When Work Doesn't Feel Like Work

I’m not a software developer. To build our electronic medical record (EMR) software we used an open source platform called OpenMRS which you can build upon and customize with the fundamentals of HTML and MySQL coding. When we implemented these systems, I was not confident that they would be long-term solutions. I felt our EMR was certainly better than the paper based record systems most clinics in Ghana use, but I believed our implementations to be a temporary solution until someone legit like EPIC decided Ghana was worth investing in. Five years later however, most of Ghana is still using paper records. I read recently that providing healthcare without an EMR in the 21st century is like being a surgeon without a scalpel. I agree, from what I’ve seen at Harvard and during my time in the industry, people are using EMR data as the fuel for many technological innovations in healthcare. We can’t let Ghana fall behind.

Old paper folder record system at the CPMR

Myself and five colleagues have registered a company here, MedData Consulting Inc., that implements EMR software for clinics. I’m not really a fan of charity, I believe social entrepreneurship is a better way to make a difference. I could implement these systems for free, but there’s no sustainability in that. I wouldn’t be employing 5 people. Buying the software makes the hospitals more invested in the EMR. Our company has completed implementations for 4 hospitals so far. We’ve got some business objectives during my time here too. The first is a technical one. There is a new opensource EMR that builds upon our current platform of OpenMRS called Bahmni. It’s linux based, which is unfamiliar to most of us, so we’re going to do some research to see if we can begin implementing this tool. This will involve playing around with an old dell console in one of my coworkers apartments on the weekends. Honestly this work is a lot of fun. These guys are smart, tech savy, and a joy to work with. 

I’m a nerd, I love playing with these computers, writing code, especially when it contributes to something meaningful. This work is my hobby. I remember when I was working in New York, the only vacation time I took was two weeks to travel to Ghana for an EMR contract we had. I remember I never understood why my Uncle Tony would take his vacation time to run a Taco stand to fundraise for his church. But it was his passion. This is my passion. It doesn’t feel like work at all. It makes me feel alive. It gives my life meaning. 

This past week, I visited two of the clinics that have implemented our EMR software. For these two clinics, the software has been running for 5 years and 4 years respectively without any major problems. The staff at the CPMR, whom I trained to manage the system, told me that the government recently did a review of various EMR systems in the country, and OpenMRS came in 3rd. I don’t know if this is good press for us or bad news for the EMR situation in Ghana, but I’m happy that our work is improving the quality of care to patients at both these clinics.

Things have been slow for the past few years, mainly because our main programmer had gone back to school, but just completed in May. Actually, 5 out of 6 of us, including myself, have decided to further our education and obtain higher credentials. One has just graduated, three are in progress, 

and one of them recently got accepted and needs some extra income to pay his tuition. He is hungry for another EMR contract. We’ll be hunting for one of those during my time here as well. My Twi definitely helps in securing these contracts. 

I also see the future of the company as moving into data analysis of the EMR data. There are plenty of pharmaceutical companies as well as technology companies like Flatiron, doing this in the states. Once Ghana gets more and more data they will need statisticians to make sense of this data. Such a venture is generally even more lucrative than installing systems. 

Again, I’m not a software developer, but a statistician. I’m very interested in the data we are producing.

Discussing research projects with Mavis Boakye and other clinicians at the CPMR

Mavis Boakye, the head of the clinic at the CPMR, has published a string of academic papers on the herbal medicines she prescribes using the data from the EMR. For me this is a dream come true, as my original goal with the EMR was to empower the clinic to conduct research into the plant medicines. Mavis is quite statistically literate, a rarity for a clinician in the US let alone Ghana. This makes her an ideal collaborator for me. We’re going to start conducting more retrospective studies on the medicines together with her providing the clinical knowledge and myself the statistical knowledge.

The second clinic, International Health Care Center (IHCC), is the oldest HIV clinic in Ghana. It’s run by Dr. Naa Vanderpuye-Donton who is half Ghanaian and half Dutch, and obtained her medical degree in the Netherlands. She is extremely dedicated to the fight against HIV in Ghana, and she wears this dedication on her sleeve. In addition to her clinic, she’s has an NGO called the West African AIDS Foundation (WAAF) which is out in the community for outreach and HIV screening initiatives. She’s often on TV for health education segments. For IHCC, implementing an EMR is even more important than your typical clinic. External programs run by PEPFAR and the Bill and Melinda Gates Foundation provide donations to reduce the costs of antiretroviral drugs that allow people living with HIV to live normal lives. Because of this, they often want to see data on how their $$ is being put to use. The EMR allows IHCC to quickly report these figures to external funders. This summer, we’re writing a paper together studying

loss to follow up among the HIV patients she cares for.

Thank you for reading. I’ll post again next Wednesday.

3tu buroni ah, ) ka Twi - “When the challenge comes, the white man speaks Twi”

While the official language of Ghana is English, the predominately spoken language is Twi. I surprise a lot Ghanaians when I speak Twi. It usually goes something like this:

Oobrooni, 3t3 s3n? (White man, how are you?)

B)kk). (Cool)

Eiii! wo t3 Twi? (Ah! You understand Twi?)

Aan3, 3tu bruni a o ka Twi. (Yes, when the challenge comes, the white man speaks Twi)

Twi is a beautiful language. It is poetic. It is tonal. There are many proverbs woven into daily conversations. It of course has no Latin roots, so the grammar is unique. Learning the language is the gateway to any culture. Speaking Twi is the main reason why I’m able to call Ghana my second home.

Visiting a traditional medicine shrine during my first trip to Ghana in 2010

This is my seventh trip to Ghana. I first came in 2010 as an undergrad for three months. I was 20 years old. I was on a research grant of a med school professor at University of Michigan. He was an OBGYN, and had a collaborator at Ghana’s Center for Plant Medicine (CPMR). Like China, Ghana has a strong tradition of plant based medicine and their healthcare system is a fusion of both herbal and orthodox clinics. Myself and another student came to study a particular plant, that had traditionally been used during childbirth. The CPMR also has a clinic where they prescribe herbal remedies for malaria, typhoid fever, hypertension, diabetes, and other ailments. They ran small clinical studies (e.g. with 15 patients) to try to provide evidence of the plant’s effectiveness, but struggled to produce convincing data. This motivated me to apply for a Fulbright, a year of research funding, when I graduated to help the CPMR clinic gather more patient data. I applied for a Fulbright twice, rejected before the interview stage at my first attempt, and accepted my second try. This brought me to Ghana for one year in 2013. 

That year changed my life in many ways, but most of all it gave me a connection to Ghana that I know will be present for the rest of my life. I now have lifelong friends here, a god daughter, and a company. I learned a new language. Although I’m not fluent, many Ghanaians have told me I speak Twi better than any white person they’ve ever met. I was fortunate during that year, I was the only foreigner at my workplace and in my town. I had no choice but to integrate into the society. I went to the market to buy products to cook Ghanaian foods. I played on my company’s soccer team. I went to church - sometimes. I attended weddings of friends and naming ceremonies of their newborns. Sadly, I even attended a funeral of a colleague from work. I experienced a completely different culture which forced me to challenge my own. Most importantly, I rediscovered my humanity, which I sometimes feel my homeland attempts to strip away from me. In the US I often feel more like a tool for someone else’s production or a dollar sign than a human being. The Ghanaian culture restored my humanity in many ways.

Godwin Danso & myself working with the Electronic Medical Record system at CPMR in 2014

The purpose of my Fulbright was simple: Gather more data for the CPMR clinic to build a body of evidence for their herbal medicines. To do so, we set up an Electronic Medical Record system, digitizing all the paper forms currently used at the clinic. This was a surprisingly smooth process, and after 4 months the clinic went entirely digital. It was one of the first EMRs in the country. A short documentary was even made about my work. In the process, I trained a few of the staff in the clinic how to implement the software, write html code to digitize forms, and query the SQL database to pull data for reports. One day, they came to me and said, “Alex, we can do this for other hospitals”. Consequently, at the end of my trip, we filed the paperwork to incorporate and became a company in Ghana. Since then, I’ve come back to Ghana about once per year for new projects. I’m proud to say together we have implemented EMRs for four hospitals: an HIV clinic, a large outpatient clinic in Accra, and two herbal medicine clinics one of which is of course the CPMR.

We are now sitting on a pile of data, untapped for the most part. For this particular trip my goal is pull, clean, and analyze some of this data in order to answer questions that are relevant to the clinics. My trip is funded by a grant from Harvard to work with data from the HIV clinic, but my first stop was to visit my oldest collaboration, the CPMR.

Arriving at the CPMR last week

Luckily, when I arrived to visit to the CPMR, Dr. Appiah, the newly appointed Director of the centre, had arrived at the same time. He greeted me in Twi and we went to his office to chat. Politically, as an outsider it’s always important than when you enter an institution in Ghana that you visit the person at the top. I believe this tradition stems from the chiefdom days, where any ausländer must get approval from the chief before settling on land within their jurisdiction. We chatted a bit about our lives. He gave me his stump speech for herbal medicine “For thousands of years our ancestors have been using these plants, often through trial and error, they found which plants cure which ailments.” What the Centre does is try to provide the scientific backing to these herbal treatments. He spoke to how they work towards identifying the chemical compounds within the plants, proving the mechanism of action, and uncovering any side effects etc. Unfortunately, given the resources of the clinic this is a herculean task. Last summer I saw at Novartis a billion dollar multinational company with essentially unlimited resources trying to accomplish the exact same thing. Novartis has chemical compound databases, state of the art animal testing facilities, the means to conduct clinical trials, world class scientists, and still many drugs don’t make the cut to go to market.

My original goal of my Fulbright was to collect data on the outpatient clinic, and then try to see if there was any indication that the medicines were working. To be honest I never achieved the latter part of this goal; however, now we have accumulated over 5 years of data in the EMR. I’m also 5 years sharper as a statistician. I’m excited to see what I find.