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SMS projects for patient referral, visit reminders, chronic disease management and others

By Joaquin Blaya, PhD Moderator | 09 Apr, 2013

We started this thread to continue a discussion on SMS based systems that started with the Ali Habib's Member Spotlight http://www.ghdonline.org/tech/discussion/member-spotlight-ali-habib-april-8--....

Here we will continue to talk about projects using SMS. I wanted to start off by mentioning to Laurien that it'd be great to talk about what you're thinking in terms of using SMS for chronic disease managment especially diabetes because we've created a system for that which we're currently implementing here in Chile. You can email me at jblaya [at] ehs.cl

Mobile Devices



enock rukundo Replied at 11:58 AM, 9 Apr 2013

Dear Ali,
I am currently working on a project entitled "sms based, patient referral system in Rwanda". Having read what you did in developing and deploying software that uses SMS notifications to help keep track of TB referrals in Pakistan and in our sister countries like Kenya and Uganda. I was touched by your work and kindly ask for you strategic and tactical guidance to implement the above said project endeavor. Here, we are talking of sms based patient referral system not specifically for TB or Malaria; for any need to transfer a patient from one level to another without passing through various levels looking for the right treatment as indicated in the attached short presentation.

I am kindly asking everyone in our Health IT community to say something maybe you met a related article, an academic paper, a research or you have an EPI to help me implement my dream project for the benefit of the patient and the health facility in general. Feel free to share with me your great knowledge and experiences good people.


Attached resource:

enock rukundo Replied at 2:30 AM, 10 Apr 2013

Hi Jo, thanks for sharing though i suspect me posting the topic in response to Ali's knowledge and experience and Lauren was interested...going to email you directly. Great.

enock rukundo Replied at 2:39 AM, 10 Apr 2013

Sorry Jo', got to know what and why you referred to Laurien...

QUENTINISA@YMAIL.COM LAME KABECHA Replied at 11:13 AM, 10 Apr 2013

hi there
we have a project of improving health innovation in botswana.

Hamish Fraser, MBChB, MRCP, MSc Moderator Emeritus Replied at 10:23 PM, 10 Apr 2013

Hi Enock, what are your thoughts about the challenges of describing the patient's problem in a text? are you expecting people to be able to send clinical images too? One approach that is being used in Rwanda and other countries is private clinical communities on GHDonline. That requires internet access but allows a fairly rich discussion of cares.

The benefit of your approach is the ability to initiate a referral from a mobile phone. Do you think smart phones would be feasible? That would be easier than a basic phone and text message. The Sana project at MIT does text and image sharing well. There was a good lecture recently by Dr Radhika Chigurupati on an oral cancer screening project in India using Sana to photograph inside patients' mouths.The web site for Sana is at sana.mit.edu. Systems like Sana, ODK, Commcare and OpenXdata all talk to OpenMRS which should in principle allow better coordination of referrals with an existing patient record or generation of referrals from the EMR.

A/Prof. Terry HANNAN Moderator Replied at 11:38 PM, 10 Apr 2013

Hamish, I have been on call a lot in recent weeks but following this discussion closely. What I like about this posting from you is the signficant number of platforms (?all mobile device based) thatlink with OpenMRS (or other open-source systems). This must surely encourage standardisation of data capture and transfer which is often a stumbling block to usability in addition to internet access. Could you expand on the term "is private clinical communities on GHDonline"? Terry

Annie Parsons Replied at 12:29 AM, 11 Apr 2013

Hi all, These resources might help: http://hingx.com/ is a database of mHealth projects, organizations and papers; and http://www.mhealthworkinggroup.org/ (try the 'projects' tab for a working list of who's doing what globally - the excel doc is unwieldy but a good place to start if you have patience). I'd be interested to hear from colleagues who've successfully scaled up an mHealth intervention about their challenges.

Ali Habib Replied at 1:44 AM, 11 Apr 2013


Picking up from Hamish's email, I agree that for generalized systems,
platforms like OpenMRS are ideal (instead of building things from scratch).
But he raised a very important question of how patient information will be
represented in the SMS messages. I think that's the key problem that needs
to be solved here. The great thing about SMS is that it is a sort of lowest
common denominator across phones and usually available where GPRS/EDGE/WiFi
are not. However there are limitations to how much data can be transferred
in this manner and what one can send. If the SMS format can be made a
standard then that opens up lots of options for mobile clients. Smartphones
could have apps that transmit data using SMS... something similar could be
done with J2ME i.e. data from forms in the app could then be transferred
over SMS. Phones that don't even have Java support could rely purely on SMS
(typed out).. this latter approach is error prone though. What needs to be
figured out is what information is being sent and how it is codified.

A/Prof. Terry HANNAN Moderator Replied at 1:57 AM, 11 Apr 2013

If this response seems simplistic it reflects where my intellect on this topic is at. The questions I would like to ask go along the following lines.
1. What 'messages' do patients want?
2. Is the mobile device in the situations we are using them messages about care TO the Patient and then Back to the senders?
3. Do we ADD the data capture element to this messaging process? This adds a whole new level of complexity to the structure of the data and to what we are asking patients to 'capture and understand'.
4. Is not the SMS response (bilateral) a data element?
5. It would seem most 'patients' as distinct from health care personnel can cope with SMS and maybe some image transfer but formal data capture might require other levels of expertise (but not beyond the patients capacities).

These are all random thoughts in a busy clinical day so I hope they are helpful. Terry

enock rukundo Replied at 7:53 AM, 11 Apr 2013

Dear, Hamish, Joachim, Anne, Terry and Ali,

*To Anne,* Thank you so much for the links, will keep checking them

*To Hamish*; Thank you for the useful number of platforms that link with
OpenMRS posted. Hamish, you have been I read and was told that you have
been an invaluable asset in the planning and evaluation process of various
health IT related programs in Rwanda. We were supposed to have you in one
of our two year Msc. Health Informatics Courses at Kigali Institute of
Health and unfortunately we missed you. And now, here we are, we have
already completed the program and we are trying to do something for our
people. In this system, please refer to my thoughts submitted to Ali as
seen below;

1. We are talking of the central level being the one with internet
connectivity i.e talking to OpenMRS or any other open source system,

2. The sender i.e nurse or medical doctor in case should be use a basic
phone. I suspect rural nurses and HC doctor not all having smart phones and
internet connectivity as the job being text messaging then any basic can do
the job unless if the project context changes the direction_ I stand to be
collected by you my seniors.

3. And reflecting on those systems i.e Sana, ODK, Commcare and OpenXdata
as long there would be no use of internet then that would be great, we can
end deciding to use anyone of those for the rural nurses to send messages.

*To Terry*, Good and short questions as usual, some reflecting my questions
to Ali as well though I decided to give everything to Ali as seen below
also waiting to see how Ali would merge them and provide useful thinking
though mine was from the nurse/doctor being the sender to the (moderator)
through the system nothing has to do with the patient in my case but
needing better orientation than pushing him/her from one level to another
looking for better treatment.

I guess this helps Ali and everyone in the community to reflect on my
project and link for better guidance_my seniors...

Now check out the long story submitted to Ali as seen below;

Here's what i stated as a problem and proposed a solution architecture
where need your guidance and expertise; a person named as my (Poor Dad)
received 6 transfers instead of one that would suffice...In Rwanda like
many other Countries, ideally a patient should enter or start from the
low-level i.e a Health center (HC) and in these HC (s) no specialist,
usually nurses and atmost one general medical practitioner available. Then
depending on the patient illness he/she should be transferred the next
level health facility i.e District Hospital (DH) and here also specialists
are limited to priority fields or non available. Then if a patient severity
illness) continues he/she is transferred from the DH to the Provincial
Hospital (PH) and then to the referral hospital (RH). All these level
accepts the local medical insurance named (Mituelle de Sante) for common
person. However, medical insurance don't cater for patients transport,
meals, accommodation along the transfer circle (chain) as stipulated

And as a result, we are trying to say it is not by the Ministry of Health
Policy or Regulation that a patient should enter into such long chain i.e
from the HC to RH (almost 5 to 6 transfers encountered). We are proposing
an SMS BASED, PATIENT REFERRAL SYSTEM that would help make a one at a time
transfer of patients be it chronic or any type of disease....

Here is our DETAILED proposed structural process of HOW the system would
look like:

1. The Nurse (Sender in this case) sends a standard coded sms to (*OpenMRS
messaging Module or build our own for:*) with patient details (the
challenge here is *what information that should be sent reflection true
status of the patient*:?, no pictures or attachment only text sms: Remember
here i mean the HC already made their mind (decision) to transfer the
patient but wants to allocate him/her to the right health
facility/specialist not simply moving patients from one level to another
i.e from the Health Center (HC) to District Hospital (DH).

2. The OpeMRS encounter named in my PPT (intermediary filter application)
re-shapes text sms’s into readable web based or emails formats (not sure
about this:?) and sent to the operator/moderator (in this case the

3. Moderator reads case details and decides the patient most appropriate
health facility that would respond to the patient case or seek guidance
from a well positioned specialist most appropriate for the patient case i.e
meaning that he/she should agree to work/volunteer i.e this referral system
should be a network of people who trust each other and want to collaborate,
capacity building and social engineering are thus very important:? But as
you all ealier stated what sms information to be fed to the moderator in
deciding the right choice and the organizational set-up and skills of the
moderator is critical?

4. An automatic email sent to the specialist for response or to the nurse
sender if the decision was made by the moderator?

5. Specialists logs in the server, reads the case history and provides a
response to the moderator and the sender.

6. The HC-Nurse (Doctor) i.e the Sender (Referrer) reads response from the

7. The sender i.e referrer reports action being taken (patient transfer
action made effective)

Am terribly sorry for giving a lot but I had to do so as for better
visibility and understanding of my context…please kindly tell which one is
which i.e you better guidance and clarifications would be awesome. And
finally, other similar question to ali would be do you think this system is
feasible, what challenges have you encountered while developing and
deploying related settings? Would you kindly list key critical steps
necessary for this system? Just to let you know that the Rwanda Ministry of
Health decided to go for OpenMRS for all Government health facilities and
my question do you think they would better communication with OpenMRS if
messaging module is developed/ existing or we will need to develop our own
or simply start a new organizational set-up from scratch? Let me stop I
might end up repeating myself:-)!!!

Thank you so much good people….kudos.

Joaquin Blaya, PhD Moderator Replied at 8:26 AM, 11 Apr 2013

This is a comment from Patrick Arida, as well as the article he mentions


Below a link to a to a research paper about the effectiveness of SMS for for Diabetes patients - I believe this question came up earlier in the dialogue stream. Sorry I'm jumping on this conversation late but the millitary medical department (US) has also had success in reaching remote patients through SMS not so much for chronic disease but more so to quickly capture 'dwindling' mental state and they code actually annotates a level of urgency so the provider/respondent know how to react.


Attached resource:

Aaron Beals Replied at 8:26 AM, 11 Apr 2013


Thank you for the thorough explanation of the system you're proposing. This makes it clearer!

In the past, we've gone through the mental exercise of exploring interaction with GHDonline / Clinical Exchange (the latter is the clinical consult system to which Hamish refers above) via SMS, and unfortunately it's hard to convey much meaningful information (in the context of *our* type of consult, anyhow) via SMS.

Perhaps if the SMS were used as a sort of pager mechanism, letting you know that a case had been posted or your case received a consult. The user would still need access to email or a browser, though.

SMS seemed better suited to logistics -- patient transfer. If I'm not mistaken, this is the type of interaction you're describing, but your idea is to connect the SMS interaction to the OpenMRS record, so the referring provider and receiving provider can both look at the same patient record.

What sort of information would go into the SMS message? A code like the patient_id or perhaps a reversible hash, coupled with a short version of the chief complaint?


Hamish Fraser, MBChB, MRCP, MSc Moderator Emeritus Replied at 8:35 AM, 11 Apr 2013

Hi Eric thanks for the clarification. What you are describing is an important need in many places – to carry out effective referrals to the correct hospital in a timely manner. It is clearly a patient safety issue as well as a concern for the comfort and the costs for the patient and their family.

The main question I had was how much information needed to be sent to allow effective and safe allocation of patients to the appropriate facility and specialist. Will the nurse have enough knowledge to make the diagnosis or will the next step be further investigations? The tension here as you note is between the availability and low cost of SMS and the more flexible but costly smarter phones. Also one of the big potential benefits for linking to OpenMRS or another EMR system is including referral messages as encounters in the patients record. Also the EMR could be used to generate the message (SMS or other format) based on existing data and additional information collected in a custom form. Most of the components of such as system already exist in some version but I am not aware of any project that has fully implemented such a referral system using OpenMRS, maybe others on the list will know.

enock rukundo Replied at 9:12 AM, 11 Apr 2013

Thank you Hamish, my mind keep thinking of RapidSMS structural framework
and connect it with this effective referrals system; figure-out the
differences and similarities...and finally how one would make something out
of the three (OpenMRS, RapidSMS and effective SMS-referral system)..

Let's work together and do something my Seniors?

Ali Habib Replied at 10:04 AM, 11 Apr 2013

Hi Enock,

Thank you for elaborating on this. Regarding the steps you outlined:

For step 4 the decision of whether to send an email or an SMS message will
depend on whether or not the average specialist has access to email. Also,
if the intent is for the patient to physically visit the site that they
have been referred to, and your moderator has the knowledge tor refer
someone to the right place, you could delay the step 5 where the specialist
logs into the system until the patient shows up at the site. In that case,
I would propose adding a step 8 to log whether or not the patient went to
the site they were referred to. It would close the loop. If patient phone
numbers are collected and patients agree to this, you may also want to look
into the possibility of reminder messages being sent at some interval until
the specialist actually logs into OpenMRS (or other EMR) that the patient
did appear at the site. We've done this in Zimbabwe with TB patients i.e.
when the patient is referred to a site the site gets a message saying that
the patient has been referred, and the patient gets a message letting them
know the site they have been referred to. Then the patient gets reminder
messages until they actually show up at the site and the site logs that
they have been there.

If OpenMRS is widely in use in Rwanda it may make the most sense to use it
here. It will allow for easier integration and, as Hamish points out, allow
you to use the OpenMRS system for storing each referral as an encounter.
Regarding the question of the SMS module to use, the messaging module
exists but we here in Karachi have had trouble finding phones/modems
compatible with the SMSLib library that it uses. Joaquin pointed me to
another module (see here: https://bitbucket.org/ehs/smsmodule ) that you
may want to investigate as well.

Regardless of the software/platform in use though, one issue is still the
data will be sent to allow the decision to be made. So when the nurse
determines that this patient needs to be referred, what is the data that is
sent out to OpenMRS (or other EMR), that will allow the moderator to
determine the appropriate site to refer to? If the nurse knows enough,
perhaps she can make that call herself and you can eliminate the moderator
altogether. If not, then I think that SMS begins to become a limitation on
the data you will be able to send. When you refer to case history being
seen by the specialist (step 5), what kind of data are you proposing will
be in that case history? That would be a good starting point to determining
what needs to be sent over.

enock rukundo Replied at 10:53 AM, 11 Apr 2013

Much appreciation Ali for the short and clear points given. The moderator here mean a person, a unit, a center or a division within an institution. I agree that the moderator should have the needed knowledge to do the job without seeking second thoughts in anycase from another most appropriate physicians or (moderator(s)).

I believe step 8 and patient reminder as a control action/measure only to figure-out if its feasible within the limits of the system. OpenMRS in its early stages not widely used in Rwanda but Government opted for it than any other systems that are present like OpenClinic in some few hospitals. OpenMRS storing referral as an encounter is great idea only to know if we go with OpenMRS or they might be something else easy to go with.....

Kind of data to be sent to OpenMRS or any other compatible system to allow decision made; i believe this standard sms case history format configuration is possible to formulate i.e see the likes from Swinfen Charitable Trust sample formats designed though having no better response now i wish a well positioned fellow would intervene and help.....only Healthcare professional training will be conducted as next step. I guess nurses not in position to know enough for an effective transfer and thus the need for a second thought from an experienced fellow (moderator)....?

For more and better understanding; well equipped specialists would help in this case...Once again thank you Ali and more insights are still needed as you read though the above comments.

Well done.

Derek Ritz Replied at 11:29 AM, 11 Apr 2013

Hi all.

I am following this thread with great interest. As part of my involvement with a community project, OpenHIE, I am participating in the development of a new "profile" through a standards organization called IHE (www.ihe.net). Profiles can be thought of as implementation guides; they describe how underlying standards will be leveraged to serve specific, defined care workflows and use cases.

Our profile project is called Care Services Discovery (CSD). Its role is to support the cross referencing and information linking between registries of care providers, the services they provide, the locations at which defined services are offered and the times when those services are available. Information about this ongoing profile development work can be found at the OpenHIE community website, here: https://openhie.atlassian.net/wiki/display/projects/2014+Connectathon%3A+Inte....

My sense is that the referral "discovery" step in Enock's SMS workflow would benefit from being able to leverage a CSD service. Indeed, that is one of the two core use cases for this profile. I would greatly appreciate input from the group regarding this and other ways the CSD service might be leveraged. As you may note from the PPT presentation made recently (Mar 19), we are expected to leverage CSD to address workflow requirements in both developing and developed country contexts. That said, as a primary author on the profile, the use cases that I've added so far are drawn largely from Tanzania and Rwanda. ;-)

I look forward to comments/feedback from the group.


enock rukundo Replied at 11:52 AM, 11 Apr 2013

Hello Derek,

I am so very excited for your prospects over this project and going into
work, Thank you for all the details you provided and by using them….I am
proud to see something coming up now and I hope we can move forward as
quickly as possible because I really want to help my country change
patients life (struggle) for the better. This, a wake-up call for all the
fellows in the know i.e thought-leaders and trusted advisors in our
community, let’s get to work together now.

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