Personal perspective

Managing health information in Cambodia: exchanging skills in a challenging environment

Julie Wilson

Introduction On a dull and cold Friday afternoon in August 2010 at the end of a busy but uneventful week, my colleague Jane and I were lamenting our feeling of doing a good job but not really feeling as though we’d ‘made a difference’.

So, as we did on so many other Friday afternoons, we jumped onto the Health Information Management Association of Australia (HIMAA) website to check the job vacancies. Jane jokingly said, ‘Oh here’s a good one for you Jules, they’re looking for a Health Information Manager in Cambodia’. I laughed it off but was immediately intrigued and couldn’t wait to get home to check it out. By the time my husband arrived home, I was convinced that I really wanted, but more needed, to do this job.

Many of us put things on hold while pursuing a career or raising a family and too many of us leave it so long that we either have a new set of commitments with ageing parents, or suffer our own health problems. It all gets too hard and there never seems to be a ‘right time’. So, with an eye on my ever-shrinking window of opportunity, and with my husband’s blessing, I started the application process for a three to six-month voluntary placement with Australian Business Volunteers (ABV), at the time funded by the Department of Foreign Affairs and Trade, to work at the Children’s Surgical Centre (CSC) in Phnom Penh.

After passing the first stage of the application process, I began the very comprehensive and interesting online learning which covered cultural awareness and skills exchange. At the end of this stage, there was an assessment, which I passed, then a face to face interview. In December, I finally received the good news that I was the successful applicant.

At the time I was the Manager of Health Information Services at Geelong Private Hospital and hoped that our General Manager would agree to me taking a few months’ leave. I like to think that my enthusiasm and determination were so persuasive that he was unable to refuse my request but, for whatever reason, he agreed and was very supportive. When I told my staff, Jane was absolutely flawed and couldn’t believe that I had been quietly plotting since she first saw the advertisement several months earlier.

I was feeling quite confident with my newly acquired knowledge but there was a lot to learn about Cambodia and even more to learn about CSC; I was off on a very steep learning curve.

What I learned about Cambodia

It has a population of approximately 16 million people, mostly following Buddhist beliefs. Khmer Traditional Medicine is still widely practised especially in the more remote provinces, where Western medicine has been slower to infiltrate.

Cambodian monks

Cambodians mostly speak Khmer, with older Cambodians also speaking French and younger people now learning English at school. Once I arrived in Cambodia, I was determined to learn more Khmer so I could converse with my colleagues and the locals but it didn’t take long to realise that the neighbourhood kids were mostly teaching me swear words.

Between 1975 and 1979 around two million people were killed under the Pol Pot regime and many more died from starvation and disease. Those with an education were particularly targeted and executed - teachers, doctors, engineers.

Many people were displaced, families separated and social structures were destroyed. Corruption became a way to survive and it is still a huge problem.

During several conflicts, around 8-10 million landmines were laid in Cambodia and, despite extensive clearing programs, it is still one of the most landmine impacted countries in the world.

By 1979 there were only 45 medical doctors for the 5 million people who survived.

Consequently, the health system is still rebuilding.

What I learned about Children’s Surgical Centre CSC was set up by a British-American orthopaedic surgeon, Dr. Jim Gollogly, in 1998, originally to treat children with land mine injuries, post treatment for their acute injury.

CSC is run totally by donations, with Australia being a huge supporter, both individually and on a corporate level. Most patients are poor Cambodians from rural villages with little or no formal education and many patients travel a long distance to be treated. All the care is free, including three meals a day for the patient and one carer.

CSC has only Khmer medical and nursing staff, apart from Dr Jim. Specialist surgical teams from all over the world, including Australia, regularly visit to volunteer their time to treat patients with very complex and rare problems. There is a requirement that the foreign surgeons can only operate alongside Khmer surgeons so skills can be exchanged and the surgical skills of the Khmer surgeons are constantly improving. Congenital malformation

As the incidence of land mine injuries has decreased, CSC now treats patients from 1 month old to over 90 years of age, with a wide range of post traumatic conditions, disabilities and congenital malformations and the numbers just keep increasing.

Table 1: Number of operations and consultations at CSC

OPERATIONS CONSULTATIONS 1998 2011 2015 2018

273 3567 4464 3921 2110 11840 24583 35202

Assignment Description

‘It is hoped the volunteer will work alongside local counterparts to update CSC’s current medical record keeping system and develop a modern, practical, information technology (IT) based medical record system. It is expected the volunteer will engage in mutual skill transfer in order to build the capacity of local staff to effectively utilise and maintain the record keeping system’.

Sounds simple enough, or so I thought!

In 2011, I arrived in Phnom Penh, having never travelled to South East Asia before. My first day at CSC was quite confronting due to the sheer number of patients waiting to be seen in a seemingly chaotic, hot and crowded work environment.

I would later realise that what seemed like chaos was perhaps the only way to provide care for so many patients and many of my Western ideas had no place in Cambodia.

Waiting area

I set about carefully observing people and documenting processes and I knew it would be important to find my key allies. I found the record keeping at CSC was basically sound and workable within the given conditions and the IT skills of the staff were most impressive.

As with many of us, their main problem was their daily work schedule was so busy it didn’t leave much time for analysing what was working and how things could be changed to improve processes and efficiencies. I would be the fresh set of eyes to help them reach their objectives. Consultations

Patient database Working alongside my Cambodian colleagues, we reviewed the quality of patient data, such as the consultation notes made each time a patient attends CSC, and found it was often missing or lacking accuracy and detail. This posed a big problem for ongoing patient care, particularly when overseas specialists are consulted.

We formulated a plan to: 1. Ensure all clinical care is documented. 2. Improve the quality of clinical documentation.

We started with operation reports, as there was already a logical, simple template in place which just needed to be followed.

On day one, we found a 32% completion rate. We conducted an education session with the surgeons which increased the completion rate to 65% over the following few weeks, then our progress stalled. I discussed our lack of progress with Dr Jim who assured me he could improve on this with what he described as a very effective effective strategy - he would dock the surgeons’ pay for every operation report not completed.

Suffice it to say, the following week the completion rate had increased to 99% within 24 hours and 100% within 2 days. The good news was that no one had had their pay docked, just the threat of doing so was enough. In a nod to skills exchange, I wondered whether this was an idea I could take back to Australia with me?

In addition to reviewing patient data, we completed an organisational restructure of the support staff to establish lines of authority and reporting and to provide an opportunity for promotion, with the intention of improving job satisfaction and staff retention. Som Chan Diman was identified as the Head of Patient Information as he already performed this role most capably. Formalising his position enabled him to manage staff with the authority to monitor performance and ensure compliance and accountability. It also provided him with a pay rate commensurate with his key role.

We reviewed and documented processes and procedures to clarify task allocation, create accountability and assist with training. We recruited and trained new staff which allowed us to address the backlog of data entry and filing of patient notes, to cull old medical records and review and update medical record forms.

I found the physical work environment was contributing to inefficiencies. For example, Diman was sitting at a desk on a chair propped up by a rock and he was constantly using a paper clip to release sticking keys on his keyboard. When I asked him whether he had asked for a new chair or a new keyboard he said ‘No, we need all our money for the patients, it’s no problem’. I explained that, in my opinion, his workplace safety was important and that he could provide a more efficient service if his equipment was in good condition. He reluctantly agreed to let me ask Dr Jim for a new chair and keyboard, which were promptly ordered and delivered, much to Diman’s delight, and mine.

At the end of my placement, all stakeholders declared the assignment had been successful. We were able to complete all tasks identified in the revised assignment description, and some extra tasks as well, and we had made valuable professional connections.

I have returned to CSC most years since 2011, independent of ABV, to review the previous year’s projects and to assist with new projects and further changes. I’m always heartened to see the initial changes to processes still being followed and that further improvements have been made as part of an ongoing quality improvement program.

Some of the additional projects since 2011 Consultation notes There are often six or more doctors consulting with patients each day for either initial consultations or post-surgical follow up. The doctors were handwriting consultation notes which needed to be transcribed onto the patient data base, resulting in transcription errors and a backlog of notes to be transcribed. We devised a plan to have the doctors enter their notes directly onto the patient database using laptops donated by South Melbourne Rotary Club. We designed portable laptop trolleys and had the CSC Building and Maintenance staff construct them. We ran an education program for the doctors with the new system being generally well received and followed. The doctors realised that it’s usually quicker to type than handwrite, there are no transcriptions errors, no backlog and the notes are immediately available for ongoing patient care.

Diman and his new chair

Laptop notes

Anaesthetic Syringe Labels During one of my visits, the anaesthetists expressed their concern regarding the poor labelling of anaesthetic syringes and identified this as a potential clinical risk. I investigated the universal colour coded standard labelling system for drugs and was able to arrange purchase of the labels from Australia. It is generally not advisable to post or freight goods to Cambodia as often goods ‘go missing’ or customs officials demand huge bribes to release the goods, so I organised the delivery of the labels in person by a group of students from a high school near me, who were travelling to Cambodia. While talking to my family members about CSC, my aunt kindly offered to support the supply of anaesthetic labels with an ongoing donation to cover the costs.

Watsi Watsi is a United States based organisation crowd funding surgical procedures for patients in developing countries. Their strict criteria include requirements that the procedures must be low cost, have a big impact and a high rate of success. Additionally, any organisation they support must be financially sustainable and transparent. Watsi assessed CSC as meeting their criteria and offered ongoing funding through online donations. Initially patients were interviewed, and a report was hand written, later transcribed and uploaded to the Watsi website with the patient’s photo. It soon became apparent that it was quite time consuming to keep up with reporting to potential donors in order to maximise this revenue. To address this, we identified the staff most proficient in English, developed a template and trained staff in interviewing patients to ensure that reporting requirements for Watsi were met. With the patients’ consent, photos and information were then entered directly onto laptops and uploaded, allowing many more surgeries to be funded.

If you’re interested, take a look at the Watsi website (https://watsi.org/) where you can donate as little as $5 toward life changing surgeries. All Cambodian patients on the website are from CSC so your donation will go towards helping CSC continue their vital work.

2016 visit – where to from here? By the time I visited CSC in 2016, I realised that I had reached the limit of what I could do from a health information management perspective. My Cambodian colleagues had made many improvements to systems and processes and, while I could assist with further development of their future plans, I thought more specialist IT skills would be of more value. There are many opportunities for CSC’s medical and nursing staff to travel overseas to learn new skills but little opportunity for administrative and other staff. I tentatively suggested to Dr. Jim that we consider the possibility of my Cambodian colleagues coming to Australia to see how things are done here. He was incredibly enthusiastic and supportive, and we agreed that Som Chan Diman, Head of Patient Information, and Sok Menglong, Manager of Administration should make the trip.

After a few months’ planning they arrived, and our health information management community came together to share their knowledge. At Barwon Health we looked at the scanned record, clinical documentation and processing of patients through the outpatient department. We spent a day at Deakin University Faculty of Health visiting virtual wards and methods for teaching nursing and medical students. At Melbourne University School of Medicine, we looked at online learning packages and at St John of God Hospital in Geelong we reviewed the scanned medical record, record forms, coding, admission process and environmental services.

Deakin University, Geelong 2017

We also spent some time immersing Diman and Menglong in our culture and lifestyle by travelling the Great Ocean Road, attending a play at the Geelong Performing Arts Centre, shopping and cooking together, including the delicious meal of the traditional Cambodian Beef Lok Lak they prepared, and meeting up with various friends and family members, intrigued and delighted to meet our international guests.

Diman and Menglong benefitted enormously from their visit, taking back information on online learning packages and a better understanding of clinical documentation and processes. The entire time they were here I could see them carefully analysing and diligently trying to work out how they could replicate the things they had seen.

Our Aussie beef is highly regarded in Cambodia and, with the help of their ex-pat friend, Lina, now living in Melbourne, they were able to cram a large amount of frozen beef into their suitcases..

They were so impressed with the cleanliness of our hospitals, they took back a microfibre mop and dusters, on the recommendation of Environmental Services staff.

From all reports, once Diman and Menglong returned to CSC, they began implementing many of the ideas they had seen in Australia and, with their newly acquired skills and confidence, they became even more pivotal in the administration of CSC.

While planning my visit to CSC in 2018, I began as usual with a discussion with Diman and Menglong. We would usually identify a small project we could work on or finish a previous project, but this time it was different. They assured me that their visit to Australia had provided them with a wealth of information and they were confident in their ability to maintain patient information and clinical documentation at a high standard. In effect I was no longer needed and, much like a mother whose child can now tie their own shoelaces, I was feeling a little superfluous but overwhelmingly proud and pleased to have been able to pass on my skills to my colleagues and support their further education.

Thearan’s wedding During subsequent visits, the focus has been much less on work and more on socialising, attending weddings and festivals and just spending time with our wonderful Cambodian friends.

On Reflection When I reflect on my connection with CSC and Cambodia, I feel a sense of gratitude for the things I have and sometimes take for granted: • The opportunities I have because of my formal education

• The choices I can make about where and how I use my skills • The generosity, friendship, mutual respect and admiration I have enjoyed with my Cambodian colleagues • Not fearing landmines when we farm our land, or our children go out to play

• Having a relatively safe health care system available to all • Having workplace health and safety protections in place.

I have been deeply affected and changed by my time working in Cambodia in so many ways: • I feel a deep commitment to living a bigger life with a smaller footprint • I believe small actions can have huge impacts

• I see redundancy as a good thing and I’m proud to have passed on my skills to my colleagues at CSC to a point that they no longer require my guidance • I know I’m capable of things far greater than my formal training or my job description • I can survive, indeed thrive, outside of my comfort zone

• Our community can be as big or as small as we want it to be, the main thing is to connect and to contribute to it.

Julie Wilson AssocDipMRA Health Information Manager St John of God Geelong Hospital and iMedX Australia Tel: +61 439 761 630 Email: toulies@hotmail.com