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Postcard #12 - Smart Prescription Testing - Bangalore


Last week we were in Bangalore getting our 6 GP’s set up with our Smart Prescription service for live concept testing. Each doctor was loaned the tech kit to enable them to test out the service (a simple laptop/printer/wifi hotspot if they didn’t already have one) and we spent an hour with each one in their clinics getting set up. We took them through the service step by step and did some role playing, and talked through any queries. We also personalised the tool for them, so that their prescriptions/follow ups are detailed correctly. We then left them to use the service for an initial 3/4 days and revisited them at the end of the week to have a detailed chat about emerging learnings.

Overall reactions have been really positive, with lots of engagement and builds to the concept to make it even more workable.

It’s been awesome to see even very busy GP’s taking the time to not only use our new service with their patients but give us rich and detailed feedback too.

Kosta onboarding Dr Idris

Our doctors

  • Three of our doctors have collaborated with us across the project and three are new to it
  • All are GP’s treating middle income patients in private clinics, seeing on average 10-30 patients a day
  • They are all aware of the issue of AMR and keen to see the issue tackled, seeing clear benefits in a ‘systems approach’ looking at patients and providers.
  • Between the 6 there are varying prescribing activities - ranging from very modest to more frequent ‘just in case’
  • They have varying degrees of tech adoption, from none to sophisticated EMR’s.
  • All are being paid to participate in the concept testing - but are also really engaged and excited from a professional perspective too.

Some key learnings and quotes

Usability

Overall the doctors have found the system intuitive and simple to use on their side, especially given it’s a prototype with limited functionality.

“I think this is user friendly, with not too much data to key in. It’s intuitive. The guidelines are fantastic, popping up in almost real time. You key in the diagnosis and it’s there. Other systems that I’ve seen (with guidelines), it takes time to search those out in a support page and bring into the consultation yourself”   Dr Idris

However, we noticed that the GP’s who don’t use tech are keen to limit their time using the tool in the consultation - as almost all of their time is usually spent talking to patients - with the prescription writing and record keeping taking up very minor amounts of time at the end.

“They (patients) might misinterpret that I am spending too much time with this, I was very cautious not to do so” Dr Niaz
Dr Niaz using the doctor's side

Patient feedback

On introducing this new (doctor’s side) tool:

“I tell them I am capturing some notes here on my side. they don’t question me” Dr Idris
“Eye contact is important. What I do normally is ask them to give me 2 minutes to type, and keep on talking to them, while I’m typing.” Dr Roshni

On introducing the SMS (patient side) service

“I told them they will receive the SMS, and give the print out also. they say, its good doctor, it’s nice. Their mobile is always with them” Dr Sharat
“The safety netting part at the end is nice, I can cut down on time because of the SMS follow ups.” Dr Roshni
“They felt happy that we are doing something additional for them” Dr Niaz

It appears straightforward to get patients on board with the new service, as long as doctors don’t take too much time away from the consultation to input the details.

Impact of the integrated Guidelines

Doctors have been feeding back that the guidelines appearing in the moment are useful reminders, and especially help with reinforcing a conversation with patients about delaying or avoiding

“The guidelines are right there, and its easy for doctors to convince the patient - because it’s very reassuring. That’s the major advantage. That in turn would help us stop the antibiotic resistance” Dr Roshni
“It would really help to make sure we’re giving a good standard of care to out patients in all times and situations. These reminders will definitely help us to make sure we are not crossing those boundaries unnecessarily, even by small errors which could have been avoided.” Dr Idris
“The SP guidelines are helpful, keeps reminding us when it’s necessary and not to take Antibiotics.” Dr Sajan
Dr Sajan

Communicating the guidelines as ‘backup’ for docs rather than ‘new info’ in the moment is key:

“If I start reading the guidelines here (to decide), they think I’m reading on the net, that the doctor is not experienced. But if I show them the guideline is supporting my decision, they will say “OK, my doctor is recommending whatever the guidelines say, and they are followed all across the world. It’s all about trust, with this patients can see that we are up to date. It gives a good impression” Dr Sharat

Dr Sharat using Smart Prescriptions with a patient

When it comes to actually changing their mind about prescribing antibiotics, it’s early days but we’ve heard that a dashboards or stats report might work best. Giving doctors insight about how often and in which cases they are not sticking to guidelines (and even what the results have been) might be more motivating:

“For tonsillitis if I can reflect back on how many patients I’ve treated without antibiotics, then if they come back to me and say they’re cured, then I can further avoid AB usage. This insight would really help” Dr Niaz

Scope for Localisation

We’ve heard from doctors that although it’s good to have international guidelines made usable, they’d like a few changes to the tool to make it feel more locally relevant:

“It would be good to put in signs and symptoms with more common words, that patient would use to describe it subjectively. Then we have our investigations, so the objective element too. Also dosages, we traditionally use 1-0-1, they don’t understand 2 x 5.” Dr Idris
“You need to make the text messages work in the language that the patient is compatible with”  Dr Roshni
The guidelines are relevant in most cases, but in some cases i have to go against them based on what I see in the clinical examination. For example one time they really needed them as they had an LRTI.” Dr Sajan

We're thinking about adding a pop up box that requests the doctors help us understand why an antibiotic was prescribed even if it was advised against, by typing in the reason. This could help us build a more local and nuanced picture of where and when guidelines are overridden, and this way we hope to make the tool more useful over time.

What’s missing?

To make it more useful and usable for more patients, we heard various requests from the doctors. These included: adding vital signs and test results, to being able to add drug interactions, allergies, and of course a wider range of symptoms, conditions, drugs on top of those pre-populated for URTI’s. A big request was saving the data to make it accessible again in future, like an EMR.

“One drawback with SP, the examination isn’t documented - the things like vitals. These are essential” Dr Roshni.

As we go forward it’s important that we keep the balance of simplicity and speed with some more comprehensive features that would encourage adoption.

So far we’ve had over 200 prescriptions made with the Smart Prescription service

A printed Smart Prescription

Next up: Nairobi onboarding

If you missed our previous postcards you can find them here:

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