Sunday, July 7, 2013

Workflow for ArogyaUDHC rural user interaction with medical student users managing ArogyaUDHC

Here is the current workflow for ArogyaUDHC rural user interaction with medical student users managing ArogyaUDHC:

As an online-physician in-charge of rural Indian patients located in the area pincode-736 who approach us for help through  ArogyaUDHC, i receive the de-identified patient information along with signed patient authorization through an email from our social worker in Mathabhanga. His current internet access issues make it difficult for him to post directly to our site

I forward all these emails carrying patient data as attachments (with the signed patient consent) alternately to our medical student site managers, Kaustav, Arko and Deepanjan (three current active members but i am sure many more shall join soon and depending on exam demands we may have to rotate our student volunteers).

The subsequent steps for the medical student volunteers are:

a) Transcribe and translate the patient's handwritten letter/history and provide a summary of his problem inputs and paste it to the UDHC narrative page along with uploading the signed 'informed-consent-authorization' from the patient as well as all the reports that are sent to you after de-identification by the social worker (de-identify them further if you find any gaps after close inspection of all the attachments including the patient's handwritten letter).

b) Once this is done and your upload is approved by the moderator/physician in charge for this particular pin-code (which currently is me), please post the link to tabula rasa and try to build up a discussion (aka patient-data-processing) that can benefit our patients to the maximum by chiefly focusing on helping to answer the patient's needs reflected in his/her uploaded narrative. See some of the current ongoing discussions around the ArgoyaUDHC patients in tabula-rasa or perhaps look at this sample case here:

Pasted below is how this patient input linked above (input from the father of a 49 day old child) was briefly processed after being posted to tabula-rasa (our social media based processing forum)

This is the processing through our email forum:

Email Input1 below:

Date: Fri, 12 Apr 2013 21:33:06 +0530

What I understood was that this is a 6 weeks old baby born at term and low
birth weight, had some feeding difficulties and has persistent jaundice
that is direct.The important causes to consider are intrauterine infections, i.e. Rubella
and CMV mainly, billiary atresias, intra or extrahepatic as gall bladder
visualised extrahepatic unlikely and also to rule out galactosemia. Out of
all the causes high possibility of CMV Needs a complete physical examination, eye examination, urine for reducing substance and further imaging of liver if indicated. Further prognosis depends on the cause

Email Input 2 below:

Date: Sat, Apr 13, 2013 at 11:56 AM

Eye examination should include - e/o cataract, chorioretinitis,
posterior embryotoxon
CMV IgM is essential
LFT- serum albumin and serum gamma glutamyl transferase are important.
Benedict's test for reducing substance in urine should be done after
pretreatment of urine with conc. Hydrochloric acid to be able to
detect lactose.
Regarding the baby's appearance, does she resemble any of her parents
or other relatives? Is her facial appearance- abnormal?
Is the baby feeding poorly now?
If yes, since when?
Is it after starting Gardenal? Is the baby still on Gardenal? If yes,
how many ml in a day?
Is the poor activity only during fever and cold episodes?
How many times does the baby pass urine in 24 hours?
It would be useful to document the weight weekly on follow up.
Has she been prescribed vitamin A & vit D? (it is not clear from the
It is important to give her weekly vitamin K injections

Email Input processing 3 (A Relevant Note of Dissent during this processing on email that i couldn't help sharing here)

Date: Sat, Apr 13, 2013 at 3:26 PM

...Also this only reflects opinion of one person and does not reflect evidence of any kind (as evidenced by the mail given below). Is this the kind of output UDHC is looking forward to give  ? I thought it is all about evidence based medicine and not opinions !!

I also doubt how impractical these suggestions are.. like CMV IgM.

I couldn't resist sharing the last input above in spite of the danger that it is disruptive and can cause confusion understanding the workflow.  The dissenter (it is always useful to have them around) raises interesting issues around practice based evidence. The fact that even a patient's history and reports are a 'particular' piece of 'individual' evidence currently remains unacknowledged by mainstream Evidence based medicine EBM (although Dr Huw, Editor of the Oxford Handbook of Clinical Specialities has recently discussed this on the Oxford UK based EBM listserv).

c) Once the medical student volunteer managing the case-information online is satisfied that the discussion/data-processing has reached an optimum climax to generate a reasonable initial output for the patient please prepare a summary output and (this part is very important) after sharing it with the online-physician in charge of this area-pin-code

Based on these inputs our Outputs to the patient and his local physician is posted here:

d) Very often we can take care of most of our patients' requirements this way online but once in a while these patients may want to visit us to seek direct care and the same patient (49 day old child) also came for a visit and by that time he had become a week older and here is the current update posted on 26 May, 2013

e) The entire case can be written for BMJ or IJUDH and co-authored by those involved in the care of this patient (including the medical students managing the website) and authorship will be allocated as per these guidelines:

See link:

Authorship  credit can be obtained for 1) contributions to conception and design, analysis and interpretation of narrative-data; 2) drafting the article or revising it critically for important intellectual content; and 3) final approval of the version to be published.

No comments: