Dec 4, 2011
Inside a hot, breezeless room, a group of women wait with their children to see the pediatrician. He is late today; he was needed to treat a sick child at another hospital some 100 kilometers away. As one of the few doctors in this rural region of Madhya Pradesh, India, Dr. Gupta sees over fifty children during a single clinic session. Sadly, these children represent only a small percentage of all the children in the area who could benefit from his expertise.
The number of trained medical professionals in the world’s rural regions falls direly short of need. According to the Work Bank, 13 African countries have fewer than five physicians per 100,000 people. Malawi, with its healthcare workforce in perhaps the most calamitous state, has only 2.22 physicians per 100,000 people. Where healthcare workers are abundant, they may not be able to dispense adequate care or accurately screen ailing patients. Compounding the problem of delivering affordable and effective healthcare is the lack of permanent and portable medical records, lack of medical diagnostic services, poor supply chains for replacing medical equipment, poor treatment compliances, slow rates of information flow, and lack of quality auditing to identify bottlenecks and quantify healthcare improvements.
Sana was born to bridge the human expertise gap between resource-poor settings like rural India and large centers of medical know-how. Sana – Spanish and Italian for “healthy” and Filipino for “hope” – is a volunteer-run organization in MIT’s Computer Science and Artificial Intelligence Laboratory (CSAIL). The organization began in 2008 when founder Dr. Leo Anthony Celi was taking the Media Lab’s ICT4D class (Information and Communication Technologies for Development, now known as NextLab), and was formerly known as MoCa. As a pioneer of mobile health (a.k.a. mHealth), Sana revolutionizes healthcare delivery in remote areas through innovative mobile information services that improve patient access to medical specialists. Distributive physician support and patient oversight through mobile technology enable faster, higher quality, and more cost-effective patient tracking, diagnosis, and intervention.
Sana’s technology is a mobile phone-based, open source software platform for telemedicine. The Android-based system supports multimedia (audio, images, and soon video), location-based data, and text. In a health clinic, a healthcare worker interviews a patient and collects data through a step-by-step clinical protocol on a smartphone. As patient data is collected and uploaded, diagnosis-specific information is automatically requested by the Sana system. The partner hospital’s physician can read the clinical information about the patient and make appropriate diagnoses and treatment recommendations from his or her urban location. If the doctor has additional questions for the patient, the questions are relayed to the healthcare worker via mobile phone. At the very end of the patient encounter, the data is uploaded to the patient’s electronic medical record, ready to be accessed during the patient’s next medical visit. The Sana system is easy to use and highly customizable; doctors can build customized questionnaires for healthcare workers and can create decision trees for diagnosis, triage and treatment to broaden the healthcare workers’ scope of practice.
New applications can be built into Sana’s software platform as demand for more mHealth solutions grow. With projects already planned and implemented in eight countries, Sana addresses the five domains of primary care (e.g. non-communicable and chronic diseases), acute care (e.g. malaria, trauma, follow-up after surgery), maternal care (e.g. prenatal check-ups), pediatrics, and mental health. Sana’s flagship project is a system for early oral cancer diagnosis and referral that was implemented at Bangalore, India’s Narayana Hospital. After screening thousands of patients, the hospital began rolling out another Sana-powered project that diagnoses and monitors cardiovascular disease using a $50 smartphone plug-in. Sana’s reach has spread to Punjab in northern India, where its technology is used to improve diabetes and maternal care. In Brazil, healthcare workers use Sana’s technology to diagnose eye disorders that cause blindness and screen for hearing impairment among newborns and kids. Healthcare workers in the Philippines use Sana’s system for hypertension management and, soon, for remote x-ray consultation. In Swaziland, Sana’s software will build a registry of all surgery patients so that they can be tracked for follow-up. Sana’s technologies will be used for tele-monitoring of diabetic patients with chronic foot ulcers in Greece. Nurses will travel from house to house, photographing wounds for remotely located specialized doctors to analyze, and can also clean wounds and facilitate hospital consultation when needed. Sana’s software helps healthcare workers in Sierra Leone address problems during pregnancy and assess tuberculosis risk. Because Sana’s software platform is completely open source, the possibilities for innovation and application are nearly limitless.
Sana’s technology is part of a holistic solution to build the local leadership capacity and commitment that are required for sustainable change, which will require more time and iterations to evaluate, as is the case with any preventative health measure. To implement projects, Sana works with in-country partner organizations, including for-profit hospitals, universities, nongovernmental organizations, and governments. Sana requires its partners to be multidisciplinary and encourages collaboration between organizations to build a robust on-the-ground team that includes clinicians, software developers, public health experts, and businesspeople. The in-country team identifies public health problems, designs an appropriate business model, and applies for project funding for implementation. At the other end, Sana’s MIT team consists of 25 specialists from diverse fields, ranging from engineering to informatics to social science. The MIT specialists aid project implementation by traveling to countries, conducting workshops for local software developers, and performing evaluation studies on Sana’s public health impact.
Sana’s model differs from other mHealth organizations, such as MedicMobile (a nonprofit organization that creates simple health applications for low-end phones), MoTech (an initiative of the nonprofit Grameen Foundation that provides relevant information to pregnant women and new mothers), TRACNet (a government program that collects, manages, and disseminates information about HIV/AIDS), and Dimagi (a software consultancy that creates open-source tools for healthcare, treating hospitals, nonprofit organizations, and governments as clients). Sana is not a nonprofit 501c(3), nor is it a for-profit venture. Rather, it is an organization within MIT’s CSAIL, an academic institution. This uncommon structure offers many benefits, including the freedom to explore new areas of interests without being restricted by clients’ or donors’ demands, a constant stream of free high-quality labor, state-of-the-art facilities, funding for MIT classes that support Sana’s work, and legal counsel. The financial and institutional support allows Sana to engage in cutting-edge activities with low risk. The affiliation also gives Sana a competitive advantage over other mHealth organizations. Nonprofit organizations are required by law to pay employees’ wages, but students and enthusiasts run Sana. Donors can influence or dictate the project scope, but Sana can selectively choose its partners and innovate quickly without approval from an external agency. Sana is not limited by tight deadlines set by donors and instead tunes its projects to students’ timelines.
Sana’s biggest obstacle is convincing patients and funders that preventative healthcare is a worthy investment. Poor patients lack disposable income, and they do not always see the value of paying 10 cents now to see the doctor and buy medications to prevent health complications occurring 10 years down the road, especially if they do not have any symptoms at present, as is the case with most non-communicable diseases. Governments may not fund Sana-type projects because they compete with other public health interventions like immunization and installing running water taps, which have proven track records of success. An information system like Sana requires several cycles of evaluation to prove its value. However, all hope is not lost – Karnataka, India’s state government, endorsed Sana’s oral cancer diagnosis pilot system and is scaling it up to screen 1.5 million patients in the state.
In the near future, Sana plans to connect its partner organizations with each other so that they can document best practices and share implementation experiences. Partner organizations that are new to using Sana’s technology should not start from scratch; they can first determine whether existing solutions are appropriate for their own context and use other countries’ experiences to aid in applying for project funding. In the long run, Sana would like to use the collected clinical data to build a computational algorithm that will diagnose and treat simple cases. For example, if a healthcare worker takes a picture of a rash, the algorithm will be able to identify the rash based on an existing database of rash photographs. This limits the demand for medical experts and frees experts to respond to more difficult scenarios.
Mobile technology is developing quickly and is continually pushing the boundaries of what is possible. Sana is committed to harnessing the power of technology and applying it to medicine, making high-quality healthcare affordable and accessible to millions of patients.