D-tree International

The story of D-tree began in Pakistan, 1986, when Dr. Mitchell visited many health facilities in ranging from well-equipped tertiary hospitals to urban clinics and rural medical units scattered throughout the country. He was sent by USAID to investigate what could be done to reduce the high number of child deaths from common diseases such as pneumonia, diarrheal disease and malaria.

Realization
In his visits to the various clinics, he soon realized that except for the small number of specialist hospitals, health workers and even physicians had minimal pediatric training. The result was that common childhood diseases were often misdiagnosed and treated randomly with whatever drugs happened to be in stock at the health facility, prescribed on the principle that maybe one of them would treat whatever was wrong with the child. The health facilities therefore regularly ran out of their monthly allotment of drugs and patients went home either empty handed or with self-filling prescriptions which they could not afford.

Dr Mitchell realized the issue at hand was not lack of health access, but rather, inadequate care. He turned his attention towards implementing standards of care, or clinical protocols, that serve to systematically diagnose, manage and treat illnesses common in the developing world.

Adaptation
This idea of clinical medical protocols was not new – they already existed in paper form, as checklists, charts and posters on the walls of clinics – but their use remained uncommon in healthcare delivery around the globe; mainly because they were difficult to adapt, disseminate and update. What was new about Dr. Mitchell’s proposal, however, was that he wanted to program these standards of care onto portable electronic devices, at the time, PDAs. He believed that if presented electronically, these clinical protocols could be easily adapted to spread quickly throughout a myriad of cultural, geographical and medical contexts and thus better support medical decision-making in resource-limited areas.

For the next few years, Dr. Mitchell continued working on the protocols and gathering support, and in 2004, he officially founded D-tree International.

Validation
After its inception, D-tree selected Tanzania as the location to prove the model could work even in a low income setting typical of many sub-Saharan countries. In 2005, 112 of every 1,000 children died before age five, mostly from easily preventable and treatable illnesses like malaria and diarrhea. Health workers could easily take care of most of the problems if they were given the tools they needed to effectively diagnose and treat these patients.

At the same time, mobile technology had entered the market and spread rapidly; by 2008 there were 9.4 million mobile phones in the country. The combination of poor health outcomes, an intense healthcare worker shortage, and widespread mobile networks made Tanzania a suitable site for D-tree’s innovative technology.

D-tree’s first projects in Tanzania succeeded in showing the advantages of electronic clinical protocols, among them:

Simplified and accurate diagnosis and treatment plans
Better identification of potentially fatal cases
Higher human satisfaction from improved health worker-patient relationship
More efficient use of the limited medication and health resources on a regional scale
Collecting data at the point of service and enabling automatic longitudinal records
These projects have been coupled with research studies to ensure they improve the care that is delivered and the health outcomes that result. Published studies (link to publications) have shown that health workers more consistently follow protocols in an electronic format, patients and caretakers appreciate the improvement in quality that protocols bring and health workers are more confident in their work when supported by electronic protocols.

Expansion
Since then, D-tree has expanded in width and depth, going into more geographic areas, including Malawi, Zanzibar, Sri Lanka, Benin and India, with protocols of more disease areas, including child health, maternal health, chronic care, HIV/AIDS, and family planning.

Envision
Dr. Mitchell’s vision, which began over 25 years ago in Pakistan, has become a reality that has changed the health experiences of over one hundred thousand patients globally. It continues to grow and contribute to creating a world in which every person, no matter where they are, has access to high quality health care.

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