mNote
Amanda Cravens, Mambi Madzivire, Isaac Penny, and Daniella Raffo

The Beginning

mNote started with two MBA students and two PhD students who became interested in community health workers. Our backgrounds are diverse: a mechanical engineer, a former biomedical engineer, a one-time information architect, and a marketeer. Two Americans, a Zimbawean, and a Peruvian. Two veterans of the dSchool's Extreme Affordability course; two of us who had never taken a formal design course.

In the initial needsfinding reports, we were drawn to the tension between how community health workers (CHW) saw themselves (as unpaid but proud professionals nominated by their community) and how often clinics or patients seemed unclear about the CHW's role in the larger health ecosystem. This tension inspired our initial Point of View as well as subsequent revisions and set us down the path that eventually evolved into mNote.

Point of View

Okoth, a passionate but under-resourced Community Health Worker needs a way to maximize his impact on his patient’s overall well-being.

(The first part of our final presentation describes Okoth's story in more detail.)

Insights and Observations from Needsfinding

We explored a variety of solutions to address this point of view and empower CHWs to better care for their patients: a system to streamline referral management and post-visit follow up between clinics and CHWs, job aides to assist CHWs visiting a sick patient in making the treat vs. refer decision, and a patient notification system for when CHWs were not able to visit as expected. As we discussed these ideas with community health workers, NGO staff, and others knowledgeable about healthcare around Nairobi, however, it became clear that each applied only to a tiny subset of CHWs. Most community health workers work with multiple NGOs and thus play multiple roles. One common denominator we identified, however, is that they all need to gather and record information and that they want to have control over how the collection happens. Currently information is collected in a paper notebook, which the community health workers use to track patients' progress, report activities to the NGOs with whom they work, and share with other community health workers for professional development.

Description of mNote

mNote is an online archive for community health worker notes. NGOs log onto the mNote website to create forms for their CHWs to fill out. mNote alerts each CHW to download the new form via SMS. When in an area with service, the CHW downloads the form via prepaid data on their midrange Nokia phone.

mNote allows the CHW to rearrange the order of questions within the form to best match their preferred workflow. MNote forms can contain prompted text entry fields as well as multiple choice fields. The CHW uploads completed forms via the same prepaid data connection approximately weekly, or whenever they are in an area of data service.

For NGOs with existing electonic medical record systems, such as the popular OpenMRS, uploaded forms are automatically synced with their server. NGOs without an electronic medical record system receive an email with the forms attached in spreadsheet or PDF format as a replacement for their former process of photocopying and interpreting the CHW's notebook. (Please see our final presentation for diagrams and more detail.)

Decisions and Insights

One of our key insights was that community health workers perform very different tasks, depending on the NGO that they are working for and which country they are located in. This has important implications:

• insights from talking to NGOs or CHWs in one setting may not be transferable to other settings
• a solution that is designed for one NGO or CHW may not be appropriate for a different NGO
• the same CHW may need multiple tools if they work for more than one NGO simultaneously
• the formats that CHWs and NGOs need or want to use to put data in and pull data out of the system are not necessarily parrallel
• we may inadvertently make a CHW's job more difficult if they need to use mNote for one NGO, but other NGOs still remain on paper based systems

Given these insights and the diversity of perspectives we were hearing about CHWs' roles, we chose to focus on a single CHW, Okoth, and make subsequent design assumptions based on his experiences.

Assumptions We Made

• The CHW is working with multiple NGOs, but he only sees an individual patient for one given NGO.
• Depending on the NGOs involved, there may or may not be overlap in the information that different NGOs want collected.
• The CHW is an unpaid volunteer.
• The NGOs have existing records systems and thus care about specific format and content of data.
• Currently, information is transfered from CHW records to NGO by photocopying CHW notebooks.
• CHWs have at least occasional access to the internet through an Internet cafe or can use a mobile data plan.
• The CHW needs to access individual records frequently, but needs access to aggregate data more infrequently.
• The CHW speaks at least basic English (though system could be adapted for Swahili).

(For more on the process of developing materials, see our collection of archived process materials).

Benefits of mNote

mNote empowers CHWs by preserving the flexibility and control they appreciate in their current paper notebooks, but adding digital knowledge management capabilities. The system allows CHWs to:

• Customize form and question order to match their workflow
• Edit previous submissions
• Access previous archived reports
• Generate summaries and reports of historic data

By creating a detailed record of their activities, mNote also has the potential to enhance the perception of community health workers as the professionals our interviews and the initial needsfinding reports suggested they see themselves to be.

While mNote, unlike other clinic-focused systems, is designed specifically for CHWs, it also provides significant benefits for NGOs who work with CHWs. By streamlining and integrating CHW data, mNote allows NGOs to:

• Avoid the cost and staff time needed to photocopy and interpret reams of paper notes
• Generate customized funding reports for donors documenting their CHWs' activities
• Have closer-to-real-time data about events on the ground and thus plan for better patient care

Next Steps and Open Questions

One of our major concerns in deciding that our user would be someone like Okoth is whether or not he is a typical CHW, or whether our solution is out of the reach of less literate CHWs. The approach that we have taken is to design for a highly literate CHW who is comfortable with technology. mNote could be made more suitable for CHWs who do not fit this description by stripping or simplifying some of the functions so that they could be used on a less sophisticated phone and require less training. Another path we explored that would be a fruitful avenue for future prototyping is a voice-based rather than text-based system, given the low literacy and visual acuity reported among at least certain segments of the CHW population, though not represented in the user for whom we were designing. Our solution requires that a the mobile phone is linked to a data plan, which implies both a higher end phone and most likely a significant financial investment. However, there are options for transferring data efficiently and cost effectively, as is demonstrated in a thesis by Stanford student Tom Wiltzius - "__Mobile Medic: Extending the Effective Reach of Mobile Data Infrastructure for Data Collection Applications in Emerging Regions__" (please contact Prof. Terry Winograd to obtain a copy).

An important next step will be to identify an NGO who would benefit from mNote and seek a partnership with them. An organisation like the Tabitha Clinic, managed by Carolina for Kibera, is an excellent candidate, since they have already demonstrated the willingness to adopt new technology. Initiating this partnership would allow us to further understand the CHWs that our target clinic employs, including their roles, educational level, workflow, etc.

By design, mNote's user is the community health worker. However, CHWs are unlikely to have sufficient funds to purchase the phone required or sufficient technical training to set up and maintain the system. Therefore, a critical question is who would be the ultimate "buyer" of this technology. NGOs may resist investing in a system that gives most of the benefit to CHWs without also deriving benefit for the NGO as well, so there would need to be a clear value proposition from the point of view of the organization. However, we believe that adoption of mNote by NGOs can be driven by their funders or by organizations whose mandate is to improve the efficiency of NGOs. For instance, a large funding organization such as the Gates Foundation could conceivably require that a system like mNote be used as a prerequisite for funding. Another possibility would be a job creation or community development focused NGO, who might be interested in mNote's potential to professionalize the work of CHWs by providing records of what they do and thus answer the common argument against paying them, which is that there is no accountability in their activities.