MEDCAP in Dili: An Unlikely Debut in Electronic Medical Records for a Suburban American Physician

This photo shows three of our wonderful local Timorese interpreters.

Today I participated in a medical clinic (MEDCAP) for local Timorese adults and children in the capital city of Dili here in Timor-Leste. We left the ship at 5:45 am while it was still dark and took the “band-aid” boat to the port with an MRE (meal, ready-to-eat) in our backpacks. The stars were beautiful. It was comforting to see my favorite constellation (Orion) above me--even here in the southern hemisphere. As we arrived in Dili, dawn was breaking over the Cristo Rei (Christ the King) statue of the Savior that overlooks the harbor. We boarded buses and were escorted by a UN jeep with its siren blaring! A New Zealand army sergeant I met told me that there are about 2000 UN troops from 43 countries here in Timor-Leste. We drove to a local school across town dodging roosters, stray dogs, and the occasional pig. Once at the school, we set up our makeshift clinic. I worked as a primary care physician (and occasional Gynecology consultant) in a large classroom with several other providers. We each took a corner of the room and set up our “consultation offices” (3 chairs, a desk, a stethoscope, a penlight, and antibacterial hand gel). We each had a local Timorese interpreter to help us understand the people, as most people speak Tetum (a few of the patients did speak English). My volunteer interpreter was a 17-year-old high school student. He comes from a district which is on the opposite side of the island and attends a boarding school here in Dili. He is anxious to improve his English and hopes to get a scholarship to attend a university in the U.S. or in Singapore.

The Navy specialists set up a portable, battery-operated Wi-Fi network in the courtyard of the school aided by contractors from Global Relief Technologies, a New Hampshire company that specializes in collecting data in remote and austere locations.

I was issued a small PDA or minicomputer with a built in bar code scanner. The patients lined up and were registered by military personnel and given a bar-coded wristband. They then received a second color-coded band, which designated them either an adult, pediatric, dental, or optometry patient. The adult patients with the yellow wristbands lined up outside our adult clinic room and were invited inside as a provider became available. As recommended by my Timorese interpreter, I welcomed them with the Portuguese greeting “Bom Dia” (Good Day) or “Boa Tarde” (Good afternoon) and then with the Tetum phrase “Di’ak ka lae” (Good or not?). I scanned the bar code on the patient’s wristband and the bar code on my name badge while my interpreter asked them about his or her presenting problem. I followed up with some questions and then did a brief, dressed physical exam. I then entered into my PDA the problem by selecting the body system and the diagnosis with my stylus. Most of the patients had minor aches and pains or rashes and coughs. One lady had an egg-sized mass in her neck. I made arrangements to have her transported out to the ship for further evaluation by the ENT surgeon on board and probable surgery. After the history and physical, I made some recommendations to each patient, and when I prescribed medications, I selected the appropriate medication and dosing from the pharmacy menu on my PDA and then hit SEND. This information was then sent wirelessly to the pharmacy and the charting was backed up on the server.

In addition to prescribing the appropriate medication such as a high blood pressure pill, an antibiotic, an anti-inflammatory cream for rashes, or a pain medication (ibuprofen), I always prescribed a supply of multivitamins and discussed smoking cessation with each patient. Most of the men smoke, and most of the women do not. After several patients, my interpreter didn’t even need me to say anything, he automatically told the smokers, “The doctor says you should stop smoking right away. It will make you much stronger if you stop, and you will feel better, plus you will save a lot of money.” (My interpreter also promised to stop smoking!) After answering any questions, I wished them “Boa Sorte” (good luck) and “Adeus” (Goodbye), and we sent the patient to the next room, which was the pharmacy.

Once we got our rhythm going, we were able to see a new patient about every ten minutes. I saw about forty patients today, but some of the doctors, nurse practitioners and physician assistants who are more experienced with the MEDCAP system saw up to twice that many patients.

We had carried several large bins with about a hundred different types of medications with us from the ship. Our U.S. Public Health Service pharmacist then scanned the bar code on the wristband of each patient. The computer would then print the instruction sheet for the medication that I had prescribed for the patient, and the pharmacist would dispense the medication and remove the wristband.

In our medical practice in Lone Tree, Colorado, we have not yet converted over to an Electronic Medical Record system. It is a very expensive proposition costing tens of thousands of dollars per provider and requiring a significant investment in time during the conversion process. Nor have we yet adopted electronic prescribing wherein a doctor transmits a prescription electronically to the pharmacist using one of the available mobile e-prescribing services. Ironically, my first experience with seeing patients with paperless documentation and E-prescribing was here in Timor-Leste on the other side of the globe!