Monthly Updates

Monthly Report for May 2008

• Functional Requirements and Software Development

The LMI Wiki has been developed and is fully functional. The code and the document for that application are available on http://wiki.ihris.org/wiki/index.php/Last_Mile_Initiative. Drafts for the voice prompt system requirements and the menu driven system requirements have been posted on the Wiki.

Discussions on equipment and software platform specifications with Qualcomm have been ongoing during the month of May. Partner Updates

Dave and Vanessa attended the Global Health Council in DC during the week of 27 May. Dave gave a talk on Open Source and Community Building and mentioned LMI at a roundtable while Qualcomm announced our partnership for the LMI project. It was at that same event that Vanessa and Dave had the opportunity to meet with Kim.

We are glad to report that our press plan has been approved by Qualcomm and look forward to SRA’s review and feedback.

We have scheduled bi-weekly update calls with Qualcomm every other week on Thursday at 11am EST. If you are available for the call on 19 June, it would be wonderful for everyone to touch base. You are of course invited to all future calls as well.

We are preparing to post all project documents (including weekly updates) on the Wiki. This is a process we have already used in Uganda and which turned out to be successful there.

• Operations

Internally, we have submitted paper timesheets for all work done prior to 05.2008 and IntraHealth’s contracts unit has submitted them to SRA along with monthly invoices. We thank you for your feedback on the submitted monthly invoice and timesheets for all work done prior to 05.2008 and will make sure to follow your comments/requests.

Now that we have the sets of functional requirements posted on the Wiki, we look forward to discussing with you how we can get SRA’s approval so that we can shift both sets to “final” status per the requirements of the payment schedule. Please note the use cases will inevitably change in small ways during the development process.

Scopes of work for travel for August and September are currently under development.

Monthly Report for June 2008

• Work Performed

Following discussions on equipment and software platform specifications with Qualcomm, we have officially notified Qualcomm of our decision to use Java rather than Brew.

We are glad that our press plan has been approved both by SRA and Qualcomm.

It was great to have you on our bi-weekly update calls with Qualcomm and to speak directly with you in the third week of June. If you are available for further calls with Qualcomm, you are of course invited as well.

Dave has been working on redoing the women’s contraceptive and children’s registry screens.

Our hardware list has been sent to and reviewed by Qualcomm which expressed its interest in supporting this equipment selection.

The LMI Wiki has been developed and is now fully functional. Drafts for the voice prompt system requirements and the menu driven system requirements have been posted on the Wiki. All further project documents will also be posted there. Upcoming Work

Vanessa is finalizing her scope of work and activity plan for her upcoming travel to Rwanda in late July, early August and is working on the draft and final Pilot Test Plans which will be developed during the aforementioned trip.

We are submitting a complete report which includes the use cases and the original forms so that we can shift both sets to “final” status per the requirements of the payment schedule. Please note the use cases will inevitably change in small ways during the development process.

• Issues

We are currently uncertain of the specific hardware that Rwandatel currently has and/or will have available to meet our equipment selection but are planning on clarifying this issue in the next month.

• Percentage of Work Done

In order to provide you with an accurate representation of the percentage of work completed versus percentage of schedule expended versus percentage of budget expended, we kindly ask for your understanding if we submit it in an upcoming weekly update so that, in the meantime, we hope you will have approved the revised activity plan sent to you by Vanessa on 6/19/2008.

Monthly Report for July 2008

• Work Performed

System use cases and functional requirements are complete and include the Ministry’s HMIS indicators and original paper forms for reference. Please note the use cases will continue to evolve over the course of the project. The latest version will always be available on the Wiki.

We have developed a Wiki on which the code and the documentation for the application are available. The option to view and to change the information is available to all who request access. We will be posting all project documents (including these Monthly Reports) on the Wiki. This is a process we have already used in Uganda and which turned out to be successful there. The LMI Wiki can be found at http://wiki.ihris.org/wiki/index.php/Last_Mile_Initiative

The proposed contraceptive screens will collect information regarding contraceptive methods used during the current and previous months. This section will also collect information for planned methods for the coming month. It will be possible to select multiple methods.

The pilot will be conducted at the health center in Busanza sector. Busanza is in Kicukiro district in Kigali province. Busanza has 36 community health workers who will be participating in the pilot. This health center was selected for several reasons: o Good success demonstrated with paper-based system o District includes both rural and urban villages o District is near Kigali (about 20 minute drive just past the airport) o Good EV-DO connectivity

The local Twubakane implementation team includes Jean Marie Sinari (Community Participation Coordinator), Gaspard Bayigane (M&E Assistant), Philbert Ndaruhutse (MIS Coordinator). The Ministry of Health team includes Dr. Emilien Nkusi (HMIS) and Cathy Mgeni (Community Health Desk).

General hardware requirements have been established and an itemized list of needs is underway. Equipment is to include a server, a laptop for use at sector level, mobile phones, and related accessories. Accessories are to include back up supplies (batteries, cords), protective cases, and options for phone use in locations without access to electricity.

An Asterisk server has been installed and configured. In order to better synchronize the various systems which need to be tied together, we will be using the Adhearsion framework which we are currently investigating. The Adhearsion framework should allow us to efficiently work from the same data despite a variety of front end technologies. Once these systems are in place we will start to focus on the menu front end for the PDA-style phones.

Vanessa’s scope of work during her trip to Kigali from July 26 through August 9 includes the following:

 Work on Sustainability Plan with Ministry and local staff  Meet with Qualcomm and Rwandatel to determine equipment and connectivity plan for pilot (Elizabeth from Qualcomm will be in Rwanda on August 4th, we have plans to meet with Rwandatel on August 6th)  Review use cases and resolve outstanding issues  Visit pilot sites with local staff and develop outline for Pilot Plan  Work on M&E plan with local staff (HQ M&E will also be in Kigali at this time)  Meet with Ministry stakeholders  Meet with local consultants able to provide implementation support  Review equipment currently available through Rwandatel and re-test internet speeds on EV-DO devices (if speeds are acceptable, we will use a mobile compatible web interface for the menu driven-system)  Investigate the in-country hardware options with an eye towards this web-interface direction

Vanessa is also building on the use cases to generate a walkthrough of the entire menu-driven system using screen shots. The screen shots will be used to finalize screen text, translations, help documents, and menu lists. Additional efforts include developing an M&E plan, a pilot plan, a sustainability plan, and a hardware requirements list.

The meeting with the CEO of Rwandatel has been confirmed for 6 August at 11am. The meeting will include representatives from the MOH, Twubakane and Qualcomm (Elizabeth Migwalla from Qualcomm will be joining Vanessa in Rwanda during the week of August 4). The meeting goal is to secure support from Rwandatel for equipment and connectivity. Materials that will be available at the meeting include project summary, draft use cases with screen shots, pilot outline, equipment and connectivity requirements for pilot, outline of planned media and community activities.

A site visit to Busanza Health Center is also planned during this time.

• Upcoming Work

The sustainability plan, pilot plan, M&E plan and press release are underway and are being developed collaboratively with Twubakane and Ministry staff while Vanessa is in Kigali.

A majority of August and early September will be taken up by work on the voice and menu systems code.

• Issues

On behalf of our contracts team, may we ask you to please find out whether it would be possible to amend the contact’s deliverables schedule so as to reflect the later delivery date of the revised use cases and of other upcoming deliverables? Percentage of Work Done We estimate that: 30% of our budget has been expended (15% time budget, 50% materials budget, makes about 30% overall); 70% of system design and development has been completed (pilot implementation is considered separately under deliverables for Qualcomm); and over 50% of schedule has been completed.

Monthly Report for August 2008

• Work Performed

Use Cases

We have put together a document with screenshots of the menu-driven system screens which is being finalized before the voice script and translations are actually begun. We have requested a clinical expert to review the terminology of the uses cases in order to ensure the clinical accuracy of the system. At the request of the community health workers, we added three general household information screens to the use cases on the topics of bed nets (availability), hygiene (water and sanitation), and insurance participation. Given ethical complexities associated with the topic of gender-based violence, we decided against the addition of the set of screens associated with this topic. We thank you for your feedback on the use cases and hope you will let us know if your technical team has additional feedback.

Partners

General results from the meeting with the CEO of Rwandatel, which took place on 6 August and included representatives from the MOH, Twubakane, and Qualcomm and whose goal was to secure support from Rwandatel for equipment and connectivity, include: -Rwandatel agreed to donate connectivity, hosting and technical expertise for the pilot. -Qualcomm and Rwandatel agreed to work jointly to provide handsets. Handsets will be EV-DO compatible. -Rwandatel verified there is good EV-DO connectivity in Kichukiro. -Rwandatel requested an MOU to outline terms of the donation. -Rwandatel would like to increase branding awareness with the pilot and would like stickers on the handsets. We are developing and MOU to confirm the working relationship among Rwandatel, the MOH and Qualcomm. This document will help to establish anticipated in-kind donations in support of the pilot.

Coding

OpenMRS will serve as the backend for the system. This should allow us to more easily track individuals and individual households. It also opens us up to more easily utilize the XForms standard in the creation of the menu system. In addition, we started to implement OpenROSA as the XForms instance to use with OpenMRS. Mark, our developer, has begun mapping the indicators to the OpenMRS system using a walkthrough of the use cases. Mark has been active on the OpenMRS developer list and is collaborating with other OpenMRS users in Kigali. This level of local collaboration is a part of sustainability plan going forward. The process of user interface is being facilitated through the use of Poedit (http://www.poedit.net/). This software will allow translators do their work offline and yield production-ready files for Kinyarwanda or French. As an alternative, our developer has also uploaded the forms to Launchpad so that a translator can use Launchpad's translation tools if they want to work on the project without installing any new software (http://bit.ly/3DuOR0). In order to give the translators some context for their work, our developer has a working prototype up at http://open.intrahealth.org/lmi/ The current code is in Launchpad. A more user-friendly format will be available soon. The Wiki has been updated with information on obtaining .pot files for translation as well as a very brief explanation of what a translator would have to do to contribute.

• Upcoming Work

Travel

Mark Hershberger (Developer) and David Mason (Program Manager) are expected to travel to Rwanda the last two weeks of September. The objective of their trip will be to review the v1.0 software with local staff and stakeholders, to prepare for the planned October pilot deployment to be funded by Qualcomm, and to ensure final SRA documentation is complete and accessible on Wiki. The scope of work for this upcoming trip includes the following tasks: - Installation of local server - Finalize arrangements for pilot - Review training needs and develop final pilot documentation as required - Review user interface with Twubakane team and adjust software as required - Deploy EV-DO enabled devices for local testing (this assumes delivery of equipment for Qualcomm and Rwandatel) - MOH stakeholder follow up and v1.0 demo - Identify method to import CHIS data into HMIS - Rwandatel follow up and v1.0 demo - Meet with local developer and ICT support consultant

Deliverables

The sustainability plan, pilot plan, M&E plan and press release are in progress. Most of the rest of September will be further taken up by work on the voice and menu systems code.

• Issues

Following discussions between Kim and Vanessa, we are awaiting SRA’s approval for (1) an extension and (2) Dave and Mark’s upcoming travel to Kigali. We look forward to hearing back from you about the status of invoices 1 and 2. We have submitted an invoice to retroactively bill the 6% fee which was omitted in the first travel invoice. We have submitted timesheets for labor for May, June, and July. We have sent you an invoice for the first $45,000 deliverable and will follow with additional requested documentation.

• Percentage of Work Done

We estimate that: 50% of our budget has been expended (40% time budget, 60% materials budget, makes about 50% overall); 80% of system design and development has been completed (pilot implementation is considered separately under deliverables for Qualcomm); and over 90% of schedule has been completed.

Monthly Report for September 2008

The month of September has been devoted primarily to (1) coding and development and to (2) planning for an extension.

Thanks to the no-cost extension that is currently in the process of being issued to IntraHealth, we look forward to continuing working on and improving the remaining deliverables through the task order’s new expected end date of 20 December 2008.

• Work Performed

Coding

• An Open Source Medical Records System (hereinafter OpenMRS) has been established to serve as the backend for the system. This is allowing us to more easily track individuals and individual households, more readily opens us up to utilize the XForms standard in the creation of the menu system more readily, and allows the system to be more easily extended to other uses. • The indicators to the OpenMRS system are being mapped using a walkthrough of the use cases. • Our developer has been active on the OpenMRS developer list and is collaborating with other OpenMRS users in Kigali. This level of local collaboration is a part of sustainability plan going forward. • The process of building the user interface is being facilitated through the use of Poedit (http://www.poedit.net/). This software is meant to allow translators to work offline and yield production-ready files for Kinyarwanda or French. As an alternative, our developer has also uploaded the forms to Launchpad so that a translator can use Launchpad's translation tools if he wants to work on the project without installing any new software (http://bit.ly/3DuOR0). • The translations on the web-forms have been tested, confirmed to be functional. The data is now being fed into OpenMRS. • A Kinyarwandan translator has been identified and we are currently working on securing this service. • Our developer is testing a few more pieces of Open Source software (Baobab, ClearHealth, and CHITS) that will help him in development process by providing a reference. He has provided information about them on the Wiki at: http://bit.ly/OpenSourceHealth

• Upcoming Work

Coding

• Objectives for the coming month include: 1. Getting all the indicators in OpenMRS 2. Having translations for the current User Interface completed 3. Complete the logic of the UI 4. Tie the UI to OpenMRS • At this stage, the web-ui will be fairly complete and would work on web-enabled phones. The next step would be setting up an application that could work on smart phones and use XForms and OpenROSA as the primary means of presentation.

• Deliverables

• The sustainability plan, pilot plan, M&E plan and press release are still in progress. • An updated schedule for the remaining deliverables will be developed to match the extension’s new expected end date for the task order.

• Travel

• Mark Hershberger (Developer) and David Mason (Program Manager) were expected to travel to Rwanda in September but their trip has been postponed to November due to unforeseen health issues. • The objectives of their trip in November, however, remains the same as that planned for September: o to review the v1.0 software with local staff and stakeholders, o to prepare for the planned October pilot deployment to be funded by Qualcomm, and o to ensure final SRA documentation is complete and accessible on Wiki. • The scope of work for this upcoming trip includes the following tasks: - Installation of local server - Finalize arrangements for pilot - Review training needs and develop final pilot documentation as required - Review user interface with Twubakane team and adjust software as required - Deploy EV-DO enabled devices for local testing (this assumes delivery of equipment for Qualcomm and Rwandatel) - MOH stakeholder follow up and v1.0 demo - Identify method to import CHIS data into HMIS - Rwandatel follow up and v1.0 demo - Meet with local developer and ICT support consultant

• Issues

• We look forward to hearing back from you about the status of invoices 1 and 2 and hope invoices 3, 4, and 5 are also being processed. • We hope to follow up with you soon concerning additional requested documentation supporting the invoice for the first $45,000. • We have submitted timesheets for labor for August and will submit those for September shortly.

• Percentage of Work Done

• We estimate that: 70% of our budget has been expended (75% time budget, 60% materials budget, makes about 50% overall); 85% of system design and development has been completed (pilot implementation is considered separately under deliverables for Qualcomm); and over 60% of schedule has been completed (based on a new end date of 20 December 2008).

Monthly Report for October 2008

The month of October has been devoted primarily to planning for an extension.

Thanks to the no-cost extension that has been issued to IntraHealth, we look forward to continuing working on and improving the remaining deliverables through the task order’s new expected end date of 20 December 2008.

• Work Performed

Coding

• Work was significantly slowed down in October to allow the no-cost extension to be issued. The following is the work we reported for the month of September and with which we will proceed now that the extension has been issued.

 An Open Source Medical Records System (hereinafter OpenMRS) has been established to serve as the backend for the system. This is allowing us to more easily track individuals and individual households, more readily opens us up to utilize the XForms standard in the creation of the menu system more readily and allows the system to be extended to other uses.  The indicators to the OpenMRS system are being mapped using a walkthrough of the use cases.  Our developer has been active on the OpenMRS developer list and is collaborating with other OpenMRS users in Kigali. This level of local collaboration is a part of sustainability plan going forward.  The process of building the user interface is being facilitated through the use of Poedit (http://www.poedit.net/). This software is meant to allow translators to work offline and yield production-ready files for Kinyarwanda or French. As an alternative, our developer has also uploaded the forms to Launchpad so that a translator can use Launchpad's translation tools if he wants to work on the project without installing any new software (http://bit.ly/3DuOR0).  The translations on the web-forms have been tested, confirmed to be functional. The data is now being fed into OpenMRS.  A Kinyarwandan translator has been identified and we are currently working on securing this service.  Our developer is testing a few more pieces of Open Source software (Baobab, ClearHealth, and CHITS) that will help him in development process by providing a reference. He has provided information about them on the Wiki at: http://bit.ly/OpenSourceHealth

• Upcoming Work

Coding

• Objectives for the coming month include:  Getting all the indicators in OpenMRS  Having translations for the current User Interface completed  Complete the logic of the UI  Tie the UI to OpenMRS • Challenges we foresee in upcoming work include polishing the code into a demo that can easily be run although based on OpenMRS, meaning the user will need to install and run a server instance of the software, which is do-able, but not for the computer novice. Having said that, the forms/screens will remain easily viewable even without running the program. In any case, the program can be made available on Launchpad and/or through the Wiki.

• Deliverables

• The revised used cases, sustainability plan, pilot plan, M&E plan and press release are still in progress. • An updated schedule for the remaining deliverables will be developed to match the extension’s new expected end date for the task order.

• Travel

• There will be no upcoming travel due to the fact that there will no longer be a pilot with Qualcomm.

• Issues

• Due to timing issues at the Ministry of Health, the pilot has been postponed until an undetermined later date. Ministry timing issues include extensive planned changes to the larger HMIS, possible changes to the community health information system (CHIS) to remove duplication of data collection among systems and upcoming changes to the province/district/sector/cell/village structure. Due to the lack of clarity around future pilot dates, Qualcomm and Rwandatel are not able to maintain their commitment to support the pilot so both relationships are in the process of being terminated. Once there is a firm pilot date we can reapply for funding.

• The Ministry has suggested we cover a few particular issues in the sustainability plan including affordability (future ability of MOH to pay for connectivity, new handsets or necessary replacement/repairs), availability of appropriate connectivity in all areas and the perception of privilege (particularly in a pilot phase, some community health workers having access to something others do not).

• Per USAID request, we are discussing the possibility of a completing a case study for the USAID website. The case study would emphasize the development process and the features of software to be released in December.

• We look forward to solving the issue of timesheets, level of effort, and the payment for the deliverables.

• Percentage of Work Done

• We estimate that: 70% of our budget has been expended (80% time budget, 60% materials budget, makes 70% overall); 85% of system design and development has been completed (pilot implementation is considered separately under deliverables for Qualcomm); and over 70% of schedule has been completed (based on a new end date of 20 December 2008).

Final Monthly Report for November and December 2008

• Work Performed

Deliverables

The tangible deliverables which we have submitted to you according to the revised deliverable schedule include:

• the Final Functional Requirement Document, which is available at: http://wiki.ihris.org/wiki/Last_Mile_Initiative#Use_Cases

• the Complete Application Development can be appreciated with a review of the package, which is available at: http://open.intrahealth.org/rwanda.tgz

• a demo of the application, which can be accessed at the following URLs. The first link is the URL one can point a phone to and which has the forms, while the other one points to the OpenMRS web front end management and reviewing data.

http://open.intrahealth.org/lmi/ Login: admin Password: adminlm1

http://open.intrahealth.org/openmrs/ Login: okebenei Password: orbalm1

Both of the logins provided will work on either the forms or the server backend. Please note, however, that it might be more interesting to use the “admin” login as more can be done with it. The “obkebenei” login is to simply simulate a community health worker.

• the Final User and Technical Documentation, which is available at: http://wiki.ihris.org/wiki/index.php/Last_Mile_Initiative#Technical_Documentation

• the Draft and Final Pilot Test and the Final Scalability and Sustainability Plans, which are available at: http://wiki.ihris.org/wiki/index.php/Last_Mile_Initiative#Sustainability_and_Pilot_Plan

The Wiki, available at http://wiki.ihris.org/wiki/Last_Mile_Initiative, remains a source of reference and documentation of all project-related activities.

• Highlights

Forms – During system design and development, Mark and Dave focused not only on the immediate data collection requirements but also on the inevitability of change. With this in mind, Mark created a library to facilitate rapid, modular development of forms allowing future data field or other system changes to be accomplished more easily. Since OpenMRS was used as a base, Mark submitted the library to them so others can benefit. OpenMRS (http://openmrs.org/wiki/OpenMRS) is a widely used and well regarded open source medical records system currently in use in Rwanda.

Wiki – Project documentation including information on system design, development, technical documentation, translation and sustainability are freely available on the LMI project wiki. This collection of resources not only provides access to the freely available code but also offers equally important documentation covering all stages of implementation. As mobile technologies become an increasingly practical, sustainable method of data collection in low resource environments, comprehensive support for local development and maintenance of such systems is critical.

Private sector partnerships – Through Qualcomm’s involvement we were able to engage local private sector support especially from Rwandatel—Rwanda’s CDMA provider. When the Ministry of Health is ready to deploy the pilot, this type of partnership will provide the greatest opportunity for sustainability through hosting support, discounted equipment and connectivity.

Sustainability – IntraHealth is committed to the successful deployment and maintenance of systems that support health workers and improve health services. In early 2009, we are launching the OPEN project which is designed to engage local technology and health leaders and students to create and sustain health systems tailored to meet urgent health care needs. As a part of OPEN, we are hoping to maintain and extend the impact of the LMI project.

• Lessons Learned

Development timeline – Within the available implementation window, it was difficult to support stakeholder involvement and system development in parallel. During the gap between RFP development and project implementation, Ministry of Health circumstances evolved and several key stakeholders changed. With that in mind, we had to renew stakeholder buy-in and shift plans for pilot implementation.

Private sector partnerships – While Qualcomm’s early support was incredibly beneficial, there were difficulties created by partnering with a technology-specific vendors. By accepting support from an organization committed to promoting a specific technology, provider and equipment choices were limited. The method of implementation was also impacted since we had to balance donor and stakeholder needs. For example, the donor was committed to using EV-DO technologies although they are not available across the country.

• Upcoming Work

All our deliverables have been completed and IntraHealth does not have any upcoming work to be completed before its Task Order with SRA ends on 20 December 2008.

• Issues

• IntraHealth has returned signed Modification 2 and the new Task Order to solve the fee issue on travel expenses. • We expect the payment of travel invoices to follow shortly after the signature of Modification 2. • We look forward to reaching an agreement with SRA concerning local LOE billed to SRA versus to Twubakane. • We expect the payment of the first deliverable invoice of 45,000 USD, submitted to you on 12 August 2008 to take place as soon as an agreement on local LOE is reached. • We are about to submit the remaining two deliverable invoices of 45,000 USD and 50,048 USD, respectively.

• Percentage of Work Done

• 100% of system design and development have been completed; • 100% of schedule has been completed (based on a new end date of 20 December 2008); • 75% of total budget expended: o 85% of time budget has been expended; o 60% of material budget has been expended.