First stage of MobilizeMRS research

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.


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  • Es Salud: if you work in the formal sector and get taxes withdrawn from your pay, then you are eligible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.


Isaac Holeman January 18, 2009 Reply

Hey Daniel,

Interesting post. I was also under the impression that there were more community health/social workers there. If you’re thinking about FrontlineSMS before any electronic health record is in place, I think communicating with patients is a good thing to explore. It’s huge that (unlike Burundi) so many patients in Peru have their own cell phones. If you want to look into providing incentives for timeliness, you should check out X out TB.

If they are looking to do OpenMRS + FrontlineSMS, the possible use cases definitely change, and there is a lot you could do for rural health care regardless of whether they have a community health worker focused model of care. Keep us posted on the OpenMRS conversations.

Daniel January 18, 2009 Reply

I was under that same impression, too. I’m thinking FrontlineSMS before a medical record system because it has a low barrier to entry, but the big thing is that this is an entirely different scenario than Mobiles in Malawi or the other healthcare implementations I know of.

The clinic is definitely going to be moving to electronic medical records, but they’re not entirely sold on OpenMRS for primary care. It’s yet another thing I have to do more research into.

Josh Nesbit January 18, 2009 Reply

Hi Daniel,

Great to read updates on your work. I have a few questions, looking over the info you’ve provided.

– What sort of area is the clinic serving? How far are patients traveling?

– How many other private clinics (of the 500-700) lie within your clinic’s catchment area?

– What are the costs, per SMS?

I like the idea of utilizing texting to provide more structure for follow-ups. What’s the breakdown of peds treatments and reasons for follow-up appointments?

This is (potentially) a great opportunity to explore patients as end users (those with phones, interacting with FrontlineSMS), as opposed to community health workers. This model is used in different fields (e.g. media outlets), but you’d be the first to apply it to primary healthcare.

Looking forward to hearing more!


Daniel January 23, 2009 Reply

@josh, re: other private clinics in the area, there are only two or three. I’m unsure as to whether these are clinics for the social good, or clinics for those who have money however. Costs per SMS are around USD $.03. The majority of the visits to the clinic are pediatric, although Wayne says that the proportions are changing.

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