In the Philippines, all deaths must be certified and provided with a cause of death before burial can occur. While this policy supports the generation of crucial mortality data, the country faces challenges in ensuring that deaths are certified accurately, particularly when occurring in the community. Since 2017, we have been working with the Philippines Government to improve death certification practices across the country by training doctors and introducing new tools to assist them.
SmartVA is an automated Verbal Autopsy (VA) software initially developed for use in countries where deaths occurring outside hospitals are unlikely to be medically certified and assigned a cause of death. This is not the case in the Philippines, where Medical Health Officers (MHOs) ensure that community deaths are certified when the family comes to collect the death certificate needed for the burial. However, assigning a correct cause of death without seeing the body or knowing the patient is a challenge.
In response to this challenge, the University of Melbourne Data for Health (UoM D4H) team re-engineered the SmartVA tool to allow doctors, using the tool and a computer algorithm called Tariff, to generate a probable cause of death that can be accessed in real time and used to complete a death certificate. In addition, the software now provides not one but three ranked probable causes of death, which offers users a choice and encourages them to use their own knowledge to provide a more detailed cause of death where possible. As the tool was designed to support doctors to accurately determine a cause of death when they have insufficient information, it became known as SmartVA for Physicians.
SmartVA for Physicians was initially piloted in the Philippines in three dialects other than English for community deaths across three regions. After an evaluation meeting with users and an analysis of the results of some 4000 VAs, the Philippines Department of Health (DoH) decided to begin progressively rolling out the tool country-wide to all MHOs responsible for certifying community deaths. User focus group discussions confirmed that MHOs overwhelmingly found SmartVA for Physicians to be a useful tool in the medical certification of deaths. In particular, they reported that the structured interview process was a helpful guide, and that the summary list of symptoms and the top three most likely causes of death were helpful in deciding the most probable cause of death.
In recognition that accurately certifying deaths can also be challenging for hospital doctors when patients are dead on arrival (DOA), DoH has requested UoM D4H assistance in piloting the use of SmartVA for Physicians in hospital emergency departments.
Until a recent change of procedure, certification of DOAs was the responsibility of MHOs rather than hospital physicians. With this change in mind and given that SmartVA for Physicians had already been demonstrated to work for MHOs in improving certification practices, DoH wants to understand whether it can also work in busy hospital settings. It is now being tested in nine government hospitals for DOA patients who arrive without medical records or other information usually required to correctly diagnose a cause of death. An evaluation meeting will take place before the end of 2020 to ascertain whether the tool can also work in hospital environments.
“We are looking closely at the uptake in hospitals,” says Dr.Lene Mikkelsen, UoM D4H Senior Technical Advisor, “as emergency room doctors may be stretched too thin to conduct the interviews. If we get low uptake because doctors have no time to conduct a proper interview, we will also see a high number of undetermined causes. In this case we would need to reconsider the implementation mechanism. This would perhaps involve using nurses instead of doctors to conduct the interviews with the family, which would provide the computer output that doctors could then use to select the most probable cause of death.”
While the use of SmartVA for Physicians in hospitals is still experimental and needs to be carefully evaluated, UoM D4H staff are confident that the evaluation of the pilot results will produce valuable insights that can be used to improve the tool for further use by doctors.
“SmartVA for Physicians has never been used like this before in any other hospital in any other country, so it is a learning experience. We are eager to see the results, and we expect they will enable us to make further recommendations about the rollout of the tool.”
Carmina Sarmiento, UoM D4H Philippines Country Coordinator
The Philippines Government has declared that it aims to have four out of every five community deaths certified with the assistance of Verbal Autopsy by 2024, an objective that may now be supported by the rollout of SmartVA for Physicians in hospitals.
“We are fortunate that our government stakeholders are engaged and proactive, and that they have made an international commitment to improve the Philippines CRVS system. We look forward to continuing to work with them to improve the certification of all deaths,” says Carmina.