Published by the Students of Johns Hopkins since 1896
July 6, 2020

Public Health Professor highlights how digital technologies can improve care in underserved areas

By WILLIAM BLAIR | November 14, 2019

Smisha Agarwal, an assistant professor at the Bloomberg School of Public Health, gave a talk titled “Digital Technologies: Shaping the Future of Primary Health care” on Nov. 8. The talk was part of the biweekly seminar series by the Hopkins Division of Health Sciences Informatics. 

Agarwal’s research advances maternal and child health through the innovative use of digital tools for clinical decision-support and the use of predictive analytics-based algorithms to improve quality of care.

She spent the talk discussing her journey into public health, which began with a primary health care community-based program in rural India that had collected health data about community members for 40 years. The program was highly celebrated in its contributions to primary health globally and included in publications by the World Health Organization (WHO). 

Agarwal’s first task working on the project was much less glamorous. The headquarters where the project was based contained 10 rooms of files, and she was directed to digitize them.  

Despite this seemingly insurmountable task, Agarwal assembled a team, training others and creating a digital system that could record the data. Her team continued on the project for several weeks until, on one fateful day, the price of onions, a staple food in India, skyrocketed. Since most of her staff were members of the community, they left the project to find other ways to make money.

Although the project could not continue, the project led Agarwal to consider new and more sustainable ways to collect health data about community members. Soon after, she joined a team in India developing the Maternal Health Reporter. 

She explained the value of the project.

“Researchers could travel door-to-door to collect information about pregnant women, which could immediately be uploaded to a server,” she said. 

In addition to simple collection of the data, the computer system eventually included decision support tools which could alert researchers whether a pregnant woman had a health risk based on data analysis. Agarwal explained that this served as her gateway into a new field.

“That experience was my accidental introduction to digital health,” she said. 

Around the time of her work in India, she explained that the focus of public health also shifted. 

“Until recently, the focus of public health was ensuring that populations have access to health. Now we know coverage does not equal quality,” Agarwal said.

On a global scale, 40 percent of deaths are due to insufficient coverage, although 60 percent are due to insufficient quality of care. Agarwal believes the use of mobile support tools is the best way to combat lack of health care quality. These tools often consist of algorithms and checklists which use evidence-based clinical protocols to screen patients according to their health status. Through this system, the community health worker can register a client through door-to-door visits.

Agarwal first instituted this new approach to data collection in a 2012 study in India focused on using digital health in family planning. Workers asked clients about their family planning needs. This experience led Agarwal to undertake her largest project to date, known as Mobile for Reproductive Health (m4RH). 

The system is an SMS health-communication program wherein clients can text a code number corresponding to a contraceptive to the m4RH hotline to receive information about its use. Since the program began in Kenya and Tanzania in 2009, it has tallied two million hits and over 300,000 unique users. This project was later expanded to use an AI-powered chatbot for primary health care. 

Agarwal’s experience in these initiatives led to her involvement in the creation of the WHO Digital Health Guidelines, a report released earlier this year. Agarwal’s team specifically examined the effectiveness of clinical decision support systems (CDSS) to improve patients’ quality of care through two studies. 

The results of these studies, published between 2006 and 2015, both corroborated the use of mobile health applications with improved health and wellbeing. 

The recommendations of the studies were eventually incorporated into the report, which created an objective guide to improve distribution and access to mobile health applications, along with a checklist for implementation of mobile health applications. 

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