E-Heza Data Solutions

E-Heza Data Solutions is a comprehensive point-of-care digital health platform that ensures high-quality, efficient care when and where it is needed most. First established to serve the Rwandan primary care ecosystem that is comprised of nurses and midwives in health centers and community health workers (CHW) in villages, E-Heza is designed to support existing government health systems and facilitates the most common workflows of frontline health workers at the community and facility levels in Sub-Saharan Africa (SSA) where large electronic medical record (EMR) systems are often impractical and where existing CHW tools struggle to adequately support the two-way communication and data management capacity that facilitates an effective and efficient local healthcare ecosystem at scale. E-Heza utilizes API integration and FHIR interoperability standards to deliver critical patient information to existing electronic medical record systems. E-Heza is a full-service primary care platform that serves multiple levels of care in one system rather than requiring cumbersome integrations at each level of the healthcare delivery system, facilitating high-quality care that encourages patient retention in care and sustained improvements in health outcomes. 

E-Heza was created to inspire high-quality care by easing workloads, providing personalized care, and streamlining data reporting to national governments. E-Heza incentivizes accurate data by using data trends to celebrate success and identify problems before they become emergencies. Similarly, filterable dashboards provide real-time insight into the health of communities from the village, health center, district, and national levels. E-Heza ensures that vital individual clinical information is available at each level of care through a shared progress report that can also be sent directly to the individual via WhatsApp. 

E-Heza incorporates best-practice clinical protocols established by the World Health Organization and seamlessly guides frontline health workers through assessment, diagnosis, treatment, referral, and case management. The activities are tailored for the skill level of the user based on user-type log-in identifiers, and patients are referred to the next level of care based on the severity of the patient’s presentation. E-Heza provides comprehensive clinical protocol and decision support for COVID-19 screening, referral, home-based care, treatment, and contact tracing functions; integrated management of childhood illnesses (IMCI) such as malaria and diarrhea; case management; pediatric care; immunizations; early childhood development; family planning; antenatal care; HIV services; tuberculosis screening; non-communicable diseases; and laboratory and medication management. 

E-Heza is built with a decoupled architecture providing both a “frontend” (where healthcare workers enter data) and a “backend” that receives and organizes that data. The frontend is developed in Elm, an open-source and functional, statically typed language that compiles to JavaScript. The backend application is served by Drupal, an open-source PHP content management system. The frontend and backend communicate through a RESTful API, which is modeled on digital health standards, including FHIR-HL7. 

Drupal was chosen specifically with scalability in mind, as its sophisticated data abstraction layer is well-tested and can efficiently handle millions of nodes of data without the need for high-level infrastructure resources and management. Drupal’s large open-source community (one of the largest in the world with millions of members) provides assurance that most problems we encounter have been seen before and that there will always be a large developer community from which to draw talent. A recent scalability test indicates that E-Heza could scale to serve an entire national context in a single instance without changes to architecture or infrastructure. Elm, on the other hand, was chosen for its efficiency in development, as a highly opinionated and statically typed language, it provides a smooth on ramp for new developers and a clear path for interoperability. The tool uses Docker and DDEV as packaging and containerization tools, and it is also integrated with Gitpod so it can be spun up in a single click for evaluation and testing. 

The application is served to the client via progressive web app (PWA) technology. The application registers a “service worker” with the client browser, allowing the web application to use local cache and storage to deliver an offline experience and store captured data during periods of low or no connectivity.  

Elm handles the sync by using a service worker to intercept requests and a custom port setup, allowing asynchronous data flow between Elm and JavaScript while keeping the context of each request for more precise, reliable syncing. In E-Heza, to mitigate sync issues, we utilize a retry mechanism where failed transmissions are queued with context in Elm’s model. Upon re-establishing connectivity, the service worker automatically retries each request, ensuring data consistency without user intervention. 

Opportunistic syncing in the background sends data in small packets to the backend, making bandwidth use minimal and ensuring the data stays on the device only as long as it needs to. Integration with Google Chrome allows users to “install” the app to a home screen and delivers a more “app-like” experience to the user. 

E-Heza Data Solutions supports the achievement of the Sustainable Development Goals for health in Sub-Saharan Africa through the scale-up of our technology-enabled model for strong community-driven primary healthcare delivery ecosystems that ensure high-quality care that leaves no one behind. E-Heza is the only digital health platform that serves the entire primary care ecosystem of local healthcare delivery systems while also achieving cost-effective multinational scale by building from standard WHO clinical care guidelines and available Digital Adaptation Kits, supporting multiple languages and workflow contexts, and ensuring scalable data architecture. 

Nurses at Health Centers and Health Posts 

When an individual presents to the health center, the nurse is guided through a comprehensive symptom review, complete medical history, evaluation of danger signs, physical exam, laboratory testing, and treatment recommendations based upon the information that is entered into E-Heza. E-Heza provides prompts for next steps, including medication dosage and distribution and follow-up appointment reminders. Follow-up visits are based upon ministry of health protocols and support danger signs assessment, symptom review, physical exam, and laboratory schedules. 

Built-in decision support makes recommendations for adjustments to medications based upon findings. Additionally, the individual’s name is placed into the CHW’s case management system to alert them to the need for a home visit to review medications and danger signs. 

Community Health Workers (CHWs) 

CHWs use E-Heza to conduct all child growth monitoring activities, antenatal care monitoring, post-partum and newborn evaluations, acute illness screenings, treatment, referrals, and management, and non-communicable disease case management. Dashboards allow CHWs to see the health of their communities and simplify reporting to the local and national government. 

Physicians at District Hospitals 

E-Heza immediately alerts nurses at health centers when an individual requires referral to a district hospital. While E-Heza is primarily designed to support care at the health center, health post, and community level, physicians at hospitals can sign in and review progress reports that list all pertinent clinical and demographic information of each community member. 

Clients/Patients 

Progress reports that contain all pertinent health information and ‘next appointment’ dates can be shared with the client via WhatsApp. 

E-Heza supports the entire spectrum of primary healthcare delivery for both health centers and community health workers. This includes full scope antenatal and pediatric care services and case management, as well as decision support and treatment monitoring. In addition to maternal and child health services, E-Heza has a robust tuberculosis and HIV case management system in place. E-Heza currently operates in three countries in East Africa. E-Heza is currently the most robust, mature, and broadly implemented digital health platform in Rwanda. E-Heza serves a catchment area of 700,000 people in four districts across both rural and urban settings, with expansion to an additional 737,135 people in two districts by the end of 2024. E-Heza is expanding to ten districts across the country in collaboration with the Rwandan National Child Development Agency (NCDA) and World Food Program. In addition to the planned expansion to ten districts, we are working with King Faisal Foundation and Imbutu Foundation to conduct a rigorous randomized control trial on the impact of high-quality, comprehensive maternal and child health care on childhood stunting. E-Heza will be used by health workers in the intervention arm to ensure all aspects of care are provided. Implementation in Burundi is underway among 200 community health workers in collaboration with the Burundi Ministry of Public Health and Village Health Works. This pilot serves a catchment area of 200,000 people and will inform the national implementation strategy. All modules have been translated into Kirundi and formally approved by the Ministry of Public Health. Similarly, a pilot is being launched in Somalia in collaboration with both Banadir Primary Health Care Consortium (BPHCC) and the Somalia Ministry of Health. Translation of E-Heza is nearing completion, and then will be piloted among 200 CHWs in Mogadishu under the supervision of BPHCC. BPHCC will provide an impact evaluation report to the Ministry of Health’s Human Resources for Health division to inform the official placement of E-Heza within Somalia’s national digital health strategy.

Software Application