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Re: [Health] Ebola, MERS, Zika, N.N. and GNU Health

From: Luis Falcon
Subject: Re: [Health] Ebola, MERS, Zika, N.N. and GNU Health
Date: Tue, 2 Feb 2016 10:17:43 +0000

Hey, Chris !

On Tue, 2 Feb 2016 12:45:25 +0700
"Christoph H. Larsen" <address@hidden> wrote:

> Dear All,
> Apologies for cross-posting, but unusual circumstances demand unusual 
> actions.
> The ongoing outbreak of the Zika virus has been declared an emergency
> by WHO, and this certainly highlights yet another time the importance
> given to disease surveillance as an integral part to health
> information gathering, processing, reporting and related
> decision-making.
> To date, we have a number of hospital health information systems, GNU 
> Health, of course, included, that do their job with various strengths 
> and weaknesses. GNU Health boasts the existing integration with
> Tryton as ERP system, which is simply great. Plus, is integrated with
> an evolving LIMS, which is of exponentially increasing importance,
> because surveillance is nothing without laboratory confirmation.
> There is DHIS2 ( as USAID-funded and endorsed
> data warehouse for health data aggregation, analysis and presentation
> at the national level, with aim to further informed, evidence-based 
> decision-making. DHIS2 has come a long way, but it is still pretty 
> clunky, well, IMHO. Modifications may not always be easy to
> implement, depending on the running version.
> Back to GNU Health: Given Tryton's scrupulously clean, lean and mean 
> data models and structure, there is no reason, why a further push 
> towards business intelligence (a.k.a. data aggregation, analysis and 
> presentation, with data mining thrown in) should not be possible.
> This could be achieved as a Tryton or GNU Health module, or via
> linking to external facilities. Solr uses Java, Lucene has been
> ported to Python... As long as this heavy stuff runs at the central
> level (Ministry of Health), this does not matter *that* much, and
> even less, if feedback of the aggregate data and analysis can be done
> via lightweight communication channels back to the field. But it
> would, of course, be nice to keep things in the lean and mean Python
> family :-D.
> Data capture is an issue: GNU Health is not offline-capable, as of
> now (correct me, oif I got that wrong!). And its suitability for
> mobile phone or tablet use is limited, because the interface has
> mainly been geared towards non-mobile technology. I know, there is an
> app, but I have seen better user experiences. Ideally, there is no
> app at all, all based on offline-capable HTML5, and running in a
> modern browser. (doing all this) might help doing
> exactly that, and could feed into GNU Health as backend, but its
> question types are a bit limited. We need the range of questions
> present in LimeSurvey (, which works
> actually very well in a self-contained Android stack consisting of
> PHP, Nginx and SQLite, with exports to a central facility via .csv
> or .xml, or to STATA or R. But with HTML5 e might be able to make
> this a bit easier. Open Data Kit tries to do this by simple .xml
> exports, but fails miserably on robustness, scalability data security
> and user-friendliness, and is poorly maintained. Plus with one toe in
> the proprietary world...
> As for GNU Health, yes, there is a need for body system-specific 
> modules, such as an ophthalmic or dental module. Also, 
> diagnostics-specific modules might help, such as a facility that can 
> display the peak expiratory flow rates in asthma patients over time.
> However, I *personally* have my doubts about disease-specific
> modules, which includes the NTD and MDG modules. Recent history has
> shown that emerging diseases move way too fast to keep up.
> Donor-inspired vertical disease-specific interventions (HIV, malaria,
> TB) have not really strengthened primary health care, because they
> were contained in a silo, and GNU Health would do well not replicate
> this model.
> Instead, Tryton's inventory and stock management suite offers already
> a model for a highly flexible alternative: The attributes model
> offers a unique way to capture any specifications of a stock item via
> a user-configurable interface. Something similar could be designed
> for disease-specific surveillance, starting from WHO's integrated
> disease surveillance catalogue to ongoing worries (EVD to newly
> emerging diseases, such as Zika and others to come.
> This would allow the creation of a capable, flexible, yet 
> standards-compliant surveillance and disease recording facility
> within hours, offline-capable, using HTML5 technologies, or a
> self-contained stack, and bring GNU Health to the community health
> workers anywhere in the world. Of course, contact tracing
> capabilities will be essential.
> Throw in a central unique identifier database (with doing the unique 
> identifier being a major legal as logistic hurdle!). and we can push
> and pull medical records across all connected health facilities with 
> considerable ease.
> I am fully aware that a lot of the above may sound a bit like a
> dream, but if we put the right tools together, collaborate and keep
> focused, it can be done.
> There have been a few recent and very laudable efforts to effect 
> surveillance in one way or the other within the group, and I think
> this is something which deserves applause and further support.\
> Did I mention that there is a lot of money out there for
> surveillance? With CDC's new Global Health Security Agenda (GHSA),
> where are very keen targets set, yet the tools are sorely lacking.
> National governments are literally creaming for easy to use,
> ready-to-deploy solutions.
> What's your take? From the field end, it's very high time, kind of
> three to twelve, to quote a recent assessment of the World's
> situation.
> Thanks a lot for your critique, comments and ideas, and stay well!
Thank you very much for this detailed email. Let me try to summarize
what I understand from it :

1) Offline data collection. My personal take is to use a netbook with
the specific module, and then synchronize the information at the main
office or the Min. of Health. Of course we can design apps that are
offline capable, but I think that we already have a robust way of
collecting data, even when there is no Internet connection. In areas
where Internet connection is available, then today you can use either
the GTK or the SAO webclient.

2) Data aggregation, reporting : Today GNU Health can aggregate /
synchronize data from different institutions, using the Tryton
synchronization engine. Once the data has been aggregated to the mian
instance at the Min of Health, you can then feed it to an OLAP engine,
or run reports directly from it. 

3) Disease-specific modules : Coincidentally, we were discussing
yesterday with our common friend Roberto Novaes from Brazil, about
vectors, Domiciliary Units surveillance, and other existing
functionality in GNU Health[1]. 

You are an expert in Tropical Medicine, so all the advice coming from
you is most welcome in this area !!

2) Keeping up with the speed of health events : You're very right.
Health events happen quite fast, but this is not new. Although we
always want quicker response times, I must say that I'm quite happy on
the feedback of our GNU Health community. For instance, Dr. Michele
Roofe and Marc from Jamaica Min. of Health sent us the new entries on
Zika virus for ICD10 . Those codes where included within ours and now
are part of the system. So, the larger the community, the faster the
updates on health related events. The modular approach to GNU Health
allows to release an update on an specific event / disease in a _very_
short time. Again, the key is the community, the technical
infrastructure is there.

3) Surveillance : Here it depends on how well people collects data and
inputs into GNU Health. I can't stress enough the importance of good
data for person demographics (eg, domiciliary units and their
characteristics), socio-economic determinants of health and
disease, OpenStreetMap links, disease groups (such as
infectious, notifiable, social diseases, ... ). If we have all this in
place, we can not only detect early outbreaks, but, what is _way_ more
important, to avoid them by improving the health promotion campaigns
and the underlying social causes of disease. That's the main reason why
I started GNU Health.

Finally, a personal note. It's a shame that there is a name for
"Neglected" Tropical Diseases. Neglected because the ones who used to
succumb to them were the voiceless of the South. Same victims of wars,
child and sexual slavery, etc ... It looks like after decades of
exploitation, it's payback time for Mother Nature and for the
underprivileged, against a ruthless, short-sighted, money-driven blind
society, who still tries to "fumigate" the problem.



> Chris

Luis Falcon, M.D., BSc
President, GNU Solidario
GNU Health: Freedom and Equity in Healthcare

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