Abstract  Electroencephalography (EEG) aids the diagnosis and characterization of epilepsy in higher income settings, but can be especially difficult to access by PWE in LMICs. Smartphones, owned by more than 2.6 billion people, now offer a potential solution for the distribution of EEG to populations globally. In this exploratory and capacity building study in the lower-income, Himalayan Kingdom of Bhutan, we will test and implement a multi- platform open-source, software application that combines off-the-shelf EEG caps with a smartphone to acquire EEG in PWE. This represents a low-cost, real-time, fully portable EEG imaging system that obviates the need for paper tracings, EEG technicians, and consistent electrical supplies. The smartphone based EEG will be clinically tested in 160 people with poorly controlled epilepsy – operationally defined as people who have experienced at least two unprovoked seizures in the prior year. The primary aim of this prospective interaction study is the estimation of the number of people with poorly controlled epilepsy who will receive improved characterization of their epilepsy syndrome on a smartphone based EEG by detection and characterization of epileptiform and background activity. Incorporation of the use of the smartphone EEG to improve a patient's epilepsy management will be tracked and analyzed. Integral to the completion of this study is capacity building for epilepsy research at the Jigme Dorji Wangchuck National Referral Hospital in Thimphu, Bhutan through the instruction of research methods and epilepsy care. Dedicated teaching of EEG acquisition and epilepsy case management in the understanding of poorly controlled epilepsy will be performed by investigators from the Massachusetts General Hospital's Department of Neurology. Building on a strong working relationship, the study will include health care workers of various levels and expertise from the Bhutanese Institute for Traditional Medicines, National Referral Hospital, and remote and rural health posts. Recruitment, enrollment, data analysis, and publications will incorporate traditional healers, as well as Bhutan's strong network of frontline community health care workers and registered nurses through the Ghesar Kyalpo University of Medical Sciences. Additional targeted areas of capacity building for sustainable epilepsy research in Bhutan include human subjects training, epidemiological methods and reporting, survey-based data collection, data quality control, and financial management of grants and budgeting. Accomplishment of the above study aims will provide the necessary data to randomize smartphone based versus usual epilepsy care in lower income countries through the scale up of this model alongside complementary mobile health technologies. Use of mHealth for epilepsy care is intended to exemplify a “disruptive” leap for PWE in lower income settings and more generally, provide reverse innovation for rural and remote populations with poor access to epilepsy care, wherever they exist.

Project Narrative A mobile phone-based electroencephalography (EEG) platform will be clinically implemented for the characterization of seizures and decision making for people with poorly controlled epilepsy in the lower middle- income Himalayan country of Bhutan. Capacity building for EEG interpretation and epilepsy research at the Jigme Dorji Wangchuck National Referral Hospital in Thimphu, including its wide network of allopathic and traditional “sowa rigpa” non-neurologist health care practitioners, will be integral to these research goals.