1. PhD Student, University of Miami
Health Systems in Urban Poverty Zones Industrial Engineering Proposals for Integrated mHealth Solutions
Caitlin Augustin
PhD Student, University of Miami
Dulce Sanchez
Industrial Engineer, Macys Corporation
Shihab Asfour, PhD
Chair, University of Miami Department of Industrial Engineering
Nina Miville, DBA
Associate Professor, University of Miami Department of Industrial Engineering

2. Project Background
Partnership with Project Medishare Hospital in Port au Prince, Haiti and Department of Community Service at the University of Miami Miller School of Medicine to identify key problems with free clinic operations and present innovative engineering solutions
Funding provided by Neighbors for Neighbors, International

3. Key Discoveries
Free health clinics (also called safety net clinics) are severely understaffed which leads to record keeping errors, misdiagnosis, and minimal patient retention
A solution to these problems can be found through the use of mHealth technologies.
mHealth technologies can be developed in house and customized to the clinic’s specific needs
Training and education materials can be provided through a web platform.

4. Structure of the Presentation
Project Introduction
Site Studies
Recommendations
Applications
Data Analytics
Web Platform
Conclusion

5. Project Introduction
The Universal Declaration of Human Rights, adopted by the United Nations in 1948, proclaimed that "everyone has the right to a standard of living adequate for the health and well-being of oneself and one's family, including food, clothing, housing, and medical care."

6. Problem Statement
The most severe problem in global public health is the profound lack of trained local healthcare workers.
The World Health Organization notes critical healthcare workforce shortages in 57 countries—and a global deficit of 2.4 million doctors, nurses, and midwives.

7. Project Objectives Identify barriers to operations in free clinics
Analyze key problems in patient retention in free clinics
Apply industrial engineering tools to enhance operational efficiency
Develop telemedicine tools for patient management in free clinics

8. General Assessment Methodology
Performed a literature review
Selected four free clinic sites
Employed industrial engineering tools of facilities layout, time studies, and work studies for onsite data collection
Conducted on-site interviews with the directors, administrators and other personnel of the mobile clinics and hospitals.
Developed analysis tools for cost analysis, resource allocation, patients seen

9. Industrial Engineering Tools Used
Risk Assessment Models: Failure Mode and Effects Analysis, health and safety risk assessment
Time studies :Patient in system and operations of the telemedicine operators
Work sampling studies: Current system analysis from doctor, nurse, check in perspectice
Time and motion studies: Therblig analysis and design to better suite the ergonomic needs of telemedicine operators.
Statistical Quality Control: Xbar and R charts created
Cost Analysis: Created a cost analysis of the cost required to implement telemedicine in various situations.
Optimization models: Usage of population density, safety and availability of routes were identify to created the optimum routes for the telemedicine operators to travel. Models include traveling salesman and product-mix
Decision Support Systems: Programs were designed in VBA/Excel for managers to create
ARENA simulation model: Model was created to analyze the impact of the telemedicine.
Engineering Project Management: Project was organized and managed using software such as Microsoft Project, and Microsoft Visio.

10. Study Sites
Eight hundred thirty-seven million urbanites currently reside in densely populated, overcrowded unsanitary conditions often lacking access to basic health, water and sanitation services.
-United Nations

11. Project Medishare Hospital Little Haiti DOCS Clinic
Study Locations
Project Medishare Hospital
San Juan Bosco Clinic
Little Haiti DOCS Clinic
South Dade DOCS Clinic

12. General Study Observations
Fundamental functions
1) providing cost-effective quality care,
2) educating the community on health issues
3) providing a medical and social structure deeply embedded in the neighborhoods
Backgrounds of clinic directors vary from certified physicians to individuals with no professional background in the medical fields
Medical record management varies between clinics but each dealt with inadequate storage, incomplete records and follow up care
All clinics are consistently understaffed and rely on volunteers to provide services
Each clinic relied on grants and donations for the bulk of its annual budget

13. Data Collection Barriers to Health Care Access
Population according to economic class
lowest 25%
26-50th %
51-75%
75-100%
Distance from Health Center (miles)
 6.7
10  10  x
Usage of Public Transportation as Primary form of transport
74.3%
39%
6.3% x
Uninsured
 36.64%
27.42%
19.85%
Immigrant Population
92.90%
 85%
50.32%
No Citizenship
49.38%
Patients
60%
25% 
15% 
Adapted from Cervantes-Rodriguez, M. Free Clinics: Their Role as Safety Net Providers 2009

14. Data Collection Hospital Services Provided

15. Data Collection Hospital Utilization Data

16. General Recommendations
Let’s send in doctors to save people from cholera. Let’s send in aid workers to build sustainable sanitation and water systems to help people help themselves. Let’s help educate Haitian children and improve the port so that it can become an exporter. But, above all, let’s send in business investors to create jobs.
-Nick Kristof

17. Recommendations
Adoption of mHealth technologies to reduce bottlenecks in clinic, have a consistent patient record, and increase follow-up care
Integration of patient records into OpenMRS
Provision of training to managers on mHealth and optimization
Usage of tools developed for data management and maximize existing clinic resources

18. Tools Recommended and Designed
End To End mHealth Applications
Android-based Sana General Form
Iphone-based mHealth engineering General Form
HTML 5 application
Data Analytics
Decision support systems for optimization of travel and ordering
Data mining tools for disease vector analysis
Arena simulation for evaluation of new techniques
Web Platform
Tools and apps for download
Videos
Presentations
Training Materials
Literature Review

19. Applications
“Biggest impacts of mhealth: patient reminders, supply chains for commodities, health records”
-Bill Gates

20. Application Design
Designed to promote patient care by providing doctor designed forms for patient intake/triage that can be operated from a mobile device by unskilled workers
Upload capability to OpenMRS
Required information
Demographic information: patient name, sex, birth date, location
Vitals: patient height, weight, blood pressure, temperature
Medical History: past surgeries, family history
Triage: why the patient is seeking treatment that day.

21. Applications Designed
SANA Android App
SeattleClouds Iphone App

22. Decision Support Systems
Data in isolation is not very meaningful. It does not reveal the total picture. You need to present data in some context. Suppose you are presenting this data; India's military budget is $ XYZ billion. This makes less sense in isolation. But once you look at it in relation to some other data point (say military budget of US) then you get a better picture. Comparison makes data more meaningful.
-David McCandless

23. Decision Support System General Questions
Distance to Care Routes
Patients seen/day
mHealth technology purchases per hospital
Distance: traveling salesman
Patients: lp optimization problem
Phones: inventory control problem

24. Ordering Optimization
Product-mix model
Inputs of hours open, investment budget, total staff, current patients seen
With a $10,000 investment budget, Project Medishare could purchase
Two tablets
Three phones
One computer training course
4.45 FTE Nurse for one year

25. Patient Maximization
Maximin model
Inputs of hours open, investment budget, total staff, current patients seen
Using mHealth Project Medishare could increase the number of patients seen per day up to 43%

26. Distance to Care Minimization
Traveling salesman problem model
Five mobile clinics maintained by Project Medishare
Travel distance to mobile clinics maintained in Haiti’s most poverty stricken areas can be reduced by over 70%

27. Disease Mapping Program
The power of mHealth allows data to be collected, stored, and analyzed virtually everywhere.
This DSS is designed for the healthcare worker with limited excel experience to create a map of disease populations and assess risk to determine treatment.
Input of latitude and longitude, type of disease (from selection menu), notes

28. we are at the very beginning of the Information Revolution.
Conclusions
we are at the very beginning of the Information Revolution.
This third revolution rewards those who control and process information. It gives them a competitive advantage, and a road to national affluence.
-William Kennard

29. Web Platform
mHealthengineering.com is a platform that hosts all applications, data tools, and troubleshooting materials for mHealth projects.

30. Project Impacts
Dissemination of viable mHealth smartphone applications
Education provided to free clinic managers
A reduction in supply costs due to the reduced use of paper and photocopying.
Maximization of existing resources
Elimination of redundancies in patient flow, mobile clinic delivery
Increases in patients seen/day
Increase in patient retention and follow up care

31. Questions?
"We need to focus on the uninsured and those who suffer from health care disparities that we so inadequately addressed in the past."
— Sen. Bill Frist (R-Tenn.), Senate majority leader on his priorities for the 108th Congress