ICT Development Programme for Supporting ICT Pilot Projects in Rural Areas 2013 (J3)
PROJECT COMPLETION REPORT
Digitalization of maternal and post-natal care system (DigiMAPS) Implementation in Bandung Barat District
Reported by: Hadi Hariyanto/Chief Researcher On August 20, 2015
PT. Telekomunikasi Indonesia Tbk. 2015 ICT Development Programme for Supporting ICT Pilot Projects in Rural Areas 2013 (J3)
PROJECT COMPLETION REPORT
Digitalization of maternal and post-natal care system (DigiMAPS) Implementation in Bandung Barat District
Executive Summary
DigiMAPS is a system consist of electronic medical record for mother & children called “KIA Online” and tele-consultation facility called “Tele-Obgyn”. Under APT J2 Project Scheme (2013), the project focused on the development of KIA Online prototype and a cloud computing-based video conferencing as a basis of Tele-Obgyn platform. DigiMAPS system had been developed gradually following lean-innovation management concept which focused on customer- problem-solution matching with rapid prototyping and validation from idea to solution. There was significant effort to establish a close relationship and learning process with prospective users of DigiMAPS, hence in the broader perspective we used a participatory research approach. By using lean innovation management, several inputs were gathered from prospective users including health authority, head of primary health centres (PHCs), midwives, obgyn doctors, and public health staffs.
In this project, the DigiMAPS system was further enhanced to achieve the pilot project objectives. This includes to leverage the original concept of DigiMAPS in Public Health Centre (PHC) in Gunung Halu sub-district, District Hospital in Cililin sub-district and Health Department of West Bandung District (WBD). The significant development of DigiMAPS Application covered a multi-screen user interface support, a decision support system, a mother alert system and an integration with medical device data. The second major development of DigiMAPS system is a tele-conference system which not only offers the tele-consultation service but also a tele-education program for midwives in the primary health centre. Furthermore we also introduced a Mobile CTG (cardiotocography) device and system to the midwives and obgyn doctors to see their comments and feedback to the system.
There are more than 400 pregnant women and children health records which were entered by 10 midwives for the period of 4 months usage from March – June 2015. These records are more than enough to bring a meaningful report which is generated by the decision support system. In addition, as the result of
2 of 49 DigiMAPS J3 project, now the users can experience some new features namely a mother alert system using SMS service and an M2M medical data presentation as part of KIA Online. Six online training and conferences were done using a teleconference platform called UMeetMe. The pilot project has been disseminated to the key persons in the Health Department of West Java Province and the Indonesian Ministry of Health in order to generate a greater awareness and to confince that KIA Online can be considered as a next generation of the PWS-KIA health information system.
By the end of July 2015, the project objectives were achieved and all activities were done (100 %). The project cost spent until July 31, 2015 was USD 129,143.90 or 86.54% of total budget approved by APT. West Bandung District commits to use the innovation resulted from the DigiMAPS project, so that WBD can be a considered for a living laboratory for KIA Online along with a primary health care information system managed by TELKOM Indonesia.
1. Project Information 1.1. Introduction This project awarded a grant by Asia-Pacific Telecommunity (APT) as an ICT Development Programme for Supporting ICT Pilot Projects in Rural Areas 2013 (J3) (supported by extra budgetary contribution by Japan). This project commenced on June 24, 2014 and completed by the end of June 2015. The total budget approved for the project is USD 129,143.90. DigiMAPS program aims to support midwives in performing mother and children health record as part of their daily task in the rural area. Based on the fact that all maternal and postnatal data are reported in paper-based formats, thus we developed a new way to capture the data then store them digitally. In addition that the data are also useful for area-based health surveillance reports, we developed new ways to aggregate the data into a management report format. Furthermore we leveraged a multimodal communication concept in order to allow prospective users such as midwives, general practitioners (GPs) and Obgyn specialists can access the application any where, any time from any devices. Multimodal communication basically refers to the use of public broadband access to reduce capex and human resource issues which are usually experienced by telemedicine initiatives. This research project was coordinated by, Innovation and Design Center (IDeC) of PT. Telekomunikasi Indonesia Tbk. (TELKOM), and fully supported by: a. Padjajaran University Faculty of Medicine / Hasan Sadikin Hospital (RSHS), Indonesia b. Health Office, West Bandung District, Government agency, Indonesia c. Basic Human Needs (BHN) Telecom Association, Japan. d. Kagawa University, Japan.
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DigiMAPS concept and system has been disseminated to the local, provincial and national authorities including: a. Indonesian Primary Health Centres (PHCs) called Puskesmas in West Bandung District. b. Referral Hospital in West Bandung District. c. Department of Obstetric and Gynaecology Padjadjaran University Faculty of Medicine Hasan Sadikin Hospital Bandung d. Health Service Office of West Java Province e. The Centre of Data and Information of the Indonesian Ministry of Health, Jakarta
West Bandung District (Kabupaten Bandung Barat) is a regency of West Java Province. It was established in 2007, formerly it was part of Bandung District. The capital of this new regency is Ngamprah, an industrial district on the west side of Bandung. It is part of the Bandung Metropolitan Area. West Bandung District is divided into fifteen sub-districts (kecamatan), two of them are Gunung Halu and Cililin.
In the proposal, we used terminology regency, county to represent “Kabupaten” in DigiMAPS J2 and J3 Proposal, however after reading English literature (Mahendra et al. 2011; Rambu Ngana et al. 2012) in Indonesian health informatics context, the terminology of District is more common, therefore we use this “District” terminology to translate the word “Kabupaten” in Indonesian language.
1.2. Project Objectives The objectives of DigiMAPS implementation in West Bandung District as stated in the proposal are a. to leverage DigiMAPS concept (APT J2 Outcome) from prototypes into a pilot implementation project in two rural area of West Bandung County (West Bandung District). b. to enhance DigiMAPS application, platform and communication system so they can improve the user experience, handle larger scalability as a new decision support system. c. to introduce of a new use-case of telepresence system to support midwives professional education. d. to design, develop and implement a mother alert system (of KIA Online) to improve K1 and K4-mother-visit coverage. e. to introduce Machine-to-Machine (M2M) communication for Mother with hypertension (preeclampsia) home care service. f. to disseminate DigiMAPS concept to the national level through Indonesia MDG Office and Indonesian Ministry of Public Health. .
4 of 49 1.3. Overview of DigiMAPS System DigiMAPS stands for Digitalization of Maternal and Post-natal care System. It is the first ICT project in Indonesia which initiated the digitalization of maternal-children health record called KIA Online which has medical M2M functionalities, SMS alert system and Decision Support System (DSS) features. By developing the electronics version of KIA, it will benefit to save, archive and trace the patient records. It also helps health staff (including midwives, doctors, public health officers) to make reporting faster, reducing data duplicity and re- entering data processes to generate a cohort report and an area-based health surveillance report (PWS-KIA). These three KIA features (M2M, SMS based alert system, DSS) & PWS KIA Online will strengthen the recording and reporting system effectively and efficiently especially in West Bandung District. It is expected that the local government can develop an intervention program more accurately, hence improving the effectiveness of the program. In the J3 pilot project context, the KIA Online has not only had three new features, but also been transformed into a new on-line system which is fit with multi-screen suitable for mobile devices as well as desktop terminal.
Table 1. Digimaps Benefit Indicator Existing DigiMAPS Target Improving data record PWS-KIA and KIA Book Direct linkage between KIA accuracy (KIA, validation requires a lot of effort book and PWS-KIA, prevent COHORT) data mismatch Improving reporting 1-3 weeks delay in reporting Reporting can be generated speed (PWS) in real time Improving data Manually, requires at least 1 Automatically calculated by analysis process day or more to analyst data system (for selected (PWS) performance report) Obgyn Support No obgyn support for obgyn Virtually present to (Tele-Obgyn and Tele- emergency situation, unless the support midwives during presence) mother transferred to referral emergency situation and hospital during professional education programs for Mid-Wives M2M Home Care for None, the mother should be Mother can stay at home to mother with referred to hospital, to do receive medical care, reduce hypertension medical check up regularly manual input by midwives
Mother alert system None, K4 is very low Improve K4 visits by mothers
Tele-consultation under the J2-Project was called Tele-Obgyn, which allowed Obgyn specialist could support midwives in the rural area during an emergency situation. In the J3 context the video conference system was extended to support tele-education programs for midwives in Gunung Halu sub-district.
A new feature called M2M for medical care was introduced in this project in order to reduce manual data input of KIA Online by midwives. Table 1 shows DigiMAPS key benefits by introducing its new features, while Table 2 gives the comparison between DigiMAPS J2 prototype and the one under J3 scope.
5 of 49 Table 2.DigiMAPS J2 vs J3 Scope Comparison DigiMAPS Ver1 DigiMAPS Ver2 Scope Prototype Pilot project Location Distric (Gunung Halu) 2 rural districts in West Bandung Regency Application First Digitalization of Mother- UI & UX enhancement Children Health Record (KIA) & Mother alert sytem Area-based health profile (PWS- M2M for hypertension monitoring KIA) (Home Care) Video Tele-Obgyn Tele-Obgyn and Tele-presence to Conferences support midwives professional education Scalability 4000 con-current users > 10.000 con-current users Users Midwives, Doctors, public health DigiMAPS J2 users + mothers officers Indicator Improve reporting speed & Home care & alert system for improvement accuracy mother to increase K4 coverage Data input Manual input by midwives/cadres Manual Input + automatic input by medical devices (Blood Pressure Monitor)
1.4. Project Team The researchers involved in this project were 12 (twelve) Indonesian researchers and 4 (four) Japanese researchers. The various competencies that required to conducting this project were as follows: broadband wireless access engineers, software developers, business analyst, and medical-informatics experts.
Table 3. DigiMAPS J3 Team No. Name Institution Position in DigiMAPS Project 1. Hadi Hariyanto TELKOM Project Manager 2. Sony Ari Yuniarto TELKOM Accounting Coordinator 3. Andri Qiantori TELKOM Acting Project Manager 4. Yudi Tri Jayadi TELKOM Researcher 5. Deni Risnandar TELKOM Researcher 6. Ghina Sujahifa Hana TELKOM Research Assistant 7. Agung Budi Sutiono MEDICINE UNPAD Researcher 8. Ahmad Faried MEDICINE UNPAD Researcher 9. Leri Septiani MEDICINE UNPAD Obgyn Doctor 10. Tono Djuwantono MEDICINE UNPAD Obgyn Doctor 11. Pupu Sari Rohayati West Bandung County Head of Health Dept. 12. Lilis Rustini West Bandung County Head of Gng Halu PHC 13. Hchihei Kurematsu BHN Association Japanese Expert 14. Kousuke Dobashi BHN Association Japanese Expert 15. Keiichi Watanabe BHN Association Japanese Expert 16. Dr. Kazuhiro HARA Kagawa University Japanese Expert
6 of 49 2. Overview of DigiMAPS System
2.1 DigiMAPS Multimodal Communication
DigiMAPS applications are enabled by multimodal communication framework. The framework identified by the following basic assumption: a. The communication networks are focus on public broadband IP networks either using wireless or wireline approaches whenever applicable in the target area. b. The communication solutions consider various device requirements including PC, tablet, and smartphone, thanks to the web-based and android-based application concepts, DigiMAPS application has been developed by considering these two concepts. c. The communication platforms are designed to support Software as a Service (SaaS) in cloud computing terminology, rather than traditional client-server approach.
Figure 1. DigiMAPS Multimodal Communication Concepts
These approaches have several advantages including capital expenditure (capex) and operational expenditure (opex) efficiency for targeted users (government, health staff, midwives and doctors), minimum maintenance efforts by the users and can be leveraged easily to cover both rural, suburban,
7 of 49 urban areas in the wider scales. However we also understand if the target users (ie. Public health department, clinics, hospitals) may want to keep KIA Online database in their intranet for security reasons. The DigiMAPS system can be adopted easily with the cost of building intranet/extranet, application servers, data storages and allocating ICT human resources for maintenance the system.
Based on survey for J3 implementation we identified the broadband access requirement as listed on Table 4.
The survey result of infrastructure requirement provided services for target users in the West Bandung District Health Office, a PHC in Gunung Halu, a PHC in Cililin and a district hostpital in Cililin (RSUD Cililin) and a provincial Hasan Sadikin Hospital (for Tele-consultation program). The result can be seen on Table 4.
Table 4. Broadband Access Requirement for J3 Digimaps No Location Coordinates Existing Implementation Infrastructure 1 West S 06o50’31.880” P2P Radio • Add optical broadband Bandung E 107o30’36.942” DL: 0.81 Mbps UL: access dedicated 1 Mbps District 0.66 Mbps Ping: 21 ms + public IP Health Office • Add 2 WiFi AP to serve 2 rooms
2 District Clinic S 7o 1’ 28.77” xDSL 3 Mbps • Existing J2 DigiMAPS, or PHC E 107o 18’ 48.42” continue subscription (Puskesmas) for 12 month Gunung Halu 3 Sub-PHC S 7o 02’ 44.87” 2G • Add VSAT 512 kbps (Puskesmas E 107o 13’ 20.82” subscription for 12 Pembantu) month Cilangari • Add 1 Wifi AP to serve 4 District Clinic S 6º 57' 17.1036" xDSL 512 kbps • Upgrade up to 3Mbps or PHC E 107º 27' 28.85" for 12 months (Puskesmas) subscription Cililin • Add 4 WiFi AP to cover all area 5 Regional S 6º 56' 37.1256" xDSL 512 kbps • Upgrade up to 3Mbps Hospital E 107º 27' 35.23" for 12 months (RSUD) subscription Cililin • Add 2 WiFi AP to cover 2 rooms 6 Province S 6o 53’ 54’’ 3G, Internet & • Add WiFi AP to cover Hospital E 107o 35’ 52’’ Intranet. tele-education room Hasan Internet DL : 0.47 – Sadikin 1.92 Mbps, UL : 0.29- 039, ping 53-161 ms
8 of 49 The infrastructures plan for J3 DigiMAPS was designed to meet the minimum requirement which can be seen as in Figure 2.
Figure 2. Infrastructure Plan J3 Digimaps for Broadband
2.2 Teleconference system Teleconference system is a video conference facility which is able to support multi-screen & multi-operating-system devices. Initially the system was designed to provide tele-consultation called TELE-OBGYN between midwives and Obgyn doctors in referral hospital to support mother treatment in emergency situation. In order to ensure that a mother with complicated pregnancy receives the best possible perinatal care for rural area in West Bandung Region, we propose a tele-ObGyn system that enhanced the care access for rural women by providing support for midwives in Gunung Halu PHC with Obgyn physicians in referral hospital in Cililin (district hospital) and Bandung Hasan Sadikin Hospital (province hospital).
In the case of pilot project, the system will be extended to provide: 1) Tele-Obgyn; point-to-point tele-consultation between midwives and obgyn doctor. This system enables midwives to communicate with the ObGyn doctors in Cililin Hospital and/or Hasan Sadikin Hospital 2) Tele-education that meet the requirement for midwive to enhance their skill and knowledge. For implementation examples, we discussed “Preterm Labour” in November 18, 2014 and “Preeclamption in November 12, 2014). In order to support tele-education events, a point-to-multipoint communication system was provided so that midwives can communicate with Obgyn to provide a professional educational programs. This system could be accessed up to 10 simultaneous users. The system could also facilitate a tele-seminar for midwives in order to improve their antenatal care skills and knowledge.
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Figure 3. Tele-education between Gn Halu mid-wives and Obgyn experts in RSHS
Figure 4. Tele-education: expert view in Hasan Sadikin Hospital
3) Record the professional education video events during tele-education programs and stored them in the repository/database for later used by other midwives. Initially it was stored locally in a personal computer. Selected videos have been uploaded in DigiMAPS website in http://digimaps.info so that it can be accessed anytime, anywhere in Indonesia.
The Figure 5 illustrate the teleconference network infrastructure system that used in this J3 project. The Obgyn expert was in Hasan Sadikin Hospital, the
10 of 49 midwives were in public health care of Gunung Halu. It was separated more than 65 kms, it needs more than 4 hours to get Gunung Halu sub-district by car or motorcycle. In the rainy season it needs longer time to get to the location.
Figure 5. Network Infrastructure for Video Conference in RSUD Cililin
Figure 6. Cloud based Telepresence in Gunung Halu
11 of 49 In J3 DigiMAPS, tele-education events could be held in 4 locations which are RSUD Cililin, Gunung Halu PHC, WBD Health Office, and Hasan Sadikin Hospital. The educators were obgyn experts from Hasan Sadikin Hospital and midwives from Cililin PHC (via RSUD Cililin) and Gunung Halu PHC. Several tele-education events were held between an expert obgyn Hasan Sadikin Hospital and midwives in Gunung Halu PHC. Figure 6 illustrates teleconference system which uses a cloud based approach contributed by TELKOM.
The schedule of teleeducation events that already performed are shown on Table 5.
Table 5. Scheduled Teleconference & Teleeducation Meeting No Topic Peer Expert Audience 1 KIA v2 Hasan Sadikin Hospital Agung Budi midwives in October 14, 2014 & PHC Gn Halu Sutiono, MD, Gunung Halu PhD and Ahmad sub-district Faried MD., PhD 2 Preterm birth Hasan Sadikin Hospital Leri Septiani, MD., doctor, midwives November 18, 2014 & PHC Gunung Halu PhD in Gunung Halu 3 Preeclampsia Hasan Sadikin Hospital Leri Septiani, MD., doctor, midwives prevention & PHC Gn Halu PhD of Gunung Halu November 25, 2014 4 Maternal report PHC Gn Halu – Health Ms Lilis Rustini Midwives, West Service Dept. of West Bandung disttrict Bandung County staff 5 Maternal and PHC Gunung Halu – Kousuke Dobashi, Tele-conference Postnatal Online Hasan Sadikin Hospital Mrs Lilis Rustini, participants, Workshop – Health Service Dept of Prof. Dr. Firman Point to March 23, 2015 West Java Province – F.Wirakusumah, multipoint Health Service Dept of drg.Oscar West Bandung – Data & Primadi.,MPH, Information Center Dept Andri Qiantori.,PhD of Ministry of Health of Republic of Indonesia 6 Annual scientific Dept. Obgyn. Tono Djuwantono, Tele-conference meeting Indonesian Padjadjaran University MD, PhD participants Obstetric Gynecology
2.3 DigiMAPS Application (KIA Online)
Under J2 scheme, the online version of KIA Book, Cohort and PWS KIA reports were developed and consisted of some basic functionalities as shown in Figure 7. In the context of J3 Project, we enhanced the KIA Online to add some modules namely a decision support module, a SMS-based alert system, and M2M for medical care modules.
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Figure 7. KIA data flow and application coverage
In terms of user interface, the new KIA Online (the 2nd version) was designed to support various screen size of mobile devices. It was referred to 10 heuristic items modelled by Jacob Nielsen (Nielsen and Molich 1990). The application was prepared and tested using this model. The target users for this application were particularly midwives, since they are key users which directly interact with mothers and children in the rural area. We gathered & accommodated their suggestion and comments in order to improve the user interface and also the application engine based on their knowledge and experience.
2.3.1. KIA Online (the 2nd Version) The new appearance of KIA online was initially designed to support smartphone and desktop terminals. However, based on readability, user convenience and optimum end-user experience, we optimised the design to support a mobile device with screen of 8 (eight) inches or above. The new appearance of the KIA online is shown in Figure 8. Ease of use and simplicity became a primary consideration of this design.
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Figure 8. KIA 2nd version on mobile GUI
The 2nd version (or tablet version) of KIA online was tested by midwives on their daily use to input mother and children health records. Test and evaluation had been performed in order to ensure the realibility of the application. The test has been arranged to ensure the midwives would be familiar enough with the application and device. In the beginning of test we offered several tablet with difference size (7, 8 10 inches), the final choice was an eight-inches tablet because it is optimum for the application readability & appearance. The KIA online can be opened in the any location where the wifi (indoor) or 3G signal are available. It will make easier for the midwives to input or check the patient data without brining cohort or KIA book when visiting a maternal mother.
Figure 9. Midwives with their tablet for data input
14 of 49 KIA Online application can be accessed through DigiMAPS website http://digimaps.info/. Only an authorized user can enter to the application and view the electronic medical record of patients. Hundreds maternal data (more than 400) already inputted by midwives since end of 2014.
2.3.2. Decision Support System A decision support system was developed as part of DigiMAPS application, so that PWS-KIA report will have a useful meaning for analysing data, monitoring and decision making purposes. The health records (mother, children cohort, registration entries, etc) can be converted into more useful information for decision making purposes by the health authorities. In DigiMaPS context, the health data were inputed by midwives directly from villages (Polindes) or a PHC (Puskesmas). The system will automatically generate the report in more meaningful presentation for decision making purposes. Figure 10 shows the illustration of how health data inputted by midwives are converted into graphics.
Figure 10. Decision Support System of KIA Online
Figure 10 shows the process of data input, recording, reporting and presenting graphical data for decision making purposes. A decision support module provides an active knowledge which was designed to assist medical practitioners or health departemen officers on decision making processes. Some examples of decision making activities such as examining the achievement of health care programmes, reviewing and analysing a patient data in more detail.
15 of 49 The data summary are presented into graphical format based on Month of Month (MoM), Year of year (YoY) of the specific subject of data. Each users can view the data via any internet browsers which also depend on their data access privileges. Figure 11 shows one of DSS graphic output to monitor the number of pregnant mothers who had pregnancy period more than 37 weeks and less than 37 weeks.
Figure 11. Graphical Data of pregnancy in Decision Support Module
2.3.3 Mother Alert System to Improve K1/K4 Visits
Based on DigiMAPS maternal and neonatus data record stored in the server, an integrated alert system was developed in order to notify the mother according their schedule of the next health check up visit. K1 is a maternal term of one visit during the first trimester of pregnancy, K4 is the fourth trimester of pregnancy visit (the first visit occurs in the first-three-month, the second visit in the next sedond-three-month and another 2 visits in the last three months). At least 4 visits should be done by a pregnant mother for the period of 48 weeks of pregnancies.
The reluctant to visit clinics and irregular visit of mother during pregnancy was identified as primary causes of maternal and neonatus fatal cases to mortality cases in the rural area. Usually mothers will visit clinics after a complication
16 of 49 occurred which prevent a proper and timely care in the local clinics (with limited facilities and obgyn doctors). Less interaction between mother and medical practitioners can cause difficulties to anticipate emergency situations. Some cases of maternal mortality issues reported this situation.
The mother alert system was built as part of the DigiMAPS system, the alert system will be functioned as a reminder system for mother and medical practitioner according to the schedule of a medical consultation. A notification message is generated based on the medical record that already stored in KIA Online and delivered to a patient’s and a medical practitioner’s cellular phone via 2G network which has very large coverage in West Java. All process are generated automatically by KIA online engine system as can be seen in the figure below.
Figure 12. Mother Alert system on KIA
In an emergency case when a patient needs to be carried to a refferal hospital, the alert system will send a notification message to a person in charge in the hospital for preparation. The contact person in the hospital will be notified for any symthomps and got an access to a patient’s medical data record based on the consent \given by the patient. The notification message will inform a medical staff to understand the patient’s condition and prepare the next process.
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Figure 13. KIA online mother alert system Illustration for referral hospital
This alert system assumed can improve K4 coverage and Pn Coverage (neonatal delivered in the health facilities) to the level of K1 achievement. According to 2010 data, K4 coverage of West Java is 67.2% which is very low compared to MDG target 90%. If we compared to the K1 coverage in West Java is 95.5% which is above MDG target 95%, we hope that the system can improve K4 and Pn Coverage. Of course to achieve this target, the KIA Online and mother alert system should be implemented in the all PHCs in the district or region, which is beyond the scope of this project.
2.3.4 M2M for home care
In the context of the pilot project, M2M for home care was considered as a new feature which touched the most advanced innovation technology of medical machine to machine (M2M) devices. The devices are connected to the KIA Online using WiFi, Bluetooth, or 2G/3G networks. A M2M module was built and tested to perform biometric and medical application on body monitoring, eg: pulse, oxygen in blood, airflow, electrocardiogram as well as blood pressure. The M2M module has been build on Arduino and Raspberry PI multipurpose board which can be seen in Figure 14.
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Figure 14. M2M KIT as part of Digimaps Implementation
In M2M module, the digital data were inserted and stored in KIA online data storage. The data were captured from a pregnant mother which included EMG, ECG, Air Flow records. Several data captures can be seen from Table 6 and Table 7 below.
Table 4. M2M Medical Home Care Records
Time Positionometer Pulsioximeter Temperature Glucometer Blood Pressure GSR 23 March 2015, pukul 18:25 Stand or sit position 23 March 2015, pukul 19:09 Supine Position bpm: 78 bpm 23 March 2015, pukul 19:09 spo2: 99 % 23 March 2015, pukul 19:29 bpm: 66 bpm 23 March 2015, pukul 19:29 spo2: 98 % 23 March 2015, pukul 19:45 36.01 degree Celcius 23 March 2015, pukul 19:46 167 mg/dL 23 March 2015, pukul 19:47 systolic: 130 mmHg conductance: 1.14 uS 23 March 2015, pukul 19:47 diastolic: 85 mmHg resistance: 805511.81 Ohm 23 March 2015, pukul 19:47 pulse: 79 bpm conductance: 0.5279 Volt
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Table 5. EMG, ECG and Air Flow records of a maternal mother
2.4. The introduction of Mobile CTG
Cardiotocography (CTG) machines are currently used by obstetricians, typically during the third trimester and in high-risk pregnancies, to measure fetal heart rate and uterine contractions as an indicator of fetal distress. The heart rate of a healthy fetus drops during a contraction and then rapidly comes back to normal. Portable CTG device could make it easy to monitor fetal health in remote locations.
As stated in the DigiMAPS J3 proposal, one of focus M2M for home care is deployment of mobile CTG. The deployment has been scheduled on March - May 2015. One mobile CTG device was tried for 3 months by midwives in Primary Health Centre (PHC) Gunung Halu. The device was provided by Mitla.co (Kagawa, Japan). It was rented with full remote support of Mitla.co team during the 3 months trial in Gunung Halu.
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Several team members (including an engineer and a midwife) have visited Japan on Januari 2015, to get knowledge transfer and detailed discussion about mobile CTG system, know how to operate the device and discussion.
Mobile CTG taking data from a measurement to get data such as mother’s contraction, baby’s heart rate, and fetal movement. The system sent the data via WiFi to a portable router. The portable router sent the data to the MITLA server via 3G network, and the server broadcast an email result to the predefined persons in charge such as Obgyn doctor or Midwives Coordinator in the primary health centre (Puskesmas).
Figure 15 MCTG Flow Diagram
21 of 49 In this project, the Mobile CTG was operated in the primary health centre of Gunung Halu, where was no Obgyn doctors. We provided a Mobile CTG instruction in English version so that midwives can use it easily. We expected they used the Mobile CTG and sent data to Obgyn doctors directly in order to support the midwives. We hope that the midwives were experience to use this portable devices, and got a sense not only how to operate the device but also to feel how useful this device to support their daily duties when visiting a maternal mother in villages.
Figure 16. Mobile CTG Unit and its accessories
Figure 17. Mobile CTG Device
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Figure 18. Mobile CTG Measurement Results
Many comments and inputs came from the midwives since they got difference proficiency level of English to understand the device menu. In general, the midwives found this device was useful and has a prospect to be used in Indonesia. However it needs further enhancement to modify the menu for Indonesian language and adapt the parameters setting which can accommodate the user’s requirement. The price of device was considered expensive and the location of server which is still in Japan, bring some concern about data ownership, availability, reliability of the internet connection in Indonesia to the Japan’s server. It was suggested that the device should be integrated to the existing M2M module in the KIA Online application, so that there will be no data integration issue, single sign-on access to the patient’s health records as well as Mobile CTG results.
23 of 49 3. Summary of The Project Cost per July 31, 2015
Summary of the financial statement per July 31, 2015 is described in the following table. Table 6. Summary of budget of J3 DigiMAPS project
Budget Approved Cost Spent Item Variance (USD) (USD) (USD)
Planning and Investigation 3,130.44 2,695.65 434.79
Equipment Procurement 108,708.38 88,427.80 20,280.58
Shipping Fees 521.76 72.99 448.77
Business Trip 36,877.50 37,947.46 (1,069.96)
Miscellaneous 0.00 0.00 0.00
Total 149,238.08 129,143.90 20,094.18
The currency rate used reffer to the rate at July 2014, the time when 60 % of budget approved received in the Telkom account. The rate at 11,500 IDR for 1 USD. • Fund transferred by APT (60% of budget approved) = USD 89,542.85 • Cost spent until July 2015 = USD 129,143.90 • Total Current Balance = USD 39,601.05
The detailed information of this financial statement is described in the Final Accounting Report. All the financial statement in this project has been compared to USD value of 11,500 for 1 USD, the same comparation was made for this along this project.
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4. Summary of the Project Activities
All researchers involved in this project, both researchers from Indonesia and Japan were actively supported all project activities. Some activities were virtually performed via email, telephone line, messenger, and other activities which required physically presence of the researchers as the nature of researcher exchanges.
a. Targeted Project Activities The project was completed in July 2015 with additional one and half month for reporting September 15, 2015, due to some key researchers were assigned to another country and unit. The overall project activities can be summarized as below. • Project Preparation • Project kick-off • System Design • System Development • Proof of Concept and Implementation of DigiMAPS J3 • Project Dissemination • Project Management & Reporting
b. Budget management strategy To manage the project achievement and milestones with the 60% of approved budget, the team prepared efficient activities in order to deal with unpredicted situation during the project. The ideation and research on Primary Health Centers and Referral Hospital in Cililin were conducted in efficient and followed a tight schedule. Equipment procurement activities were planned and executed according to the schedules. The priority consideration of the procurement activities was based on the devices, equipment availability and the exchange rate of device’s price, since some devices and equipment should be purchased in US dollar and the IDR per USD exchange rate was under pressure from Rp. 11.500 in July 2014 to Rp. 13.500 in July 2015. Tight budget management strategy was taken to deal with IDR exchange rate increase as shown on Figure 19. The fluctuation of USD exchange rate was also experience to support traveling expenses and Mobile CTG rental. Priority was also assigned to support Japanese expert came to Indonesia in March 2015 and June 2015, and Indonesian expert came to Japan in June 2015.
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Figure 19. IDR to USD exchange rate in 12 months of Project Duration
DigiMAPS team learned and agreed to prioritise any activity with high prority to meet the project objetives. For business trip, all team members agreed to optimize the approved budget of J3 DigiMAPS and operational budget. c. Project Activities Accomplished until July 31, 2015 The summary of project activities which had been done until July 31, 2015 can be summarized as below:
1) Project Preparation Project preparation aimed to inform, gather ideas, design the project management scope and schedule with all partners including Health Office of Bandung West District, TELKOM, UNPAD/RSHS, Bandung Creative ID and BHN.
2) Project Kick Off This meeting was held through a video conference facility between Indonesian researchers and Japanese researcher in September 25, 2014. The final project scope and timeline were discussed including objectives of the project with all activities that would be achieved. Defining project output and clear statement of milestones, as well as person in charge in every activity.
3) System Design As both multimodal communication and application became enabler facilities for maternal antenatal and postnatal care process, they were designed and developed accordingly based on the facility survey result in Gunung Halu and Cililin sub-districts. Distance, geographical isolation, unreliable electricity supply of Gunung Halu sub-district
26 of 49 became major challenges for J3 DigiMAPS team to design and implement the suitable solution. In addition, the team should coordinate with multiple health institutions within the district (WBD) such as Hospital, and PHCs which made the implementation process took some time until the solution delivered and installed in Cililin PHC, Gunung Halu PHC, Cililin Hospital and West Bandung Health Office in Ngamprah, Padalarang. The infrastructures and KIA Online were developed and installed gradually from November 2014 to February 2015. As we used Agile Software Development process, KIA online was tried gradually from October - November 2014 (Phase I) and from February – March (Phase II). Finally all infrastructure, KIA Online, Mother Alert System, M2M Home Care, and Mobile CTG were ready to support a formal trial which conducted in March 2015.
4) Telepresence Trial and Events The audiences for J3 DigiMAPS trial were the midwives, obgyn expert and government officers. Since the multimodal communication link was installed on the area, several test and trial had been arranged to facilitate tele-obgyn and tele-education events between midwives and obgyn doctors. The multimodal infrastructure link installation activities is shown on Table 4 and the scheduled telepresence events on Table 5.
5) Project Coordination & Workshop with Japanese Experts Project coordination and workshop were arranged during mid of January 2015 when J3 DigiMAPS team members conducted site visit to Japan. A tight schedule of meeting and discussion were arranged on the visit, eg: MCTG explanation and Hello Baby program meeting with Mitra.Co, Video conference system demo and J3 DigiMAPS discussion with Kagawa University, Kagawa Hospital visit for MCTG implementation, visit to medical data center arrange by STNet.co, introduction of medical electronic device arrange by BHN, and site visit Kashiwano-ha Smart City
The second project coordination and workshop with Japanese expert were arranged during end of May 2015. A short scheduled were arranged for 5 days visit in Tokyo. Came with the Digimaps team in this visit are: the Head of Health Office of West Bandung, the Coordinator of Nutrision and Child Care of West Bandung District, the wife of West Bandung District Mayor, Mrs Elin Suharliah (she is coordinate the campaign for regional Family Planning and Integrated Health Posts/Posyandu for antenatal and postnatal health), the wife of West Bandung District Secretary), Mrs Dewi Wulandari (She known her activities in regional Family Planning). West Bandung
27 of 49 District provide their own budget to support their team travel to Japan, except for the head of health office district (dr Pupu Sari Rohayati) which is part of DigiMAPS team. The activities in this second visits were about to explore medical technologies in Wireless Japan Expo, in depth discussion of Digimaps implementation and Lunaluna system with MTI Ltd, demo and discussion of M2M devices arranged by MTI Ltd, site visit to Kashiwano-ha Smart City, and site visit to Keio Hospital, met with Indonesian Diaspora representative in Tokyo.
6) Proof of Concept and Implementation of DigiMAPS J3 As a complete system, all part of J3 DigiMAPS multimodal technology were installed and operated to serve Gunung Halu, Cililin, and West Bandung.
In March 2015, during the first visit of Japanese Expert to West Bandung District, we arranged a multi-point teleconference to officially launched the trial of DigiMAPS system in the district. Figure 20 illustrates the teleconferences connecting the health office in west Bandung district, the Data Centre of Ministry of Health in Jakarta, The health office of west java province in Bandung, TELKOM Innovation & Design Centre in Bandung, PHC in Gunung Halu, and Hasan Sadikin Hospital.
Head of Data and Information Center of Ministry of Health of Republic Indonesia. Jakarta Cloud based teleconference Head of Health Service Dept of West Java Province on Bandung.
Head of Health Service Dept of West Bandung Telkom Innovation & Design Center, Municipaltiy on nGamprah West Bandung. Bandung
Prof. Dr. Firman F. Wirakusumah, dr., SpOG(K) Public Health Service of Gunung Halu On Hasan Sadikin Hospital, Bandung
Figure 20. Digimaps’ Teleconference in March 2015
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During the visit of Japanese Expert in West Bandung District, we arranged Mobile CTG demo and a short training for midwives. The training was conducted by Mitla.Co team. Many comments and inputs came from audience since the midwives got difference experiences of foreign language of the device menu. Site visit to the posyandu (integrated health service posts) were become another agenda of Japanese Expert on their visit.
In the middle of June 2015, the second visit of Japanese experts was arranged for several purposes, eg: evaluation of Mobile-CTG use, evaluation of M2M device, site visit to an integrated health service post (posyandu) in Cilanghari to check the broadband connectivity, access KIA Online and in depth discussion with local government of West Bandung for next project and commitment. In the second visit, Mr Takashi Michikata (Programme Officer of APT) and Mr Pornchai Leelapornchai (Project Coordinator of APT) were also attended to provide some valuable feedback and testimony about the DigiMAPS project.
In the 4rd day of this visit, Japanese expert team was met with the 2nd Assistant of Major of West Bandung County, Mr. Sulaeman. During this occasion, the team presented and discussed the progress of DigiMAPS pilot project in the district and the roadmap of DigiMaps implementation.
7) Project dissemination had been done through workshop and face-to- face meeting with respective goverment in national, provincial and district level.
No. Activity a. Ngamprah.West Bandung. September 17, 2014. Digimaps meeting with West Bandung municipality staff. b. Jakarta. October 21, 2014. Meeting with National Secretary for MDG of Republic of Indonesia. Meeting agendas: DigiMAPS introduction, project implementation and field trial in Banten Province. c. Japan. Januari 13 – 21, 2014. Coordination and Workshop with Japanese Expert. During the visit, the scheduled arranged are: MCTG explanation and hello baby by Mitla.Co- it was continued with Kagawa Hospital visit for MCTG implementation, video converence system demo and discussion for implementation with Kagawa University, d. Jakarta, February 6, 2015. Meeting with the head of data & internet centre (PUSDATIN) of the Indonesian Ministry of Health, Mr. Oscar Primadi to introduce the DigiMAPS concept and to understand the government eHealth strategy. Along with the visit, we introduced
29 of 49 NTT Data researchers to the government which have a similar agenda about eHealth, mHealth and its possibility to collaborate with Japan. e. Gunung Halu, March 22- 27, 2014. Proof of Concept and Implementation of DigiMAPS J3. It was the time for Japanese Expert to visit Indonesia. Some agenda was arranged during their visits, eg: MCTG demo, Telepresense for multilocation demo, KIA 2nd version demo and meet with Indonesian experts, Japanese experts, government from district, province and the ministry of health level. f. Tokyo, May 29, 2015. Meeting with MTI Ltd in Nishi Shinjuku, Tokyo. From Digimaps team, Agung Sutiono san presented all DigiMaPS concept. From MTI Ltd presented Lunaluna care system and M2M device has developed. g. Bandung. June 26, 2015. Meeting with the 2nd Assistant of Major of West Bandung County, Mr. Sulaeman, to present and discuss about the progress of DigiMAPS implementation in the district. h. Bandung. June 27, 2015. In deept discussion of Digimaps evaluation. All Digimaps included BHN and Mitla team has discussed any finding, comments and suggestion according to the project.
8) Project closing The project closing will be done as soon the project reports have been submitted and gotten an acceptance from the APT secretariat. All participants will be informed for the completion of the project.
5. Suistainability of DigiMAPS Project
5.1 Local government commitment
The most important things are the sustainability of DigiMAPS. As we have discussed with local authority of the West Bandung District, that they will commit to continue the DigiMAPS applications by using their own budget. This will be expanded into other sub-districts in the West Bandung District.
Since the application is very useful and important to monitor the mother and children health, mortality and morbidity, this systems will be supported by the health department of the West Bandung District.
In 2015, PT Telekomunikasi Indonesia, tbk and the government of West Bandung District signed a contract of health information system (ePuskesmas)
30 of 49 implementation for 36 locations in West Bandung District. As per Ministry of Health roadmap toward a more integrated health information system for primary health centres, different surveillance system software should be integrated into one generic health information system, in order to simplify the recording and reporting system for primary health centres (Puskesmas). One of consideration for future roadmap, the DigiMAPS application and features might be added as part of the maternal and children health care modules within ePuskesmas system which can be accessed by midwives in the districts. The novel contribution for DigiMAPS application are mobile platform, SMS alert, M2M medical device integration and decision support system. Of course there are plenty of issues should be considered before the integration including technical, copyright and business issues.
5.2 Integration with Health Information System Since 2010, Telkom has initiated e-Health service through a corporate social responsibility (CSR) program. It cover technology dissemination, training for local government and solution deployment. It was started with ePuskemas and eHospital program for several area in Java in 2011. Telkom already defined the Health Information System (HIS) to leverage health service base on information technology. The ePuskesmas and eHospital are two of products included in the HIS. Telkom also actively contributes in the Forum of Indonesia’s Health Information Technology (FIKI). FIKI is organized by Indonesian Clinical Epidemiology and Evidence-Based Medicine (ICE-EBM) in cooperation with CEEBM FKUI-RSCM (Cipto Mangunkusomo Hospital), SIMKES UGM and PIKIN (Association of Indonesia’s Health Information Technology) and participated by all players and observers of health information technology from all over Indonesia. Telkom learned that the key challenge in developing e-health initiative in Indonesia is how to improve interaction among health service stakeholders so that it gives benefit to the health ecosystem in Indonesia. It has been planned for integration of Digimaps and e Puskesmas. The integration will be arranged in the data communication or application programming interface (API) level. Point of integration and API library will be defined by Digimaps team and Telkom team. The requirement for actual integration initiatives are expected to be done before November 2015.
31 of 49 6. Conclusions
All activities of the project up to July 31, 2015, comply with the initial planning with some minor adjustment. The Indonesian researchers have completed the design of the system, the procurement, installation, trial and evaluation. The current achievement of the project is 100 %.
BANDUNG, 30 August, 2015
Hadi Hariyanto Chief Researcher
32 of 49 References
Mahendra, A., Sillabutra, J., and Keiwkarnka, B. 2011. "Midwives’ Intentions Regarding Use of Electronic Medical Records in Health Centres in Lebak District, Banten Province, Indonesia," Journal of Public Health and Development (Vol. 9:No. 3), p. 15. Nielsen, J., and Molich, R. 1990. "Heuristic Evaluation of User Interfaces," in: Proceedings of the SIGCHI Conference on Human Factors in Computing Systems. Seattle, Washington, USA: ACM, pp. 249-256. Rambu Ngana, F., Myers, B. A., and Belton, S. 2012. "Health Reporting System in Two Subdistricts in Eastern Indonesia: Highlighting the Role of Village Midwives," Midwifery (28:6), pp. 809-815.
33 of 49 ANNEX-1
Digitalization of maternal and post-natal care system (DigiMAPS) Pilot Project Schedule in West Bandung Count (2014-2015)
No Task Name Start Finish Jun Jul-14 Aug-14 Sep-14 Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15 Apr-15 May-15 Jun-15 Jul-15 Aug-15 1 Official Project Start from APT 24-Jun 25-Jun Start 2 Project Preparation & Internal Project Kick Off (Indonesian Partners) 2-Jul 22-Jul 3 Idul Fitri National Holiday 22-Jul 11-Aug 4 Site Survey & Coordination with Bandung Barat Government 11-Aug 31-Aug 5 Official Kick Off of DigiMAPS J3 (all partners) 1-Sep 11-Sep 6 Implementation of KIA Online version 1 (D2 Phase 1) 11-Sep 10-Nov 7 System Design KIA Online Phase 2 Design (D2) 1-Nov 24-Dec Multimodal Communicaiton Design & Telepresence System (D4) 1-Oct 30-Oct Tele-Obgyn & Profesional Training Course Design (D3) 1-Oct 30-Oct M2M for Home Care (D5) 1-Oct 24-Dec 8 System Development Device & Comm. Hardware Procurement and Delivery (D2) 1-Nov 29-Jan Telepresence Procurement: studio, user room & Event Setup (D3) 1-Oct 29-Jan KIA Online Phase 2 Development (D2) 1-Nov 29-Jan M2M Procurement, Development and Integration with KIA Online (D5) 1-Dec 1-Feb 9 Proof of Concept and Implementation of DigiMAPS J3 Final preparation of KIA Online ver 2, Telepresence, M2M 1-Feb 20-Mar Trial Kick Off, demonstation & discussion (with BHN, MITLA, Goverment 23-Mar 27-Mar Trial & observation at users location 23-Mar 26-Jun Data Analysis 1-May 30-Jun 10 Dissemination (D6) Publication, Presentation and documentation 1-Apr 30-Jun Workshop & project dissemination (with APT, BHN, Government) 24-Jun 26-Jun 11 Reporting & Project Management (D1) Interim report 1-Nov 26-Nov INTERIM Project Coordination & Workshop with Japanese Experts (Japan) 14-Jan 20-Jan ProMeeting Project Report & Workshop with Japanese Experts (Japan) 26-May 30-May ProMeeting Final & accounting report 1-Jul 21-Aug FINAL Project closing 21-Aug 1-Sep Accounting Reports
ANNEX-2 DETAIL DESAIN OF INFRASTRUCTURE DEVELOPMENT
A.2.1 Regional Hospital (RSUD) Cililin detailed architecture
Figure A-1 Blueprint of RSUD Cililin floor 1
Birth Medical Room
WiFi AP
Gateway xDSL
Figure A-2 Radio Planning RSUD floor 1
Figure A-3 Blueprint of RSUD Cililin floor 2
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WiFi AP
Gateway existing xDSL
Figure A-4 Radio Planning RSUD Cililin floor 2
A.2.2 Distric Clinic (Puskesmas) Cililin
Figure A-5 Blueprint and Instalation for Puskesmas Cililin
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Figure A-6 Radio Planning for Puskesmas Cililin
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ANNEX-3 PICTURE of ACTIVITIES UNTIL JULY 2015
Ngamprah.West Bandung. September 17, 2014. Digimaps meeting with West Bandung municipality staff.
In picture: Hadi Hariyanto and team had a meeting with the Head of West Bandung Health Office and her staff to explain about J3 DigiMAPS Project and Applications. Any comment and idea related to DigiMAPS were gathered and accomodated in the DigiMAPS development and implementation.
Gunung Halu.West Bandung. September to November, 2014. Development phase of the 2nd version of KIA ONline. We invited user for comment and idea.
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Ngamprah.West Bandung. September 18-19, 2014. Site survey for multimodal communication deployment
Gunung Halu. October 14, 2014. Introduction to the 2nd version of KIA Online.
First use of the 2nd version of KIA Online. The session held by Agung Budi Sutiono, MD, PhD and Ahmad Faried MD., PhD for mildwives in Gunung Halu PHC.
Jakarta. October 21, 2014. Meeting with National Secretary for MDG of Republic of Indonesia. Meeting agendas: DigiMAPS introduction, project implementation and field trial in Banten Province.
40 of 49 In picture: Mr Dr Dicky Budiman, MSc,PH (Vice Executive Secretary of MDG) with J3 DigiMAPS team member Ahmad Faried., MD.,PhD
Celak. October 2014. Product Validation and getting some comment for KIA 2nd version. It was also used to capture user behavior on data input by using tablet computer.
Gunung Halu. November 18, 2014. Telepresence meeting entitled Preterm Birth.
In picture: Obgyn expert Leri Septiani, MD., PhD shared her knowledge of Preterm Birth to midwifes in Gunung Halu
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Ahmad Faried MD., PhD and Gunung Halu primary health center midwives joined to the telepresence session.
In picture, team has prepared the video conference in West Bandung Government Office. Tokyo. January 13-21, 2015. Project Coordination and Workshop with Japanese Expert.
In picture, the Digimaps team learned about MCTG from ms Ashami Kondo. The meeting has arranged in Mitla.Co office, Takamatsu. The agenda was continued with Kagawa Hospital visit for MCTG implementation live demo.
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The Digimaps team has visited Kashiwano-ha smart city, see and learn about ICT based health service and business model. Bandung. March 24, 2015. Proof of concept and implementation of Digimaps J3. It was the time to proof Mobile CTG, Telepresence and the 2nd version of KIA Online that can be operated to support the antenatal and post natal health care services.
Mr Hironari Kono was in discussion with the midwives about their experience to use Mobile CTG.
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Ms Eiriko Suzuki was in her demonstration of helping a mother by using Mobile CTG Gunung Halu. March 24, 2015. Telepresence was arranged for multilocation attendances. It was connecting Gunung Halu, Ngamprah, Telkom office (Bandung), Hasan Sadikin Hospital (Bandung), Health Service of West Java Provice (Bandung) and Data & Information Center of Ministry of Health of Republic of Indonesia (Jakarta).
In picture, 6 locations was connected by Telepresence.
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Local government of West Bandung Prof. Dr. Firman F. Wirakusumah, District joined in the Teleconference. dr., SpOG(K) joined in the Telepresence, he gave his speech for the project and share lot of his experience of maternal and neonatal care
Bandung. March 25, 2015. Accepted by Government Secretary for Bandung Barat Authority – Mr. Maman Sulaeman. In this session, the Digimaps team reported the activities of Digimaps in Gunung Halu and Cililin.
In picture, DigiMAPS team met with Government Secretary for Bandung Barat Authority. Mrs Pupu Rohayati Basarah (Head of Health Service Department) added some information about public health condition in West Bandung District.
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In picture, photo session with Mr. Maman Sulaeman and Mrs Pupu Rohayati Basarah. Bandung. March 25, 2015. Met with Indonesian Health Expert in Hasan Sadikin Hospital Prof. Dr. Firman F. Wirakusumah, dr., SpOG(K) Chairman of Health Technology Working Group. Medical Faculty of Padjajaran University Hasan Sadikin Hospital
Tokyo. May 29, 2015. Met with MTI Ltd in Nishi Shinjuku, Tokyo. In depth discussion of Digimaps and Lunaluna System
In picture from Digimaps team, Agung Sutiono-san presented about DigiMaPS concept and Mobile CTG.
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In picture, from MTI Ltd presented Lunaluna care system and M2M devices. As seen in the picture Ms Nami Kurume showed the Lunaluna system and M2M device connected to the system.
Bandung. June 25, 2015. The 2nd Visit of Japanese Expert to Indonesia. The agenda for this visit were about Mobile CTG evaluation, M2M demonstration and project evalution. Also came and joined during this visit were: a Project Coordinator of APT (Mr. Pornchai Leelapornchai) and Programme Officer of APT (Mr. Takashi Michikata).
In picture, Toshihiro Kishikawa san and Eiriko Suzuki san on their activities of operating the Mobile CTG for maternal contraction in third trimester of patient.
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In picture: site visit to Cilanghari Healh Center. Its about 1,5 hours traveling to the west of Gunung Halu sub-district city.
Bandung. June 26, 2015. Discussion with the 2nd Assistant of West Bandung Major, Mr. Sulaeman. The Digimaps team reported a brief explanation about the project, its progress and roadmap.
Bandung. June 26, 2015. In depth discussion of Digimaps evaluation. A lot of finding, comment, and input come from the project member.
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