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Ask Slashdot: Printing Options For Low-Resource Environments?
bjhonermann writes "The Zambian government (along with partners) are currently rolling out an electronic medical records (EMR) system in public health facilities. The project has been going on for some time and is already in 600+ facilities with more than 700,000 patient records. One problem we're facing is that most information is still being double entered in the EMR as well as on primary paper documents at the facility, and sometimes additionally transcribed to paper registers. This double/triple entry takes time away from nurses who are already in short supply. There's an inability to fully move away from partially paper based systems both because clients often move between 'paper clinics' and 'electronic clinics' in the same communities and for follow-up care, and because the power systems in many sites are unreliable and require that there be sufficient paper backups of records for operations during periods where power is unavailable — perhaps for weeks at a time. We're providing solar panels and battery backups for sites, which work increasingly well with newer low power CPUs, but even if the power issue were solved this would not address the need for portable paper documents. The key objective of eliminating redundant manual entry of forms and paper registers by nurses might be accomplished if we had low cost low power B/W printers available at sites so that critical information could be entered electronically and then printed out as needed, either for client carried purposes (transfers/visits to 'paper facilities') or to serve as local backup when power is an issue. However, we've yet to find printing solutions that seem appropriate to the context and are hopeful the Slashdot crowd may have some ideas."
Read on for some more specific criteria.
bjhonerman continues,
"Criteria we're looking at:
1. Reliability: The printers need to be very low maintenance and be able to cope with dusty environments.
2. Cost: Obviously, costs need to be kept as low as possible. No cap on the cost of printers precisely, but the net cost per page over time is critical. More expensive printers with cheaper and standard consumables are likely to be preferred to cheaper printers with expensive consumables.
3. Ink duration/lifespan: While all sites would be printing at least weekly, the amount actually printed may vary between no more than a few pages each week to several hundreds of pages. This means that whatever ink/toner cartridge/etc needs to have a long shelf life as well as lifespan. Zambia is not terribly hot, but has a humid rainy season and no climate control can be expected.
4. Low power consumption: As stated, ~15% of sites (and growing) are operating only with solar panels.
5. Quality: The quality of the printing can be quite low. Must be legible but can be ugly. No need for color. However, the pages/text need to have approximately a 5yr duration before the ink is unreadable.
6. Label Printing: There is also a need to print labels for specimens (freezer tolerant) and for drug dispensations. This may well be a different product, and early implementations will be in higher volume facilities that might not be as sensitive to power, but there will be a need for a low-power version eventually.
Our instinct is that dot-matrix printers would fit the bill nicely, but the options there seem to be limited and the long-term sourcing of supplies (ribbons, perforated paper) isn't entirely clear. What other options would the Slashdot community recommend?"
"Criteria we're looking at:
1. Reliability: The printers need to be very low maintenance and be able to cope with dusty environments.
2. Cost: Obviously, costs need to be kept as low as possible. No cap on the cost of printers precisely, but the net cost per page over time is critical. More expensive printers with cheaper and standard consumables are likely to be preferred to cheaper printers with expensive consumables.
3. Ink duration/lifespan: While all sites would be printing at least weekly, the amount actually printed may vary between no more than a few pages each week to several hundreds of pages. This means that whatever ink/toner cartridge/etc needs to have a long shelf life as well as lifespan. Zambia is not terribly hot, but has a humid rainy season and no climate control can be expected.
4. Low power consumption: As stated, ~15% of sites (and growing) are operating only with solar panels.
5. Quality: The quality of the printing can be quite low. Must be legible but can be ugly. No need for color. However, the pages/text need to have approximately a 5yr duration before the ink is unreadable.
6. Label Printing: There is also a need to print labels for specimens (freezer tolerant) and for drug dispensations. This may well be a different product, and early implementations will be in higher volume facilities that might not be as sensitive to power, but there will be a need for a low-power version eventually.
Our instinct is that dot-matrix printers would fit the bill nicely, but the options there seem to be limited and the long-term sourcing of supplies (ribbons, perforated paper) isn't entirely clear. What other options would the Slashdot community recommend?"
You already noted dot matrix printers (or impact printers as they're known in the industry). Don't worry about supplies not being available in the foreseeable future. These things are used EVERYWHERE, particularly in industry. You'll be able to buy supplies for years and years. Good-quality printers are reasonably priced too (about the price of a mid-range commercial black and white laser printer), and they last forever. I tend to prefer OKI printers.
You might also look into thermal printing. I'm less familiar with them, and I don't think the results would be as good (either in terms of ink longevity or the paper's longevity), but it's something to consider.
I would not consider inkjet or laser printers.
'print on demand' has always carried certain basic requirements, that if unavailable for any reason force a rethink. Options include printing elsewhere, then bringing to the point of need, or not relying on printing at all.
In this example, I'd do my best to avoid print all together.
You're assuming that throwing some hardware into the mix will fix this problem (as is apparent by the detailed hardware specs you're supplying). It will not. I speak from experience as having been part of a multi-million dollar project to to convert a group of US hospitals from paper charts to EMR back in the late 90s.
Think very carefully about what you're trying to achieve here. Essentially what you're doing is conceding that the EMR cannot be the entire record, and thus by supporting paper you are reverting back to the paper record being the authority in the patient record. We made that mistake as well, and the result was consuming VASTLY more paper after the EMR was installed than before when the records were totally paper.
The problem is that medical records are incremental. If a patient comes in and has some lab work done as a followup to make sure a treatment is having the desired result, then you have a set of new information. You have two options here. You can either print out a new sheet with just the new information, and throw that into the paper chart, or you can reprint tables of existing information so the new information is integrated into the old information in a more usable way. Throwing a new piece of paper into the record is a horrible option. That is not the way the paper record worked before when entirely paper, and it results in a fragmented record that a physician must flip through page after page and try to condense the information all in their head.
Look back when records were 100% paper. It was optimal from a resource / paper standpoint. Most of the records were actually blank forms, and the providers would simply enter new information by hand. So a nurse may have a chart in table form where they can record vital signs. The information was laid out in such a way that a physician could easily scan across the values and observe changes over time. The beauty of this is a single piece of paper is only needed for many incremental documentations. There is no good equivalent for this with an EMR with printed records. You cannot add information to an already printed document that was generated in an EMR. If a nurse documents directly on the output of an EMR then you're hosed. You now cannot throw that piece of documentation away and completely regenerate it when new information has been added to the EMR. It will be a nightmare, and the worst possible result, which is having information strewn across multiple formats, systems, and even across multiple pieces of paper.
Really, the only proper solution is all or nothing. Either make the EMR work as it is supposed to, or go back to totally paper records. There is no in-between, and if you attempt it you will be printing far, far, far more paper than ever before.
One final comment, is if you're intending on using printed records for only one specific use, like physically transferring records to a new facility, then that is fine. However using them as backups or working documentation will not work, as I said before, because they are incremental documentation that cannot easily be appended to in paper by an EMR.
Better known as 318230.
currently rolling out an electronic medical records (EMR) system in public health facilities...
Okay, good...
We're providing solar panels and battery backups for sites, which work increasingly well w
One cloudy day and your doctors can't access critical life-saving patient data... and people die. Might I suggest a generator, with fuel, like other hospitals have?
might be accomplished if we had low cost low power B/W printers available at sites so that critical information could be entered electronically and then printed out as needed, either for client carried purposes (transfers/visits to 'paper facilities') or to serve as local backup when power is an issue. However, we've yet to find printing solutions that seem appropriate to the context and are hopeful the Slashdot crowd may have some ideas."
Yeah, actually, just google for "battery powered printer". Amazon sells them. But I strongly suggest you fix your infrastructure problem (reliable power) before you increase your reliance on it as you are proposing...
#fuckbeta #iamslashdot #dicemustdie
Seriously they can be had quite cheap on the refurb market, and they are built like tanks. They will **easily** do a million pages though you will need to service them with maintenance kits these are cheap. I have seen them going strong at over 1.5 million pages. Most of the second hand ones are at a tiny fraction of these sorts of page numbers. Spares are readily available, if they don't have network cards, then JetDirects are dirt cheap on eBay. Compatible toner cartridges are really cheap as well. Might need memory upgrades, these are cheap as well.
In the end they don't build them like this anymore.
For freezer proof labels then you need specialist label printers with specialist labels. They are not cheap to buy or run...
Cost per page is practically zero.
Unless you fry the electronics any maintenance is strictly mechanical in nature - no surprise issues with drums or fuser-kits needing replacement or anything ink related (from leaking to clogged nozzles).
Ribbons can be refurbished and re-inked OR you can use carbon paper like back in the typewriter days - and depending on the printer and acceptable quality of the printout you can use carbon paper to print several copies at once.
Perforated paper is not a "must" - sheets work just as fine.
Only issue being that if your sheet feeder does not work you have to put them in manually one at a time.
Mit der Dummheit kämpfen Götter selbst vergebens
A lot of folks have talked about a lot of different pros and cons with various solutions... I'll provide one other... the technological learning curve necessary to repair one. In that case - 8/9pin DMP is your best bet.
Ink Jet and Laser (which can have the lowest overall cost) - have much of the mechanism 'hidden' from inspection due to their nature. Also, Laser has a humidity issue to be worried about with the paper - too moist paper jams and toner doesn't stick (fuser ends up drying the paper rather than fuse the toner). To dry and the electrostatic mechanism has a hard time working. Thermal - with the heat you are going to fry your paper stock.
Similar to the 10,000 year clock, almost the entire working mechanism is open to inspection and analysis as to how it functions. With not much more than a #1 & #2 Philips screwdriver, 1/4" blade driver and a pair of pliers you can field strip the machine down to just about nothing. Get the dust, jams, monkey poo, whatever out of the unit, drop of sewing machine oil around the pins to free them up (if necessary) and get it back up and running in short order.
One of the manufacturers even had a ribbon that had a small felt inker built in. I just refilled the inker with off the shelf stamp pad ink and was back up in running with lovely, rich blacks.
The programming necessary is just so old-school as to not be funny... Almost all of them, OKI, Star Micronics, Epson, etc. all used Epson FX escape codes for everything... no brainer to add the codes to the program to do stuff like skip to top of form, set tabs, bold, underline, etc. And, almost all of them have UNICODE BMP 0000-00FF installed - allowing you to properly print in languages such as French - which is a sizable chunk of Africa.
I would stay away from the 24-pin units - why? The pins are so small they tend to tear up the ribbons.
As for your specimen printer -- pre-printed stick on labels that they write on with a Bic ballpoint pen (solvent ink, not water-based crap like Uniball). If you want it printed - I liked the suggestion of a hand-held Dymo labeler. I'd stay away from pTouch - they have this nasty habit of wanting to throw away a chunk of ribbon/tape every time you use it. Totally wasteful.
As for the post about all electronic or all paper - in a first-world country you make sense. In the third world - you are absolutely clueless. The work needs to be able to get done regardless of the current monsoon, dust-storm, or power disruption. They don't have the luxury of sending people home because the systems are down. You say that after they spent hours walking just to get to the clinic - you might just get a spear in your gut or a bullet in your head.