Wednesday, June 14, 2017

Top 10 lessons learned when installing digital imaging in developing countries.

Patient at Zinga
Children's hospital,
close to Dar-es Salaam,
recipient of a Rotary
 International grant for
imaging equipment
Installing a digital medical imaging department in a developing country is challenging, which is
probably an understatement. The unique environment, lack of resources, money and training, pose barriers to creating a sustainable system.

As anyone who has worked in these countries will attest, sustainability is key, witnessed by the numerous empty buildings, sometimes half finished, non-working equipment due to lack of consumables, spare parts, or simply not having the correct power, A/C or infrastructure environment. 

I learned quite a bit when deploying these systems as a volunteer, especially through gracious grants by Rotary International and other non-profits, which allowed me to travel and support these systems in the field. Some of these lessons learned seem obvious, but I had to re-learn that, what is obvious in the developed world, is not necessarily the case at the emerging developing countries of the world. 

So, here is my top 10 lessons learned in the process:

1.       You need a “super user” at the deployment site with a minimum set of technical skills. Let’s take, as an example, a typical digital system for a small hospital or large clinic, which has one or two ultrasounds, a digital dental system and a digital X-ray, either using Direct or Computerized Radiography (DR or CR). These modalities require a network to connect them to a server and a diagnostic monitor and physician viewer. Imagine that the images don’t show up at the view station, someone needs to be able to check the network connection, and be able to run some simple diagnostics making sure that the application software is running. In addition to being able to do basic troubleshooting on-site, that person needs to also function as the single point of contact for a vendor trying to support the system and be the ears and eyes for support.

2.       Talking about “single point of contact,” I learned that it is essential to have a project manager on-site, which means that one person arranges for equipment to be there, knows what the configuration looks like, checks that the infrastructure is ready, does the follow up, etc. It is unusual that the local dealer does all of this. There also might be construction needed to make a room suitable for taking X-rays (shielding etc.), A/C to be installed to prevent the computers from overheating, network cables to be pulled, etc.; there has to be a main coordinator to do this.

3.       You also need a clinical coordinator on site. This person takes responsibility for X-ray radiation safety (which is a big concern) and also doing the QA checks, looking for dose creep (over exposing patients), reject analysis (what is the repeat rate for exams and why are they repeated). With regard to radiation safety, I have yet to see a radiation badge in a developing country, which is common practice for any healthcare practitioner who could be exposed to X-ray radiation in the developing world. As a matter of fact, I used to carry one with me all the time when on the vendor site and being in radiology departments on a regular basis. I would get calls from the radiation safety officer in my company when I forgot that I had left the badge in my luggage going through the airport security X-ray scanners. There is little radiation safety infrastructure available in developing countries, and the use of protective gloves, lead aprons and other protective devices is not always strictly enforced, this is definitely an area where improvements can be made.

4.       Reporting back to the donors is critical. There are basically three kinds of reports which are preferably shared on a monthly basis, as a matter of fact, this is a requirement for most projects funded by Rotary International grants: 1) The operational reports that include information such as number of exams performed by modality (x-ray, dental, ultrasound), age, gender, presenting diagnosis, exam type, etc. 2) The clinical reporting which includes the quality measures such as exposure index, kV mAs, etc. and 3) Outcomes reporting which includes demographics, trends, diagnosis, etc.
The operational reporting will indicate potential operational issues, for example, if the number of exams shows a sudden drop, there could be an equipment reliability issue. The clinical reporting will show if the clinic meets good practices. The outcomes reporting is not only the hardest to quantify but is the most important as it will prove to potential donors, investors and the local government the societal and population health impact of the technology. This information is critical to justify future grant awards.

5.       Power backup and stabilizers are essential. Power outages are a way of life, every day there can be a 4 hour or more power outage, therefore, having backup batteries and/or generators in addition to having a local UPS for each computer for short term outages is a requirement. One thing we overlooked is the fact that if we have power from the grid, the variation can be quite large, for example, a nominal 220V can fluctuate between 100 and 500 Volts. Needless to say most electronic equipment would not withstand such high spikes, so we had to go back in and install a stabilizer at one site after we had a burnout, which is now part of the standard package for new installs.

6.       Staging and standardization is a must. When I tried to install dental software on a PC on-site in Tanzania, it required me to enter a password. After getting back to a spot where I could email the supplier, I found that the magic word “Administrator” allowed me to start up the software, however, not until a loss of a day’s work as the time difference between the US and East Africa is 9 hours. After that, It took me only 5 minutes to discover the next obstacle, “device not recognized,” which did not allow the dental byte-wings to be used for capturing the X-rays. This caused another day delay as it took me another night to get an answer to solve that question. This shows that installing software onsite in the middle of nowhere is not very efficient unless you have at least 2 weeks time, which is often a luxury. And this was just a simple application, imagine a more complex medical imaging (PACS) system requiring quite a bit of configuration and setting up, it will take weeks.

There are a few requirements to prevent these issues:

1) Virtualize as much as you can, i.e. use a pre-built software VM (virtual machine) that can be “dropped in” on site. The other advantage of the virtual machine is that it is easy to restore to its original condition, or any other in-between conditions that are saved. It is interesting that the “virtualization trend,” which is common in the western IT world in order to save on computers, servers, and most importantly power and cooling capacity, is advantageous in these countries as well but more for ease of installation and maintenance reasons.

2) Stage as much as you can, but do it locally. If you preload the software on a computer in the US, ship it to let’s say Kenya, first you will be charged with an import duty that easily can be 40%, and you also might send the latest and greatest server hardware that nobody knows how to support locally. Therefore, the solution is to source your hardware locally providing local support and spare parts, and then stage it at a central local location that has internet access to monitor the software installation and then ship to the remote site.

3) Use standard “images” which goes back to the “cookie-cutter” approach, i.e. have a single standardized software solution, for maybe three different sizes of facilities, small, mid-size and large, so that the variation is minimal.

7.       Use a dedicated network. This goes back to the early days of medical imaging in the western world. I remember when we would connect a CT to the hospital network to send the images to the PACS archive, it would kill the network because of its high bandwidth demands. It is quite a different story right now, the hospital IT departments have been catching up, and have been configuring routers into VLANS that have fiber and/or gigabit speed connections to facilitate the imaging modalities. But we are back to square one in the developing world; networks, if available, are unreliable, might be open to the internet and/or computers that are allowed to use flash drives (the number one virus source), and therefore connecting these new devices to that would be asking for trouble. Therefore, when planning a medical imaging system, plan to pull your own cables, and use dedicated routers and switches. If you use high quality programmable and managed devices, it could become the core of the future hospital network expanding beyond the imaging department.

8.       Have an Internet connection. The bad news is that there is typically no reliable or affordable internet connection, however, the good news is that the phone system leapfrogged the cable infrastructure and therefore you should plan for a G3 compatible hot-spot that can be used to connect a support expert and take a look at the system in case there are any issues.

9.       Training is critical. Imagine buying a car for your 16-year-old daughter and just giving her the keys and telling her that she’ll be on her own. No-one would do that, but now imagine deploying a relatively complicated system in the middle of nowhere, which will allow people to make life-and-death decisions, without any proper training. I am not talking about clinical training on how to take an X-ray or do an ultrasound, but the training on how to support these systems that are taking the images, communicating, archiving them and displaying them. You need a person who takes the weekly back-ups to make sure that if there is a disk crash they can recover the information, who will do the database queries to get the report statistics, do the troubleshooting in case an image has been lost or misidentified, is the main contact to the support people at the vendor, and so on. On- the-job-training will not be sufficient. The good news is that it is relatively easy to create training videos and upload them on YouTube (or better send them on a CD as internet access might not always be available).

10.   Do not compromise on clinical requirements. I have seen darkroom processors being replaced with a CR and a commercial (i.e. non-medical) grade monitors to look at the images in a bright environment. This is very poor medical practice. No, you don’t need two medical grade 3 MegaPixel monitors at the cost of several thousands of dollars. Clinical trials have shown that a 2 Megapixel has the same clinical efficacy as a 3MP, but requires a user to use its zoom and pan tools a little bit more, which is acceptable in these countries. Therefore, the key is to use a medical grade monitor, which is calibrated to convert each individual grayscale value into a pixel that can be distinguished from each other. If this is not the case, there is no question that valuable clinical information will be lost. Also the so-called luminance ratio (difference between dark and white) does not have to be as high as long as the viewing environment is dark enough. So, as a rule of thumb, use an affordable medical grade monitor and put it into a dark room (paint windows, walls, hang curtains), don’t skimp on these monitors.

In conclusion, none of these lessons learned are new, we learned most of these 20 years ago, but the problem is that most of them might be forgotten or assumed, at least that is what I did when venturing out to these developing countries. The good news is that we can apply most of what we have learned and therefore be successful in providing imaging to the remaining two-thirds of the world that does not yet have access to basic imaging capabilities and thereby still make a major difference.