Social change
EMRs and Paper Records: Co-existing in Hospital Ecosystems
Fundamental to the job of a user experience (UX) designer is a clear understanding of users, their needs, skills and priorities. As part of my experience on Bahmni's design team, our challenge was in building a feature-rich hospital management system for users unfamiliar with technology. The system needed to work for low-resource (including monetary, infrastructure, and human resources) environments.
The end users of Bahmni are typically doctors, specialists, clinical and non-clinical staff at hospitals located in remote parts of the world, most of who rarely use technology in their daily life. This is telling of the digital literacy divide even among highly educated people like doctors. Bahmni takes careful steps to bridge this divide by including features and enhancements that are designed with these users in mind.
[Admin staff at JSS, India searching for a patient’s record]
During my visit to JSS (Jan Swasthya Sahyog), a hospital using Bahmni, I observed that most are ‘repeat patients’ — those who are undergoing continuous treatment and returning periodically on the doctor’s advice. In order to be identified as a registered patient, they were expected to carry a printed registration card to the hospital. Often, these cards were either misplaced or dog-eared potentially requiring re-registration and causing duplication of patients.
With Bahmni, this problem was eliminated. A simple search finds the patient information. His/her card can be instantly recreated and the doctor has access to all health records for examination. For instance, when I was there, a patient named Ram came by without his ID. Searching for the name ‘Ram’ gave us tens of patient records. It is for scenarios like these that the multiple identifier functionality is designed — it lets users search using other identity documents such as a government-issued identity card or a mobile number. Multiple identifiers act as filters, helping us find the right patient through a process of elimination.
[Health assistants working with Bahmni]
Every week, health assistants at the hospital meet to discuss their cases with their respective senior doctors and share their learnings. These discussions involve cases ranging from simple to highly complex ones. To keep track of their cases, health assistants use Bahmni.
Most health assistants use Bahmni in their local language as that is what they are more comfortable with. This improves accessibility, transparency and brings contextual understanding to the work environment. This also eliminates any misunderstanding and increases medical accuracy. Moreover, this makes it easier for them to add data into the system. With continuous use, users have become efficient and are able to identify patient problems better.
[Lab technician directly entering lab findings into the system]
The process of getting tests done in the lab was long and tedious — it involved a lot of paper records and back-and-forth between the doctor, patients and the lab technician. For instance, at JSS there were 3-5 different kinds of samples drawn for testing in as many sections within the lab. The typical process is that the assistant technician performs the tests and writes the results down in a book. Then, the senior technician validates this. This means that there were 3-5 records in 3-5 different books, which made validation cumbersome.
Now, through Bahmni, the doctor directly intimates the lab technician of orders. The technician performs the tests and records the results into the system. With Bahmni, validation by the senior technician can be done in one screen, all in one place. The visibility this provides helps reduce errors and save time.
[Doctors investigating the x-ray of a patient]
Radiology is among the most labour-intensive departments. Bahmni has digitized and significantly simplified the process. With Bahmni, the doctor prescribes the required radiology for a patient, during which he is presented with all the different x-ray options to choose from. Once the doctor clicks on the option he/she prefers, the radiology department processes it and sends it back to the EMR.
The doctor can access the ordered radiology on his/her screen instantaneously. He/she can also zoom in and get a detailed view of the x-ray, add notes for later reference. The entire process takes minutes to complete, unlike the earlier process where the doctor and patient had to wait for hours. Moreover, this process has completely eliminated the hazardous print of x-rays.
Having all past diagnosis, medication, vitals and lab results all on same screen ensures the doctor doesn’t miss out on any information he/she needs to deliver healthcare.
[Screenshot of a patient dashboard]
The dashboard is presented with various visual cues to help highlight problem areas. For instance, under ‘treatment’, the medication the patient is currently on is highlighted in orange to help the doctor focus on what’s current. Similarly, if a patient’s hemoglobin level is less than the standardized value, the interface highlights it in red to instantly attract the doctor’s attention to it.
[Back office staff updating patient information]
One of the biggest challenges of public health management is the unavailability of data at the right time to conduct any analysis. Over the years, we have made little progress owing to the monumental amount of paper records involved. Imagine the transformational predictive insights that can be gleaned from say 50 data points from the 300 patients per day for a year — that’s potentially five and a half million valuable data points.
Bahmni collects data from all patients and keeps track of their health and progress. The report generation module allows the administrators of the hospital to generate reports based on duration, diseases, format etc. This gives the hospital administration a consolidated report which enables quicker decision making on disease breakout, affected areas and the treatment required for it.
Similarly, data produced by hospitals are also of profound use to researchers. At Possible, Nepal, I met several researchers, who were working on medical research projects in specific disciplines. Bahmni became powerful technology support for them as it collects, aggregates and presents data that is sparse.
Designing for low resources and low digital literacy, and building Bahmni has been one of the most rewarding projects of my career. I’ve had the opportunity to observe the way users have taken to Bahmni and I was nothing short of amazed at the ease with which the product is being used. I’ve learned that the challenges of building this kind of product are unique. Key to addressing these challenges and meeting the needs of our end users, is to intricately understand their situation, empathize with their lived experience, and validate your ideas with users.
In an effort to achieve a useful product experience, as part of my visit to the implementation site, I spent a week there observing users, their tasks and their interaction with the EMR. I spent time with them and made conversation. After the familiarization stage, I carried a probe sheet to document my understanding of user needs, pains, gains, wants, behaviour, environment, etc. When designing new feature ideas and improvements to address issues, I now discover, test and collaborate with doctors and hospital workers to make it both intuitive and useful.
My time with the users of Bahmni has given me a stronger, more meaningful impression of the on-ground reality surrounding our product. This only inspires me to work towards building a robust product, filled with user-friendly features, evolving through continuous end-user feedback. By combining feedback, future trend study and design thinking, this product can be a universal health information system catering to low-resource environments all over the world.
The end users of Bahmni are typically doctors, specialists, clinical and non-clinical staff at hospitals located in remote parts of the world, most of who rarely use technology in their daily life. This is telling of the digital literacy divide even among highly educated people like doctors. Bahmni takes careful steps to bridge this divide by including features and enhancements that are designed with these users in mind.
Strengthening Search with Multiple Identifiers
[Admin staff at JSS, India searching for a patient’s record]
During my visit to JSS (Jan Swasthya Sahyog), a hospital using Bahmni, I observed that most are ‘repeat patients’ — those who are undergoing continuous treatment and returning periodically on the doctor’s advice. In order to be identified as a registered patient, they were expected to carry a printed registration card to the hospital. Often, these cards were either misplaced or dog-eared potentially requiring re-registration and causing duplication of patients.
With Bahmni, this problem was eliminated. A simple search finds the patient information. His/her card can be instantly recreated and the doctor has access to all health records for examination. For instance, when I was there, a patient named Ram came by without his ID. Searching for the name ‘Ram’ gave us tens of patient records. It is for scenarios like these that the multiple identifier functionality is designed — it lets users search using other identity documents such as a government-issued identity card or a mobile number. Multiple identifiers act as filters, helping us find the right patient through a process of elimination.
Expanding the Language Capacity for Better Training
[Health assistants working with Bahmni]
Every week, health assistants at the hospital meet to discuss their cases with their respective senior doctors and share their learnings. These discussions involve cases ranging from simple to highly complex ones. To keep track of their cases, health assistants use Bahmni.
Ye list hai na, isse dekh kar sab sahi se kar lete hein, (We are able to do everything accurately, looking at this list.)
Most health assistants use Bahmni in their local language as that is what they are more comfortable with. This improves accessibility, transparency and brings contextual understanding to the work environment. This also eliminates any misunderstanding and increases medical accuracy. Moreover, this makes it easier for them to add data into the system. With continuous use, users have become efficient and are able to identify patient problems better.
Minimizing Errors with Digital Lab Records
[Lab technician directly entering lab findings into the system]
The process of getting tests done in the lab was long and tedious — it involved a lot of paper records and back-and-forth between the doctor, patients and the lab technician. For instance, at JSS there were 3-5 different kinds of samples drawn for testing in as many sections within the lab. The typical process is that the assistant technician performs the tests and writes the results down in a book. Then, the senior technician validates this. This means that there were 3-5 records in 3-5 different books, which made validation cumbersome.
Now, through Bahmni, the doctor directly intimates the lab technician of orders. The technician performs the tests and records the results into the system. With Bahmni, validation by the senior technician can be done in one screen, all in one place. The visibility this provides helps reduce errors and save time.
Print-Free Radiology for Reports in Minutes
[Doctors investigating the x-ray of a patient]
Radiology is among the most labour-intensive departments. Bahmni has digitized and significantly simplified the process. With Bahmni, the doctor prescribes the required radiology for a patient, during which he is presented with all the different x-ray options to choose from. Once the doctor clicks on the option he/she prefers, the radiology department processes it and sends it back to the EMR.
The doctor can access the ordered radiology on his/her screen instantaneously. He/she can also zoom in and get a detailed view of the x-ray, add notes for later reference. The entire process takes minutes to complete, unlike the earlier process where the doctor and patient had to wait for hours. Moreover, this process has completely eliminated the hazardous print of x-rays.
Better Visibility to Patient History with Display Controls
In low-resource environments, the problem of incomplete and missing or patient history is highly prevalent. Even in cases where the patient carries a folder of past records and diagnosis, it is time-consuming to peruse and find relevant information from all the sheets of paper. With Bahmni, the doctors have instant access to a patient’s entire history by simply entering their patient ID into the system. In addition, they can use Bahmni’s display controls to quickly and efficiently scan through the information.Having all past diagnosis, medication, vitals and lab results all on same screen ensures the doctor doesn’t miss out on any information he/she needs to deliver healthcare.
[Screenshot of a patient dashboard]
The dashboard is presented with various visual cues to help highlight problem areas. For instance, under ‘treatment’, the medication the patient is currently on is highlighted in orange to help the doctor focus on what’s current. Similarly, if a patient’s hemoglobin level is less than the standardized value, the interface highlights it in red to instantly attract the doctor’s attention to it.
Preempting Disease Breakout with Real-Time Data
[Back office staff updating patient information]
One of the biggest challenges of public health management is the unavailability of data at the right time to conduct any analysis. Over the years, we have made little progress owing to the monumental amount of paper records involved. Imagine the transformational predictive insights that can be gleaned from say 50 data points from the 300 patients per day for a year — that’s potentially five and a half million valuable data points.
Bahmni collects data from all patients and keeps track of their health and progress. The report generation module allows the administrators of the hospital to generate reports based on duration, diseases, format etc. This gives the hospital administration a consolidated report which enables quicker decision making on disease breakout, affected areas and the treatment required for it.
Similarly, data produced by hospitals are also of profound use to researchers. At Possible, Nepal, I met several researchers, who were working on medical research projects in specific disciplines. Bahmni became powerful technology support for them as it collects, aggregates and presents data that is sparse.
Looking Forward
Bahmni is a feature-rich product designed to meet the needs of doctors and healthcare workers left out of the ever evolving standards of digital literacy and access in low-resource environments. Every feature is being carefully considered, tested, validated and implemented to ensure real problems are addressed efficiently. In addition to the big ones above, there are many distinct features such as observation forms and treatment flow that help users manage a sea of patients on daily basis.Designing for low resources and low digital literacy, and building Bahmni has been one of the most rewarding projects of my career. I’ve had the opportunity to observe the way users have taken to Bahmni and I was nothing short of amazed at the ease with which the product is being used. I’ve learned that the challenges of building this kind of product are unique. Key to addressing these challenges and meeting the needs of our end users, is to intricately understand their situation, empathize with their lived experience, and validate your ideas with users.
In an effort to achieve a useful product experience, as part of my visit to the implementation site, I spent a week there observing users, their tasks and their interaction with the EMR. I spent time with them and made conversation. After the familiarization stage, I carried a probe sheet to document my understanding of user needs, pains, gains, wants, behaviour, environment, etc. When designing new feature ideas and improvements to address issues, I now discover, test and collaborate with doctors and hospital workers to make it both intuitive and useful.
My time with the users of Bahmni has given me a stronger, more meaningful impression of the on-ground reality surrounding our product. This only inspires me to work towards building a robust product, filled with user-friendly features, evolving through continuous end-user feedback. By combining feedback, future trend study and design thinking, this product can be a universal health information system catering to low-resource environments all over the world.
Disclaimer: The statements and opinions expressed in this article are those of the author(s) and do not necessarily reflect the positions of Thoughtworks.
