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.

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.

These needs tie into the intra-clinic collaboration. On Monday and Tuesday, Health Bridges International and Medical Ministry International will be holding a conference in downtown Arequipa to bring together as many players in private, public-sector health care as possible and hold a discussion on how to improve the efficacy of healthcare delivery by cooperation. According to Wayne, there is no central record keeping of healthcare in Arequipa. There are, however, four-ish different methods of delivery:

• MINSA: through the Ministry of Health, and this is the primary source for most Peruvians
• Es Salud: if you work in the formal sector and get taxes withdrawn from your pay, then you are eligible
• Military and police hospitals
• private clinics (including for-profit and non-profit) – ballpark of around 500 to 700 of varying sizes in Arequipa

About 50 or so of these private clinics, along with government officials, have been invited to the conference at the beginning of the week. At the end of the first day, we’ll pass out a survey [Google Doc] asking questions to try and establish both the type of information to be shared and best medium to share the information through.

In any regard, this little project was the first reason I was destined to come to Arequipa. The second is a project Isaac Holeman and I are working on called MobilizeMRS. The concept is to bridge the gap between SMS (short message service, or text messages) and MRS (medical records system). The first step in the process, or in Peru at least, was going to be to introduce the clinic to FrontlineSMS and see if we could find an experiment to use it on. If they don’t already have one, getting the clinic on an electronic medical records system is a bit more difficult of a process.

Most immediate issue: this clinic implements primary care, unlike most of the use cases I’ve found for FrontlineSMS thus far.

This means that instead of focusing treatment on HIV/AIDS and Tuberculosis, they deal with “Western diseases,” or  obesity, diabetes, etc. This also means that the only “community health worker” they have is Maria, who is more of a social worker than anything else. It’s not a huge hang-up, but has made the questions I came down here with (i.e. how many community health workers are there in the network, how far do they travel, etc.) mostly obsolete, and means we’ll have to experiment with how SMS might be useful.

We have an idea, however.

Peruvian patients are notoriously tardy. It’s just not really a cultural expectation to be “on time.” In a clinical setting, this means you have to run at less than optimal efficiency, because you really don’t know for sure who is going to show up when. You also don’t know when you’re using your resources to their fullest potential.

The idea is to change this by incentivizing “on time” behavior. We’re considering doing a trial run with pediatric patients because the clinic needs to do follow-up appointments with about 150 kids. To experiment with this, we could assign 50 kids to three different morning sessions. Session one is the control, meaning we would just tell the parents that they should bring in their children between hour X and hour Y on Tuesday morning. For session two on Wednesday morning, we would send a blast text message out to the parents on one of the days preceding that they could get 50% the consultation fee (which is 3 soles, or about a dollar), if they showed up within an hour of hour X. They would each have a unique confirmation code to reveal in order to get the discount. Session three might have the opportunity to receive priority treatment if they showed up promptly. In short, I think the plan is to create an experiment like this and see what the ROI of improved communication with patients might be.

An important note about establishing ROI: it’s really, really important to have baseline numbers. This is particularly hard to do in the Alta Cayma clinic, as I imagine in many clinics, because so much data is left untracked. On top of that, all of the records right now are paper, which makes tabulation a pain. There are a few simple data points I’d like to start tracking as soon as possible: average length of time spent in line to see the doctor, number of patients that leave before seeing a doctor, and number of patients per hour by the day. These should be as easy as marking the time the patient was checked in and was seen by a doctor on their chart.

A couple of final questions about using FrontlineSMS:

• Has FrontlineSMS been implemented in other primary care settings?
• What are some ways FrontlineSMS can be applicable to primary care?

OpenMRS is going to be a whole other beast, I think. I’m heartened to learn that they’ve already been thinking about electronic medical records significantly, though, and plan on including me in a few hour meeting on Thursday to discuss potential options and ideas.

The first destination is Arequipa, in southern Peru, to do research for Health Bridges International (HBI) on how the clinics serving the Alto Cayma catchment area can better coordinate efforts, share resources, and work together. The specialty I hope to bring is identifying ways in which communications technology (like a Google Group, WordPress blog, or SMS) can enhance collaboration. Wayne and I worked on a questionnaire a while back that will be implemented at a healthcare providers conference on Monday and Tuesday. Here are some of the questions we’ll be asking:

• What types of resources are you commonly lacking?
• Do you have internet access?
• Do check email regularly? How often?
• Are you interested in collaborating with other local clinics/ organizations?
• Would you be interested in sharing specialty consultations?
• Would you be interested in sharing supplies or resources?

We’ll be trying to keep it short, but I’d enjoy any and all feedback on the questions we’re asking, as well as ideas on how to connect clinics with limited resources.

Along with doing research for HBI, I’ll be doing interviews to gather information for MobilizeMRS, a project with Isaac Holeman and (hopefully) Lewis & Clark Direct Action. These interviews, which will probably be video too, will try to deduce:

• A solid use case for FrontlineSMS in the HBI clinic in Arequipa
• What different stakeholders think the project can do
• The organization of the community health workers network
• # of trips made per day by community health workers + doctors, average distance of each trip, and how they travel
• Access to electricity

Thanks to Josh Nesbit for feedback on the scope of this research.

At the end of January, I’ll be headed to Cajamarca to work on Oregon Direct Action’s water project in San Pablo, Peru.

More soon, I promise. Final boarding time now. If you’re going to down there at the same time, hit me up. I think I’d like to do a few weekend trips to get away from work. And an FYI for those of you that follow me on Twitter: I hope to tweet as I’m traveling around. Twitter no longer delivers international SMS, however, so the conversation might seem a bit one-sided at times. My apologies in advance.

Onward!

Wow. So sweet. I’m not entirely sure what the next steps are, but this is a huge stride forward for bridging the gap between SMS and OpenMRS and empowering healthcare providers.

My good friend Isaac Holeman and I entered an application on Friday to NetSquared/USAID’s Development 2.0 challenge. They’re looking to give $10,000 dollars to a project using mobile technology (like SMS or phone-based applications) that “[maximize] development impact in areas such as health, banking, education, agricultural trade, or other pressing development issues.” We think we’ve got just the idea.

We’d like to put together a bridge between mobile phones, potentially FrontlineSMS, and OpenMRS, a super neat medical records system that is beginning to gain a lot of traction in Africa because of Paul Farmer’s Partners In Health. Specifically, this would allow community health workers in the field to access and interact with the medical records database. This would, for instance, allow them to instantly query the last time a tuberculosis patient had reported taking their treatment medicine. Isaac and I are also very interested in sorting together an OpenMRS module that would “watch” the data going in and out of the database. If a bit of data passed through tagged with, say, “#emergency”, it would go to whomever the on-call doctor was. This type of functionality, as far as we can tell, doesn’t already exist. We think it would be sweet if it did.

Now, most of this project is in the very preliminary stages. With your help, though, and funding from NetSquared/USAID, we can take it to the next step. Here’s the details:

• Voting started on Monday and will run until Friday at 5:00 pm Pacific.
• To vote on our application, you must first register.
• Once you’ve registered, you then have one (1) ballot with up to five (5) votes. You have to vote at least three (3) times.

Our application is called “Mobilizing Medical Records In Resource Poor Settings“. We would be very much obliged if you took the time to vote for us and, if you do and leave a comment on this blog post, I’ll send you a personal thank you.

Also, if you don’t know who else to vote for, there were a few other projects which caught my eye:

• Providing Business Opportunities Information To Farmers And Producers Via SMS
• QuestionBox – Democratizing Information and News for the Illiterate, Poor and Unconnected
• Building A Sustainable Supply Chain For Portable Appropriate Technology

Most importantly, I think these types of projects show that mobile connectivity has tremendous potential to empower positive change. We think our project can do the same for healthcare. Thanks for the support!