Health Information in Developing Countries
A NextGen Free-Standing Perspective
Article
By Allen Cheng
An established information infrastructure in the developed world has made accessing health information a facile task. In a span of minutes a patient may coddle his curiosity by self-diagnosing an illness, investigating the origin of the disease, reading on different treatment options, and checking the background of relevant doctors and hospitals, all tasks simplified by the wide availability of the internet. Recent medical information and research journals can be disseminated to doctors, describing current trends in disease or new treatment methods. Colleagues can consult each other across the country instantaneously, ensuring the best treatments for their patients. Electronic medical record systems allow seamless sharing of patient data among different clinics, documenting histories, drug regimens, referrals, and existing conditions. These capabilities save time and reduce mistakes.
And if all else fails, the internet itself can help the doctor diagnose. In a letter in the New England Journal of Medicine, a New York rheumatologist describes an infant with unusual symptoms, confounding the establishment of a consensus on one of several diagnostic possibilities. [1] When the presenting fellow was asked to explain how he arrived at his diagnosis, an uncommon genetic disorder that was later confirmed, he replies, "I entered the salient features into Google, and it popped right up."
In contrast, health workers in impoverished countries are starved of the relevant information typically accessible to their colleagues in other places. Hospitals in remote areas with virtually no roads, electricity, or basic communication means often have to function almost autonomously without access to medical information or colleague support. In turn, the hospitals are difficult to monitor, making assessment of healthcare standards difficult. While improving conditions in a developing country will eventually spill into its healthcare sector, a host of obstacles currently hinders physicians who desire the best for their patients.
Moving Patient Records
A lack of communication infrastructure increases the difficulty in moving patient data to different locations, which can be a severe hindrance to health programs. The Association for Private Health Facilities in Tanzania (APHFTA), which manages several nationwide health programs, is familiar with this situation. Its latest initiative is a diabetes program that will distribute diagnostic and treatment tools to eighty clinics across Tanzania and cover several million people. The resulting patient data will be a crucial source of information in assessing the effectiveness of the program and monitoring the rising diabetes risk in Tanzania. Discovering correlations of disease with geographical locations, demographics, socioeconomic conditions, and other chronic conditions can greatly improve strategies to target this disease.
However, moving thousands of patient records across a country not completely connected by paved roads is a difficult problem. Many of the targeted clinics are in remote rural areas, making communication difficult. “We simply cannot assume that clinics have access to the internet or even good medical record systems in place,” explained Dr. Nguke Mwakatundu, the director of the program. “Some clinics are difficult to reach even by telephone.”
The solution is to move all the diabetes medical records on paper from the clinics to regional offices of APHFTA by a courier service, which is usual for programs of this scale. The records will then be transferred to a central location for electronic processing. Although this method engenders difficulties in clinic compliance and program efficiency, Dr. Mwakatundu is resigned to the problem, saying “until things improve drastically, maybe in a few decades, we will have to continue doing things this way.”
The lack of a fast, efficient way to handle patient data has larger implications for differences in healthcare in Africa. “Africa is already lagging behind the developed world by decades,” Dr. Mwakatundu explains. “The efficient methods of communication available in countries abroad allow them to conduct insightful epidemiological and public health research at a much faster pace. While we wait for an infrastructure to slowly build, the gap will continue to grow very quickly.”
New Solutions
But new efforts to bring modern record systems to developing countries, often via foreign nonprofit work, can help equalize differences in health information infrastructure. To support an AIDS treatment program handling thousands of patients in Haiti, Partners in Health developed a strategy to improve clinical communications and data analysis in rural areas. [2] Connection to the internet by a low-cost satellite link opened access to medical resources, consultation via email, and more efficient coordination between clinics. A web-based electronic medical record system then allowed secure data management without the obstacles involved in local data management at each clinic. User-friendly tools to produce statistical data were also developed, facilitating analysis of demographic trends.
The new system greatly empowers participating clinics, allowing, for example, the automatic identification of AIDS patients receiving an insufficient drug regimen and prompt notification of their clinicians. Systems like these have been found to improve quality of care in HIV patients. [3]
Of course, not all programs introducing computerization in developing settings can claim success, as the lack of infrastructure can prove overwhelming to the best of intentions. A project to install a hospital information system in South Africa for 42 hospitals was intended to improve communal access to patient information, standardization of treatment procedures, and improve management of hospitals. [4] The system developed new methods of indexing and tracking patients, regulating appointments, reporting results, and managing finances. Each hospital was meant to have its own server to manage its own data, which would be sent to a central location.
The program, however, met many failures in implementation, including delays in functionality testing, ineffective training, and failure to respond to technical concerns. The organizers of the program rationalized these failures with multiple reasons. They found that the users, while instructed thoroughly on how to use the new tools, did not understand why they should. Moreover, the developers of the program underestimated the complexity of healthcare processes. A computerized process would be a costly unwelcome barrier before seeing an anxious patient, decreasing its attractiveness for adoption by hospital staff. Both factors would have a costly toll on user compliance.
Finally, the authors admitted that the cost-effectiveness of the overhaul was not formally assessed during planning, ignoring the possibility that an electronic system was wholly unnecessary. Failures in efforts like these are not restricted to developing country settings – the United Kingdom has seen its share of failed health information systems.[5]
Looking forward
The widespread failure of efforts to introduce computerized medical systems points to problems greater than a defective infrastructure. The lack of a need for such a system or cost-ineffectiveness can undermine the noblest of sentiments and render efforts futile, squandering much-needed funds in resource-poor settings.
Nonetheless, simpler improvements in infrastructure such as access to the internet and email entail few disadvantages. The newfound ability of a remote clinic to communicate and consult with colleagues can be a blessing that grants better health outcomes. Gradual building of a foundation for efficient communication will decrease the gap between healthcare in different worlds, allowing doctors like Dr. Mwakatundu to better manage patient care.
Allen Cheng is an Associate Editor for the Next Generation and a member of the Harvard class of 2009.
References
- Greenwald, R. “And a diagnostic test was performed.” NEJM 353:2089-90 (2005)
- Fraser, HS et al. “An information system and medical record to support HIV treatment in rural Haiti.” BMJ 329:1142-6 (2004).
- Safran C et al. “Guidelines for management of HIV infection with computer-based patient's record.” Lancet 346:341-6 (1995).
- Littlejohns, P et al. “Evaluating computerized health information systems: hard lessons still to be learnt.” BMJ 326:860-3 (2003).
- Audit Commission. “For your information: a study of information management and systems in the acute hospital.” London: HMSO, 1995.