PRISMS neonatal care mobile app

Neonatal mortality in Uganda has been 27 per 1,000 live births since 2006 (Harris, 2018). Two-thirds of these deaths can be prevented by quality care during and after birth (Enweronu-Laryea, 2015), but frontline health workers face rapid decay of clinical knowledge and skills (Bang, 2016) and lack high-quality clinical decision support and local data to facilitate continuous quality improvement (CQI).

PRISMS addresses these needs, facilitating routine newborn assessment and providing real-time clinical care guidance through a mobile application for health workers. We propose to extend PRISMS to cover 40% of health facilities (hospitals and health centers) in Uganda, assess neonatal mortality and quality of care prospectively, and develop a module to facilitate community follow-up of neonates, to be tested and scaled to cover 20% of Uganda’s population. This can significantly improve neonatal care and reduce in-hospital neonatal mortality by >20% and overall neonatal mortality by >10% in Uganda (PJHA 2019). 

Worldwide, an estimated 2.5 million babies died in the first 28 days of life in 2018. Neonatal mortality rates are 28 and 26 per 1000 live births in sub-Saharan Africa and South Asia, compared with rates of 2 and 3 neonatal deaths per 1000 live births in Western Europe and North America (UNICEF,2019). In Uganda, over 32,000 neonates died in 2018 (UNICEF, 2019). The neonatal mortality rate has remained high at 27 per 1000 live births since 2006, despite an increase of institutional deliveries over the same period from 42% to 73% (UDHS, 2016).

PRISMS is a job aid for frontline health workers. It addresses neonatal mortality in Uganda by supporting adequate implementation of “best practices” of newborn care.  Health workers face decay of knowledge and skills related to essential neonatal care over time (Bang et al, 2016). This directly impacts quality of care and clinical outcomes. For babies born in health facilities in Uganda, only 68% receive a postnatal check within two days, and key national stakeholders cite the quality of health workforce training and adequacy of supportive supervision as significant challenges to provision of basic neonatal care and newborn resuscitation (Mbonye et al, 2012). 

PRISMS is an evidenced based mobile app addressing health workers’ needs for clinical decision guidance and evidence-based CQI of neonatal care. The password protected Android application provides health workers in health facilities with a user-friendly platform for collection of routine assessment data and real-time clinical care guidance based on assessment findings, and seamlessly aggregates and presents facility-level data for quality improvement. Clinical assessment and care algorithms used in PRISMS are informed by the Canadian ACoRN Primary Survey (ACoRN, 2017), the World Health Organization Newborn Care Guidelines and WHO Manual on Management of the sick young infants up to 2 months (WHO, 2017; WHO, 2019), and the Ugandan National Newborn Care Guidelines, and will be updated to reflect forthcoming WHO Newborn Care Guidelines such as the WHO Midwifery Education Toolkit on Essential Newborn Care. Preliminary data indicate quality of neonatal care and data collection have improved with PRISMS. In-hospital mortality was only 8.2% in hospitals implementing PRISMS compared to 15.3% in control hospitals (p-value<0.001), with lower mean duration of hospital stay seen in PRISMS centres as well (3.9 days versus 5.2 days, p-value=0.001). Clinical assessment completeness also notably improved in hospitals implementing PRISMS.

The target populations for PRISMS are health workers, particularly the 13,164 nurses and 5,970 midwives who provide over 90% of all newborn care in Uganda, and the over 1 million babies born or treated in health facilities yearly in Uganda (MOH Uganda, 2019). Ugandan nurses and midwives face pressure from understaffing, with a current health workforce stock of 1.87 workers per 1000 population, well below the WHO recommendation of 2.5 workers per 1000 population (MOH Uganda, 2019). They also suffer from gaps in training and supportive supervision specific to neonatal care. Health facility assessments across Uganda indicate that less than 15% of hospitals have job aids for neonatal resuscitation, managing small babies, managing infections, or identifying newborn danger signs (Mbonye, 2012).   

PRISMS was developed with substantial input from healthcare workers involved in neonatal care at Ugandan health facilities. They shared their needs and ideas in over 20 focus group and key informant interviews, with nurses, midwives, and pediatricians all involved in beta-testing the application. We will continue to involve health workers in the design, implementation, and use of the PRISMS to ensure it continues to meet their needs and best serve the neonates in their care. 

PRISMS is strongly aligned with the MIT Maternal and Newborn Health Challenge,

• Addressing the problem of neonatal mortality, meeting the identified need for clinical decision support and reliable data for CQI among health workers caring for neonates in hospitals and health centers in LMIC.
• Using a low-cost mobile application solution to ensure healthcare workers in these settings have the real-time clinical decision support they need to provide high-quality neonatal care informed by the most recent international guidelines and facility-level data.
• Focusing on the target population of healthcare facility staff who care for hospitalized newborns in LMIC.

Several interventions have been or are being developed and tested, including several using mHealth technology, to address the stubbornly high neonatal mortality rate in Uganda. FamilyConnect is a digital technology currently used by the Ugandan Ministry of Health to send targeted life cycle-based messages via SMS to pregnant women, new mothers, heads of households, including male partners, and caregivers with information on what they can do to keep themselves and their babies in good health during the critical first 1,000 days of life. While this address home-based care of neonates, it does not address the needs of healthcare workers providing critical care for hospitalized neonates, as PRISMS does.

NoviGuide is another software application that provides health workers in Uganda with symptom by symptom interpretation of neonatal assessment findings as information is entered into the application. This piecemeal information provision makes assessments long and complex, and potentially could affect acceptability, usability and scalability in high volume and low resource settings with scarce staffing. Alternatively, PRISMS uses a streamlined neonatal assessment intake form and provides a consolidated, actionable guide on what to do and how to do it in a care message. This feature was specifically requested for by health workers during PRISMS development and is highly appreciated. Our virtual CQI meetings that utilize PRISMS health facility-specific data is a distinctive feature that is driving adoption and utilization of PRISMS. PRISMS users feel a sense of belonging to a supportive care network of collaborative learning. 

PRISMS was developed in 2014 and has iterated through 6 versions to date from v1.0 to v1.6. Version 1.0 was developed on the Symbian Operating System that was running on Nokia phones in 2014. This version was SMS based and all clinical findings were sent to the server via SMS and received by a two-way SMS gateway. The setback with this version was the size of the screen and the software architecture. In 2015, PRISMS was moved to the Android platform and has since iterated through two versions: v1.2 and v1.3.

PRISMS is a digital third-party mobile application that leverages the Android Operating System to provide newborn care clinical decision support to healthcare workers and visualize aggregate facility-level data to promote CQI. It is based on native Android, enabling us to provide the user with the best experience in terms of speed and the ability to use all features of the device. The PRISMS app also uses a retrofit library, allowing data to be synced bi-directionally from the app to the server in the presence of an internet connection on the app side. The server is hosted by Linode server and is autonomously managed by E-Wall Technologies. Data analytics at the server are built using “Archon” a PHP open source data analysis framework which aggregate data to each hospital using PRISMS and provides quality improvement data. All data are processed in line with current regulations, or with the European Union (EU) Regulation no. 2016/679 (General Data Protection Regulation).

We tested PRISMS v1.3 in a feasibility and acceptability study with pediatricians and at a remote health facility in Mbarara Uganda with midwives. Our findings showed that: i) midwives from the remote health facility felt more empowered to manage the sick newborns; during the deployment period, we had no referral, an increase in the admissions and all admissions were managed in the facility and recovered, and ii) pediatricians were reminded of aspects of care that they had forgotten (Data et al, 2016). We evaluated this version of PRISMS and found clinical decision support was being provided via the app on an average of every 3 minutes. In 2017, we developed a more robust version that iterated through versions v1.4 – v1.6. 

At present, PRISMS v1.6 is actively used in 8 health facilities in 4 regions in Uganda. The technology has been used in assessment of over 50,000 newborns.

Preliminary data indicate that quality of neonatal care and data collection have improved with PRISMS. In-hospital mortality was only 8.2% in hospitals implementing PRISMS compared to 15.3% in control hospitals (p-value<0.001), with lower mean duration of hospital stay seen in PRISMS centres as well (3.9 days versus 5.2 days, p-value=0.001). Clinical assessment completeness also notably improved in hospitals implementing PRISMS.

PRISMS is currently used by 8 health facilities in 4 regions of Uganda and has been used in assessments of over 50,000 newborns to date. On average, each facility assesses at least 7,250 newborns each year.  In five years, a single facility will have assessed 36,250 newborns. 

At least 40% of all facilities with neonatal care services in Uganda will be using PRISMS by 2025, representing over 120 health facilities (Uganda MoH, 2008). The planned module allowing community follow-up of newborns will be used by at least 20% of village health teams in Uganda by 2025.

The PRISMS team aims at doing the following in the next five years:  i) design a robust community component that will enable Community Health Workers (CHWs) to follow-up newborns in the community that are discharged from health facilities or born at home, with the ability to refer sick babies, ii) implement this community module and assess its impact on quality of neonatal care and follow-up in the community, as well as on neonatal mortality, ii) expand PRISMS to additional facilities with a target of reaching at least 40% of all facilities that have neonatal care services in Uganda by 2025, and iv) expand to additional districts to cover at least 20% of the village health teams with community component by 2025.

The is a challenge with PRISMS data storage. The data PRISMS collects is considered healthcare data. In Uganda, this data is required to be hosted only in secure government-controlled servers. We have secured the required government partnerships in Uganda and have the PRISMS data secured on the National Information Technology Authority (NITA) servers. Data storage regulations and requirements may vary from country to country, so scaling up in countries with requirements like Uganda will require additional procedures for ensuring compliance with applicable data protection legislation.  

The PRISMS team will use our experience in Uganda to discuss related data storage requirements in every country we intend to scale into. This way, we can initiate and more accurately anticipate the time requirements to attain data storage alignment with national policies. 

The PRISMS team is currently composed of 3 full-time staff and 4 part-time staff. 

linary team of clinicians, public health specialists, technology developers and business managers have worked together for the past seven years, since PRISMS’ inception in 2014.  Team members include i) lead pediatrician, Dr. Santorino Data MBChB, MMed Pediatrics; Dr. Data is a lecturer of Pediatrics at Mbarara University of Science and Technology, and the Country Manager for the Consortium for Affordable Medical Technologies in Uganda. Dr. Data has a wealth of experience in technology development for health, and innovation management.   ii) Eng. Martin Mukama Bsc.Comp.Eng, Msc. HIT;  Martin is a seasoned software developer with experience that spans to over 8 years. He has developed and led implementation of both health and e-governance software in Uganda. He leads the development and updates to the PRISMS application. iii) Dr. Francis Bajunirwe PhD: Epidemiologist.  Dr. Bajunirwe has extensive experience in the design, implementation and analysis of community-based implementation studies and clinical trials. 

We have partnered with Doctors with Africa CUAMM in the deployment and implementation of PRISMS in four health facilities across three districts in Northern Uganda. Evaluated data from one of these facilities showed a reduction in neonatal mortality from 20% to less than 10% within 3 months of PRISMS deployment. CUAMM brings in over 60 years’ experience in the support to hospitals in northern Uganda to improve maternal and neonatal health through skills building for staff – tools, training, continuous coaching and mentorship, and equipping of health units. PRISM complements these efforts with focus on improving care for small and sick neonates.

CUAMM has partnered with the WHO Collaborating Centre for Maternal and Child Health in Trieste (WHO CC) over the past 4 years to design and implement maternal and child health research projects in Uganda. The PRISMS team will partner with the WHO CC as we look to grow our business, relying on their recognized expertise in neonatal care and research, as well as their participation in developing the current WHO guidelines on neonatal care. They will provide technical guidance on neonatal care and coordinate PRISMS efficacy and cost-effectiveness research and data analysis.  

PRISMS is a subscription-based mobile application. Our business model is based on quality improvement partnerships with Health Implementing Organizations, health facilities, and government. We provide our clients: 1) access to the PRISMS platform for collection of neonatal health assessment data and provision of real-time clinical decision support in the form of detailed care guidance informed by the most recent international guidelines on neonatal care, 2) training on PRISMS server-end data visualization and utilization, 3) active participation in virtual CQI meetings in collaborative learning zones, and 4) implementation of collated and vetted end-user requested technology changes.  

Our neonatal care improvement partnerships and PRISMS subscriptions are currently our main sources of revenue. Initially, PRISMS development and deployment depended on grant funding. Though this is still a significant part of our revenue in this technology growth phase, revenue generated from partnership contracts is contributing to sustainability. Our partnerships have included the Uganda Government through the Ministry of ICT and National Guidance, Baylor Children’s Foundation in Uganda, Clinton Health Access Initiative in Uganda, and Doctors with Africa CUAMM. 

The PRISMS team is applying to Solve in order to succesfully plan and implement the sustainable growth of our low-cost, effective mobile application providing real-time clinical decision support and aggregated data for CQI for healthcare workers at health facilities in LMIC. We have been successful in securing grant support for the development of the health facility module of the application, beta testing and initial roll out in eight health facilities across four regions in Uganda. 

We seek some additional funding for development of a community module to allow follow-up of infants born in the community or those returning home after a hospital birth by village health teams, providing real-time clinical decision support as well as referals for sick neonates. 

We also seek to draw on the wealth of expertise and experience of the MIT Solve community to develop a sustainable plan to expand coverage of the PRISMS app in Uganda and to scale to other LMIC as well. 

Becoming an MIT Solver team will provide us with access not only to potential funders, it will also provide us with the mentoring, guidance, and networking to broaden our skillset, create a sound business plan, and expand our life-saving application to other countries suffering from high neonatal mortality rates.

Our team promoting the growth of the PRISMS neonatal care mobile app is very well qualified for the Innovation for Women Prize. Our goal to improve neonatal care and reduce neonatal mortality in LMIC addresses the quality of life of many women and girls in these settings. In addition to reducing preventable morbidity and mortality among newborn girls and boys, our application empowers healthcare workers providing neonatal care in health facilities, the majority of whom are women. The impact of improved quality of life for newborn babies reverberates through their communities, with mothers and other female caregivers and family members enjoying less physical, psychological, and financial strain as a result of the improved health and survival of the infants in their care.

With the support of this prize, we will fund beta-testing and piloting of the community module we propose to develop as an MIT Solve Maternal and Newborn Health Challenge team. These steps are essential prior to scaling up this complementary component of PRISMS that addresses the needs of newborns after they leave the health facility, providing efficacy data to inform future revisions to the module and attract additional funding for national and global scale-up.

The additional funding will also enable creation of a French-language version of the application, and potentially beta-testing of the French version of PRISMS in Burundi. 

Our team promoting the growth of the PRISMS neonatal care mobile app is very well qualified for the Health Workforce Innovation Prize. We provide a low-cost solution to improve health workers’ newborn assessment capabilities in health facilities in LMIC. PRISMS was developed together with the nurses and midwives who attend 68% of hospital births in Uganda, which ensures that it addresses their most pressing needs when caring for neonates. It improves on other eHealth solutions for care of hospitalized neonates by providing a streamlined data entry process and a single, comprehensive guideline for care of each neonate based on their assessment findings. It also provides health facilities with visualization and coaching to facilitate efficient and effective use of aggregate data from PRISMS for CQI.

With the support of this prize, we will fund beta-testing and piloting of the community module we propose to develop as an MIT Solve Maternal and Newborn Health Challenge team. These steps are essential prior to scaling up this complementary component of PRISMS that addresses the needs of newborns after they leave the health facility, providing efficacy data to inform future revisions to the module and attract additional funding for national and global scale-up.

Our team promoting the growth of the PRISMS neonatal care mobile app is very well qualified for the Bill & Melinda Gates Foundation Funded Award. We aim to improve neonatal care and reduce neonatal mortality in LMIC through the growth and eventual global scale-up of our clinical decision support mobile app for healthcare workers caring for hospitalized neonates. Our team is led by Mbarara University, a public university in Uganda, and we plan to consult with the Ugandan Ministry of Health as we continue to refine and disseminate our mHealth solution for newborn health.

With the support of this prize, we will fund beta-testing and piloting of the community module we propose to develop as an MIT Solve Maternal and Newborn Health Challenge team. These steps are essential prior to scaling up this complementary component of PRISMS that addresses the needs of newborns after they leave the health facility, providing efficacy data to inform future revisions to the module and attract additional funding for national and global scale-up. The funding will also cover scaling up the community module to cover at least 20% of the Ugandan population. This prize will enable creation of a French-language version of the application and beta-testing and piloting for both the hospital and community PRISMS modules in Burundi, a crucial step in furthering the spread of our app.