(Summer 2014) Anita Liu, ’17
Anita Liu (’17, Computer Science and Molecular Biology)
Anita spent the summer in Boston interning for Vecna Cares Charitable Trust, a non-profit organization partnered with Vecna Technologies. She improved Vecna Cares’ suite of CliniPAK products, which allow healthcare providers to efficiently record patient data at the point of care while providing real-time reporting. Her software work focused on implementing biometric identification as an option for registration to improve efficiency and consistency. She also helped the team deploy CliniPAK software in the St. Anne’s Worcester Free Clinic.
Entry 4: Final Reflections
A lot of people like to complain – or at least voice concerns – about the rapid gains in technology in the modern world. Electronics in every form seem to be taking over our lives, and a certain distrust of the new products poised to replace humans is to be expected. I personally never subscribed to this line of thinking. Growing up in the Silicon Valley, I never heard technology described in any way but positive and full of potential. I loved computers and the convenience they offered as much as the next millennial. When I started learning computer science, I grew to love technology, and specifically computers, even more. I had discovered a world of predictability – of ones and zeroes that I could wrap my very logical mind around. Computers, it seemed to me, could and should have a place in every aspect of the world to make human lives better.
Certainly, I thought, this should also extend to health care. I was enamored with the idea of entwining two fields I felt so passionately about. For example, there is a clear need for improvement in health care in medical record systems. Many clinics and hospitals even in America still rely heavily on hand-written notes and paper files. They have indeed proved usable for patient care but offer little opportunity for big-picture data analysis and capture. In addition, paper records are unreliable and difficult to revisit and summarize. Why wouldn’t a health care facility want to use electronic records? Add the fact that I find typing more convenient and efficient than writing by hand, and I thought the appeal of an EMR was clear. (The need for electronic medical records in even more underserved communities abroad such as Kenya and Zanzibar is in fact more clear. My own experience at my internship laid predominantly in a domestic context, however, so my reflections lie predominantly in the domestic field.)
This lead me to my internship as a software engineering intern at Vecna Cares Charitable Trust. I wanted to use my tech-savviness to create awesome new features that a clinic would use to improve their own user experience. And, for the most part, I got to do just that. I was blessed with a patient, knowledgeable supervisor who taught me about a host of computer languages and tools. He both guided me through general concepts of software design and showed me specific software skills. I worked on a biometric identification project that will not only make the updated CliniPAK product more efficient and usable but also sleeker and cooler. I gained all the experience I had expected and more in software engineering and got a great view into what the career of a programmer is really like. I continued to discover my love of computers and even their idiosyncrasies, motivating my decision to change my major at MIT to Course 6-3, Computer Science and Engineering.
But, thanks to the team’s flexibility, I also had the opportunity to help with software deployment at a Worcester Free Clinic at St. Anne’s Church. I expected a smooth and relatively trouble-free process, with at most a few technical issues here and there. Instead, I encountered intense confusion, frustration, and even outright rejection. Just the simple act of carrying in a box full of laptops set one of the clinic clerical worker directors off immediately. A sweet old lady who had dedicated eighteen years to managing St. Anne’s, she was most unhappy that computers had wormed their way into her clinic. Though she had been informed before of the new systems that would be coming, once the threat became very real she also became extremely threatened.
The push-back from the clinic that would then ensue was not limited just to clerical workers who tended on the older (and therefore generally less open to new technologies) side, however. Even doctors and nurses, young adults adept at using their smartphones and laptops, were reluctant to use the new technology. We had created web-based workflows that could be run on donated laptops that would record data in an EMR system. The clinic originally intended to use data gathered to compare usage of St. Anne’s against visit type data for other Worcester Free Clinics. They also wanted a more reliable, up-to-date record system and a way to identify potential superusers of the system. (Patients often take advantage of free clinics to obtain unreasonable amounts of medication or to exploit doctoral services.) All of these goals, however, were unclear to the people actually working at the clinic. The board of directors may have approved the project with a holistic view and long-term goals in mind, but people actually working in the clinic found it hard to see such far-reaching consequences.
The murky motivation for changing an already well-established system annoyed workers at the clinic, but the nature of technology compounded their negativity. When the Vecna Cares team met with clerical workers at the clinic, we discovered that many of them felt technology would put them out of a job. They fundamentally mistrusted computers and viewed them as a cheap replacement for human work. A lot of doctors and medical students in fact complained that computers took away from the patient experience significantly. They found it difficult to gave patients the attention and interest necessary when they were busy trying to figure out how to work the new computer system.
This general dislike of computers in fact itself stemmed from a lack of understanding of both the purpose of the EMR as well as a lack of training. It was easy for Vecna Cares to assume basic computer competencies when building the software – knowing how to scroll, how to click on things, how to type, and how to open new windows and tabs to access the Internet. These assumptions were unfortunately untrue. I was often called over to patient examination rooms by doctors with technological questions such as “Why is the entire screen blue?” It was obvious for me that that was the result of accidentally highlighting the screen, but the doctor deemed me to be a technological genius when I pointed this out. Similarly, we received numerous urgent requests to fix the screen since text seemed to be disappearing from the screen. It took us less than a second to figure that the clinic workers weren’t scrolling down enough to continue to view the text.
The final contention the workers at the clinic had with our technology was its incompatibility with established de facto rules. After my first visit to the clinic, I reflected on the unavoidable fact that nothing always happens as predicted. But the problem, I found, was deeper than small things going awry here and there. We had created an excellent product that was “cool,” “exciting,” and “innovative.” But all of these descriptors, so often used by engineers passionate about the scientific value of their work, meant nothing in terms of usability in a medical context.
All these observations lead me to one of the most important lessons I learned from my internship. The utility of technology in healthcare has been touted increasingly in the last few years, with government continually finding ways to stimulate clinics and healthcare centers to switch to electronic systems. Yet so many people still complain about the inefficiency of hospital operation and records. The reason for this, I believe, is a fundamental disconnect between the producers of technology – engineers – and the users of technology – doctors. Engineers too often fail to consider the importance of doctors’ requests, whereas doctors do not understand the limitations and usage of technology. I want to bridge this gap, offering a unique perspective as a student of both computer science and healthcare. Through Vecna Cares, I have come to understand what the need for people who understand and care about both the engineering and care viewpoints and developed clearer personal and career goals for myself.
Entry 3: Community Voice
(This is an entry written by Emily Wang, one of my supervisors and the main project manager for Vecna Cares Charitable Trust. She has worked both in the Cambridge office and on the ground at various deployment sites such as Kenya and Nigeria.)
Vecna Cares provides technology to strengthen health systems in underserved areas, starting with better patient-centric data at the primary health care level. Our suite of hardware and software products overcome hurdles to delivering healthcare technology in developing settings: poor infrastructure, low computer literacy, and overtaxed human resources. Our flagship product, CliniPAK, is a portable server with full network and power management running off of solar, battery, and AC power. We use this as a platform to deliver a streamlined and easy-to-use electronic health record (EHR) to healthcare workers serving vulnerable patients worldwide. With a focus on primary care, especially maternal and child health, we are dedicated to providing better patient data at the frontline of health, especially in circumstances where continuity of data across care is important.
In Kenya, we work in the Transmara District. Six hours from Nairobi, the majority of the 40 public health centers in the district do not have electricity or running water. They are able to use CliniPAK to easily capture patient data at the point of care which greatly eases their reporting burden at the end of each month. In Worcester, Massachusetts, we support a set of free clinics run by UMass medical students. With a constantly cycling set of volunteers, they need something simple to use with low maintenance overhead in order to track patients between clinics and better understand the services that they are providing. We also support clinics in Haiti, Nigeria, and medical missions looking to streamline their operations and clinical data capture.
One of the primary challenges of patient data is positive patient identification. In many developing countries, spelling can be flexible, patients are unsure of their age, and government issued ID can be sparse. In this situation, traditional means of identifying patients (name and DOB) easily result in duplicate records for a single patients. With these challenges, biometrics is an appealing solution. Of the numerous biometric solutions available: fingerprints, palm vein, retina, fingerprint scanning remains the most widely used and reliable one. Implementing this in conjunction with an EHR requires multiple pieces. First, the scanner must be compatible with the tablet or computer that is being used. Secondly, the EHR must be able to capture the fingerprint and send it to the server. The fingerprint image is then transformed into a template which is used to search for the patient.
Fingerprint integration has been a feature we’ve been wanting to develop for quite some time and we will begin upgrading sites to include fingerprint over the next few months. Next steps include increasing our flexibility to use different fingerprint devices and hashing algorithms as well as integration with mHealth solutions. On the implementation side, there challenges to overcome as fingerprints are not reliable for young children. Even with these challenges, we’re excited about the benefits for patient-level and aggregate-level data quality.
Entry 2: Software in Action
One of the biggest highlights of my internship at Vecna Cares so far happened last Tuesday, when I headed over to the Worcester Free Clinic in St. Anne’s Church with the team.Tuesday was deployment day for our CliniPAK software at the clinic. While our system had been tested at two of the other Worcester clinics, St. Anne’s was the biggest clinic yet, and implementing a whole new electronic record system was quite the adventure.
The clinic runs weekly in the evening for two to three hours; on Tuesday, another intern and I arrived on site an hour early to begin setting up and training. We had obtained 18 donated Dell laptops with the Vecna software installed. The biggest challenge was, however, not the physical setup but rather training the medical staff in how to use the software and demonstrating why the new system would be useful. This was lesson one of the evening: the importance of training and explanation. While the CliniPAK was designed with a relatively intuitive user interface, it was impossible to predict what might be confusing to someone accustomed to years of using paper records. I personally quite enjoyed explaining the registration process to all the staff members and getting to know them in the process. It was a wonderful opportunity to not only get to know the people who would be helped by the new system but also to hear feedback.
Although many of the staff were initially resistant to the idea of re-hauling an entire system of patient records, they quickly warmed up to the system with a little practice. The first patient took a full twelve minutes for one staff member to register, but the next only took five, and soon we had worked out an efficient system for registration. A lot of the nurses and staff members soon realized the utility of not needing to dig through piles of unorganized folders for often indecipherable paper notes. For example, one elderly woman came into the clinic regarding some concerns she had about her diabetes. After being left waiting for a full hour because her previous paper files were entered under the wrong letter, she was then told her blood work from the previous week was nowhere to be found. Having an electronic medical record (an EMR) system would have prevented these problems. For me, this was lesson number two: familiarity is key. Getting to know the easily understandable system made all the staff members much more enthusiastic about moving the entire clinic’s system to EMRs and helped them understand the utility of the technology.
The next lesson I learned reflected on long-term goals and potential for Vecna Cares. After the very busy two-hour clinic period was over, the staff members were full of suggestions and ideas for new features. The new system, they informed us, would work great “as soon as a few bugs are fixed.” However, these “tiny bugs” ranged from extremely simple changes to requests for fairly diverse features that would require time and effort for us to implement. This leads into one of both Vecna and Vecna Cares’s most important future goals – making the product easily modifiable by the clients. The current process for even the tiniest of error fixes is complicated and not very efficient. The clinic has to call Vecna Cares with complaints and suggestions, where the issues are filed away. It could take months before the software engineering team has the time to address the problem, meaning the clinic has to wait an extremely long time just to change the heading of a screen. To best accommodate all the potential requests from the clinic, it would be best to design a system that allows a layperson healthcare administrator to fix software-related features.
Finally, as the team recapped what we had learned from the experience and gathered our thoughts, I found one very important lesson emphasized. Despite months of working with the clinic in preparation, the unpredictable still happened. We had studied the previously instituted workflows for tuberculosis testing in the clinic, for example, but were unable to account for a number of de facto traditions and logistical issues. Designing an account for the doctor to sign off on PPD (tuberculosis) tests fit into the established procedure on paper, but nurses ended up running back and forth to ask the doctor to sign off on the tests anyways. The doctors were simply too busy diagnosing patients and prescribing medications to regularly check their computers for new tuberculosis testing patients. Numerous similar concerns arose throughout the evening from all levels of medical staff, leaving the team with a lot to think about. Nothing works in the field quite the way one would expect, and the clinic visit definitely taught me the importance of extensive communication and testing.
At the end of the day, the most important lesson of the night for me was, of course, seeing the impact the CliniPAK already had and could have in the future. I loved watching the staff steadily realize the usefulness of EMRs. Some were skeptical of the extra work that was required at first – typing can be hard! – but the ease of keeping everything in one place and getting a holistic view of the clinic data soon convinced them the work is worth it. I also saw the need for my own personal project – integrating biometric identification. The finished code will not only make the registration process considerably faster and less tedious, but will also become applicable to various other important peripheral features such as scanning and printing. The last few weeks at Vecna Cares have been incredibly eye-opening, and I can’t wait to see more of the impact I can make through Vecna Cares.
Entry 1: Beginnings
Last Friday marked the end of my first week interning with Vecna Cares, the nonprofit part of a healthcare information technology company called Vecna.
But what does that mean? People are often confused about what exactly Vecna is. Some assume it is a medical supply company, and others only know that it develops software for the healthcare industry. The products that Vecna creates are, in fact, at the junction of computer science and healthcare. Vecna focuses on using computer technologies to create products that streamline and standardize clinics for both patients and administrators. Vecna Cares, for example, implements CliniPAKs (Clinical Patient Administration Kits) in countries such as Tanzania and Nigeria. Clinics in these countries typically rely on disorganized, unsustainable “databases” consisting of haphazardly recorded paper notes. What happens when the people who created the original system move to a different place, or doctors try to find records on a patient from two years ago? CliniPAKs help organize and standardize clinical records, opening a whole world of possibilities for administrators to spot trends and track patients. Vecna Cares has implemented these products in numerous clinics already and is constantly working to improve and expand their functionality. Vecna Cares is a perfect representation of the company’s motto — Better Technology, Better World. This is where my internship comes in.
As a pre-med student interested in global health who also loves the power of of computer engineering, I initially found it very difficult to find a summer opportunity that would encompass both interests. Vecna Cares offered a perfect chance to explore how computer science can impact global health issues. My project for the summer initially involved integration of currently existing CliniPAK programs with mobile devices. This would entail both software development in Vecna offices (in Cambridge) and communicating with teams working on the ground to test the products. In addition, I planned to incorporate the products with DHIS2, an external reporting platform. I hoped to not only gain experience with a wide variety of computer programs and software tools but also learn more about the nature of global health over the summer.
However, within these past first days, I quickly learned one of my first lessons about working in global health – the importance of flexibility. The field is extremely fluid and unpredictable. With ever-changing requests from clinics in real-time, it is impossible to foresee what the priority of tasks will be or how resources will need to be allocated. In my first week of work, I ended up helping prepare the new Vecna Cares website to be rolled out as soon as possible for the benefit of both potential and current clients. Although I did not expect this project, I found I thoroughly enjoyed the combination of design and programming.
I’m now really looking forward to the coming weeks I will spend at Vecna. The Vecna Cares team is an incredible group of people dedicated to service and excellence, and I can’t wait to learn from their wisdom and advice. Whether working on integrating biometrics (fingerprint recognition) into the system, making the CliniPAKs mobile, or improving the readability of the website, I am sure I have much to learn.