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Postcard #13 - Smart Prescription testing in Nairobi, Kenya

Last week the IDEO team were in Nairobi, Kenya getting our doctors on-boarded with our Smart Prescriptions service. We met them at the start of the week to get set up, and returned for an in-depth interview at the end of the week to capture some initial feedback. We also met with 2 patients to get their feedback on the idea from a conceptual standpoint.

We’ve had a few hiccups with bugs in printing, wifi connectivity in the clinics and patients on one network not receiving the SMS messages, but overall we are up and running and resolving these issues. The doctors are excited and enthusiastic about the concept and their patients seem to be responding well.

Jenny and Halima (our clinician) talking through her SP feedback

A bit about our doctors

We have 4 GP’s and one clinician collaborating with us in Kenya

  • All of the GP’s are new to the project, the clinician we have on board from previous rounds. One of our GP’s is an infections specialist at a consultant level.
  • They range from a few having simple clinics with no tech set up, serving the lower end of middle income, to those operating modern clinics which have already gone paperless - serving middle to upper income patients
  • Similarly to in India, they are noticing high incidence of URTI’s in their patients at the moment due to the rainy season
  • They see fewer patients than in India, at most 10 per day. They spend 10-30 mins with each one and charge between 300 and 2000 Kenyan Shillings per apt (£2.50-£15)
  • All are aware of the issue of AMR - and mention that it’s a significant issue in Kenya due to problems at all levels across the health system. These include lack of regulation in pharmacies (only psychotropic drugs are properly controlled), misunderstanding of antibiotics a patient level and lack of usable protocols from government

Some initial feedback

Good overall response to the idea. We’ve heard the doctors talk about the value SP can add to the doctor patient relationship, which is really encouraging:

"Patients are curious to know about how they're managed. They'll be really impressed by this openness (the simple follow up messages about what the condition is). Many health workers have been trained by the government system which is not so user friendly - explaining medical terms to patients is not a strong point, and they're never told what to expect. I think this would generate repeat patients" Dr Lemmy
Dr Lemmy
"This will help me tell my patients that "taking antibiotics will be of no benefit to you, don't spend your hard earned money" Dr Fred
Dr Fred describing the impact SP could have on patient relationships
"This is a plus, the advice on text about whether I should go out with friends, drive, whether I'll feel nauseous today. It's the icing on the cake," Jakki, patient

Playing back prescribing behaviours

All of the doctors were open to seeing insights about how their prescribing behaviours match up with guidelines, in a weekly or monthly email report.

"This would be wonderful. I'd want to see the number of patients we saw, my prescribing methods against the guidelines, and which medications I prescribe a lot. It would improve our clinical care" Dr Lemmy
"It would be a good opportunity to learn about antibiotics, and if they are necessary" Halima, Clinician

One emerging learning is that this type of feedback and auditing combined with the in the moment reminders will both be required to drive down unsafe prescription.

Competing with EMR's

One challenge we have had is that on returning to some of our Kenyan docs we heard that they were using the system at the end of the consultation rather than as they go. When we asked why, we heard that for doctors using EMR's already, it's double work.

“It’s such a simple system, it’s easy to remember the info and input it at the end. I have to also keep a record in my normal EMR” Dr Jaffer

We have asked all our doctors to try using it as they go with patients even though it’s a new behaviour, so we can really stress test whether reminders before prescribing can help. Overall though, this feedback indicates that unless our system can compete with a more comprehensive EMR it will be more difficult to have doctors adopt. This is particularly the case for patients with chronic conditions such as diabetes and hypertension, where records of each consultation need to be logged and referred back to (not currently possible with our system).

As an interim workaround, we added an open field box where the doctor could add any additional consultation info that they wanted, and encouraged them to print twice, saving one copy if they wanted save their consultation to refer back to.

Using the tool for URTI vs other conditions

We also heard that selecting symptoms, conditions and drugs from the pre-populated lists is quicker for the doctors than typing into open fields.

"I find it easier to just find and click than be typing" Halima

That meant that doctors were more likely to use the tool for URTI's than other conditions. In the future we feel the tool is more likely to be adopted if it is designed for use with a wider range of conditions that GP's encounter. However we've still seen a good number of uses for more general cases, which doctors mentioned is because the printed prescriptions and automated SMS follow ups feel like a nicer offering to patients than what they currently use.

Sticking to guidelines

We heard doctors are overriding the guidelines in certain cases, but they feel justified in doing so, giving reasons such as the below:

"Sometimes an antibiotic is given because lab tests (e.g. Haemogram) indicate it’s needed" Dr Michelle
Dr Michelle in her clinic
"Sometimes it’s based on signs/symptoms that aren’t there in our list but still indicate bacterial infection, like a specifically high fever-  of say 39 vs 38.5, a rash, or very rapid heart rate. Or it could be environmental factors such as presence of bacterial strep throat in a household" Dr Jaffer

We know that doctors are more likely to override or ignore reminders unless they feel relevant to their practice, so requesting that the system documents elements like this from clincial examinations is good feedback for the next version of the tool.  We’ve asked our doctors to keep capturing these as they go so we can discuss during our follow up interviews in the coming weeks.

Up this week

This week we're back in London synthesising our learnings, reviewing the designs and beginning our storytelling narrative ahead of the CTA conference.

Missed our previous postcards? Find them here:

Postcard 1

Postcard 2

Postcard 3

Postcard 4

Postcard 5

Postcard 6

Postcard 7

Postcard 8

Postcard 9

Postcard 10

Postcard 11

Postcard 12

And don't forgot to follow our progress @projectmarvelous