Posted by Duncan Maru, MD, PHD
Throughout my training in medicine, I have experienced the central role that effective communication plays in the care of patients. Despite working in several hospital settings that use extensive wireless and electronic telecommunications, I remain dumbfounded by the challenges we as doctors have in communicating with nurses, respiratory therapists, and other physicians. These challenges are only magnified when we are delivering health care in a place such as rural Achham where electricity and internet and phone lines often work sporadically.
To illustrate, I’ll provide a scenario that is representative of many of the experiences I have had during the course of being a resident in internal medicine and pediatrics in Boston. A patient suffers an upper gastrointestinal bleed while in a teaching hospital in the United States. The nurse identifies this, logs on to his computer, pages the cross-covering intern doctor (the junior physician who has never met the patient but who is the first responding doctor). Two minutes. The cross-covering intern gets the page while in the emergency room with a different patient whom she is admitting to the inpatient unit of the hospital. Three minutes. The intern finishes talking with the patient, and tries to find an available phone. Two minutes. By the time she gets to a phone and dials back the nurse, the nurse has already left his station. The unit secretary puts the intern on hold while overhead paging the nurse. In the meantime, the intern looks up the “sign-out” (documentation used to convey information between the different covering doctors). She notes that the last documented physical exam is from three days ago, and no mention is made of what the patient has for intravenous access (important for resuscitation efforts in the case of a bleed). Five minutes. Finally, the nurse calls back. Over the phone, the intern and the nurse decide the patient needs better intravenous access, an acid-blocking medication, and a tube that goes from the nose to the stomach. Three minutes. The gastrointestinal specialist (expert in all things pertaining to that remarkable food processing factory running over several meters from the mouth to the anus) will need to be called in case the patient needs to have an emergent procedure that only the specialist is licensed to do. The acid-blocking medication then needs to be approved by the pharmacy. Ten minutes. In the meantime, the intern has just been asked to re-evaluate that emergency department patient. Seven minutes. Finally, the intern pages the on-call gastrointestinal specialist. The specialist, in the middle of a procedure, calls back fifteen minutes later. The intern has already moved back to another part of the hospital. Three minutes. The specialist pages back the intern with a different call-back number, and finally, all of 39 minutes into a potentially life-threatening bleed, the intern has the specialist on the phone.
All that this extensive prologue is to say is that healthcare is a complex logistical operation and paging systems and electronic medical records and phones all facilitate the work but do not solve the fundamental problem of getting information from one provider to another in a timely manner. Now, let’s get to the point of this blog post: telecommunications in rural Achham. Compared with caring for a patient in Boston, Nyaya faces a whole different set of telecommunications challenges as we go advocate, innovate, and problem-shoot our way to providing essential healthcare in one of the most remote places on earth. A while back, in the early days of setting up the Sanfe Clinic, I wrote a blog about our challenges with telecommunications in rural Achham. Telecommunications has remained central to our endeavor. In fact, one of our goals for 2009 from our Vision page on our wiki was the following:
To have effectively lobbied Nepal Telecom to create a CDMA tower making mobile communication accessible to the bulk of the villages in which we work.
We transmit financial data, ultrasound images, clinical outcomes measures, operations details, and day-to-day challenges and successes over the internet from Achham to our colleagues in Kathmandu and New Haven and Boston and (as is the case for me currently) Louisville. Our care team is much more geographically complex than even the byzantine hospital structures in Boston that I navigate as a resident doctor. Still, the basic infrastructure has remained essentially the same since that post; Achham has continued to suffer from the infrastructure damage and neglect is sustained during the civil war. Recently, however, that Nepal Telecom has just recently a wireless tower (over the bandwidth known as CDMA; for definitions see our wiki) in a neighboring hill in the community of Chaukhutte, Achham. This represents a huge advocacy victory on the parts of the people of Achham, as improved wireless communication will help the business and personal lives of the citizenry, as well of course in making our own hospital operations more effective. Nyaya Health team members have been involved in advocacy efforts, and we are proud to have been part of the process that ultimately led to the building of the tower.
- Former Nepal Telecom Office in Mangalsen, Destroyed During the War
So, what might the expanded access to wireless signal entail? Currently, we use CDMA wireless primarily for making phone calls. Communication between Kathmandu and Achham via phone will be more reliable, allowing us to coordinate supplies and volunteers traveling to the Bayalpata Hospital. It will allow us to more reliably communicate with the district hospital in Achham’s center. Additionally, through the use of mobile phones, we hope to better connect our community health workers and other government and private healthcare providers in the district with our hospital.
Internet via CDMA is more pricey than our current other option, satellite (technically, VSAT ). The reason for this is that charges for CDMA are on a per-MB usage basis (around 3 Rs per MB), whereas our contract with our satellite providers is on a monthly basis. Nyaya uses a large amount of bandwidth, around 30,000 MB per month download and 5,000 MB per month upload. For CDMA, that would cost over 100,000 NRs per month, far exceeding our current 20,000 NRs satellite fees. Still, in the long-term, as bandwidth over CDMA improves and as costs come down, wireless will be the strategy we use for communicating with each other and with other providers within the district. Erecting multiple satellite hubs, given their requisite electricity connection and high up-front costs, will not be financially beneficial compared with CDMA. As such, we will use this when we eventually start using internet-based technologies to allow, for example, a community health worker to send a picture of a rash to our clinicians at the Bayalpata Hospital.
Whether caring for an upper gastrointestinal bleed in Boston or combating a cholera epidemic in Achham, effective healthcare rests upon our abilities as providers and managers to communicate with each other. The new wireless tower in Achham will help Nyaya in our own mission, provided that we continue to develop communication systems appropriate to the task at hand.