ICTUpdate - a current awareness bulletin for ACP Agriculture

A locally developed touchscreen computer system helps to guide staff in rural health centres in Malawi through diagnosis and treatment procedures.

Malawi only has 280 doctors to serve its population of 14 million people (according to WHO statistics). Average life expectancy is just 43, maternal mortality rates are high and an estimated one million people are HIV positive. Since 85% of Malawians live in rural areas, the majority of people receive their medical care in health centres where, on average, one nurse is responsible for the medical needs of 25,000 people. These healthcare workers provide a vital service but to maintain even a minimum standard it is essential that they follow a series of rigorous procedures when dealing with each individual patient.

To support rural health professionals and guide them through diagnosis and treatment processes, Baobab Health, a Malawi-based non-governmental organization, has developed a touchscreen clinical workstation (TCW). The TCWs are more robust than desktop computers or even laptops. They can withstand hot, dusty environments and are less reliant on mains electricity which is very important in many areas of Malawi where the power supply can be unstable and unreliable. The touchscreen system also removes the need for external devices such as a mouse or keyboard.

When a patient visits a clinic equipped with the workstation, a nurse or medical assistant can quickly register the patient and go through a routine series of questions. The software programmed into the TCW ensures that no important details are overlooked. The data captured on the system during patient visits can also be used at the national level for policy making and analysis.

A visit from an HIV positive patient taking anti-retroviral drugs, for example, typically requires 10 to 15 questions like: Able to walk; Evidence of side effects; Number of tablets remaining. The TCW leads the healthcare worker through these questions, analyses the results and recommends further treatment. This allows minimally trained care workers to perform complex diagnoses and treatment for HIV care.

The TCW also helps to improve the accuracy of clinical data gathering, especially when compared to traditional paper form methods. Written details can be inaccurate or misread which can lead to critical mistakes in decision making, but the TCW can validate data as soon the nurse or assistant enters it.

For instance, a child attending the clinic may have a height of 119 cm. A nurse enters the height into the device but accidentally transposes the last two digits, entering the height as 191 cm. Based on the patient's current age, the TCW will alert the nurse that a height of 191 cm falls outside the expected range of height for a child of that age. The nurse can then immediately recheck the data and enter the correct figure. In a more traditional system where the information is captured and analyzed retrospectively it would be impossible to verify the result so quickly.

The nurse is also able to use the TCW to view the patient’s past medical history with, for example, previous weight values displayed as a graph. The nurse can easily see that a child has had consistently low weights, compared to age and height, which could indicate a chronic condition such as failure to thrive due to mother-to-child transmission of HIV. A child with historically normal weight values but a showing a sudden reduction could suffer from an acute condition such as gastroenteritis.

The value of past medical history is not limited to a series of vital signs. The frequency with which a patient has sought care, the nature of past illness, results of laboratory and x-ray or ultrasound investigations and medications prescribed can provide valuable information for managing a patient's illness.

Solutions

Baobab had two main challenges when it came to designing the TCW. Firstly, the device had to be strong enough to withstand regular, daily use in harsh environments. It, therefore, has no moving parts, using a solid state drive instead of the more usual hard disk drive, and it has a fanless cooling system. The device uses a read-only Linux operating system which is less vulnerable to virus attacks and doesn’t allow anyone to save or install unnecessary software or files. This makes it impossible for users to do anything except what the system was designed to do.

A typical clinic would be fitted with one server computer, a battery charger, four TCWs and two label printers, all of which can run reliably for more than 24 hours if the mains electricity supply fails. The server computer uses very little electricity. It has an external power supply with a backup system consisting of four, 12 volt batteries that recharge when grid electricity is available. These batteries need to be replaced every two to three years but new batteries are available locally and replacement is very simple.

The second challenge was to make sure that the device would be easy to use for people with little or no experience with computers. While training people to use a mouse or a keyboard is certainly an important task for the modern age, the healthcare crisis in Malawi requires a more urgent approach. The touchscreen interface means that a literate person can learn to use the workstation with very little training. In fact, a healthcare worker with no previous experience with computers can learn to input data into the TCW within 10 minutes. Colleagues can provide most of the training which removes the need for expensive specialist trainers and courses.

It was important for Baobab that all of the software for the system was developed in Malawi. This has helped to develop local expertise and ensures that on-going development and maintenance can be carried out quickly and easily. The developers released the software with an open source licence and have made the code available for anyone to download from the internet.

Adaptable

Seven sites currently use the TCW for patient registration and they have now registered more than 800,000 people, over 7% of the total population of Malawi. Patient registration used to take more than ten minutes per patient and caused long queues. Now the process takes less than one minute for new patients, and less than ten seconds for returning patients.

Six health centres use the technology to manage the anti-retroviral treatment (ART) of more than 18,400 patients (13% of all patients receiving ART in Malawi). The Ministry of Health has found that HIV clinics relying on paper forms struggle when they have to deal with more than 1,500 patients on ART, but the Baobab ART system allows clinics to reliably handle many more. The largest site using the Baobab system has more than 6,000 patients receiving treatment at this time..

Baobab intend to introduce their ‘point-of-care’ touchscreen devices to more rural sites in Malawi, many of which are off the main electricity grid where the low-power system will run entirely on alternative energy sources, such as solar or wind power. The company recognize too that their approach to managing HIV positive patients could be applied to other chronic illnesses like diabetes and hypertension. They also plan to work more closely with the country’s Ministry of Health to develop a central repository of patient data and provide a mechanism to make the information available between hospitals and clinics.

Pragmatists often argue that money should not be spent on computers when pharmacy shelves are bare. But many people who work in the field acknowledge that shelves are bare not because of lack of funds to buy drugs but because of the lack of systems to manage the inventory effectively. The situation is clearly complex, but it is likely that the solution to understanding these problems will come from trying alternative approaches and learning as we go.

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Michael V. McKay is the lead software developer and Gerald P. Douglas is the founder of Baobab Health