An Electronic Health Record Engineered for Care Quality

40-80% of clinical decisions in Low-and-Middle-Income countries (LMIC) do not adhere to scientific evidence with 4 out of every 10 patients harmed while receiving primary or secondary care. This corresponds to at least 2.6 million preventable deaths annually (WHO, 2019).

The first cause of sobering healthcare realities in LMIC is information overload. Providers routinely face the cognitive burden of more than 75 patients per day combined with 50,000 diagnostic codes and 4,000 drugs. Low doctor-to-patient ratios (Senegal 1:10,000 vs. U.S. 1:350) further make overworked and overstretched medical professionals prone to mistakes.

The second cause is insufficient data for health care oversight and response. The vast majority of medical facilities in the world lack even a basic electronic health record (EHR) and still rely on paper-based systems—leading public health databases to receive information that is typically outdated, inaccurate, and incomplete. Furthermore, private facilities which dispense over 50% of care, even in LMIC, are not subject to the same operational standards as their public counterparts, meaning reported care quality has to be taken at face value -- a grand leap of faith.

Walking Doctors' (WD) electronic health record system specifically addresses these two problems starting in the outpatient setting—it guides the provider-patient interaction using checklists which simultaneously capture rich diagnostic and treatment data from the visit. It can then organise and transmit health services and clinical results data to existing local and national databases, such as the District Health Information Systems (DHIS2), for real time aggregate analysis and response.  

With more and more countries implementing national health insurance, the adoption of EHRs that can help drive quality care improvement is critical to improving sobering health statistics in the context of equity, waste prevention and value-based care.

Walking Doctors (WD) has developed an electronic health record (EHR) that uniquely incorporates best practice protocols for hundreds of diseases and conditions into a user-friendly medical data management system available in multiple languages (presently English, Spanish, French and Indonesia). Designed specifically for the challenges faced by providers in low and middle income countries (LMIC) including scarcity of computers and spotty internet, the WD system addresses the twin problems of information overload and incomplete data sharing:

1. A library of dynamic checklists. When a clinician wants to act on a diagnosis, they select from one of over 275 clinical checklists to verify and speed up safe patient care. WD’s integrated evidence-based checklists include clear diagnostic and treatment data that can be used by healthcare providers and less clinically-trained physician assistants, midwives and nurse practitioners alike. This is vital in countries like Senegal  -- the site of this MIT/SOLVE proposal-- where most care is delivered by general practitioners or non-doctors overseen by general practitioners. Sometimes adjustments to checklists are necessary for local, specialty and epidemic contexts, for example evolving covid and monkey pox threats. With WD's EHR, medical leadership can perform dynamic configurations to checklist content in minutes that is instantaneously disseminated to providers across a health system.

2. Real-time quality feedback. The WD system shows the clinician before the chart is closed, a real time red light/green light quality status bar for the most important diseases across diagnostic, treatment, and patient education domains. Clicking the status bar displays a decision tree that highlights either the correct steps taken or which part of the clinical protocol logic is missing, such as prescription of the wrong class of antibiotics. This reinforces the latest standards of care for health staff, gives instant feedback when they deviate, and promotes staff satisfaction regarding delivery of high-quality care.

That's at the provider level. At the system level, health leaders can review aggregate facility performance as result of checklist use to guide programs and policy. Though presentation of system performance is rare even in high-income countries, it is essential to LMIC where patients present to care sicker and scare resources must be accounted for.

3. A Rich Medical Record. As clinical staff move through protocols embedded in WD checklists, they confirm signs, symptoms and treatment. This automatically creates a detailed medical record, enabling a host of uses: A doctor can see a complete patient history. A Director can sample charts in the emergency room. A District Health Officer can review the medical management surrounding a maternal death. Patients can gain first-time access to their health records with reminders of their diagnoses and care plans. 

4. Integrated Pharmacy Management. WD has a complete pharmacy management module that includes, clinic formulary, dosing, drug inventories, stock-keeping, pricing and report writing. There is no need to use competing software. Dramatically improved pharmacy management is especially imperative in public health centers , which run their own pharmacies, where medicines are often over-prescribed on the one hand, and stocked-out during emergencies on the other.

5. Data and Systems integration. Within security controls, all of the data in the WD system can be exported or integrated with local, regional, or national public health systems such as DHIS2. WD already maintains integrations with Indonesia’s national health insurance program, BPJS. We are not aware of any competing EHR that can record and share commensurate breadth and quality of data because of formalisation of patient-provider interaction around checklists. 

6. The unique simplicity and power of WD’s approach is demonstrated by a clinic implementation time of 3 days supervised by a 3-person local team. WD was developed by clinicians who reimagined EHRs -- even for $1B dollar systems operating in high-income countries -- to make work safer and faster as the key objectives. Keep in mind, more than 50% of users believe their EHRs should be completely overhauled (Harris Poll, Stanford 2018). Consistent with WD EHRs high quality build and modern UX is compatibility with smart phones in places where desk top computers and electronic touchpads are scarce.

7. Off-line functionality. Connectivity in the world is increasingly ubiquitous but still there are places and times when the internet turns off. When this happens, WD utilizes local hotspots to allow mobile devices to continue sharing and interfacing. When internet connection is reestablished, locally stored data is beamed back into the cloud. Baseline, WD is built with state of the art application design principles, allowing it to run on networks with limited bandwidth.

In Senegal, of 16.7 million residents, approximately 38% live below the income poverty line (income of less than $1.90/day) with 16% of the population highly vulnerable to falling into poverty. Senegalese -- the targets of this MIT/SOLVE proposal -- are critically reliant on quality health care to prevent prolonged work absences, unnecessary expenditure of money, and permanent disability during periods of sickness. But as mentioned, 40-80% of clinical decisions in low-and-middle income countries (LMIC) do not adhere to scientific evidence with likely 4 out of every 10 patients harmed during care. These challenges are much encapsulated in sobering maternal and infant health statistics. 1 in 317 Senegalese mothers dies during childbirth. The maternal mortality rate in the U.S. by comparison is 1 in 4,200. In Senegal 32 of 1,000 children do not live to celebrate their 1st birthday. The U.S. infant mortality rate is 5.4 per 1000.

With NGO partner Le Korsa, WD is committed to reversing dismal health trends for patients throughout Senegal. Diversity of context and people will demand multi-pronged solutions, but all will require concurrent continuous application of the bet clinical decision support and health system management tools. This is WD's EHR.

Walking Doctors (WD) foundation story was first narrated during the 2014 West African Ebola epidemic and the difficulties in managing both accurate patient care and wider public health information and needs. Founder and CEO Dr. Wilson Wang, then working for the International Rescue Committee, saw first-hand how every aspect of the response was impacted by the interplay of poor record-keeping, low standards of supportive clinical care in treatment units, high mortality rates, lack of community trust, poor uptake of public health messaging, and poor data quality and sharing in low-and-middle-income countries (LMIC) (Time Magazine, 2014).

WD’s electronic health record (EHR) is well positioned to scale to address the problem of high medical errors, to improve outcomes, and to maximize efficiency in the most challenging health care environments. Building upon a successful two-year pilot within 7 Indonesian health centers whereby protocol adherence increased from 35 to 85% across all diseases and complete medical documentation rose from 1 to 95%, WD's EHR now runs in 10 healthcare facilities in Indonesia including 2 dental offices and 1 pediatric practice in Jakarta; in Liberia's only pediatric Diabetes Type I clinic in Monrovia; and as of 2022, in Keur Djiguene Yi, a free Woman and Children's Health Center in Dakar, Senegal - WD's first operation in French! WD follows a SaaS model, whereby facilities pay for EHR subscriptions (and computers) from their own operational budgets as opposed to being provided them as grants. This uniquely addresses the typical sustainability dilemma of innovation adoption in LMIC. 80% of WD users continue their subscriptions past two years.

KEY TEAM MEMBERS

Walking Doctors brings together a rich and diverse set of individuals with expertise in emergency and primary care, health system strengthening, software development, and data science. 

Dr. Wilson Wang, founder and CEO, is based out of New York. He is a pediatrician with expertise in health sector behavior change. For 5 years he lived in Rwanda, Liberia and Indonesia working with the NGOs IRC, SAVE, and PIH to build and maintain healthcare systems in collaboration with local governments. Dr. Wang trained at Children’s Hospital Oakland. He earned an MPH at UC Berkeley and MPA from Harvard’s Kennedy School. He is Associate Professor at NYU’ School of Global Public Health. He also practices emergency pediatrics at New York City's Public Hospital in East Harlem.

Ryan Witt, CTO and co-founder, is also based out of New York. He specializes in leading teams in networking, ad tech and data science. He has written software for Disney and Facebook and scientists at Caltech, MIT, Brown and NYU. Ryan founded mobile advertising, social intelligence and data science infra-structure companies. Ryan received his Computer Science training at the California Institute of Technology.

Joaquin Budiaman, Senior Engineer, is in Buenos Aires, Argentina. Joaquin was part of WD’s first cohort of engineers. Joaquin is a full stack hacker, meaning he can code from all sides of the system, developing content that is intuitive and pleasing to users while making sure data is securely and expertly organized for storage, access and use.

Silvia Nurdin, Medical Director, is from Aceh, based in Jakarta, Indonesia. She is a general physician with fifteen years of experience working with international organisations in support of health systems. Dr. Nurdin received an MD from Syiah Kuala and MPH from Adelaide U., Australia.

A 6-person Clinical Advisory Board provides critical contributions to WD's EHR checklist content. Board members are highly respected and accomplished international healthcare experts from Harvard, Hopkins, the Navy and UCSF.

PARTNERSHIP

Partnership is a constant priority for WD. For this MIT/SOLVE proposal, we elaborate new implementations in Senegal with academic support from the United States.

1) Le Korsa is an international NGO that has worked out of Senegal supporting health care projects for over a decade. Le Korsa sponsors Keur Djiguene Yi Women and Children's Clinic in Dakar, a current user of WDs EHR. Based on this success, Le Korsa wants to expand EHR use to Wassadou Clinic a primary care facility serving a cachment of 20,000 in Senegal's eastern region of Tambacounda, 2.5 hours from the regional Capital. Its doctors, midwives and nurses see more than 12,000 patients a year. While Wassadou is a private facility, public healthcare infrastructure in the region is insufficient. By law, all activities in Wassoudou are reported to Senegal's Ministry of Health in the form of reports painstakingly gathered from paper medical records.

Sinthian Clinic is even more remote abutting Senegal's border with Mauritania and Mali, more than 7.5 hours from the Capital of Tambacounda. Thousands of villagers are reliant on Sinthian for their primary care which in 2021 recorded 14,000 visits. EHR access for Sinthian providers and patients alike would be transformative and serve as a model for many similarly distanced healthcare facilities in sub-Saharan Africa where the lights (and internet) are commonly turned off. Sinthian like Wassoudou exclusively employ hand written medical records.

2. The Health Ministry in Senegal is just initiating efforts to install electronic health records in primary and secondary healthcare facilities. The Ministry has green lighted the pilot of WD's EHR in the aforementioned contexts enabling large automated and high-quality secure data sharing into its new national health information repository. The political complexity of data system integrations should not be downplayed. But WD has success integrating its EHR with BPJS, Indonesia's national health insurance exchange.

4. NYU School of Global Public Health (SGPH) is among the largest public health learning institutions in the world producing more than 250 MPH graduates annually. WD's CEO, Dr. Wilson Wang, is Associate Professor at SGPH, so can naturally tap into the School's health management and biostatistical faculty expertise and associated NYU departments including computer science, business and economics. If WD were to receive MIT/SOLVE support, Dr. Wang would build positions for student researchers to help implement and document project outcomes, thereby training the next generation of experts in clinical decision support, data sharing and results measurement technology in LMIC.

LACK OF INSTITUTIONAL COMMITMENT AND SPECIALTY RESISTANCE

Doctors initially are surprised when presented with an electronic health record (EHR) that encapsulates their knowledge within checklists. Also, there is a tenuous relationship between healthcare facilities and Ministries of Health, whereby the Ministry expects to control introduction of health tools that healthcare staff paradoxically don't want or for which they do not want to wait. Senegal's Health Ministry funds about 80% of all health care facilities.

WD proposes that MIT/SOLVE spur the pace of health care improvement by subsidising EHR training costs and subscription fees for 2-years for a cohort of primary care clinics within Senegal. This eliminates key barriers to EHR adoption while giving health leadership first-hand experience and rationale to continue subscriptions beyond the initial period of support, which takes time to budget. While WD’s modest subscription fee pays for itself over and over again, subsidized EHR training and subscription are needed to incentivise health systems leaders who currently operate without even a basic EHR, and who may be slow to realize the value proposition of quality-focused data management systems against competing work demands. 

Also, WD’s EHR is complete but like all new technology requires adjustment to local care culture to increase staff buy-in an acceptability. This will now include off-line functionality via local hotspots and baseline excellent UX on a simple smart phone. Smart phones are now ubiquitous in most parts of the world -- Personal computers and touch tablets still are not.

IMMATURE LOCAL DATA REGULATIONS

Walking Doctors operates under the highest standards of data security. It applies U.S. patient privacy (HIPAA) standards as a baseline. Patient data is stored in the cloud at dual AWS sites in case there is a data breach or black out. WD’s CTO is a data security expert. And WD will never sell its data to marketers. Yet, electronic health data management capacity in low-and-middle-income countries is nascent, which commonly leads to Health Ministries stalling innovations in data sharing for lack of standards on patient data definition, format, transfer and storage. MIT/SOLVE undoubtedly has experience working with Health Ministries on health innovations that do not compromise data privacy and security, while working on codifying standards when not present. WD would welcome such prestigious company in elaborating Health Information System requirements.

Increased compliance to medical protocols reduces suffering and death in low-and-income countries (LMIC) where health challenges are immense. Our innovation dramatically improves health provider adherence to clinical protocols without slowing down care. At the same time, we make available data on patient outputs and outcomes in near real time to speed-up health system improvement at programmatic and policy levels. In short, WD provides LMIC access to a resource essential to healthcare improvement and oversight at affordable cost, fundamentally challenging the low-bar standard typically laid out for LMIC health systems.

We achieve both high care quality and health system accountability by having doctors and health staff work through evidence-based checklists. These checklists are contained within a user-friendly electronic health record (EHR) built to make medical work faster, safer and more collaborative. Checklists work across all industries –- from the complex and high-stakes aviation industry to the ubiquitous fast-food industry –- because their format is logical and familiar. There is ample reason to believe that this applies to healthcare too. Within individual medical fields, this has been shown to be true: Surgery (Gawande), Intensive Care Deep line placement (BMC Infect Dis. 2018 Jun 8;18(1):267), and neonatal feeding (Annals of Global Health, Jun 2014. 80(3)). Why not deploy checklists in the support of care for all diseases and conditions? WD is the answer to this question.

WD’s clinical checklists allow for a fast complete construction of the medical note, communicate to the nurse what labs to draw, send drug prescriptions at the right dose to the pharmacy, manage the facility drug stock and itemize the bill. At the administrative level, use of WD checklists signals when there is a death, when drug inventories fall low, and when disease incidence is too high. In short, WD checklists become indispensable to health care system performance. WD’s current users produce complete charting over 95% of the time. They increase health provider adherence to protocols from 35% to 85%. Audit times for deaths is reduced from 1 week (and travel time) to 30 minutes. Ministry of health leaders are presented with clear actionable System-wide performance maps.

Of course, checklists cannot stand alone. They have to be contained within a system through which all health staff pass, reminding clinicians of the evidence base in the course of work but also easing health care “pain points''. Health staff in LMIC want an EHR. Doctors are frustrated at the inability to conduct research. Nurses have difficulty reading orders that are scrawled. Film that leaves the radiology department is immediately lost. The lab places critical results atop a large paper pile. Meanwhile, amidst all the care challengers, Administrators don’t know where to direct scarce resources or magnify successes. WD's EHR directly addresses these challenges.

And yet EHR procurement and implementation in LMIC is usually fraught. Lack of an affordable, customisable, and available EHR is the main reason cited for adoption delay. Indeed, the biggest EHR in Sub-Saharan Africa OpenMRS cannot be easily adjusted and does not support hospitals. Private EHR’s are built for billing capture and cannot be repurposed for quality. 

In contrast, a three person team implements WDs EHR in health centers and clinics in only a few days. WD features are rapidly adjustable including translation into multiple languages (WD is currently offered in English, French, Spanish and Indonesian). Changes to patient registration, drug store, prescription format, reports and performance indicators are accomplished on the order of hours. WD is sold at a facility subscription price easily incorporated into facilities' operating budgets. This ensures long-term sustainability and institutional investment in a product which users are happy to use.

YEAR ONE

The project will achieve two primary outcomes: Significant reductions in preventable sickness and death and routine utilization of performance tools by District and Ministry leadership to drive health system improvement.

Walking Doctors offers an electronic health record (EHR) uniquely built to increase compliance to medical protocols, avoiding errors in care and preventable death. Research funded by Gates estimates that 30% of all deaths in low-and-middle-income countries (LMIC) can be prevented by access to primary care, but only if delivered effectively (Lancet, 2018). Accordingly, we will raise documented care effectiveness by 100% at Le Korsa's clinics in Wassadou and Sinthian and two public primary care facilities of the government's choice. Calculated against Senegal's crude death rate this will correspond to 40 lives saved in the Tambcacounda region alone.

That’s at the patient-provider level. WD’s build produces protected and anonymised structured-data for public health. Such data, stratified by geography, gender and indicators of socioeconomic status has enormous potential to inform health care programming. Accordingly, we expect district Ministries to routinely utilise data automatically transferred from WD’s EHR during all health planning meetings. 

Finally, Ministries will use WD's easily customisable checklists to rapidly disseminate information and care protocols for evolving threats like Covid and Monkey pox to providers across the health system.

YEARS 1-5

Based on year one successes, we plan to rapidly expand EHR use throughout Senegal thru meetings, presentations, advertisement and word of mouth with a target of 1.5 million patients cared for by providers using a checklist-based EHR. This corresponds to about 300 clinics and health centers from a total of ~1,200 primary facilities of which 25% are private.

With 2 million patients receiving high quality primary care, this means in Senegal (1.5M x 5.5/1000 x 0.3 x 0.6)** 1485 lives saved. This likely underestimates WD's impact as we expect other EHR vendors to imitate WD's checklist methodology including in neighbouring Guinea and Liberia. To WD, there is more than enough work to share!

Finally, public facilities typically adopt innovations of the private sector, not the other way around. So at least 50% of the increase in primary health care clinics  during years 1-5 using WD's EHR will occur in public primary clinics and health centers.

** Lives saved = # patients x crude mortality rate x primary care impact x  improvement in care quality using WD system

The goal of this project is to decrease patient morbidity and mortality from preventable errors in care. To achieve this, we will ensure that primary care providers refer to evidence-based protocols as a routine part of care. In turn, health leadership will share high-quality health services and clinical results data with the Ministry of Health, quarterly.

KPI: 80% of cases employ Walking Doctors (WD) checklists in the management of patients

Specific Objectives include:

1. Incorporation of national protocols into WD’s electronic health record (EHR)

KPI 1a. Ministry formally approves WD checklist content

2. Structuring of national protocols into easy-to-follow electronic clinical checklists

KPI 2a. Number and type of health care facilities

KPI 2b. Number and type of health providers

KPI 2c. Number of patients seen

KPI 2d. 100% improvement in patients diagnosed according to protocol

KPI 2e. 100% improvement in patients treated according to protocol

KPI 2f. 100% improvement in patients receiving complete education

KPI 2g. 100% improvement in patients with emergencies transferred per protocol

KPI 2h. Top 15 most common diagnoses with performance

KPI 2i. Qualitative study

3. Public facilities utilize the WD system in a manner that brings them at least on par with EHR use and quality care measurement in the private sector

KPI 3a. < 5% difference in performance between public and private facilities across diagnostic, treatment and patient education domains

KPI 3b. Districts build WD subscription fees into their budget by the conclusion of the project

KPI 3c. Half of new WD EHR users come from the public sector

 4. District Leadership respond more quickly and effectively to medical events and health emergencies

KPI 4a. 200% improvement in number of mortality audits

KPI 4b. 200% improvement in District response time to complete mortality audits

KPI 4c. Review of electronic performance dashboards routinely incorporated by health leadership into performance review meetings

KPI 4d. Qualitative study

Clinicians cannot consistently and successfully navigate over 50,000 diagnoses and 4000 medicines without explicit presentation of protocols in the course of patient care. In the 21st century, this means protocols for the range of diseases reformatted into easy to follow checklists, contained within an electronic health record (EHR) that healthcare providers like to use.

Checklists work across all industries – from the complex and high-stakes aviation industry to the ubiquitous fast-food industry – because their format is logical and familiar. There is ample reason to believe that this applies to healthcare too. Within individual medical fields, this has been shown to be true: Surgery (Gawande), Intensive Care Deep line placement (BMC Infect Dis. 2018 Jun 8;18(1):267), and neonatal feeding (Annals of Global Health Jun 2014. 80[3]). Why not deploy checklists in the support of care for all diseases and conditions? WD is the answer to this question.

WD’s clinical checklists are dynamic and as mentioned contained in an electronic health record (EHR) thru which all health providers pass. Filling out a checklist instantaneously constructs a complete medical note, calculates the correct dose for medicines and establishes clear lines of communication between doctor, nurse, lab tech, and  pharmacist. At the administrative level, use of WD checklists provides the source data for performance dashboards that signal when there is a death, when drug inventories fall low, or when disease incidence is too high. In short, WD checklists become indispensable to health care system performance. In a two year pilot covering 50,000 patients, WD produced complete charting over 95% of the time. It increased health provider adherence to protocols from 35% to 85%. Audit times for deaths were reduced from 1 week (and travel time) to 30 minutes.

In the WD system, checklist are the way health providers document and act on patient care decisions. This strategy aligns with behavioral health theory whereby decisions can be positively influenced by making the correct choice obvious (thru explicit presentation of protocols), employing some degree of peer pressure (users know their performance is being measured and compared) and making the sum of work easier (thru checklist integrations)

The electronic health record (EHR) vehicle WD uses is created with java script, the language of the internet, meaning access to WDs EHR is easy and  ubiquitous. In this project, we provide off-line technology through local solar/battery powered hotspots, but ultimately comprehensive care data is shared in the cloud.

EHRs contain sensitive data. From its inception WD Engineering has made it a policy to adhere to the highest standards of data security, system availability and patient privacy, exceeding typical standards used in the healthcare industry in the United States and Europe.

This is a summary of some key practices. 

Reliability Practices

·      Data must be stored in at least two geographically distinct data centers and be durable in the event of one of the data centers becoming unavailable for any reason

·      Every data processing subsystem must be composed of multiple individual resources that are located in at least two geographically distinct data centers. Such subsystems must be designed to survive the unavailability of a single data center.

·      Network connections into Walking Doctors systems should terminate close to the end user as possible.

·      Customer data must be separated such that data resources for customers may be operated independently of each other.

Security Practices

·      All data, (including medical data) must be encrypted both in transit an at rest.

·      All cloud systems involved in data processing must be configured in accordance with the Cloud Security Policy.

·      Customer and staff logins to our applications use cryptographically signed, expiring access tokens that can be revoked.

·      Customer passwords must be evaluated on the basis of an estimated password strength of “Safely Unguessable” as determined by the Zxcvbn password strength estimation algorithm.

·      Employee and contractor passwords must be evaluated on the basis of an estimated password strength of “Very Unguessable” as determined by the Zxcvbn password strength estimation algorithm.

·      Where possible, medical data must be cryptographically signed by users that last updated the data. 

·      We employ automatic systems for detection, notification and remediation of software vulnerabilities, as well as manual review of system changes.

Privacy Practices

·      Access to patient data is not granted by default to customer users, but rather granted explicitly by a customer user with administrative privileges.

·      Employee and contractor system access must be granted and reviewed in accordance with the Access Control Policy.

·      Access to patient data by Walking Doctors employees and contractors is made on a least authority basis. By default, only the CEO, CTO and senior members of the Operations team have access to patient data for the purposes of system’s monitoring and maintenance only.

In the Walking Doctors (WD) system primary health care data is collected naturally and directly from patient-provider interaction documented on an easy to use, user-centric, and cloud-based electronic health record (EHR). Unlike competing platforms, WD users produce complete documentation more than 95% of the time because its EHR is built around clinical checklists that aid health care providers in correct diagnosis and treatment, while enabling a series of convenience features: Using the checklists in patient care simultaneously writes the medical note, prescribes available medicines at the right dose, automates complex calculations, itemizes the bill and produces quarterly reports.

In essence, the WD EHR offers a lot for everyone. We have seen our current customers literally collapse in tears on the few occasions the internet has turned off. ("How are we expected to work!") As such, a part of MIT/SOLVE support will be devoted to elaborating off-line EHR functionality in the form of local hotspots to support care in the most hostile settings. Indeed, the Walking Doctors mantra remains: Quality Care. Anywhere.

The checklists which form the basis of Walking Doctors (WD) electronic health record (EHR) directly address disparities in care confronting women, girls and minorities thru care standardisation. For example, HIV and TB checklists simplify complicated testing, medicinal regimens, and follow-up protocols for the most marginalized groups, ensuring high quality care even for rare diseases typically managed by non-specialists.

Additionally, WD's EHR captures protected and anonymised structured data for public health and analytics. Such data, which includes minorities and those with varying socioeconomic status, has enormous potential for new forms of analysis on disease prevalence and characteristics. This will be a rich resource for doctors, public health departments, ministries, and researchers typically confronted with data accuracy and collection challenges, which thwart understanding of healthcare disparities in the first place.

WDs CEO is a person of color. WDs Medical Director is Muslim, Indonesian and a woman. Four of six of WDs clinical advisors are underrepresented minorities and half of them women. Walking Doctors foundation story narrates a first-ever attempt to bring a quality-engineered electronic health record to the world's poorest citizens. The fight for global health equity is at WD's core.

In 2019, Walking Doctors successfully completed a 18 month pilot of its cloud-based, quality-focused electronic health record (EHR) in Pakpak Bharat, Indonesia—a District of 50,000 residents in remote northern Sumatra. In doing this, WD transitioned all 7 District Health Centers from paper medical records to an EHR, decreased registration time from 20 to 5 minutes, increased chart completeness from 1% to 95% and improved adherence to protocols from 35% to 85%-- across all diseases. The Governor of Pakpak Bharat was so pleased with the results including savings from a 50% reduction in unnecessary prescriptions that he built WD subscription costs into the District's budget for three years. This provided proof-of-concept for Walking Doctors' SaaS business model, even when working with governments. 

The idea that health staff would use systems that simplified their daily work we assumed. What we did not predict was how health staff would use WD clinical support features for continuing medical education, as a source of professional pride, and as a springboard for creativity—WD’s pharmacy management system, performance dashboards, triage alert system, and dental features were all developed in collaboration with Pakpak Bharat colleagues over the pilot. So in Pakpak Bharat, WD showed it could bridge the relationship of software purchaser not being the primary software user by satisfying the needs of all parties in the health care system.

That WD could work in the harsh conditions of Pakpak Bharat gave WD confidence to expand to Indonesia’s bustling capital of Jakarta with its 10 million residents. WD recruited 10 private clinics and dental offices each representing about 5 thousand patients to use its EHR. The challenging nature of these customers acquired through door-to-door sales spurred the development a new self-sign up process with 100% contactless training. This new implementation model is currently being tested with private lactation consultants in the United States (WDLacation.com) with the potential to rapidly expand sales in low-and-middle income countries that is not common currently .

In February 2022, the NGO Le Korsa began using WD’s EHR at its free women and children’s clinic Keur Djigeune Yi in Dakar, Senegal. The success of this project brought Le Korsa and WD together as partners for a USAID proposal to bring electronic health records into the Capitol's two busiest hospitals. Up to this point, the government of Senegal has been unable to develop or find an affordable, customizable EHR that impacted care outcomes. In seeing the WD product (in French no less), the Health Ministry committed to purchasing follow-on subscriptions which it did not find expensive. This project would expand WD impact to include secondary and tertiary medical facilities.

Users of Walking Doctors (WD) electronic health record (EHR) In low-and-middle income (LMIC) countries pay for their own subscriptions. This provides a logical empirical route of sustainability for tool essential to health system improvement.

Still, help with subscription fees increases the pace of technology adoption. This eliminates the number one barrier to EHR uptake -- money -- while giving healthcare leadership first-hand experience, rationale and lead-time to continue subscriptions beyond the initial support period, which takes time to budget. 80% of WD subscribers maintain their subscriptions beyond two years. In short, once heath facilities start using WD's EHR, users (and patients) quickly become aware of the indispensable nature of a checklist-focused, user-centered and modern electronic health record.

The success of Walking Doctors (WD) 18-month pilot in 2018-19 of its electronic health record (EHR) in 7 Health Centers in Sumatra, Indonesia resulted in a District budget line of $300 per Health Center per month for a period of three years. Indonesia has over 10,000 Health Centers.

WD awaits decision on a 2-year USAID petitioned grant to support Senegal's pre-eminent public hospitals, Diamniadio Children's Hospital and Fann Speciality Hospital in Dakar. Each of these public facilities has agreed to pay a $30K annual maintenance fee following successful implementation of WDs quality engineered electronic health record (EHR). Both institutions despite caring for hundreds of thousands of patients a year still use paper medical records.

CEO Wilson Wang is in conversation with Gates Foundation, which is interested in expanding Telehealth access in Indonesia. Serendipitously, the majority of WD customers are in Indonesia and WDs EHR already offers a Video-health platform.

In addition to its 10 primary care and dental clinics in Indonesia, WDs EHR operates at KDY Women and Children's Health Center in Dakar, Senegal and in Liberia's only pediatric diabetes clinic in Monrovia -- all achieved through door-to-door sales. So while WD's marketing strategy is currently B2B focused, with the right resources and relationships, a B2C strategy could work too.