January 2010

“Biggest support we have had has come from the clinicians”

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Multi Disease Surveillance System (MDSS) is an open-source health information system, running in 27 government hospitals in Sri Lanka. Developed on Linux operating system, using InterSystem’s CACHE database, MDSS has shown tremendous success in improving healthcare delivery and hospital operations. eHEALTH recently caught up with Dr. Denham Pole from Swiss Red Cross in Colombo, who is the mastermind behind this achievement. Excerpts from the interview.

Dr Denham Pole
Consultant – Medical Informatics
Swiss Red Cross, Sri Lanka

Please tell us about the genesis of your work in Sri Lanka.

I came to Sri Lanka in the end of 2001 to work as a healthcare consultant in a Japanese project to improve blood transfusion services. We built up a new blood transfusion service centre in Narahenpita, Colombo and started training the staff on cell matching and modern blood transfusion activities. The high point of my work was to involve in the development of a new blood transfusion centre, which was finished about a year ago. After the completion of that project, just as I was about to leave Sri Lanka, Tsunami hit the country and I stayed on. When WHO’s Tsunami activities finished, the Red Cross came up with a project to install computers in hospitals in Tsunami affected areas. WHO transferred me to the Red Cross and since the last three years we have been installing systems in hospitals in the Eastern province.

How was the multi disease surveillance system (MDSS) developed?

WHO believes that surveying into individual diseases is not one of the best ways. You can check on diseases like malaria or dengue, but the best way to go, from a public health point of view is to look at all diseases. WHO is always pushing the hospitals to record all diseases of patients admitted, which will generate a simple patient record of all patient admissions with their diagnosis. I was involved in the development of some of the early systems that WHO produced. We installed the system across 6-7 hospitals but WHO did not have the resources to follow up these systems. So they sorted other firms and that’s where the Red Cross came in. It was essentially a WHO project to start off with, but it was later taken over by the Red Cross.

How big was the team that worked on MDSS?

In WHO, we just had a team of three people for installation in about 6-7 hospitals. We had to rely on commercial companies for hardware. Certain computer schools provided training and the program was written by a software house. However, we soon realised that a more efficient way would be to have this done under one team. So, when Red Cross came with their budget we took up a team of about 14 people.

With around 27 hospitals installed we had around 16 people, which we gradually reduced to 8 and at the end of the project, all these people will be absorbed in government services.

Is MDSS an open source solution? 

It is open source, in the sense that we are using Linux, which is an open source operating system. The Cache database is a proprietary database and it uses very standardised data bases like SQL, Java and so on. The design of the system and the methods that are used are pretty obvious to anybody. The Swiss Red Cross has funded this system and they own its rights and they would want it to be used worldwide. They would be pleased to let people adopt the system, provided they are aware of using the Cache.

What factors led you to choose the Cache database?

Cache has a very long history and the technology that underlies Cache is about 30 years old. It started being used a lot in the medical area. When I was in Switzerland, I came across the predecessors of Cache, which gradually developed from a simple command language system to an SQL system with a data dictionary. The modern versions of Cache are  very powerful indeed. In Switzerland Cache and its technology are used widely by the government and industry. Later, in Egypt I used the experience of Cache to encourage the development of a Cache system over a 3 year period.

When I came to Sri Lanka, I was a bit concerned about using Cache because it was unknown in this part of the world. However, with experiment and experience using other systems, we found that Cache was a much more powerful solution than any of the others available. Finally, we contacted InterSystems and with their help we gathered enough courage to install Cache in Sri Lanka. The University of Colombo, the PGIM and various other institutions have now started to  looking at it. It is only a matter of time before Cache would move into the mainstream.

Did your system inspire others to take up Cache in Sri Lanka or adjacent areas?

At the moment, it is starting to take off. We gave a course to 30 doctors in the post graduate institute of medicine and they were all very enthusiastic about Cache. In fact, all of them developed a little database during the course and I am sure they will start using it more and more in their work. Now, some groups including the University of Colombo are considering to adopt it.

So far, its only in Sri Lanka and the Swiss Red Cross project will come to in 2009. We are hoping that it would start to spread across other Sri Lankan provinces. The northern province has shown some interest and we are now looking at Colombo, because that is the place where things happen in this country.

What were the challenges faced in designing the system? 

Our biggest problem was that we were trying to computerise something that almost did not exist. However, the positive thing was that the doctors realised that this was a big weakness as they did not have any record of the patients. So there was a pressure on the staff to start keeping records and that made our job easy. The challenge was that we were dealing with a very low level of development, to start off, with the medical records.

Was there lack of record keeping culture or were the records maintained in paper format?

I think that it is partly culture. The doctors here keep a lot of information in their heads. Records in Asia, are not seen as a very central part of transactions, but that has to change as medicine becomes more complex and treatments become more sophisticated. The doctors are now realising that they can not carry on like this for long and I already see a cultural change happening.

What are the medico-legal issues involved in storing electronic medical records?

When it comes to documentation, people working in the hospitals are not very aware of the legal situation. We, obviously, had to take guidance from the legal people in the health ministry and they came to the conclusion that although keeping records in books is a good idea, yet it is not legally binding to keep records in books. The records need to be maintained, whether you write them in books or type them into the computer, provided the user is identified, time of input is recorded and the records do not disappear. So there were essentially no legal hassles in maintaining records in an electronic format.

How can the implementation of health informatics be facilitated?

The government has a big role to play in providing leadership. For instance, in using electronic records in hospital, if we look at the American approach, there are financial incentives and if the hospitals don’t use electronic records they are penalised. In this country, the government needs to take a more positive role in increasing the use of computers in maintaining medical records. I don’t think they need to push in standardisation in terms of having systems that interact with each other. Cache is a system which can very easily communicate with the other systems. The Ensemble, for instance, is specifically designed to communicate with other systems. So I think it is too early to standardise because we don’t know what to standardise on.

Can the challenge of standardisation be overcome if the data can be bypassed from one format to another?

Yes, I think standardisation was a problem with computers about a decade ago but with modern computer techniques it is no longer much of a problem. I think, as of now, the government just needs to encourage the use of computers.

Clinicians often face a lot of difficulties in using HIS. How have you addressed this challenge in your system?

The biggest support we have had in the last three years of development has come from the clinicians. In fact, we have not received this kind of support from senior administration and the central government. Its the clinicians who see the real benefits of having the electronic records because it is something they have never had before.

How do you see the future of health informatics? How will health IT change healthcare forever? 

D e v e l o p i n g countries can often make a lead in technology from doing nothing to using modern techniques in different areas without going through the intervening steps, which is certainly the state with computers and we have already seen computers spreading to banks, insurance agents and other areas.

There is very rapid development in this part of the world as they leap over all the steps that Europe and America have to go through. We can not predict the future but I would say that we will soon have electronic records in most of the hospitals in this part of the world.

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