Archive for category Sometimes it works
A View From Xela. Implementing FreeMED in Guatemala.
Posted by redlinedoc in AccessMedcineNY in Guatemala, Medicine, Sometimes it works on October 12, 2010
Jeff and I undertook implementation of FreeMED an Open Source Electronic Medical Record and practice management system for the Pop-Wuj Clinic, a primary care, non-profit, free and open clinic in Quezeltenango, Guatemala. 
The clinic, founded by members of Pop-Wuj Spanish School, (http://www.pop-wuj.org/) a non-profit school for teaching Spanish language, and Dr. Jonathan St. George, an emergency department physician at Weill Cornell Medical Center . Dr St. George began with a space and a concept and has with coordination with the Timmy Foundation staffed a regular clinic with a full time physician and assistants, recruited a part time dentist and a part time community physician to work in the clinic.
Students of medicine or allied fields attending Pop-Wuj Spanish Language school assist with chores and triage at the clinic in the morning and then attend their language classes in the afternoon.
It is planned for the clinic to be self sustaining. To derive funds, we will offer continuing medical education courses in Travel and International Medicine. the staff, all volunteer, will make the courses available, and the fees used to fund the clinic and operations. We plan to use Open Source Training tools as a basis for online and study courses both for Pop-Wuj school and for Access Medicine, the teaching wing. We hope to prove this funding model within three years.
The installation of FreeMED was not without its problems. Servers donated by SGI/Rackable Systems complemented laptops donated by Jeff’s employer helped get us off the ground. Immediate problems with infrastructure, the system wasn’t at all grounded coupled with a need for stable power, necessitated the purchase of a UPS to protect the servers. Difficulty with the structures which are of concrete and re-bar hindered good WIFI transmissions within the building. We capitulated and wired the building for CAT5 (ish). I say “ish”, because the local wire is probably CAT3 maybe. We didn’t have any interference problems that we could pick up.
Once hooked up, we split the system for registration, triage, physicians and pharmacy. Registration has been by hand and is transiting well to the electronic system. The intake person has good aptitude with computers and was a quick study with some help. Triage, which is really vital signs and complaint are done by visiting medical students. An immediate difficulty is that the person in this position changes sometimes several times during clinic hours. There is very little regularity and registering each of these people will create some problems. At the moment, we’re continuing to register each person in the system and privilege them as such. The suggestion, by some, that we create a group without name, is problematic from several standpoints.
Physician training was minimal because of initial delays in deploying the system. However, I spent time with the physicians and we have enabled remote secure access so that they can use and manoeuvre through the system. For the most part, physicians are not the stumbling block.
There is a large pharmacy and much of the medication for patients is dispensed from this bank of medications. We did not pre-enter the medications and are still working ways to get some handle on the bulk of and entry of these medications.
The dental portion of FreeMED will be implemented once the medical is stable and in use. FreeMED continues to evolve. There were some specific changes made to accommodate the needs of this clinic and its staff. We hope to have some hard statistics from the program by mid year with full integration of the old (paper) medical records. The Fujitsu corporation has donated scanners which will enable us to port paper records into the system.
Once we have fully implemented FreeMED in the clinic, we hope to add Android capability to the Xela system, allowing for remote access as well as telemedicine conferencing. The Android capability, already built into FreeMED permits recording and transcribing of teleconferences directly to the medical record. Other Android features are planned. FreeMED does work seamlessly to provide access by Android to appointment and other portions of the system including the internal messaging system. There are other anticipated donations of medical equipment including monitors to the clinic. Those too are planned to be integrated using the SHIM portion of FreeMED.
FreeMED is an opensource GPL-licensed product, in use worldwide. FreeMED recently announced the release of the 0.9.0 beta version. More information is available through the FreeMED website.
If you are interested in helping with the clinic either by donation of time, energy, equipment or monies, please contact donations at popwujclinic dot org Another trip to the clinic is planned for May. If you have an interest in international or travel medicine and wish to contribute by taking the offered courses and /or contribute expertise contact.
Xela and the clinic the 21st
Posted by redlinedoc in AccessMedcineNY in Guatemala, Medicine, Sometimes it works on September 24, 2010
Sorry for the long delay out there but there have been some connection problems as well as difficulties uploading photos to FLICKR so that they won’t take up all the room in the world. Tuesday was clinic day at Pop-Wuj in the city. The line up for clinic is not unlike that at CHS.
As a clinician I tail around one of the local doctors, Dr. Christian. He works Tuesday, Wednesday and Thursday’s at the clinic and does a small wound clinic on Tuesday and Friday mornings. Although there are many out-clinics — helping in the pueblos, the clinic here is run regularly and the out clinics when there are volunteers or students to help with managing the ‘stuff’ of setting up a clinic away from a home base.
The most surprising and yet elemental thing for me is the similarity of the patients here and at home. Our first wound care was an ulcer caused by a hot water burn. She has a fluid load and some swelling as well as some mild but growing venous stasis. Wound care here is much the same, debridement, support.
Our next, came without her support hose. ”I left them at home today”, she said. When challenged about wearing the stockings regularly – she doesn’t. They itch in the late day when the sun is up and out. I gave her a strategy to wear them only in the morning. She laughs, the way my patients in the states do. Dr. Christian and I exchange a knowing glance. She might. She gives us both kisses and warm handshakes. Its all the same.
More patients. There are a lot of musculoskeletal complaints here. People use their bodies as handcarts. From the women who cary 20-30kg loads on their heads to the men who carry 100kg sacks of dirt or stone or concrete on their backs using a headband, the difficulties are related to a harsh life here. None of that is evidenced in the clinic – they are all grateful to have care. No one pushes. No one shoves. There are children everywhere and most of them a bit bashful. Being nearly 1/3 taller than most I look rather giant to most of them.
The line trickles in and in two rooms with some seen on the cuff, we see 63 patients in about 5 hours. The care? First rate given some of the limitations. There is no EKG. Blood pressure monitoring is done in a clinic where you can scarcely hear yourself let alone small variations in sound. Medicine is, for the most part donated and solves many of the problems. There isn’t much polypharmacy here. Even older folks walk nearly everywhere.
We are trying to install FreeMED but the problems not forseen are overwhelming. Although there are three pronged outlets in the clinic, none are really grounded. Wiring to light fixtures appears as if done with bell wire. The WIFI unit in the school isn’t readily accessible (a minor problem). The clinic too needs some reorganization. A lot of donated stuff has been in boxes awaiting trained and eager hands to triage (yup triage) the medications. Overall it gets done. Our primary server got mis directed in baggage and we’re waiting for it to be delivered. The secondary waits.
Jeff and I are staying at a Bed&Breakfast called Casa Manen, about a mile (all uphill) from the clinic. We’re getting used to the altitude, about 8500 ft here in Xela.
Tomorrow we go to an outlying clinic about 1/3 of the way to Guatemala City to deliver health care to a small pueblo. We’ll be mounting the entire team plus medical students who are here to learn Spanish at Pop-Wuj. There’s a lot of preparation and Jeff is going to look at the organization from a systems perspective to get better grounded to bring the records out side the clinic.
Technology Advances. People stay the same.
Posted by redlinedoc in Medicine, Sometimes it works on March 18, 2010
We often take for granted that people really understand technology. We recently installed a new computerized (well somewhat) Medical Record System in our workplace. It makes you go …hmmm.
This past Friday a co-worker came to me waving a sheaf of papers. “I did what you wanted. I put the orders in the system. I’ve been waiting a month and nothing (emphasized with the sheaf of papers) shows up on the computer.”
Nonplussed I asked “What’s this about?”
(as if to a small child) “I take the sheets. I put the order in the computer and then I write “SCANNED” on the paper. Its not showing up! This system doesn’t work at all!”
I look at the desk and sure enough there’s a pile of papers, each with “SCANNED” written on the face. (I did manage a straight face). ” You really need to send them downstairs to BE scanned. Its a machine”
I thought this would be the end of it. Yesterday one of the other team members tells me she was button-holed on the stairs about why nothing is showing up yet in her orders when she did everything we’d asked.
Well…. almost everything. Technology advances. People Stay the same (with apologies to Leigh Rubin).
it couldn’t hurt .. or could it
Posted by redlinedoc in Commentary, Medicine, Sometimes it works, Universal HealthCare on October 12, 2010
I’ve been watching with interest the current Republican party dance around repeal of the Healthcare insurance legislation just passed. Its a sad bit of badly made political salad with very little for those who need health insurance, a guaranteed business for the insurance companies (universal sign up), guaranteed pharma profits (no pharma negotiation) and extension of the market for about 40% of those who are still uncovered or uninsured.
State legislatures, not to be overlooked are trying their best to carve themselves in our out of the new Heatlhcare bill by blocking advances or by shouting states rights. With hard economic times, its easy to get voters to hear the shouting but miss the salient points.
We’ve missed the boat, again. Smoke and mirrors and distraction reign supreme. The emperor, or his bill, have no clothes. This does not cover a majority of the uninsured. I’m waiting to see how those who are unemployed, now some approaching the 2 year mark, will pay for this bit of fluff. The state’s assistance systems were already at a foundering point and shoving the burden to physicians and hospitals for the under and uninsured will only exacerbate the problem.
There’s a bit of shuck and drag going on here. We’re told that we need to work to pass this. We’re told it will bankrupt us. We’re told this is socialism at its worst. Socialism?
Today one of the walking wounded comes to the clinic. She works 40-50 hours a week, full time she’s told, at one of the local hospitals. To expedite services the hospital contracts out its housekeeping. The firm, to keep profits ripe, they don’t pay insurance. Hmm. Ok. We took what was a paid in-house position, took away the benefits, hired the same folks to do the same job so that the profits would stay as high as maybe ….
I digress. Here’s a full time working person with no insurance. How is a public option for her, socialism? From where I sit, we pay into the medicare system. We pay it in wages and taxes and reap a long term benefit devoid of the need for stockholders to benefit. Although an inconstant fiduciary, generally governments have handled trust funds much better than banks or insurance companies, always looking to the next gaming table, ripening the profits.
If we allow the loud shouts to take back the minimal advances, and I agree its far from perfect, we’ll end up with still more uninsured. The hidden cost of the ‘uninsured’ long patched over by draining high end payments from private insurers into the unbalanced pot is at an end. The insurance blokes, have cut off that avenue. The uninsured now go to emergency rooms, expensive care, and not much of it.
Emphasis from the Healthcare Plan was on primary care, extending to patients the ability to see and to find competent expert medical care. If we persist at deconstructing the fragile imperfect house, we’ll have but a very expensive house of cards fallen loosely and very expensively apart. Threats of Medicare cuts are more thunder than substance. We do need government to help us. Watch carefully.
business+ethics, ethics, fairness, FQHC, Health+insurance, Medicare, other+peoples+money, poor+insurance, poverty, risk, single+payor, underemployed, underinsurance, underinsured, vulnerable, work
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