Daniel Bachhuber's weblog

Thursday morning, Wayne, Karen, and I went down to the clinic in Arequipa to discuss OpenMRS, FrontlineSMS, and MobilizeMRS with Lilia, the director of the clinic, and Maris, the assistant director of the clinic. There were a few goals to the meeting: understand the rudimentary electronic medical records system (EMR or MRS) in place now, assess the pros and cons of that system vs. OpenMRS, and discuss the possibility of running a clinic efficiency experiment with FrontlineSMS. We got through the first two agenda items pretty well but, being on Peruvian time, didn’t make it very far into the third.

Brain and note taking dump ahead.

The clinic has an EMR at the moment which is very limited. It was developed by a local programmer they still have good relations with and, every time they want expanded functionality, they just ask he (or she) to build it. Furthermore, the clinic staff has been talking over the last year about different ways to expand the tools. At the moment, it captures data about the patient, vital signs, and has a free text area for diagnoses. Continuing development on this software will require significant money, of course, which is why OpenMRS is probably a better long term option. Writing software for a pretty common use case doesn’t make much sense when there are customizable open source options available. Thanks to a relatively fast internet connection today, I was able to upload a HD walkthrough of their current EMR:

Tour of the clinic’s custom EMR from Daniel Bachhuber on Vimeo.

One fairly significant problem we faced Thursday morning, however, was trying to convince the clinic staff of the merits of OpenMRS without a full featured online demo or video tutorials. I personally haven’t experimented with the software very much, nor do I know all of the useful components of a medical records system, so I couldn’t necessarily sell the software with my salesmanship.

Wayne, being proactive, took the conversation from step zero so that Lilia and Maris would be able to help assess the merits and demerits of their current system:

Basic needs of a Medical Records System from Daniel Bachhuber on Vimeo.

According to the doctor, the basic needs of a medical records system are three-fold:

1. Documentation – an EMR should have the ability to take notes and capture information on labs, Rx, Dx imaging, etc. Most importantly, this information should be searchable.
2. Networking -  an EMR should lend accessible communication, both internally (within the clinic) and externally.
3. Decision support – an EMR should be intelligent, and assist the clinic staff in identifying high-risk patients, etc.

Once we had these criteria established, we started talking about the pros and cons of using their current system.

The pros of their system are:

• Easy implementation – the software is already installed on the computer and they know how to use it.
• Design specific to clinic – they can choose how they want the software to operate because they direct the development of it.
• Know[n] commodity - they know what they’re dealing with.
• Personal sw. provider – the developer is local and can come to the clinic to provide support, etc.
• Economically speaking + impact – Cheap for what it does.

The cons of their system are:

• Design specific – the design of the software is tied very much to the needs of their clinic today, and not five years in the future.
• Expandability – uncertain as to how difficult it is to extend the system.
• $ for upgrades – have to pay to have the developer build every single upgrade. Also, only the developer knows how to build or maintain the system.
• Don’t really know “OpenMRS” – don’t have the proper education materials to illustrate the power and flexibility of OpenMRS.

The unfortunate thing is that their current system doesn’t match up to the needs of an EMR very well. As it stands, it’s not much more than a data storage tool. They use it to house basic information about the patient, symptoms, and diagnosis, but it isn’t very useful as a tool to manipulate the information. On top of that, the networking support (connecting computers in the reception with those in the doctor’s rooms and farmacia), has yet to be built and decision support is cost ineffective.

The clinic is interested in OpenMRS, however. On Monday or Tuesday, Wayne will be showing Lilia and Maris a demonstration of the EMR he uses back in the States. This will ideally convince them of the practicality of having a robust EMR. We’d also like to get them to a clinic in Peru that has a working demo of OpenMRS soon. If this proves feasible, then we might be able to send the programmer they have to an implementer’s training with PIH.

A thought on bringing the programmer into the fold: this might actually be an economic enterprise for him or her. My thinking is that there are a number of clinics in Arequipa still using paper records, so if the clinic HBI works with becomes a local model for using OpenMRS, then that might get the other clinics interested in medical records and incentivize the developer to get to know OpenMRS better.

In the interim, though, the clinic will still put a bit more money into the system they already have.

On the note of SMS, we discussed the possibility of how mobile might be useful to increase clinic efficiency:

Day seven, Arequipa from Daniel Bachhuber on Vimeo.

The idea wasn’t very well received, though, because the assumption is that the demographic that the clinic serves most likely will not have cell phones, and the clinic staff couldn’t really understand how the technology could be useful. Anecdotally, however, a doctor said the penetration of mobiles in this market is near or over 90%, a statistic which doesn’t seem too unrealistic to me. Furthermore, I think that mobiles could play a significant role in improving the efficiency of the clinic.

We’ve got an experiment cooking too. Building upon the pediatric idea briefly outlined in my previous post, we’d like to have a control group, an experimental group which receives a reminder for their appointment, and another experiment where the group receives a unique code for a discount on their appointment. In preparation, the clinic will start collecting cellphone numbers at registration. Ideally, this experiment will be later this spring or early in the summer.

One last thought on efficiency: we’d also like to run a two week experiment (probably in February) where patients receive a time-stamp upon checking in to the clinic, and another one when the doctor takes them for their appointment. I think mobile could a tremendous impact on the clinic’s ability to efficiently deliver healthcare (the concept of being on-time for appointments is nearly zero), but baseline numbers will be really important to calculate impact.

Day one in Arequipa: asking as many questions as I possibly could about how Health Bridges International’s partner clinic in Alta Cayma operates. This research will serve two purposes: extensive background for how MobilizeMRS might be useful, as well as assessing resources for intra-clinic collaboration. 

A little background. The catchment area for the clinic in Alta Cayma includes 30,000 to 35,000 people. From this population, the clinic saw 22,000 visits in the past year, with between 15,000 and 17,000 unique patients. Recorded number of visits to the clinic is increasing at a rate of 4,000/year. The clinic is pretty well resourced, according to Wayne of HBI, with a team of physicians (rotating 5, not all full time), dentists (2), nurses (9, not all full time), pharmacy (4), management (2), and two specialists, a psychologist and opthamologist. Essential medications are provided through a Catholic charity program and they can get most others through donations. Where the clinic lacks is primarily in specialization, health education, and patient care advocates.

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Sometimes it’s difficult being the web guy at a student newspaper. Although you’re absolutely certain “online” is going to play a significant role in the future of your organization, you’re not able to articulate the urgency of your position well enough to make the decision making wheels turn. It’s frustrating, to say the least. From the thinking and idea stealing I’ve done in the past week, I think there are at least three threats facing student newspapers who don’t reinvent themselves as multi-medium digital news organizations:

Threat one: Monetary. Advertising revenue dries up on the print side, print costs go up, and your online product isn’t compelling enough to generate the same type of revenue. That, or your online product is College Publisher and you can’t even boost the advertising revenue if you wanted to. One counter argument is that student newspapers could just go to student government to up their funding, a “bailout” of sorts, but I don’t think that could ever be a long term solution.

Threat two: Staff disappearance. Students no longer want to work at their student newspaper because their industry of choice has a bleak future. Jessica DaSilva is already facing this challenge at the Independent Florida Alligator and, as I commented, this could be the greatest short term threat, especially if your paper isn’t perceived as all that digitally progressive.

Threat three: Dearth of talent. Publishing and monetizing news online is quite different than print, and requires a skill set that potentially isn’t represented by current staff. The further a newspaper gets behind, the more it will have to invest when it does decide to make the gigantic leap in the future. This financing to buy talent might have to come out of its investments or from a significant fundraising drive.

At the moment, this is threat identification and analysis. I don’t have exact solutions to any of these issues right now. My hope, though, is that by studying and mapping out the specifics of each threat we can develop strategic plans to make the transition and keep campus journalism alive.

One aspect of Whitman Direct Action’s (WDA) 2007-2008 Sadhana Clean Water Project is the Appropriate Technology Study Group, looking at the socio-political constraints to clean water access in the Kolwan Valley of southern India. Traditionally, WDA has been an implementing organization, generally working with an in-country, non-governmental organization (NGO) to bring a piece of technology to a community or region. In early conversations with one of our collaborating partners, Sadhana Village, we determined it would be more poignant to rather work to understand why water access projects aren’t adopted to the degree hoped, and establish some of the challenges they face.

The Kolwan Valley [Google Maps], where we conducted our research, is an area an hour drive from Pune. It is comprised of 17 villages, or 19 if you count the larger Paud [Google Maps] and Kolwan [Google Maps]. The large majority of households earn their income through subsistence farming, with wheat and sugarcane being the primary crops, and everyone else through a small variety of other means. At this point in time, there is almost zero industry in the valley. This could soon change because of the proximity to a rapidly expanding urban center (Pune). Village size is generally between 70 and 400 households, which are then commonly split into between two and five “wadis” or pockets including the village proper. Composition of the wadis is, for the most part, determined by socio-economic background; for instance, in many of the villages we worked in, there was a “harijan vasti” scheduled caste (SC) families. Governance is done on a local level by the Gram Panchayat, a “democratically” elected body responsible for the basic issues of each village, and on a wider scale by the Gram Sevaks and regional Indian government. The structure of these villages, and of the valley, is as such to provide characteristics unique to the area and threaded throughout India.

Data collection done on the ground by participants in the study group consisted first of surveys coordinated by two partners, Mahindra United World College of India and Gomukh Environmental Trust, and implemented by high-school students of both MUWCI and the valley. Over two hundred responses from nearly all of the villages were collected. A second, preplanned component of the research was a series of focus groups and/or discussions with different types of groups from the valley, including scheduled caste women, school children, and the Block Development Officer (BDO), an official responsible for the government-sponsored water management projects. With one of our goals being to collect information on the same topics related to water availability, water quality, water quantity, and sanitation from different stakeholders, we found it was also wise to interview some member of the Gram Panchayat to get an “official” view of those aspects in each village. This detailed information on where certain wadis get their water, how much they get, and so on proved to be crucial in determining which water sources, or points of distribution, we should test.

Our guiding focus for the Water Quality and Quantity Addendum was originally to determine whether the water in the valley is generally safe to drink or not without further treatment, as well as to collect the supplementary data to establish a need for better water management. One reason for this is to partially substantiate the report produced by the study group; it will be important when we pen the paper to prove there are both socio-political constraints in the region and that the valley has a water problem to begin with. Although much of this type of information should be available from the Indian government, we decided, with more explanation later, to go ahead and do independent testing of the basic indicators of water quality:

• pH
• Temperature (C)
• Fecal coliform
• Turbidity (NTU)
• Dissolved oxygen (mg/L)
• Total nitrate and nitrite (mg/L)
• Biochemical Oxygen Demand (mg/L)
• Chloride (mg/L)

The tests were done through a variety of means. Dissolved Oxygen, pH, and temperature were all done in the field, as well as total nitrate, nitrite, and chlorine when the Lifewater kits showed up, and we took samples for the rest. On returning to the lab, the water for fecal coliform tests was placed on a culture of McConkey’s Agar for 24 to 48 hours. They were then assessed for growth of lactose and peptone-producing colonies, indicative of E. Coli, Salmonella, and other bacteria potentially harmful to human health. The pros and cons of each testing method will be documented in the full report.

As with working in any foreign country, there were, and still are, many challenges to getting the necessary hard data required for such a report. A significant amount of time, anywhere between one and four hours per village depending on how many cups of chai forced upon the team, was required to do a Village Water Source Worksheet [HTML], the first step towards understanding where we should test. Another timesink was that each one of these worksheets required at least one and sometimes two or three translators. This can easily magnify the amount of time needed as a question must first bounce from person to person and then the answer back the same path. One justification for why these questions have been necessary is that reliable information from the government is notoriously difficult to get, in both time consumed and accuracy. For many complex reasons, very basic data on water quality, quantity, and access sometimes either does not exist or is falsified. On top of that, there is an extraordinary bureaucracy to work through in order to obtain stats. The first person you talk to will pass you on to the next, and so on and so forth.

Regardless of these difficulties, we were still able to test 15 points in 11 villages assessed.

By testing for basic indicators of water quality, and surveying for hard data about the water sources in each village, we will be able to establish far more than just whether the water is generally safe to drink or not without further treatment. For instance, determining whether there is a presence of fecal coliform in the water can validate the accuracy of statements on both how often the water is treated and tested. If the man in charge of treating the water says he puts TCL in every day, but there is bacterial growth in the sample taken, there we will be able to document that there is a disconnect somewhere along the line. Furthermore, if the water source is being tested regularly, and there are indicators that the water is unsuitable for human drinking, then there should be action by the local and regional government to correct the problem. A presence of bacterial growth in the water could indicate some breakdown in the societal mechanisms required to provide safe drinking water. It is in ways like these that the hard data we’ve collected on the ground is proving to be a valuable asset.

With all of that being said, a fair bit of work still needs to be done. The collection of raw data from the Appropriate Technology Study Group is only just now being synthesized for analysis; through this project, we’ve been able to come to the overall conclusion that data collection is a time-consuming process. If it is at all possible, we would like to obtain the official water quality data from the government to see how it compares to our information, as well as use it to describe the long-term trends of the valley. It’s accuracy, of course, would have to be taken with a grain of salt. We made a request for this information to the BDO a couple of weeks back, and promised we could get it, but it has yet to come. It will also be important to continue tracking down the appropriate climate and water availability information to be able to compare how much water villagers perceive there to be compared to how much there actually is in each season, in addition to being used to depict the characteristics of the valley. Furthermore, it could be interesting to get hard data on how much water is being used for what, including what quantity is diverted away from the valley for use in Pune. The other data required to support certain arguments in the report will likely arise as we continue to figure out which specific dynamics in the Kolwan Valley inhibit access to clean and reliable drinking water.