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Jan 9, 2012


I visited JSS a few days after Saptarshi.  Since starting work on this project, I have been told by multiple people that JSS was an amazing operation that accomplishes a lot of great things.  What I saw did not disappoint. The hospital has achieved such a great reputation locally that patients come from hours away, sleeping at the hospital overnight just to visit the outpatient clinic.
As great as what JSS does, it was clear watching the process that there are a number of opportunities for improved efficiency throughout the entire process, and this is where the Raxa project comes into play.  From the moment registration is installed at the hospital, and with the rollout of each module, we will have an immediate impact, helping JSS further streamline their operation without having to add staff or facilities.
But improving efficiency is just the beginning. For example, from being at the hospital and getting a sense of the kind of cases they see, it has become clear that there is immense value in the data they are collecting. By moving to a unified OpenMRS database, we will be able to analyze the data to spot and predict of trends, enabling targeted, proactive preventative measures. Exciting stuff…

Manor Lev-tov



January 8, 2012


Hello contributors,

I was at JSS during Christmas 2011 and spent 3 days there. This was my first visit to JSS, although I had read few papers and heard from other people about JSS.
The visit was very useful to see how the context was described in the different use-cases and also through the photographs which Daniel had posted earlier.

I also installed iDART pharmacy system <> , which is an open-source pharmacy package created by developers at cell-life. iDART is used at ARV clinics in South Africa and hence we need to make some changes to iDART to be useful to JSS. Anyways, since it is always easier to give feedback once something is up and visible, I installed iDART at one of the clinicians computer and did a small training/feedback sessions with the pharmacy staff. Will make those into tickets <>  and document the feedback in the next week or so. It will be interesting to get feedback and activity from people who have looked at pharmacy systems in the past... as well as gather willing contributors to take a stab at simple tickets.

I have blogged about some of my observations and what I'd hope we'd get out of the EMR here:

Saptarshi Purkayastha




December 31, 2011


Dear Fellow Contributors:


As 2011 winds down, it seems worthwhile to take a look at where we have reached on this ambitious journey. Conceived only earlier this year, the operations of the Raxa JSS EMR project began in earnest in August with the recruitment of all of you whose contributions now form the backbone of this project.  Contributors from leading academic departments of computer science and health information (e.g. Carnegie Mellon, Stanford, MIT, Harvard, NYU, IIT-D, IIIT), software companies (e.g. Microsoft, Google), user experience designers as well as interested healthcare and management professionals were the first interested parties. With the help of JSS staff, we created User Stories – detailed, granular, accounts of health information flow within JSS – and started converting those User Stories into User Interface designs and then software blueprints.  Next, we divided up our efforts into modules and created an aggressive timeline to finish the initial development effort by the summer of 2012.  We created an online wiki, elicited interest from our fast-growing bank of volunteers via online forms and allocated them into module development teams.  On the 23rd of October 2011, during Stanford’s Code-the-Change Hackathon at Facebook’s campus in Palo Alto, CA, the first lines of code were committed to our project and we were on our way.


Today, on the eve of the New Year, we can count more than a hundred volunteer contributors amongst us.  Designers, developers, technology gurus and healthcare professionals located all around the world collaborate on the Internet knitted together by multiple weekly meetings in cyberspace. We have ambitious goals for our software; 1) We want it to be easily upgraded and are using HTML5/CSS/Javascript as our technologies, 2) We want it to leverage existing work and are thus using OpenMRS (with able support by the OpenMRS community) and 3) we want it to be useful for people with limited literacy and connectivity such as those served by JSS – we have a large voice initiative organized by world leaders in speech processing at Carnegie Mellon as a sub-project which aims to connect providers, Community Health Workers (CHWs) and patients with our larger system.


The doctors and staff at JSS are now using a pharmacy management system that will connect to our software and are getting excited about the benefits that the rest of the system will bring to the patients at JSS.  Our efforts have piqued interest - other groups in India and elsewhere are showing interest in implementing our system, once it is functional, amongst their populations and in their practices. While this project is ambitious and would ordinarily cost millions of dollars to implement, we have gone further than we imagined possible with just voluntary support and hard work from all of you.  In the New Year we will start raising funds for the project – to create the support structure and staff that will ensure the success and future of this effort.


2012 will be a busy but exciting time for the Raxa JSS EMR.  In January, we hope to complete the implementation of the first set of modules and commence the development of the remaining modules earmarked for the first rollout.  We plan to have the initial development completed by April and, after testing and bug-zapping, hope to have the system up and running at JSS shortly after.  Following that, as data is generated in the system, we will start generating the analytics and other data and create the extensibility that will make the system informative and valuable for others.  While this will take more hard work, we are creating something truly unique – a digital information system that will positively impact people’s health across the world.


From all of us, thank you for your contributions and we wish you a very Happy New Year!


Raxa JSS EMR Project


Dr. Surajit Nundy <>



December 17, 2011


Dear Friends, 
During Oct/Nov 2011, I visited Jan Swasthy Sahyog and worked there for a 
month. I am a physician specialising in Cardiology, practicing in the US. 
Two of the founders of JSS were my batch mates at AIIMS. 

Jan Swasthya Sahyog (JSS) is a voluntary, non-profit, registered society 
founded by a group of health professionals committed to developing a 
low-cost and effective health program that provides both preventive and 
curative services in the tribal and rural areas of Bilaspur district of 
Chhattisgarh state in central India. 
Staring from an empty lot, JSS now has a 50 bed hospital, an OPD which 
caters to about 1000 pts /wk, a well developed surgical and obstetrics 
program and an extensive outreach program. The average patient utilizing its 
services is extremely poor, malnourished,  uneducated and devoid of any 
meaningful government health services. Most of them do not even know their 
age. The medical conditions are often advanced since they often do not have 
the means to get help early. Most travel long distances to reach the clinic. 

The dedication of the doctors is exemplary.These are physicians who left 
their cushy life and exciting careers in a big city and moved to rural 
Chattisgarh with their families. They often work 12-14 hr days/6 days a 
week and take overnight call. The level of poverty, volume of work, and 
helplessness of the patients is mentally taxing. 
Despite all the challenges, reasonable care is being provided to people who 
would otherwise not have access to modern medicine at all. 


The one challenge JSS faces is the lack of data that could give us a 
comprehensive analysis of the frequency of health problems faced by the 
community. The data on effectiveness of treatment at a community level is 
also lacking. JSS would like to have a database from which patent's medical 
problems, treatment and its outcomes can be analysed. This will help guide 
us in modifying our treatment strategies. An example would be management of 
tuberculosis patients. JSS treats about 600 TB patients per year. These 
patients require treatment for 1 1/2 years with multiple medications. Due to 
lack of a computerised database, JSS is unable to adequately track treatment 
for these patients and know the final outcomes. Putting in another way, a 
lot of hard work is done at JSS but which treatment strategies work and 
which need to be modified is not known because a statistical analysis can 
not be performed. An electronic medical record will be very useful to track 
patient progress. The data obtained will help modify strategies of 
treatment . There will certainly be reduction in errors. 


I am pleased to see that a group of individuals lead by Dr. Shuro Nundy and 
Daniel Pepper have started the effort to develop such a system. I believe 
that this is a extremely important step towards streamlining the management 
of these patients. Based on this data, one would like to continue strategies 
that work and modify or even abandon current patient treatments that are not 
effective. The limited resources that JSS has could them then be utilised 
more judiciously. 
Of course in India and all over the world there are many institutions facing 
similar challenges. Once developed the EMR system could be used in these 
centers as well. 

I commend everyone involved in developing the JSS EMR system. I know you are 
working on a voluntary basis. The doctors at JSS need your help to provide 
better care to their patients. 
Good Luck! 
Satish Goel

Satish Goel



Greetings from all of us at Jan Swasthya Sahyog!

We are really excited about the EMR project, which has brought several 
talented and dedicated people on a platform, and has the potential to 
spearhead a revolutionary change in the way medical information is currently 
handled, interpreted and used, both by the health care providers and the 
recipients of this care. The great strides that this work has been able to 
take is proof of what good teams can do in such short time periods.

If we look at the present scenario in the JSS Out Patient Department (OPD), 
with the limited manpower, we are overwhelmed by the workload. Many 
patients, whether they suffer from Tuberculosis, cancer, Rheumatic Heart 
Disease or whatever, drop out of treatment and fall through the net.  One 
look at the OPD registration room and one can make out the wealth of data we 
have to practice evidence based medicine. With proper digitization of this 
data we hope to be able to closely track our patients during treatment and 
follow up, see for ourselves the impact of different interventions, may be 
even look at cost vs benefit, keep patients better informed, help physicians 
in decision making and practice rational medicine, share information at 
different levels within the health care provisioning setup so as to improve 
knowledge, efficiency and morale of the staff, and many other benefits.

Even though the market abounds with EMRs of differing capabilities, most are 
cumbersome for physicians, and this remains a major bottleneck for their 
optimal usage. Doctors don¹t have the time to see patients and also input 
data. The key to a successful medical record is therefore a user interface 
that simplifies data entry and does not become a burden for the doctor in 
terms of his or her work output.

For an organisation like JSS, where community health work goes hand in hand 
with hospital care, the different modules of this package can be integrated 
and the available information be used to the optimum benefit of the patient, 
and help further integrate the community processes with the hospital and 
health work. This could be a model that any other organisation working in 
Health could use. The USP of this software would be its friendliness with 
the users and the ease of use; no extra time than what is currently spent on 
records should be required of the physicians.

While we congratulate this team for its initiative, I also take this 
opportunity to express one major area of concern. This is with respect to 
the subsequent optimal maintenance, trouble-shooting and fine tuning of the 
software and hardware onsite over the long term. We sincerely hope this 
would be adequately addressed. To this end we would encourage as many team 
members to visit JSS.

Once again, wishing the entire team a great success!

Yours sincerely, 
Dr Raman Kataria

Raman Kataria




November 3, 2011

We are all aware of the huge number of Œdeprived¹ people in this world ‹ 
deprived in various ways but most notably in the three basic needs: food, 
water and shelter. The fortunate ones like me contribute a miniscule of my 
income occasionally to NGO's about whom we know very little but hope are 
honest. There is no dearth of money in India and probably no dearth of 
people willing to give substantial sums, as long as they are assured it will 
be used properly. The problem with all aid - government funds and well 
meaning schemes alike - is that it never reaches the actual beneficiaries. 
There are so many middlemen in this chain that by the time it reaches the 
last step, more than 99% of the initial sum has been gobbled up. Even our 
Prime Minister, Dr. Manmohan Singh, laments about this problem when he 
sanctions billions to help the poor, but considers himself helpless. 
Ultimately it is delivery that is the key to help the deprived. JSS is just 
that. Not many people believed that these eight doctors (later ten) who set 
out to do this task back in 2000 would reach anywhere near the true need. 
Eleven years later when one looks at JSS you realize how much can be 
achieved if you are determined to the cause. To me, JSS is the ultimate 
proof of the importance of delivery in this entire Œsocial welfare¹ 
concept‹it also tells me that all else is hogwash, whether it is Bill Gates 
donating billions or my own brother donating 500 US dollars. If we are 
serious about doing something for the ones on the road the only way is by 
being the person of delivery.

My association with JSS dates back to 2001 when I came back from my yearlong 
fellowship in Cardiac Electrophysiology in London. I came to know that 
Yogesh/Rachna, Raman/Anju, Anurag/Madhavi and Bishwaroop/Madhuri (the 4 
couples who started JSS) had started working in a run down shackle in 
Ganiyari, a village near Bilsapur. Fortunately for me, I decided to go to 
Bilaspur to see the work and today I am thankful to God for having Œsent¹ me 
there.  Without seeing JSS and its surrounding no one can even imagine the 
magnitude of poverty in India and also what can be achieved if one has 
his/her heart in the right place. Over the last 10 years I started going to 
the place more and more frequently and as of today manage to spend at least 
4-5 weeks in an year there, one week at a time. The clinic at Ganiyari grew, 
the patients increased and the staff increased. Simultaneously, the village 
program started reaching out more and more into the interiors of the state. 
Going to the villages is not an easy job‹generally it is hot and humid, the 
road is a test of your bodies flexibility and endurance, and the Mahindra 
jeeps that are very sturdy and appropriate for the difficult terrain do not 
provide you with a comfortable seat. It used to be 2-3 hours drive one way 
early on but over time the clinics went even deeper into the forest and the 
doctor would have to stay overnight in one of the villages to be able to 
give adequate time at Bamni, one such village.

I was inspired by the inner strength of each one of them. To carry on 
working daily in those circumstances was just mind boggling. There was no 
scope for anyone to take leave or relax for a few hours or say on a morning 
³I am not feeling too good, so I can¹t go or I will go late.² The work 
pressure was just too much, mainly because of the number of patients. 
Everything had to be done by yourself‹there were no trained nurses, no 
technicians, no orderlies or super-specialists ‹ everything from diagnosing 
a cutaneous hemangioma to multiple sclerosis had to be treated right there. 
The width/breadth of the cases was just unimaginable‹most urban Indians feel 
that poor people do not suffer from the Non Communicable/lifestyle related 
diseases like diabetes, hypertension and coronary artery disease. Here at 
Ganiyari each patient had a long story to tell‹there were no common colds or 
constipation who could be sent off lightly; every patient needed all the 
resources we could muster. Over the years a lot of people have suggested 
cutting down on the numbers. In fact most non-Indians who have come and 
worked for some time are unable to understand why this cutting down is 
impossible. They don¹t realize that numbers can be cut if these people have 
an alternative‹in Chhattisgarh there is hardly any place that provides high 
quality care at such a low cost. Even JSS, that charges Rs10 (US $.20) for a 
visit is expensive for them. Patients take loans of Rs 20/30 and one such 
person walked 7 km to return a loan of Rs 13!! If you don¹t see them today 
they will either go back home or keep staying at Ganiyari till he can 
finally get into the system. Sending them back is as good as a death 

In all these years I have stayed only once at Ganiyari‹long ago when we had 
very few ³pucca² houses‹probably none, with a completely cemented roof. All 
Œbuildings¹ had thatched roofs with lots of spaces wherein any lizard/snake 
could easily come through. It was rainy season and Yogesh told me about lots 
of ³kraits² (one of the most poisonous snake in the world) in the campus, 
some of them falling from the top when you opened a door or a window. Snake 
bites were common, not only in Ganiyari but also in the surrounding villages 
and we would get 1 or 2 cases of snake bites every day in the emergency 
department. Yogesh and I were sleeping on separate beds (please dont get 
ideas!), not sleeping exactly as I could not even bat an eyelid while Yogesh 
slept peacefully. I was wishing I had eyes all round my head and on top too 
to be able to spot ³one² when it came thru the door or fell from the roof!! 
I don¹t think I have stayed over night after that ­ so much for my 
determination to ³deliver.²

In these 10 years of my association with JSS I have probably seen over 400 
patients with heart disease predominantly Rheumatic Heart Disease. RHD is 
among the lesser known cardiac disorders wherein a person who gets a sore 
throat by a specific bug (streptococcus) develops antibodies against his own 
valves in the heart that then gets destroyed. The disease is in some way 
linked to poverty and therefore is uncommon in the western world. The 
disease is mostly seen in children and young adults and leads to severe 
disability and death. Even though we can replace these valves by open heart 
surgery, the artificial valves are nowhere near the natural ones and need a 
very close monitoring, that is impossible for the poor. In the absence of an 
Electronic Medical Record system I have no idea of what has happened to over 
300 of these patients, 30-40 odd of whom underwent a balloon dilatation at 
AIIMS by me and probably 10-15 have had valve surgery done. I only know 
about the small numbers who continue to follow up with me‹what is happening 
to the majority, I have no idea. Progression of this disease can be halted 
by regular injections of penicillin but children obviously don¹t want them 
and even for adults getting a shot every 21 days is not easy. With an EMR we 
could easily trace out the defaulters, get hold of the Village Health Worker 
who could then ensure better compliance. An EMR would be able to give me how 
much these people have spent over the last 5 years coming to Ganiyari, 
something that is so important for planning resource allocation. Over 60-70 
of these patients are awaiting surgery but there is no program in the 
country that gives them early treatment. To convince the policy makers I 
need details of all these patients before I can tell them about how serious 
this problem is.

An EMR is a necessity today for every hospital. Even today, India¹s premier 
medical institute, AIIMS, the so-called leader of medical care in India, 
doesn¹t have a good EMR. It is very easy to manage finances, stores, 
purchases, even most laboratories etc, from commercially available software. 
The biggest challenge lies in digitizing patient records, be it in the OPD 
or in the wards. Given that we barely get five minutes to see a patient how 
can we imagine inputting the patients history, examination and management 
into a computer? The West and most of the private sector in India doesn¹t 
suffer from these numbers. In addition, it is easy to get data entry 
operators, system administrators etc in cities but impossible to get them at 
Ganiyari. Even if we could get some people, medical records data entry is 
not easy because of the technical terms, that not everyone is aware of. So 
it boils back to the physician entering this data‹the interface is critical 
to its success and as of now voice recognition (unfortunately still not 
perfect) may be the key.

The critical element of the EMR we are looking at is entry of medical 
records in a format that is easily and accurately stored and retrievable. It 
will help patient management, ease the work pressure by removing duplication 
of work and add to our knowledge of various disease aspects. The EMR has to 
be good enough to be implementable across the board to all health care NGOs 
and hospitals serving the needy in the entire globe.

DrRajnish Juneja <>




October 20, 2011

Dear Friends,, 

Jan Swasthya Sahyog (JSS) has its Health Centre in Ganiyari, in the district 
of Bilaspur 
of Chhattisgarh state of central India. This is a socio-economically 
backward region of 
India with many problems of widespread poverty, illiteracy, low educational 
levels, poor 
sanitation etc. All these factors have a direct bearing on the health 
situation of the 
people living in the area. 

Working at JSS is extremely demanding and challenging. As the public health 
system in the 
area is largely dysfunctional, there is always a demand for the basic health 
that JSS provides. At our Health Centre, there are always a large number of 
people with 
different problems waiting to be seen. Many of these patients have travelled 
distances to reach Ganiyari - some of them even come from the neighbouring 
districts of 
Madhya Pradesh state. 

The patients who reach the Health Centre at Ganiyari present with a very 
wide range of 
problems. Communicable (infectious) diseases and surgical conditions are the 
frequent. But non-communicable diseases (eg. diabetes and hypertension) are 
also often 

With the increasing numbers of patients accessing our health services, we 
have been been 
facing increasing  problems with our current medical record system. This 
system is paper 
based and analog. Many of our patients visit our Health Centre  several 
times. In 
addition, we manage a large number of chronic diseases and conditions (both 
and non-communicable), whose patients regularly visit over several months or 

The Electronic Medical Record (EMR) system you will be working on will fill 
an important 
need at our Health Centre, by making patient records and their contents 
accessible. It will be a significant value addition to our services, and 
eventually help 
to improve the quality of care that we provide our patients. It will also 
help to analyse 
our health care and provide data for research purposes. 
On behalf of my colleagues at JSS, I thank each and every one of you for 
your time, 
effort and interest in this venture. 
Ravi D'Souza. 
Ravi D'Souza............E-mail: 
c/o Jan Swasthya Sahyog,............. 
I-4 Parijat Colony,................... 
Nehru Nagar,..........Telephone: (07752) 428229 
Bilaspur 495001,................... 
Chhattisgarh State, India..........................