels back to the field. But it would, of course, be 
nice to keep things in the lean and mean Python family :-D.

Data capture is an issue: GNU Health is not offline-capable, as of now 
(correct me, oif I got that wrong!). And its suitability for mobile 
phone or tablet use is limited, because the interface has mainly been 
geared towards non-mobile technology. I know, there is an app, but I 
have seen better user experiences. Ideally, there is no app at all, all 
based on offline-capable HTML5, and running in a modern browser. 
http://wq.io (doing all this) might help doing exactly that, and could 
feed into GNU Health as backend, but its question types are a bit 
limited. We need the range of questions present in LimeSurvey 
(http://www.limesurvey.org), which works actually very well in a 
self-contained Android stack consisting of PHP, Nginx and SQLite, with 
exports to a central facility via .csv or .xml, or to STATA or R. But 
with HTML5 e might be able to make this a bit easier. Open Data Kit 
tries to do this by simple .xml exports, but fails miserably on 
robustness, scalability data security and user-friendliness, and is 
poorly maintained. Plus with one toe in the proprietary world...

As for GNU Health, yes, there is a need for body system-specific 
modules, such as an ophthalmic or dental module. Also, 
diagnostics-specific modules might help, such as a facility that can 
display the peak expiratory flow rates in asthma patients over time.

However, I *personally* have my doubts about disease-specific modules, 
which includes the NTD and MDG modules. Recent history has shown that 
emerging diseases move way too fast to keep up. Donor-inspired vertical 
disease-specific interventions (HIV, malaria, TB) have not really 
strengthened primary health care, because they were contained in a silo, 
and GNU Health would do well not replicate this model.

Instead, Tryton's inventory and stock management suite offers already a 
model for a highly flexible alternative: The attributes model offers a 
unique way to capture any specifications of a stock item via a 
user-configurable interface. Something similar could be designed for 
disease-specific surveillance, starting from WHO's integrated disease 
surveillance catalogue to ongoing worries (EVD to newly emerging 
diseases, such as Zika and others to come.

This would allow the creation of a capable, flexible, yet 
standards-compliant surveillance and disease recording facility within 
hours, offline-capable, using HTML5 technologies, or a self-contained 
stack, and bring GNU Health to the community health workers anywhere in 
the world. Of course, contact tracing capabilities will be essential.

Throw in a central unique identifier database (with doing the unique 
identifier being a major legal as logistic hurdle!). and we can push and 
pull medical records across all connected health facilities with 
considerable ease.

I am fully aware that a lot of the above may sound a bit like a dream, 
but if we put the right tools together, collaborate and keep focused, it 
can be done.

There have been a few recent and very laudable efforts to effect 
surveillance in one way or the other within the group, and I think this 
is something which deserves applause and further support.\

Did I mention that there is a lot of money out there for surveillance? 
With CDC's new Global Health Security Agenda (GHSA), where are very keen 
targets set, yet the tools are sorely lacking. National governments are 
literally creaming for easy to use, ready-to-deploy solutions.

What's your take? From the field end, it's very high time, kind of three 
to twelve, to quote a recent assessment of the World's situation.

Thanks a lot for your critique, comments and ideas, and stay well!

Chris

--
Dr Christoph H. Larsen
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