Dan Harris

Lessons learned from digital innovation in analogue communities

We’ve been working with Ensemble Pour la Différence and the people of Kivu, a region in the Democratic Republic of Congo, since 2015 to find ways to improve everyday life with digital innovation. The Congolese people have the motivation and the awareness to change their situation for the better, but they don’t have the means. Fjord and Ensemble have the means, but we aren’t Congolese and we must learn from them to understand their needs.

I recently had the pleasure of sharing the work we’ve done and lessons we’ve learnt at Cannes Health and wanted to summarise it here as well, as there are things we can all take from it. Project First Light consists of two initiatives, setting New Hope Hospital up with a digital patient management system, and bringing the internet to the remote island of Idjwi. Here, I’m going to focus on the former: let’s hear the story of a local doctor and the challenges he faces on a day to day.

Dr Pascal and New Hope Hospital

The Democratic Republic of Congo – or the DRC – is extraordinarily rich in natural resources. Its untapped mineral deposits are estimated to be worth as much as US$24 trillion, and yet, it’s one of the very poorest nations on the planet, ranked 176th for human development by the United Nations.

One of Project First Light’s major initiatives is with Dr Pascal and New Hope Hospital – a much-needed clinic in a town called Kavumu, in the East of the country, which he set up in mid-2015.

Kavumu suffers an alarming mortality rate. Dr Pascal most frequently helps families stricken by malnutrition, malaria, injury, and a well-documented sexual violence problem. His vision is to provide healthcare across the region, and New Hope Hospital is the first step.

During our first talks with Dr Pascal and his staff about their needs, it became clear that the most urgent challenge was patient management. All records were handwritten in notebooks, carefully cut out and stored in lockers, but the paperwork would quickly become damp in the humidity or go missing. With more patients arriving every day, maintaining their records on paper was becoming impossible, and keeping medical billing up to date was an arduous, time-consuming task.

We initially looked at improving their paper process, but we soon realised that a step-change was needed so we started to research digital options. We settled on OpenMRS, an open-source patient management system, which very quickly changed things:

No video?
Dr Pascal describes the situation before OpenMRS: long queues, the hours of waiting and the paper trails for the 80 patients who came each day. He says that with OpenMRS, it’s easier to find people in the system when they return and it makes everything faster.

Installing OpenMRS at New Hope Hospital

The advantage of open-source software is that it’s publicly accessible, so we can rely on a motivated network of global contributors to help us solve any issues, and to develop the system’s capability.

We knew that our solution had to be resilient to the specific ergonomic and environmental factors, including an unreliable electricity supply. We repurposed a low-power home-entertainment PC as a server, and gave nursing staff rugged Android tablets, on which the staff could continue to log important patient records even when the power switched to back-up motorcycle batteries.

The staff had never used kit like this before, so we provided on site training, and returned a week later to repeat it. The key to success was the strong support from Dr Pascal, and the way the hospital administrator has taken ownership to make sure the system keeps running. Between them, they found two local technologists who could develop add-on modules to make Open MRS a complete, customised end-to-end management system.

Unexpected Design Culture

Design Culture is difficult to embed and drive in technologically advanced countries; people have been working with tools and the processes they know so when you try to execute a transformation, they sometimes put up significant resistance.

New Hope Hospital’s staff have immediately – and unknowingly – adopted a Design Culture that would be the envy of many of our clients. They’re totally geared up for change, because they instantly see the massive disparity between what they were doing, and what we show them as an alternative.

What has OpenMRS changed?

Firstly, Dr Pascal can now get more people through the door for the attention they need, and he can treat them with the benefit of immediate access to their medical history. It might sound obvious, but this is nothing short of revolutionary for New Hope Hospital’s patients.

The amount of administration time this system saves has allowed Dr Pascal to expand his operation, doubling his staff. Those staff are competent, and offer treatment at rates that some people can afford. Perhaps one of the most rewarding results was that the system proved pivotal in securing a contract for the hospital to treat up to a thousand United Nations employees.

Liquid Expectations

You might have heard Fjord talk about Liquid Expectations: every time we encounter something new and surprising, it changes our expectations for everything else – regardless of whether they’re in connected or comparable industries.

New Hope Hospital patients’ expectations are being exceeded by what Dr Pascal and his team have implemented:

No video?
Dr Pascal describes the element of design, which delights patients who have never seen this level of digitisation in any other part of the economy.

OpenMRS is acting like a marketing tool. The term “marketing” feels a bit out of place in this context, but what we mean is the way in which the word spreads that there is life-saving medical attention available. OpenMRS fascinates people, and the hospital has developed an excellent reputation, both for the level of care and for the patient experience.

Of course, patients return because they are sick and because the hospital offers good treatment – but it’s by no means irrelevant that people believe it is modern and progressive because of the new system. People are now travelling up to 80 kilometers to this hospital, and it’s impossible to overstate what this means. It can take all day, maybe two days to travel 80 kilometers on Congolese roads.

This is how Dr Pascal describes a typical patient journey now:

No video?
Dr Pascal talks through the whole process: The patient arrives at reception and is registered. He/she goes through to the doctor’s office and he already has their records on his screen. He orders any necessary tests, which are done immediately. The doctor receives the test results and writes a prescription, which is sent automatically to the on-site pharmacy. The patient then collects his/her medication on the way out.

Back to basics with a mobile app

Very few people have the resources to pay for a smartphone, but many Congolese people have basic mobile phones, so SMS is a useful tool. We’ve helped Dr Pascal and his patients with a simple mobile application, whereby the patient sends the hospital a reference number by SMS, then they get a call, which plays a recording from Dr Pascal.

His message could include:

  • an explanation about their prescription and what they need to do
  • information about common illnesses
  • instructions on how to use mosquito nets
  • and advice about how to clean their homes effectively, to prevent frequent recurrences of malaria.

Malaria is the single biggest killer in the community, and these text message explanations could genuinely save lives.

What’s next?

In the future, Dr Pascal would dearly love to develop the mobile apps to share first aid advice with people before they come to the hospital. It takes so long to travel to the hospital, people sometimes don’t survive the journey:

No video?
Dr Pascal tells a true story about a child who had a marble in his mouth that blocked his airway. His family didn’t know that all they needed to do was press on his abdomen to dislodge the marble. They brought him straight to hospital, but he died during their 2km journey. If they could have contacted the hospital before leaving home, they’d have been told how to release the marble. Dr Pascal says there’s no denying that mobile applications can save lives.

There are no ambulances in Kavumu, so hospital patients walk, are carried, or bounce along dirt roads on the back of a bike. We’d like to find a way to get patients to and from the hospital more comfortably and quickly, but the complications are almost unimaginable. For a start, people in Kavumu don’t have formal addresses, so we need to work out how they’ll explain to the ambulance service where they are. It may be that we create a system whereby people text their local chief’s name, because a chief looks after one village, and can therefore become a place marker.

What we’ve learned

Starting from zero

In the work we do for our other clients, when we set out to design a service, we’re often asked to work with existing systems or platforms, and design something that sits alongside, is embedded within, or connected to them in some way.

When we started work in the DRC, there was no existing infrastructure. No systems. No legacy. No hardware. No established user behaviours. One of the key things we’re taking away is the experience of starting from nothing. It’s taught us how to decide when and how we really should start from zero, and when to work with what we have.

Embracing change

We spend a lot of time designing strategies that enable our clients to transform into Living Businesses – businesses that are set up to change quickly and efficiently whenever the digital landscape around them evolves. New Hope Hospital could be classified as a Living Business. They trust that digital innovation will improve their lives – whether they are staff or patients at the hospital, their willingness to embrace new ideas is the key to their future progress.

Start-up environment

With our work on New Hope Hospital, we were working within a pseudo-start-up environment. There was great clarity on what was needed, so we didn’t waste our limited time and resources on optional extras. They needed specific problems to be solved – quickly. The sooner we got effective, working solutions in place, the more lives would be improved, extended, and even saved.

Digital innovation for change

The systems Fjord and Ensemble Pour La Différence helped to create will continue to improve life in Kavumu for many years to come. And what’s really exciting is the possibility that this could be an example for others in the region and beyond.

Dan Harris

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