Saturday, November 3, 2007

So, what are you gonna do?

Before I jump into my latest entry, I wanted to share with you maybe the greatest picture I've ever taken. We met this fellow on an adventure we took a couple of weeks ago. I'll let you know more about this guy and what we were doing there next week. For now, onto the question at hand: what are you gonna do?

Depending on who we were talking to, this question was usually somewhere around the tenth folks would ask us after we told them we were going to Mozambique: “So, Kevin, what are you going to be doing while Lara is working in the clinic?” Generally my response went something like “Ha! Good question!” And it was, because I really didn’t know. Everyone would laugh, but occasionally someone would ask, “Seriously, what are you gonna do?”

As evidenced by a recent conversation I’ve had with our friend Jeremy (of the Vienna Wilsons), people obviously still wonder this a lot. Luckily, I think I’ve finally come up with an answer: information technology.

Yeah, that’s right, computers. Here in the third world. They’ve got them, you know. Some of them even speak Portuguese. And they go along way to helping people get better.

Here’s how it all works: everyone understands how medical practitioners (doctors, MAs, NPs, etc.) can help people. Also, you may be familiar with the role of community outreach. For instance, we have people here whose job it is to take medicine and food to people who aren’t able to leave their homes. They also go find people who haven’t shown up for their appointments for whatever reason (it’s too far to travel, they're too sick to travel, they died, etc.) Both of these direct-care roles are made much easier by what is known as a Medical Records System (MRS for short).

Let’s say you go to your regular pharmacy to fill a new prescription. After your pharmacist looks up your records on his computer, he types in the new prescription and a red light goes off: this medication will react with another medication you are currently taking. This simple example is how medical records systems can save a life.

MRS is usually a database technology that stores patient information and all of the definitions that are required to make sense of that information (i.e. patient x has y disease, we are treating him with z drug, he came here first on this date, and is due back on this date). So MRS can keep track of an individual patient’s records, but why does that matter in our setting? To understand that, you have to understand the importance of adherence in an antiretroviral (anti-AIDS) drug regimen. (big thanks to Lara for technical direction on these next few paragraphs)

Just like there are different bugs that are all “the cold”, there are different subtypes of HIV virus that are all “HIV” (“the cold” is actually different viruses, but this comparison works for us). Some subtypes of HIV are more common than others, and different types of HIV can be treated with different drugs. One patient usually will carry several subtypes of HIV that are in competition with one another, and all of these subtypes are constantly mutating in the body. A patient is generally given multiple drugs to attack various subtypes by various means, but as all of the subtypes mutate they can change in ways that can make them less susceptible to the drugs that currently exist.

When you treat someone for HIV (or any other infectious disease) you are killing the bugs you know how to kill but clearing the way for the bugs we don’t know how to kill. That’s usually not so bad because most drugs will have some effect on all of the HIV, and the patient will get better. However, when you stop taking that drug, the first bug to come back is the bug that hasn’t been directly suppressed (the mutated bug that is less susceptible), and restarting the drugs will have less or no effect on that subtype of HIV. Then we’ve lost that drug for that patient and we have to switch to different (and usually more expensive) drugs.

This is a particular problem for tuberculosis care. TB is really good at mutating. Whenever you let up on a treatment, the bugs that survived your last attack grow back fast. This is how nightmares like MDR (multi-drug resistant) and XDR (extremely drug resistant) TB get started. People start taking drugs, then stop, then start back and stop again. They continue down this cycle until the type of TB they have resists most (if not all) of the drugs we have. Then they give it to someone else and suddenly there’s a new TB strain that we can’t stop.

(PUBLIC SERVICE ANNOUNCEMENT: This is why your doctor always tells you to take all of the antibiotics prescribed to you. We don’t want a mutant pneumonia epidemic. Take all of your medicine! And don’t insist on taking antibiotics when you just have a cold, even if it lasts for 2 weeks. They won't help.)

How can technology help with this? Folks here are only given a limited amount of medication at a time, and they have to come back to the hospital to get more. If they don’t show up for their next scheduled consultation, our computers send up a red flag and we send a community outreach person to go find them and find out what’s going on. Often that leads to treatment, education, or home-based care, and we can keep fighting the bugs.

The other way to use an MRS is epidemiological information. If we have all of the information for all of the patients in the whole district, we can know what diseases are more prominent in that particular district and plan to get medications there for that problem. Also, we can keep up with patient indicators on a large scale and see if we are doing our job correctly.

One excellent example of MRS helping in the third world is the story of OpenMRS in Kenya. It’s a magnificent program. You can watch a video about it by clicking here. It’s a 50-minute PowerPoint presentation that gets a little technical towards the end. Don’t watch it all, but please take a look because it goes a long way to explain what people like me can do in the third world.

OpenMRS ss great because it’s open source. This means that it’s free in both meanings of the word: free like free pizza and free like freedom (thanks Eric). This is great for two (duh) reasons: first, we don’t have to pay to install it or pay licensing fees. Also, it’s free in the sense that you can change it to suit your needs (which you’re not allowed to do with proprietary programs like Microsoft’s Access). So if you want to have a feature that doesn’t exist, we can alter the program itself however we want it. For example, it could know patients’ families. If your aunt has TB, your doctor will ask you when the last time you visited her and get you tested.

Speaking of changing the program, the spirit of OpenMRS falls directly in line with our mission here. Coming to Mozambique and fixing their problems for them is fine, but what are they going to do when we leave? Not only was OpenMRS written to be rewritten for specific needs, it’s meant to be changed and managed by the people it serves. Relief organizations always strive for sustainability; the success of the project shouldn’t depend on the presence of the organization. What better way to involve and empower the educational infrastructure of Mozambique than to have them write and maintain their own MRS system?

Now all of these ideas are wonderful, but as it stands right now we have some health posts that don’t have electricity or running water. That makes it kind of hard to implement a network-based MRS, so Friends in Global Health is getting these places wired up. For instance, we’re talking with a company that can supply solar panels to charge car batteries that run the lab machines and computers out in the districts. In the most remote places, we’ve met with companies that can provide satellite Internet at DSL speed. It’s really expensive, but it could allow a medical technician in Gíle to send a patient’s X-ray to a doctor at Vanderbilt for a second opinion. It’s called telemedicine, and it rocks.

My own work is based in this system. Since there are going to be computers in every health post we operate in, why not get all the folks who work there on them? I’m developing a simple version of what’s known as a Learning Management System (LMS). If you’ve ever taken an online class, you’ve used one. It’s essentially an online training program. We’ll be modeling ours after the continuing medical education programs that health professionals in the US use. All the local people who work for us (nurses, technicians, lab folks, data managers, etc.) will have an account and they will be assigned digital classes they have to take. The doctors that we send out there will be able to create new classes when they see a need and upload it to the system. We’ll give tests and evaluations, and those scores will be available to our administrators anywhere they have Internet access.

So that’s what I’m doing here, and that’s why I haven’t blogged for a month. I’ve latched on to the IT guys and I'm keeping myself busy learning computer languages. It’s incredible how much you can find out on the Internet. I’ve been reading about eight hours a day all month. It’s a lot of work, but it will hopefully be something that can impact healthcare in this region for a long time.


Anonymous Anonymous said...

You Go Boy!!! I knew you would find your nitch!! It is so awesome that you two are actually able to do something that really "makes a difference". What a special opportunity you've been given that so many of us could only wish for. We love you & look forward to more....Aunt Margaret

November 3, 2007 at 5:17 PM  
Blogger Mac said...

Wow...and I had trouble when Yahoo changed its email format! I showed my mom and sister Angela (who you two need to meet as soon as you come back...she is fun) the dancing and drum video on YouTube. Then today I thought of you both because I went to a performance put on by Rwandan children here in Chattanooga that had drums, dancing, and singing. Keep posting videos! You guys should do video blogs and give us a virtual tour of your humble abode. I want to see the giant bats! Love you guys!

November 3, 2007 at 6:39 PM  
Blogger Laine said...

Reading this, I can feel your excitement about this project. All I can say is, "HOW WONDERFUL"! A new marriage, a new country, a new project that will make a difference is a "my cup 'runneth' over" life, one that we all can appreciate. And as a photographer, I must say that the photo of the child is GREAT. He is either excited about life or he caught from you.
Thanks for taking the time to write and take care.

November 4, 2007 at 7:09 AM  
Blogger Linz said...

This sounds like an amazing new and Lara are truly going to change the lives of the people of Mozambique. What a great opportunity! I love and miss you both...Linz

November 7, 2007 at 7:33 PM  
Blogger Burke said...

Kevin, very nice blog. Paul stumbled upon it and shared it with me. OpenMRS would be honored to have your help. Obrigados!
FYI- there are some folks working on OpenMRS implementations in Mozambique; we'd be happy to get you in touch with them if/when you like (you can reach us via paul or burke at openmrs dot org).

In any case, best wishes to you and Lara. Keep up the good work!

November 7, 2007 at 8:56 PM  

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