A simple way of looking at the health systems in developing economies’ health systems is a series of levels between the center and the periphery. Workers at the periphery are usually the point of contact between the health system and the population to whom the healthcare is delivered. The closer one gets to the periphery–what we call frontline health–the clearer the limits to the availability of professional technical staff and equipment are obvious.
New frontline health service models are introducing a cascade of innovative technologies from mobile payment platforms to telemedicine and enterprise level health record systems to the various levels of the health system. Yet, what is overlooked, particularly in low-resource-settings is that introducing “state of the art” innovation, and operationalizing it are not the same things. We often leap into the “how” before we have achieved competency in “what” we are trying to do.
In health, inefficiency and poor management can mean a loss of life, not just market-share, and as African health systems face an evolving set of challenges such as noncommunicable diseases and implementing universal health coverage, management and operations are critical to getting more out of limited resources. Sometimes all you need is to improve what you do; and increasing the efficiency of low-tech is the breakthrough. A prime example is with health data: It doesn’t have to be electronic, but it does need to be accessible and organized–and you don’t need enterprise level technology for that.
Data, organization, and information
A main challenge to providing ongoing care and treatment to hospital patients in Ghana is the difficulty of retrieving, or sometimes even just locating, patient records in a timely and systematic manner. When the patient is first treated or admitted to the healthcare facility, they get a health record. On subsequent visits, patients can wait for as long as three hours for records to be located–if they are lucky. In cases where the records cannot be located, the clinic creates completely new records for the patient. The patient ends up with many records, their medical history scattered in different files and at different locations. In bigger facilities, the different departments each create their own records, making clinical decisions and communication among the different clinicians extremely difficult, if not impossible. In certain situations, the health facilities are even compelled to allow the patients to take their records home.
The result of this poorly designed system are long waiting times for patients at the records department due to the missing and misfiled records. Storage space also becomes a major problem and it is common to see improvised records centers scattered all over a health facility. This leads to wasted human and financial resources, and a loss of revenue.
To solve the problem, many facilities have decided to go “paperless” and digitize their medical records system. Over the years, huge sums of money has been invested in digitization. But despite the investment, there is very little evidence of improved service delivery. The long lines are still present and patient wait times have not been significantly reduced. The computer systems seem more to be hindering than helping the smooth delivery of services: It is now common to see patients waiting because the system is “down.”
Health facilities are learning the hard way that developing computer-based hospital information systems is not a trivial task. Managing the technology itself is a complex task and demands its own expensive specialists, who are very often not readily available. Apart from the problem of the lack of accompanying infrastructure–irregular supply of power, poor reliability and cost of Wi-Fi and internet connectivity, and need for the maintenance–the introduction of the technology puts a premium on new ways of doing things, which the facilities are usually not prepared for.
Too often, the existing manual system is being digitized without sufficient thought to the objective. The design and implementation of the organizational changes that are required are often ignored or not properly managed. Installing electronic systems on top of a collapsed paper-based system just creates more chaos, since this only perpetuates the existing deficiencies. Technically sound systems end up organizationally disastrous.
But a less flashy solution works much better: An electronic records management system (ERMS) designed to manage the manual health records from the creation to final disposal has proven to be very successful and has been in use in some hospitals in Ghana since 2011. This was done by reorganizing the filing system, considering the backgrounds and capacity of the staff, and then designing a system as close as possible to what the staff was using. There are still physical records, but the ERMS uses bar codes to monitor and tracks their movement, so staff always know where to find them. This reduced the average time of file retrieval from three hours to less than 10 minutes.
Paper, printers, and perception
In Kenya, ultrasound technology is covered by the National Health Insurance Fund and teleradiology systems and businesses are streaming in from the Middle East. But the services and the imaging technicians, sonographers, and radiologist are clustered in large cities like Nairobi and rural health centers often cannot afford to purchase ultrasound systems. Public regional hospitals have imaging services, but typically the lines are long. Coupled with the hours of travel time to reach the clinic in the first place, it means patients often have to spend inordinate amounts of time to get an ultrasound.
Often the long wait times are not just because of a shortage of machines, but an asymmetry of resources: not having the appropriate staff who have been trained and certified while medical devices sit idle or are improperly used, creating false-positives and generating unwarranted costs and draining health system resources.
At ReaMedica Health, we provide diagnostic services and maternal health education. We provide limited ultrasound screenings to communities that would not have facilities with ultrasound services nor services that are affordable to the communities. Antenatal ultrasound screenings depend on technology, but can only be safely provided by trained medical professionals. Our midwives are trained and certified by GE East Africa to perform these ultrasound screenings using GE portable ultrasounds.
Our antenatal screenings were designed to leverage technology in a way that we could affordably offer quality point-of-care imaging services. We perform the scans and Bluetooth transfer the images to an expectant mother’s smartphone, transfer those images to the rural clinics’ record systems and then return to our facility, where we strip the images of any patient information and then upload the scans to our partner, Whitekoat, in California. Over the next 10 to 12 months, a machine-learning system will be developed via Whitekoat’s Synapse platform to improve the quality of our point-of-care scan services by independently examining the images. But the on-the-ground reality is that data plans are expensive and few rural clinics have Wi-Fi. So despite Kenya’s 95% penetration of mobile phones, paper remains the medium of choice for health records.
When we first demonstrated our portable scanning services, we got a lot of questions about the validity of our services. Not because they doubted the ultrasound machines or training certification, but because the paper we printed the ultrasound images on was regular paper. Using regular A4 paper had invalidated the credibility of the scanning service because some health officials and administrators have only ever encountered ultrasound images on thermal paper. The first test of credibility for clinics and administrators is not the image quality but the type of paper the images are on. We had failed the tactile test of quality: the look, feel and familiarity of thermal paper printouts.
Learning from the Ghana example, we deconstructed our imaging service to be as close as possible to what the standard practices are in the provider community. Providers serving impoverished communities use paper files, not electronic record systems, and the patient will need a physical file with the scan images if they are referred or if they intend to deliver in most public facilities. A system that would reduce paper files is exactly a system which the rural community health providers would not accept.
So based on the poor reception, we had to redesign our service model. And rather than a perfect solution, we tried to be less wrong. We now print our images using a photo printer and glossy photo paper (despite the fact that printing on a photo printer is about seven times more expensive than printing it on regular paper). The redesign is far from elegant, but image printouts on glossy photo paper are familiar, accepted, and trusted by providers. The ultrasound screening images and the patient report are saved and brought back to our clinic where we organize the antenatal scan images and then print them out on photo paper. We then arrange a courier to take the patient files back to the rural clinic. The saved images are then uploaded to the Synapse platform.
Health innovations in the developing world must support the overall objectives of improving service performance. The introduction of innovations usually require changes in the working processes. In managing those changes in low-resource settings, it is critical to achieve the right mix of the technology and manual systems–and to ensure that the changes are going to be accepted by the workers. Otherwise, even the smartest innovations will sit, unused, not helping anyone.
Prince Boni is the executive director of Tabs Consult. Michael Seo is the managing partner of ReaMedica and ReaMedica Health Kenya.