developing countries hardware history open source presentation ruby on rails touchscreen volunteer Mike McKay recently took Baobab on the road, after being invited to speak at RailsConf Europe. He went and told the Ruby on Rails world about how rails is helping to fight HIV in Africa. He brought to life the HIV epidemic and showed how healthcare workers are being guided through treatment protocols and getting decision support from the data in realtime. Check out the slides from “Africa On Rails” for more information.
September 28th, 2007
developing countries eVCT documention hardware software touchscreen vct vct videos In 2004, Baobab introduced a radically different methodology for using information technology (IT) within the VCT environment. Baobab’s eVCT system essentially eliminates the paper-based entry method with a computer-based model that is more accurate and flexible than the paper-based model. Most importantly, the solution is locally designed and implemented to meet the constraints and challenges of a developing world hospital.
This video presents the results of an independent analysis conducted on both counselors and clients that used the system.
To view all of our videos on the HIV eVCT System, click here.
Click here for our write-up of the Baobab HIV eVCT System.
August 31st, 2006
appliance developing countries eVCT documention hardware software touchscreen vct videos video In 2004, Baobab introduced a radically different methodology for using information technology (IT) within the VCT environment. Baobab’s eVCT system essentially eliminates the paper-based entry method with a computer-based model that is more accurate and flexible than the paper-based model. Most importantly, the solution is locally designed and implemented to meet the constraints and challenges of a developing world hospital.
This video demonstrates the registration functionality of the eVCT system.
To view all of our videos on the HIV eVCT System, click here.
Click here for our write-up of the Baobab HIV eVCT System.
August 31st, 2006
CD4 Instrument Interface developing countries hardware software In developing countries test results obtained from laboratory instruments are typically transcribed by hand onto a reporting form and recorded in a lab register for redundancy and possibly subsequent statistical analysis. This process has a number of weaknesses:
- Recording the same data in two different areas is inefficient and makes poor use of technicians’ time in an area where human resources are generally inadequate to start with.
- Transcription from the instrument to paper is subject to error. Misreporting of lab results can lead to an intervention not been made when it should have been (e.g. Hb reported as 9.5 when it was actually 5.9 so transfusion not done) or an intervention being made when it was not necessary. The consequences of misreporting can be costly as well as dangerous to the patient.
- If results are to ultimately end up in electronic form, whether it is an onsite laboratory information system or an electronic medical record at the care provider, the data will need to be entered into a computer. This provides a second opportunity for the introduction of errors.
The scale-up for the treatment of HIV in the developing world has presented challenges in the management of CD4 data. In a review of procedures currently used by a central hospital laboratory in Malawi that processes approximately 150 blood specimens for CD4 counts per week, information about the patient and their lab results are transcribed (computer to paper, paper to paper, or paper to computer) a minimum of four times between the time in which the blood sample is sent to the lab and when lab results are sent back to the clinic. As noted above, this is not only an inefficient process but repeated transcription increases the likelihood of transcription errors.
While CD4 instruments are increasingly being deployed to meet the challenges of treating HIV, there is minimal investment in the accompanying hardware and software to interface with the instrument. From the perspective of an audiophile this is analogous to having a high-fidelity sound system but living next to an amusement park. The noise confounds the process. The consequences of mismanaging CD4 data include having to repeat a test (wasting reagents and human resources), starting a patient on ART when not appropriate, not starting a patient on ART when appropriate, and changing or maintaining a regimen inappropriately.
August 30th, 2006
appliance challenges developing countries eVCT documention hardware hiv power server software touchscreen vct
Traditionally, a VCT Center in Malawi uses a paper-based system for collecting data during a counseling session. Essentially, a counselor writes down answers to specific questions on a multi-page form during the session. These forms are then manually re-keyed into a personal-computer based system by a separate data-entry clerk; this system is then used to generate monthly, quarterly and annual reports. The paper-based entry is filed for future reference.
This approach has significant drawbacks:
- Data completeness: During the VCT session, the counselor may leave blank entries in a form, either intentionally or unintentionally. This would most likely not be caught until the data re-entry phase, at which point it is significantly harder to get the information (e.g., the patient may have left, the counselor may confuse sessions when trying to recall the answer, etc.)
- Data validation: During the VCT session, there is no validation that the answers being entered are correct. For example, a patient could be listed as “male� and “pregnant�. If this discrepancy is caught during data re-entry, it is likely much harder to resolve the discrepancy, assuming that a) the data entry clerk catches the error and b) is motivated to resolve the discrepancy instead of simply entering bad or false data (e.g., assuming that the patient was male and therefore not pregnant instead of female and pregnant).
- · Data Re-entry: Re-entering data from a form to a computer increases the risk that data is being captured inaccurately and there are limited ways of validating that it was entered correctly.
- Multiple data sources: Once data is entered and a form is filed, there is a high likelihood that there are discrepancies between the paper form and the computer system. More importantly, when attempting to do analysis or reporting, it is difficult to determine which system has the most accurate information.
- Limited re-use of data: Traditional VCT systems are not designed to connect to additional IT systems (e.g., ART programs). In addition, given the dual-entry required, it is more complicated to change this system than if it was entirely computer based.
In 2004, Baobab introduced a radically different methodology for using information technology (IT) within the VCT environment. Baobab’s eVCT system essentially eliminates the paper-based entry method with a computer-based model that is more accurate and flexible than the paper-based model. Most importantly, the solution is locally relevant, designed and implemented from the ground up in Malawi with local staff to meet the constraints and challenges of a developing world hospital. For example, Baobab places a strong emphasis on keeping costs low by using locally bought parts, open-source software and a number of internally developed innovations.
At a high level, an eVCT implementation provides a counselor with a touch-screen based appliance which they use for real-time data entry. The graphical user interface is intuitive for a novice user; we have quickly seen new Baobab appliance users enter data at virtually “touch-type� speed with a little practice. The appliance guides a counselor through a counseling session sequentially; this approach ensure data completeness, as well as internally logical responses (e.g., a male can’t be entered as pregnant). Every counselor’s appliance is connected to a battery back-up system which can power the system for over 10 hours without grid power; the back-up battery system is also capable of powering the central server which captures the data.
Each component of eVCT was designed with a keen eye towards local applicability, low cost and either redundancy or ability for “plug & play� replacement. Specific examples include:
- Appliance instead of a personal computer: Baobab has developed a low-cost and application-specific appliance for data entry with touch-screen functionality. This appliance is used at the reception for registering a patient, testing lab and clinic for entering information, and in each of the counseling rooms. In addition to costing less than 15% of a personal computer, this appliance has additional benefits, including a) low power consumption enabling future integration with renewable energy sources such as solar power, b) is powered through its Ethernet connection, greatly simplifying deployment by not requiring an outlet, and c) has no useful utility other than VCT, thereby reducing the risk of theft.
- Redundancy through low-cost computers for server: Baobab is leveraging a low-cost implementation of RAIC (“redundant array of inexpensive computers�) for its central database server which stores and manages data. Baobab’s current incubation has a small footprint to reduce shipping costs and storage space, uses 5% of the power of a traditional server-class computer, can easily run from battery backup or multiple power sources, is widely available and inexpensive, and matches the IT needs of the eVCT application.
- Deep-cycle batteries instead of universal power supplies at every point of failure: Baobab has developed and deployed a deep-cycle battery system to provide continuous back-up for extended power outages – up to 10 hours or more from one charge. Baobab’s battery backup system is designed on locally sourced and maintained batteries which are also significantly less expensive than traditional UPS backup systems (which typically have a 15 minute or so power backup ability).
Most importantly, Baobab technology has been deployed and proven in a number of applications, including Pediatrics, Registration, Pharmaceutical Management, and HIV/AIDS treatment, among others. Baobab is continually refining its technology and implementation model based on feedback from users, innovations and incubation projects from its staff, and input from partners. Finally, the overall cost of a complete eVCT system is cost-competitive with a paper-based system (which requires investment in a personal computer and associated software and technology).
The eVCT system is currently being used at the following locations:
- MACRO (Malawi AIDS Counseling & Resource Organization): Deployed in 2004; currently spans 3 counseling centers, has 25 workstation appliances and counsel approximately 50-75 clients per day.
- The Lighthouse (Kamuzu Central Hospital): Deployed in 2005; currently has 7 workstation appliances and also counsels approximately 50-75 clients per day.
During the pilot implementation of eVCT at the MACRO location, a study was conducted to assess the impact of the system implementation on a paper-based site. The study concluded the following:
- Using an anonymous questionnaire, the VCT providers (receptionist, counselors and lab technicians) were surveyed after the system had been in place for five months. The response rate was 12/14 users. Results were:
- All 12 respondents reported they preferred to use the touchscreen system versus paper forms.
- All 12 respondents reported the touchscreen was faster to complete than paper
- Of the 12 respondents, 11 reported having occasional technical problems, primarily related to prolonged power outages. Based on this feedback, the UPS-based back-up system was replaced with the deep-cycle battery technology innovation
- In addition, exit interviews were conducted with 60 clients.
- Responses indicated that the introduction of the touchscreen computer into the counseling session had no negative impact on the counseling process.
- Twenty-three clients (38%) reported not noticing use of the touchscreen computer during the VCT session
- Negative feedback received through open-ended questions focused on issues unrelated to the use of the touchscreen during VCT, such as long wait times at the VCT center.
For the complete documentation on Baobab’s HIV eVCT System, see the following document: Deploying Baobab Health Partners HIV eVCT System
August 30th, 2006
care database developing countries hct open source openmrs software vct vct openmrs migration The Baobab Voluntary Counseling and Testing (VCT) System is currently used in more than ten sites throughout Malawi. It allows clients to anonymously be tested for HIV, Tuberculosis, and other diseases. Registration clerks, counselors and lab technicians enter the collected information into Baobab touchscreen systems in real time. Though counseling, referrals, and general awareness are the primary goals of any VCT centre, data collection and analysis are a close second.
Until now, Baobab has used a proprietary data model for all of the data collection. With the latest release, Baobab has developed a set of SQL scripts that allows existing VCT deployments to migrate their data to the OpenMRS data model. By registering triggers in the MySQL database the system can continue to update the OpenMRS database as the VCT data is updated. This allows site facilitators to utilize open tools for analyzing the VCT data.
Why Choose OpenMRS?
The Open Medical Record System is a common framework upon which medical informatics efforts in developing countries can be built. It is currently in use in Rwanda and implementations are being built around the world. Using a shared data model across disparate installations and regions enables wider analysis of successes, failures, and general trends. The shared data model will enable each site to improve care based on the comparable results, successes, and assessed need making a better experience for each client.
Get the Code
Baobab has published the code under the MIT license on Google Code.
August 30th, 2006
developing countries history projects History
Baobab Health Partnership was founded by Gerry Douglas and Dr. Thuy Bui in late 2000 as a direct result of their work with the health care system in Malawi between 1995 and 1997. Baobab’s first project was the development of a touchscreen-based patient management information system in the paediatric department of Lilongwe’s main hospital. The goal was to provide “proof of concept� for the use of appropriately engineered information technology by clinicians to improve the completeness and accuracy of data routinely collected for national level planning.
The concept was proved, and subsequent projects included modules for other hospital departments as well as highly specialized systems for VCT and HIV treatment. Over the course of the past six years, the hardware and software has been continually improved and a host of other technologies have been added to the Baobab toolkit.
Most recently the Baobab real time patient management system has been demonstrated at various international conferences (like PEPFAR, ART-LINC). Interest levels have been high, particularly due to the ease at which data is captured, and there are now a number of requests for similar systems to be deployed in other developing countries.
August 29th, 2006
developing countries hardware server High system availability is critical in settings where computer downtime would have a negative impact on operational goals. Such mission-critical settings include air traffic control, banking and nuclear reactor control. Server class computers differ from generic computers in that they have features that contribute to high availability (maximizing server uptime).  High availability is generally achieved through the use of redundant components. The two most important components of the system that are redundantly replicated in server class computes are the power supplies and the hard disks, these being the most common elements to fail. Server class computers typically include a large amount of disk space and memory as well as fast processors in anticipation of supporting hundreds of potential users. Such configurations are typically large making them hard to transport and expensive to ship, consume large amounts of power (300 Watts or more) and have a starting price of approximately $1,500 (US price, shipping not included).
Baobab systems are real-time systems. That is to say, clinicians will use the system while seeing patients in the clinic. Any gaps in system availability will almost certainly have a negative impact on data capture. Consequently high availability is a key requirement. Many of the other features that accompany redundant power supplies and hard disks, however, such as large amounts of disk space (150GB and upward), large amounts of memory (2GB), and high speed processors are often unnecessary if the average number of potential users is 5 (not expected to exceed 15 at the largest sites). Furthermore, these features unnecessarily increase the physical size of the computer, the cost (initial purchase and shipping) and greatly increase the power consumption of the computer.
Baobab has developed a solution that provides high availability server capabilities for a fraction of the cost, size and power consumption of off-the-shelf server class computers. The solution is based on a technique called “redundant array of inexpensive computers� (RAIC). With RAIC, two or more computers are configured to operate redundantly, thus achieving high availability. Baobab has selected the Hewlett Packard eVectra legacy computer to be used as a RAIC component computer. The eVectra has several features that make it highly suitable for this application:
- Small footprint (30cm x 30cm x 10cm) – Greatly reduces shipping cost and storage space required on-site.
- Low power consumption (approximately 17 Watts compared to roughly 300 Watts used by server class computers) – Greatly lengthens system runtime on backup power.
- Run from an external power supply similar to that used on a laptop computer – Allows for dual or triple redundant power to be added with minimal effort and expense. Additionally can be run directly from the battery backup system (more efficient).
- Inexpensive and widely available on the used market – Reduces cost and simplifies procurement for wide scale deployment.
- More than adequate speed for database application – Matching the hardware with the specific needs of the task provides the optimal cost benefit.
August 29th, 2006
developing countries hardware power The challenges to providing constant and stable electrical power are many. The classic approach to maintaining power during short-lived power outages is through the use of uninterruptible power supplies (UPS). When mains power is available a battery within the UPS is under constant charge. In the event of a power failure the electrical energy stored in the battery is converted from DC to AC to power the computer. Unfortunately UPS technology is poorly suited to applications where prolonged power outages (greater than 15 minutes) occur. Additional drawbacks to using UPS technology in developing countries are the lack of infrastructure required to repair them when damaged and the lack of availability of the specialized batteries contained within.
An alternative approach is to use locally available deep-cycle lead-acid batteries. Storage of electricity through the use of such batteries is a far more cost-effective solution. Comparing the cost of a UPS battery with a deep-cycle battery is illustrative. The cost of a 12V, 7 Amp-hour (Ah), Gel Cell battery for a UPS costs approximately $25 in Malawi (~$3.58 per Ah). A 12V, 96 Ah deep cycle battery is approximately $110 (~$1.14 cents per Ah), a factor of 3.1 times cheaper based on storage capacity. Additionally the local capacity to repair UPSs in Malawi is extremely limited.
Baobab has developed a cost effective solution to provide multi-hour battery backup. The system is based on a telecommunication standard of 48 Volts DC derived from a set of four deep-cycle batteries connected in series. Batteries are charged from mains power when available. In the event of a power failure the batteries provide DC backup power to all essential system components. The charger and four batteries are installed in a locally built steel cabinet to prevent against theft (Figure 1). The system was first implemented in January 2005 and is now in use at 4 sites in Malawi. An additional benefit of this configuration is that the battery charger can easily be replaced with solar panels and/or wind turbines for sites with no electrical supply.
Below is a photo of one of the battery backup systems that Baobab has deployed.
August 29th, 2006
challenges developing countries Stories of failed computer implementations are widespread, and not limited to developing countries. Failed implementations can result from many factors. In Western settings the most common reason for a failed implementation is lack of user adoption frequently resulting from a mismatch between the user needs and system capabilities. The root cause of this mismatch is a lack of understanding of user needs by systems developers.
Developing countries are faced with many additional challenges to successful implementations including:
- Absence of unique patient identifiers
- HIV/AIDS pandemic
- Low levels of computer literacy among health workers
- Under-trained and inexperienced clinicians
- Limited healthcare budget
- Low staffing levels
- High turnover among staff
- Inadequate security / high risk of theft
- Inadequate infrastructure for equipment maintenance
Baobab has developed a number of innovative technologies on-site in Malawi to address these problems. They will be described in subsequent posts.
August 29th, 2006
