NextGen: FHIR-ing up SMART-Care

Fragmented primary health care in Indonesia includes some of these problems:

• Underutilization of data: minimal use of data for action in primary health care.
• Poor data flow and communication: Lack of seamless information exchange between different levels of care (community, clinics, hospitals).
• Lack of data standards: results in poor interoperability for data systems.
• Inefficient service delivery: Disjointed services lead to gaps in care and delays in treatment.
• Limited access to information: Challenges for healthcare providers and patients in accessing relevant health data.
• No appropriate support and optimization for the frontline health worker: where they are being the very first line with the community, they need to be supported properly.
• The distance between care facility and the community: with the global technology development, this should not be an issue, the increase of smartphone use must be an advantage to the health care giver to reach the community faster.

Team-based care, is a model that aims to comply with the patients needs and preferences by promoting and empowering frontline health workers. The first key of the innovations, Open Smart Register Platform (OpenSRP) is an integrated and interoperable digital health information system mobile app for frontline health workers. OpenSRP is a digitalization of the paper health care registers which conform to HL7 Fast Health Interoperability Resources (FHIR) standards and build under Android FHIR SDK, created to aim for better person centered care by an integrated team of providers. While implementing the team-based care model, this system of end-to-end care complements and leverages the whole model. Individuals receive care from a team of health workers and facilities that are linked via interoperable data centered around care plans.

The apps built on OpenSRP enable digitalization of the paper health care registers that many frontline health workers use then enable them to be in the ecosystem of data flow for action on FHIR. It was co-created by SID, WHO, ONA Systems, IRD, and others. OpenSRP apps enable data sharing and data use for action in real time, and are interoperable and built on HL7 FHIR standards. Our goal is for health care to be client-centered. And with OpenSRP each frontline health worker can be equipped with an app, and be part of a team of coordinated workers who place the client at the center of care. OpenSRP allows multiple healthcare providers and workers to interchange information, allowing everyone to update and access the most updated patient data. This fills the information gaps between facility-based electronic medical records and the community and clients. This system is integrated with Indonesia’s national health information system, SATUSEHAT, allowing interoperability with the national platform. 

Digital transition system alone is not enough, human resource management needs to be improved at the same time. This will allow a better and faster solution for enhancing the healthcare system. Besides the architecture of OpenSRP, we also integrate some key features supporting the utilization of the health data,  for the better flow of frontline health workers to follow up and close the gap in care. The main objective is to address end-to-end care, where each of the patient’s needs are addressed fast and promptly by enabling dynamic support for frontline health workers.

Key Features of the data utilization

1. Dynamic Worker Support

A key feature focusing on daily field-activity. Dynamic worker support was initially a shifting of manual scheduling to automated scheduling of frontline health workers, where problems occurred with efficiency and quality of the tasks. Components of the Dynamic Worker Support including:

• Automated assignment and scheduling for every frontline worker, based on their ability and location, and patients needs. This automated schedule includes the tasks needed to be performed by the frontline health workers, every client’s care plan, gap care and missing data.
• Operator as a team-leader of frontline health workers, who will be able to monitor and assist the frontline health workers during field activity. Operators assist on detailed tasks written for each of frontline health workers, communicate frontline health workers with targeted patients through a monitored and centralized call, and give feedback to each of the frontline health workers during or by the end of the task.
• Live tracking of frontline health workers, where operators would be able to see the positions of each frontline health worker during the work hour, and send fast help if any of the frontline health workers need it during their visit.
• Check-in check-out, attachment, signature, and correlating feature for a clearer objective of visit for frontline health workers. With these features, operators and other personnels in need would be able to give more objective feedback to each frontline health worker.

2. Call Center Integration with WhatsApp API  

We optimize WhatsApp for sending tailored health education messages, reminders for visits to health facilities, enabling the continuum of services for every individual, from community to facility n.

Despite the advantages of WhatsApp, it is not a one-size-fits-all solution. In rural settings we found beneficiaries who lack access to the internet or familiarity with social media platforms such as WhatsApp which can limit their ability to receive essential health messages and reminders. To address this challenge, SID has incorporated a Call Center service as an alternative channel for delivering health information, reminders and consultations. This addition ensures that health communication efforts are inclusive and can reach a broader audience. By combining WhatsApp’s automation capabilities with the personalized interactions facilitated by the Call Center, SID enhances maternal compliance with antenatal care (ANC), postnatal care (PNC), and other crucial health services. This integration ultimately contributes to the improvement of family health outcomes.

The Call Center and WhatsApp API integration represents a significant shift in health communication, transforming it into a proactive and efficient system. This dual-channel approach not only ensures that health services are accessible to all, including the most vulnerable populations, but also emphasizes continuous monitoring and refinement. Such efforts highlight SID’s commitment to innovation and serve as a model for leveraging technology to achieve better public health outcomes.

The integration provides numerous key benefits:

• Efficiency: The use of automation reduces the need for manual tasks, enabling agents to dedicate their time and effort to addressing more complex cases that require human intervention. This improves operational productivity and ensures faster service delivery.
• Inclusivity: By combining WhatsApp and the Call Center, SID ensures that beneficiaries from all backgrounds, including those with limited digital access, are reached effectively. This dual-channel strategy eliminates communication barriers and expands outreach to underserved communities.
• Personalization: Tailored scripts and carefully crafted messages ensure that interactions retain a human touch. This approach maintains empathy and understanding while benefiting from the scalability and efficiency of technology.
• Proactive engagement: The system’s ability to send timely follow-ups ensures that care gaps are promptly identified and addressed. This proactive approach enhances adherence to health services and improves outcomes for beneficiaries.
• Accountability: Comprehensive quality assurance (QA) processes, combined with detailed monitoring of communication activities, uphold high standards of service. These mechanisms provide transparency and foster trust in the system’s reliability and effectiveness.

The integration of Call Center and WhatsApp API serves several objectives:

• Enhance efficiency: Automate routine health reminders and reduce manual effort.
• Improve accessibility: Provide communication options that cater to diverse technological capabilities.
• Ensure proactive engagement: Address care gaps promptly through timely follow-ups and escalations.
• Streamline monitoring: Use real-time dashboards and reporting tools to track communication outcomes.

WhatsApp API Features and Workflow

Automated Messaging

• Campaign setup: Templates for messages such as ANC and PNC reminders, immunization alerts, and care gap notifications are pre-designed and approved. The WhatsApp Business API ensures timely and automated delivery to targeted contact lists.
• Monitoring delivery: Message status (sent, delivered, failed) is tracked via real-time dashboards. This data helps refine messaging strategies and identify potential issues.

Chatbot Integration

• Interactive chatbots provide instant responses to frequently asked questions and deliver health education content. Features like quick replies and call-to-action buttons allow beneficiaries to easily access additional information or services.
• Unresolved queries are escalated to live agents for personalized assistance.

Data Integration

• Beneficiary contact lists are updated dynamically from tools like Kobo Toolbox. New contacts are validated through introductory WhatsApp messages, ensuring data accuracy.
• Regular reports on message delivery and engagement metrics are generated for internal review and process optimization.

Call Center Features and Workflow

Automated and Massive Personalization

• Predictive dialing: This feature allows the system to automatically dial a high volume of numbers from a pre-uploaded contact list. Calls are routed to available agents once answered, enabling efficient handling of outbound calls. Scripts are displayed on-screen to maintain consistency and professionalism.
• Manual dialing: For smaller campaigns involving fewer than ten contacts, agents manually dial numbers and record outcomes in a centralized reporting system. This ensures even small-scale communication needs are addressed effectively.

Escalation Process

• WhatsApp messages are monitored for a 24-hour period. If unread, they are flagged for follow-up calls by the Call Center team.
• Call outcomes are categorized as answered, no answer, rejected, wrong number, or inactive number. Persistent unresolved cases are escalated for home visits by field health workers, ensuring no beneficiary is left unsupported.

Follow-Up Strategies

• Home visits: Frontline health workers are deployed to visit beneficiaries with unresolved issues.
• Routine scheduling: Automated systems help plan recurring home visits or follow-ups.
• Request-based visits: Beneficiaries can directly request home visits via WhatsApp or during phone interactions.

Quality Assurance

• Daily QA checks are conducted on 10% of answered calls. Metrics include script adherence, resolution rates, and agent professionalism.
• Data and call recordings are regularly reviewed to maintain high communication standards.

Integrated Workflow

Message Initiation

• WhatsApp API sends automated health reminders to beneficiaries. These messages include antenatal and postnatal care reminders, vaccination schedules, care gaps, and educational content.

Monitoring and Escalation

• The Call Center monitors WhatsApp message statuses. Unread messages trigger follow-up calls, ensuring all beneficiaries receive the intended information.
• Persistent unresolved cases are escalated for direct intervention, such as home visits.

Continuous Improvement

• Feedback from beneficiaries and operational data are analyzed to refine communication strategies. Dashboards and daily reports provide actionable insights to improve engagement and efficiency.

3. Local Area Monitoring Dashboards  

   The dashboards are designed to provide granular insights and operational support for Puskesmas, village and district health office. Each feature is tailored to ensure actionable data is available in real time. The key components include:

• Real-Time Monitoring: Dashboards display up-to-date information on ongoing activities, such as the number of home visits, antenatal and postnatal care services, immunizations, and follow-up activities.
• Alert System: Automated alerts for overdue tasks, missed follow-ups, or care gaps ensure timely interventions. These alerts are displayed on the dashboard and flagged for both operators and Puskesmas staff.
• Geographical Insights: Location-based data on patient distribution and frontline worker activities is represented through maps, enabling better allocation of resources and identification of high-risk or underserved areas.
• Integration with Higher-Level Systems: The dashboards are designed to integrate seamlessly with higher-level health systems using FHIR standards. This ensures interoperability and efficient data exchange between Puskesmas and regional or national health databases, including direct integration with the national health information system (SATUSEHAT)

The OpenSRP apps built on FHIR address the issue of data interoperability, enabling each of the care data to connect to every resource to create more complete records. It also allows different subjects of health to see and perform different types of care, like midwife, cadre, vaccinator, and doctor to fulfill their respective roles, developing a comprehensive system of team-based care.

The utility features of the system then creates a daily data loop for better data for action operations. All of the subsystem is integrated in a looping flow, enabling faster problem detections and action for care, to make sure each of the health care delivery is both effective and responsive to create a better team-based care model. Since the system is automated, the result is expected to remove delays in action, to support frontline health workers efficiently, and improve the quality of care and patients outcomes through the community. Using this system, we expect patients to receive complete, continued, and quality care, particularly for essential care such as antenatal care (ANC) and postnatal care (PNC), realizing an all-rounded primary care from health promotion to disease prevention, treatment, and rehabilitation.