A new healthcare project in Zambia is trying to integrate supervisors, clinics, and community healthcare workers (CHW) into a system that can improve patient service and provide more data about the effectiveness of care. Because of the technical challenges in an extreme rural setting, unique solutions are required. According to Cory Zue, chief technology officer of Dimagi, CouchDB went a long way toward keeping a consistent set of records under extreme circumstances. The full story will be laid out in Zue’s talk at the upcoming MySQL conference, but here’s a sneak peak.
You’re involved with a rural healthcare project in Africa. Can you talk a bit about it, and how CouchDB is being used?
Cory Zue: We chose to use CouchDB for very specific reasons for our project, which had to do with it being very good at replicating itself. The project is an effort to deploy health record and data collection systems to extremely remote, rural clinics in Zambia. Working in that environment, we’re facing a lot of really challenging technical limitations. If you’ve only worked in America or in Europe, you don’t necessarily run across these types of issues.
We’ve got computers at clinics that are maintaining patient records. That data needs to sync to cell phones and to a central server, but around 35% of them don’t have power, so we’re installing solar panels. So one limitation is that that the system has to work on low resources.
None of these clinics have Internet out of the box, so most of the time our only Internet connection is through a GSM modem that connects over the local cell network. It’s very hard to move data in that environment, and you can’t do anything that relies on an always-on Internet connection with a web app that is always accessing data remotely.
CouchDB was a really good option for us because we could install a Couch database at each clinic site, and then that way all the clinic operations would be local. There would be no Internet use in terms of going out and getting the patient records, or entering data at the clinic site. Couch has a replication engine that lets you synchronize databases — both pull replication and push replication — so we have a star network of databases with one central server in the middle and all of these satellite clinic servers that are connecting through that cell network whenever they’re able to get on, and sending the data back and forth. That way we’re able to get data in and out of these really remote, rural areas without having to write our own synchronization protocols and network stack.
It could be argued that the same money could have been spent on things like medicine
and staff. What makes this project cost effective?
Cory Zue: That’s something that we are constantly thinking about in my organization. In this case, the goal of the entire project is to prove the benefit. This is actually part of a five-year research study that’s looking at improving primary care through better oversight and through community health worker integration with the health system.
What we’re looking at are two arms: One is that when the data gets to a central place, people like district supervisors can have performance indicator reports that give them a sense for how well the clinic is doing, how well they’re following protocols in terms of things such as taking vitals at every visit. They get a report and then they can come and talk to the clinic about what they’re doing right and what they’re doing wrong.
The other arm that is more interesting, and I think the arm that has more of an impact, is integrating the community health workers with the primary care system. In many of these places, the community health worker is the first line of defense between a person getting sick and what they do about it. The system creates cases or follow ups, from visits to the clinic, that tell the community health worker: “This person had a problem. You should go follow up with them in five days and make sure they’re okay.”
By sending data through the cell network and then back down to applications that are running on the phones at the community health centers, community health workers are able to find out about complications and people they need to check on. The entire workflow of patient tracing, from clinic to community and then back to the clinic, can be much more complete.
How has the project been going so far?
Cory Zue: This project kicked off in September and it will be going on through the course of the next five-plus years. Hopefully we’ll find that the system was a smashing success and it will continue to live on or evolve past that time.
Anecdotally, the thing that we’ve heard so far is about the visibility of the data in terms of, for the people who oversee these clients, just having any idea of what’s happening on the ground. We haven’t gotten a lot of feedback from the community health workers yet, and so as we continue to grow out we’re really looking to focus on getting testimonials from the actual CHWs and the patients that are affected.
This interview was edited and condensed.