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?"

Comments

Impact printers and thermal printers

[Anonymous Coward]

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.

Re:Impact printers and thermal printers

[BaronM]

Yep -- OKI dot matrix printers. They're not going anywhere and are essentially bulletproof.

Re:Impact printers and thermal printers

[bill_mcgonigle]

Agreed. It's even possible to re-ink the ribbons in the field if the labor is less valuable than the cost of a replacement ribbon.

The one other thing that might be considered would be an inkjet with a continuous feed ink system. The ink is only expensive if it's purchased singly - by the gallon it's fairly inexpensive. Inkjets might be lower power than dot-matrix.

Don't trust thermal output for more than a year, and the paper is expensive.

For specimen labelling, you pretty much need a Zebra stripe printer for top-quality solution. They're not cheap, especially since you'll want an on-site spare. A Dymo label printer might get by if no substantial longevity is required of the labels and you use some of the third party freezer labels. Those are very low power devices.

Re:Impact printers and thermal printers

[ShanghaiBill]

Yep -- OKI dot matrix printers. They're not going anywhere and are essentially bulletproof.

I agree. But it is also important where they are located, and how their use is accounted for. They should be placed at least 100 meters from the users, in an area that is neither heated nor air conditioned. Each dept should be billed in proportion to how much they print. Even better would be to set up individual accounts, with a cash bonus for saving paper. If the incentives are right, people that "need" to print, will find ways to modify their workflow.

No good solution

[Dan East]

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.

Refurbished LaserJet 4000/4050

[jabuzz]

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...

Dot-matrix printers

[denzacar]

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.