At one hospital in Kano, Nigeria, 50 babies are born each day. And it's not exactly prepared to handle them all. "We’re talking about one midwife taking three deliveries at a time," says Evelyn Castle.
Nonetheless, Castle aims to create digital records of those births and the hundreds of others happening across northern Nigeria each day – even as she and another American expatriate, Adam Thompson, are working to digitize the health records of adults across the region, including polio cases and expectant mothers who've tested HIV positive. It's an enormous task, but the size is only part of the problem. Castle and Thompson are introducing western technology to facilities that aren't familiar with it – and may not have the resources to handle what they are familiar with.
"This is one of the most difficult places on the planet – in many ways," says Andrew Karlyn, who spent three years as the country director in Nigeria for the Population Council, a nonprofit that seeks to improve living conditions in places across the globe. "If you’ve got a barely literate medical technician, who only knows how to use a microscope to look for Malaria and fill in a form, you can't just put a fancy computer in front of him and expect him to use it."
Or, as Castle points out, if a midwife is juggling three deliveries at a time, recording the details isn't high on the list of priorities.
The answer is to use technology that fits the environment – or at least comes close to fitting. Under the aegis of their nonprofit, eHealth Nigeria, Castle and Thompson have built a digital records system meant to eventually serve healthcare facilities across the region, but it doesn't use the sort of specialized health care software in U.S. or even everyday database software. There's no Kaiser software. And no Microsoft. The system is based on OpenMRS, an open source health records system designed specifically for use in underdeveloped regions.
First created in 2004, OpenMRS is now used in countries across the globe, including Rwanda, Mozambique, Haiti, India, China, and the Phillipines. As Karlyn and others point out, the platform is hardly reinventing healthcare in the poorer parts of these countries, but it is having some success – eHealth Nigeria being a prime example. "It's really just a drop in the bucket – but that's important," Karlyn tells Wired. "But they're building confidence in the system, demonstrating how change can happen. That attracts resources, and eventually, that makes a difference."
OpenMRS began as a research project spanning Indiana University and Eldoret, Kenya's Moi University. Paul Biondich and Burke Mamlin, two physicians and investigators at Indiana's Regenstrief Institute, had spent time in Kenya, where a local health institution was using Microsoft Access to help support HIV care, and they saw first hand that the database wouldn't suit the project at hand. OpenMRS was their response.
"What we saw in Kenya is what we see in similar environments today: the emergence of a healthcare system without a lot of the technology infrastructure that you and I take for granted in an environment like the U.S.," Biondich says. "They’re constantly trying to come up with ways to be efficient with information, but they don't have the wherewithal – and they certainly don’t have a lot of resources they need – to be able to think about building information systems for their environment."
Westerners were constantly building new healthcare systems for these places, he says, but people found them difficult to use – and difficult to maintain and upgrade. OpenMRS would seek to solve both those problems. And according to Karlyn, it has succeeded – at least in small ways. Part of its success is merely down to the fact that it uses open data formats, not a proprietary format controlled by a big software vendor.
"It's very interactive and there’s a very low barrier to entry: It’s easy to jump right in," Karlyn says. "There are technology concerns there, but at least you know what you can produce: You know that if you store records with it, they won’t be in a proprietary format that they won’t be able to access. People [in these regions] have come to believe that you can’t trust technology because it fails you, and this helps them trust it."
Castle and Thompson have heavily customized the platform, but they agree that it suits their needs in ways that standard software could not. "The people that are using our system are not exactly the most educated of people; a lot of people have never used a computer before. We have to start them with, how do you use a mouse," Castle says. "Introducing a Microsoft or a Kaiser platform is not going to work for them. The software we use is a lot more simplistic and a lot more user friendly." And for an NGO (non-government organization) like eHealth Nigeria, it doesn't hurt that OpenMRS is free.
In many cases, the system actually bypassing computers in favor of cellphones – which are much more prevalent in the region. They've added their own SMS (simple messaging system) gateway, and this allows the system to, say, automatically send text messages to patients as well as health care workers. Castle and Thompson are working to connect between 45 and 60 facilities to the system, so that they can better provide health services for HIV-positive pregnant women.
The system is housed at data center Castle and Thompson have built at Kano, in the same building as a local ISP. It's meant to juggle health records from hospitals and pharmacies across the region, but it's a far cry from the massive computing facilities driving big-name businesses in the U.S. or across Europe and Asia. It's a single rack of low-powered AMD Opteron servers.
The irony is that a very small solution fits this very large problem.