Better than the original.

The kicker at the moment is that the lady who owns the land for one of the tanks (most immediately above) now doesn’t want water being taken off her land for the community’s use. Her husband signed an agreement 14 years ago supposedly, but the widow was reportedly never aware of the contract. A bit of the disagreement:

My reason for being in Cajamarca this month is to solidify Oregon Direct Action‘s (ODA) project for the month of July. ODA is a student organization I started last May with Shane Lofgren and a few others. It’s based off of my experiences with Whitman Direct Action and concepts around an open source organization. Our goal is to bridge the gaps between education and international development, and use 12 months of effort from ambitious undergraduates to help solve some of the world’s most basic issues. In my opinion, though, it shouldn’t require a month of groundwork to figure out how we can contribute to efforts in San Pablo.

On Thursday, I had the chance to speak for an hour with Mark and Vinay of an innovative organization called Akvo. It’s goal is to open and simplify the reporting around water and sanitation projects and, in the process, improve the capacity of development organizations to achieve their goals. In my opinion, open source means transparency but it also means, and more importantly, open collaboration. By actively publishing what you’re working on, both the successes and challenges, you’re lending the opportunity for others to take part of the project too.

The first thing to address, however, is the paradigm shift from closed to open. In many sectors, it’s a scary thought to go from only publishing information through a communications manager (or some sort of filter) to making as much data available as possible. My opinion is, and I’ll get to this more in a later piece, that transparency is actually a competitive advantage, and that the first organizations to be as transparent as possible will gain an edge. Funders will become addicted to the wealth of information they have to make their decisions, and organizations that open up an order of magnitude more information for the funder to manipulate will be more desirable. Openness builds trust. The way that Akvo is going to be able to “sell” this, however, is by being able to attach some sort of economic benefit to their really simple, open reporting, both in the ability of the organization to generate more funding and also the value in open collaboration with peers, “pro-ams”, and other interested parties.

It’s also my opinion that Akvo needs to be able to sell their service in terms of being explicit about problem(s) they solve. This could be a 30 second video or two paragraphs, but I wasn’t able to find anything satisfactory on the website.

The second issue in opening up information, and making project data transparent, is determining the best format and means for doing so. I would start iterative reporting with the tool that comes most naturally: mobile (SMS, images, and video). Once you have a stream of information coming from a project, then you’ve got to figure out the context filters. When we started thinking about this at ODA, we broke down our data into four tiers: team, partners, community, and world. Of course, all of the information would be open and accessible, but there would be different delivery mechanisms (email, RSS, etc.) for ensuring you only received the information you needed.

It would be wonderful if Akvo could be the open database for synthesizing project information; and as a part of the workflow and processes, structure the project information such that it’s in a digestible, relevant format. It would be a project wiki that has: background information on the area (size of the community, primary livelihoods, average income, etc.), where the project currently stands (most recent updates via a blog and wiki), relevant budget and financial documents, podcast stream of reports from the field, and images and video which are geographically connected to the project. The important thing is that this database would be built on open standards. It should be the engine that connects you with the information you need, based on your context.

The advantages to open in reporting are many. Most significant to my situation is the ability for potential collaborators to contribute to development work. I still consider myself a student, I’m only 21, but I would like to break tradition and continue to learn in higher impact settings through experiential education. Just think of all of the essays that get printed and then go into the trash. Instead, that productive capacity should be put towards the really big problems we have in the world. If we could lower barriers for students to get involved with projects like Green Empowerment’s and others, the consequences could be tremendous. I think open sourcing development organizations one step in the right direction.

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 view of the main street running down Alta Cayma. As the city grows, it expands outwards, and the distance from the center is a decent ruler for measuring socio-economic status. The houses, businesses, and infrastructure closer to the hub are significantly nicer than those in the periphery. Conversely, a view up the street running out of town (from a few blocks higher):

Rural poor come to the city looking for new livelihoods, and the easiest place to start is on the outskirts of town.

Also, a wee little video of the same area.

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!

Haiti’s road to ruin – Straight.com
Haiti’s environmental woes in a nutshell, and how they’re even more applicable after the hurricane.

Why not writing a story is innovation – Publishing 2.0
Down with rewriting and publishing press releases (and other such nonsense)!

The Newspaper Industry and the Arrival of the Glaciers – Boing Boing
Clay Shirky (aka Man of Foresight and Infinite Wisdom) saw all of this happening in 1995, and argues that the downfall of newspapers arrived at the same rate as glaciers. Really, I think this is a telling example of how we need to develop better long term thinking (and acting) abilities.

Peru aims for zero deforestation – BBC
The Peruvian government is requesting $25 million a year for the next 10 years to combat deforestation in the country. Deforestation in Peru contributes to less than 1% of greenhouse gas emissions worldwide.

How Risky Is India? – BusinessWeek
A piece touching the stability of the business climate in India because of the recent violence in Mumbai. Notes events from the last ten years to support the claim that the country might not be as stable for investment as thought. No mention of the environment or state of natural resources, however.

via Publish2

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!

ColaLife is a “campaign to try and leverage the distribution muscle of a multi-national corporate institution to get life saving medicines to children in developing countries.” In short, to convince the Coca-Cola Corporation that it is worthwhile to distribute rehydration salts through their robust and well-developed delivery network, apparently a weakness of most non-governmental organizations. Those spearheading the ColaLife campaign, to my understanding, have focused their advocacy efforts largely online, using a Flickr Group, a Facebook Group, and a Twitter account to raise awareness, organize people, and spread the word. Coverage in traditional media is also a goal, obviously, but it’s interesting for me to watch, among with other reasons, because I think this “social internet” now has the critical mass necessary to be used as catalyst for a singular goal. ColaLife, in my opinion, could be a ground breaking test case.

As a plus, I’ve finally found a good cause for a random series of images I took while in Peru last summer. Sweet, huh?

and India: