One thing that’s caught my attention as we walk the streets of Huaraz is how many Chinese _____ there are. Chinese restaurants, Chinese medical clinics, etc. It would be interesting to study cultural influence as a function of languages used in public signage.
It’s easy to lose sight of the bigger picture in the smog of every day busyness. Constant emails and things to do can point you in a direction you simply assume is progress.
Project shipped — on to the next one. Always working towards more, better, faster. Busy, busy Baxton.
In some senses, I think connectedness makes us a surrogate for the goals of the network. We lose our individuality. I have always been a wanderer, and even I have been subsumed.
Tonight, I’m flying down to Peru to meet up with Leah and do some good old fashioned trekking. She’s been in-country since last week, working up a storm. I hear Belen Hospital may even soon have a website on WordPress.com. We’ll meet in Lima and take a bus to Huaraz.
Huaraz is known as one of the best launch points in South America for outdoor adventure. It sits at 10,000 feet in a valley nestled between two of the tallest mountain ranges in the world. We’ll spend a day or so getting our gear together and adjusting to the altitude. Once we’re ready, a three or four day trek on the Santa Cruz trail awaits.
For reading material, I have William Hertling’s AI Apocalypse (sequel to the epic Avogadro Corp.), Vikram Chandra’s Sacred Games, and Cutting for Stone by Abraham Verghese. To occupy the hours of walking and dinners made over a camp stove, I have the best traveling companion in the world.
The unexamined life may not be worth living, but I find it harder and harder every day to put aside time to examine it. Fortunately, there are still many adventures to be had. In those adventures I can find the opportunity to wander.
¡Hasta luego! See you all on the 29th.
Last Wednesday, I had the opportunity to travel again with Green Empowerment and check out the water project in progress in the community of Suro Antivo. Through a combination of municipal and foundation funds, the small collection of houses is finally going to receive safe and reliable water access to their households. To date, most families have to get their water from unimproved sources. There are two tanks being built, and one being refurbished, which will supply water to each house through a gravity-fed system:
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:
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:
According to the doctor, the basic needs of a medical records system are three-fold:
- 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.
- Networking – an EMR should lend accessible communication, both internally (within the clinic) and externally.
- 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:
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.
In about a half hour, I’m headed on Continental Flight 308 to Houston, hopefully ending up in Lima at some point tonight. The plan as it stands now is to spend two months in Peru enjoying the summer and working on a few different projects.
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.
Of interest in the past week:
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.
The cool thing about grants is that they will often fund the neat idea you have. The not-so-cool thing is that they generally take a lot of work and luck to be accepted.
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!