New frontline health service models are introducing a cascade of innovative technologies from mobile payment platforms to telemedicine and enterprise level health record systems.  Yet, what is overlooked, particularly in low-resource-settings is that introducing innovation, and operationalising it aren’t the same thing.  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 non-communicable diseases and implementing universal health care, 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.  An example would be with health data, it doesn’t have to be electronic, but it needs to be accessible and organised and you don’t enterprise level technology for that.

Photos – before and after

Data, Organisation and Information

A main challenge to providing ongoing care and treatment to hospital patients in Ghana is difficulty of retrieving, sometimes locating, patient records in a timely and systematic manner.  A health record is created when the patient is first treated or admitted to the healthcare facility.  On subsequent visits, patients could wait for as long as three hours for records to be located, if they are lucky.  In cases where the records cannot be located, completely new records are created for the patient.   The patient ends up with many records with their medical history scattered in different files and at different locations.  In bigger facilities, the different departments create their own records making clinical decision making and communication among the different clinicians extremely difficult, if not impossible.  In certain situations, the health facilities are compelled to allow the patients to take their records home despite the implications.

The results of the poor records management systems, long waiting times for patients at the records department due to the missing and misfiled records. Storage space becomes a major problem and it is common to see improvised records centres scattered all over the health facility.  This leads to wasted human and financial resources and the loss of revenue.

To solve the problem many facilities have decided to go “paperless” and digitise the medical records system.  Over the years, huge sums of money is being invested in digitisation.  Despite the huge investment there is very little evidence of improved service delivery in the health services. The long queues are still present and patient waiting time has not been reduced any significant.  It is now common to see patients waiting because the system is “down”.  The computer systems seem more to be hindering than helping the smooth delivery of services. What is apparent are the problems and pressures that the computer-based information systems have brought.

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 which are very often not readily available.  Apart from the problem of the lack of accompanying infrastructure such as the regular supply of power, the resource cost, the reliability and cost of wifi and internet connectivity, the maintenance capacity and the employment considerations, the introduction of the technology puts a premium on new ways of doing things, which they are usually not prepared for.

Too often the existing manual system is being digitised without sufficient thought to the objective.  The design and implementation of the organisational changes that are required are often ignored or not properly managed.  Installing electronic systems on top of a collapsed paper based is creating more chaos since this only perpetuates the existing deficiencies.  Technically sound systems end up organisationally disastrous.

An electronic recordkeeping system (ERS) 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 and technology is not the first consideration.  This was done by; reorganising the filing system, considering the backgrounds and capacity of the staff and a strategy to design a system as close as possible to what the staff was using.   The ERS monitors and tracks the movement of records in the department and reduced the average time of file retrieval from three (3) hours to less than ten (10) minutes.  Using bar codes, specific locations are allocated to the health records and with the absence of unique identifiers for citizens, multiple identifiers are used to retrieve records including, patient numbers, names, mobile phone numbers etc.  Misfiling has been reduced to a minimum by marking across the files on the shelves.  The system has been designed to provide information used to consistently maintain sufficient filing room by removing inactive records on a regular basis.  The system promotes the longitudinal health records system where a client/patient uses a single record throughout the various departments and finally it provides the data for the establishment of an electronic medical record information system.

Paper, Printers and Perception

In Kenya, ultrasound technology is available, it 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 urban centres like Nairobi and rural health centres often cannot afford to purchase ultrasound systems.  Public regional hospitals have imaging services but typically the queues are long and so the hours of travel time are likely met with an equivalent wait time.

In low-resource health settings, the lack of resources is a bit more complicated than merely a lack of resources.  Often it is an asymmetry of resources, without the appropriate staffing through training and certification, 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.  Our ability to bring limited antenatal screenings to communities that typically would not have access to affordable quality care is enabled by technology but dependent on training and logistics.  Our midwives were trained and certified by GE East Africa to perform limited antenatal ultrasound screenings using GE portable ultrasounds.

Our limited antenatal screenings were designed to leverage technology in a way that we could affordably offer quality point-of-care imaging services.  We would 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 would upload the scans to our partner, Whitekoat, in California.  Over the next 10-12 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 very few have smartphones and even fewer rural clinics have wifi.  So despite Kenya’s has a 95% penetration of mobile phones paper remains the medium of health records.

When we first demonstrated our portable scanning services the validity of our services was strongly questioned; not because of they doubted the ultrasound machines or training certification but because of the paper.  Using regular A4 paper had invalidated the credibility of the scanning service.  By not providing the images on thermal paper, a medium the administrators equated with credible imaging services, our whole service was viewed as substandard.  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 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.  Designing a system that would reduce paper files is exactly a system which the rural community health providers would not accept.

The redesigned service model is far from elegant, but the process allowed us to operationalise technology built on a foundation of trust and provider acceptance.  The antenatal ultrasound images and the patient report are saved and brought back to our clinic. We then organise the antenatal scan images on a laptop and then print them out on photo paper.  Printing photos requires a photo printer, ink cartridges and photo paper which per sheet is about seven (7) times more expensive than printing it on regular A4.  We then arrange via motorbike to courier back the patient files to the rural clinic.  The saved images are then uploaded to the Synapse platform.

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