Early exposures to healthcare in Ecuador
In the United States, we have a healthcare system composed of many entities (hence its complexity). There are both positives and negatives to the system, but what you cannot deny is that it is a system in which (most) patients have access to healthcare. My question is: what happens when you create a new system in a place where a platform previously did not exist?
My first experience on the provider side of healthcare was in rural Ecuador. Early in college I joined a club called Timmy Global Health (TGH). TGH’s mission is to “expand access to healthcare and empower students and volunteers to tackle today’s most pressing global health challenges.” What cannot be gleaned is that TGH commits to a community and returns every 3–4 months to provide continuous primary care. Our group provided healthcare to communities on the outskirts of Quito, Ecuador, where the poor rural migrants, indigenous to more remote areas of Ecuador live. There are no healthcare facilities in these areas and the nearest hospital is at least an hour away. The communities technically have access to government healthcare facilities (mostly to the north), but as far as the communities are concerned, there was no healthcare system.
TGH created a healthcare system by connecting community leaders, local hospitals, local medical professionals, and their own volunteer community back in the US. It works and here is why:
- TGH partners with a local hospital/non-profit, Tierra Nueva, to provide acute care, specialist care, and follow-up labs/imaging. This allows the primary care clinics to escalate care when necessary. The cost of care from these referrals is subsidized by TGH through donations.
- TGH works with community leaders. Prior to a medical service trip comprised of college students and healthcare professionals, TGH works with community leaders to make sure that the community knows about the clinic and also sells tickets for admission to the clinic. The tickets are nominal ($1 during my trip) and are not a huge cost for patients but enough to make sure that patients are engaged. After the mobile clinic at the community, the community leaders serve in a surveillance capacity by alerting TGH and Tierra Nueva if there are any patients that have become severely ill in between trips.
- TGH cultivates a US based volunteer community. The college students serve as Timmy’s core base of volunteers and find medical professionals to accompany them on trips. They also fundraise to pay for the referrals and medicines prescribed. This not only gives students a direct way to contribute to a charitable cause in a meaningful way, but also gives them some healthcare experience in the process.
- Rinse and repeat. TGH took this model and began applying it to other communities in Ecuador and in different Latin American countries in need of healthcare systems.
TGH capitalizes on the strengths of its stakeholders. As the healthcare system has matured, the challenge for TGH is to transform their healthcare system to be self-sustaining and more independent from outside resources. This will likely require additional stakeholders to buy into the system.
During a college summer, I volunteered to further examine the perceptions and trends of chronic diseases in TGH’s rural Ecuadorian communities. Certain chronic diseases that were more commonly seen in developed countries, like hypertension and diabetes, began to appear in these resource-poor communities. Through this research, I learned that rates of chronic disease were increasing in these communities and the chronic nature of the diseases actually made it very difficult for patients to get their illnesses under control.
There is a fundamental issue with these diseases — an information asymmetry between doctors and patients. With infectious diseases, patients generally know something is acutely wrong with their health and have a high impetus to seek care. However, the manifestations of chronic diseases usually have no short-term symptoms, but rather, long-term consequences in the form of stroke, heart attack, neuropathy, and peripheral artery disease, to name a few. Thus, in order for patients to buy into the treatment over the short-term, a high amount of health education has to flow from the doctor to the patient. This is the information asymmetry divide that doctors are challenged to overcome with their patients.
As I was wrapping up my research, it was clear to the site leader and me that there needed to be a program that specifically addressed the needs of patients with chronic diseases. This program was started after my time but I could envision a system in which the community leaders were educated about chronic diseases. Then these community leaders could follow-up with patients more frequently as a way for surveillance in between medical service trips. By educating the community leaders, we could move one more step towards dissolving the health information asymmetry.
At the same time that I was conducting my research into chronic disease, I met two individuals who were building an electronic medical record (EMR) for TGH. The challenges were high: minimal budget, no existing infrastructure, and no reliable internet connection. The team consisted of a backend engineer and a front-end designer. The EMR solution addressed the challenges in the following way:
- Minimal budget: Each mobile clinic only requires one expensive laptop that serves as the mobile database for the clinic. Volunteer computers and tablets serve as supplements. (cheap laptops that can run an internet browser are also available)
- No existing infrastructure: A local network via Wi-Fi router and Ethernet is set up. Volunteers and healthcare professionals can access the EMR by connecting to the network and then loading the EMR in a web browser. A username/password is required to gain entry to the database. As patients progress through the clinic stations, the EMR is updated. Electricity backup supports the network and the main computer.
- No reliable internet connection: At the end of every clinic day, the laptop that serves as the database is backed-up to the cloud when a reliable internet connection is available and the information is synced so that all the databases are updated.
In retrospect, not only is the above an elegant solution to building an EMR but also an amazing feat having been mainly built by two programmers. This is an EMR that was purposely built for the needs of the healthcare system that TGH setup and it’s certainly reflected in its ease of use and versatility for delivering healthcare. As I was leaving, more functionality was being built into the system: a medication tracking system for inventory management and an interface for hospital/healthcare professionals for referrals and patient follow-up.
The next versions of TimmyCare are now being built and I am interested to see what additional functionality will be built in. Also, as more technology gets into the hands of resource-poor communities (cell phones) there may be a great way to build in more functionality for the patients.
Wrap-up & questions
In review, my experiences in Ecuador exposed me to the challenges of delivering healthcare — especially in areas that are resource limited. It requires buy-in from all stakeholders and the utilization of the unique advantages belonging to all participants in the system. The experiences also exposed me to the importance of health literacy and a reliable record keeping system. I look forward to seeing how TGH deals with the challenges of maintaining levels of care over the long-term and creating more self-sustaining healthcare systems in the regions they operate in — as their healthcare is still dependent on outside volunteers and charitable funding. Nevertheless, in my opinion, TGH is an incredible nonprofit organization.
Stakeholders: Do current stakeholders in the current healthcare system have adequate and balanced representation/skin in the game?
Health Literacy: What is a scalable way to improve health literacy? Does health literacy help patients navigate the healthcare system? If not, how do you make navigation both informed and simple?
Electronic Medical Records: If you abstracted away the complexity of billing and reimbursement in healthcare practices, how would an EMR be built? What does a patient-centric EMR look like?
Thanks to Katrina Kovalik!