RTI ppt template

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ZEPRS The Experience of the Zambian Electronic
Medical Record System 29 May 2007
RTI International is a trade name of Research
Triangle Institute
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ZEPRSThe Experience of the Zambian Electronic
Medical Record System

• Context
• Objectives
• Inputs
• Outputs
• Impact on Patient Care
• Making it Open
• Making it Scale
• Questions Comments

Chawama clinic MCH waiting room, Lusaka, Zambia
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Context

• Maternal mortality rate 940/1000
• Lifetime risk of death in pregnancy 1/25
• Disability Adjusted Life Years (DALY) at birth
  30.7
• Nearly 1/3 women infected with HIV
• Virtually all modern health care for 2 million
  women in Lusaka provided by 23 clinics and the
  University Teaching Hospital (UTH)
• 13 of 23 clinics provide antenatal care, 9 with
  labor wards
• 47,000 estimated total obstetric cases (2002)

Children outside Chainda Clinic, Lusaka
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Context

• All medical records on paper
• Protocol and records in reasonable order, but
  significant problems in operation
• Frequent failure to follow up patients diagnosed
  with STDs
• Failure in some cases to test for STDs
• Patients may move among clinics, but limited
  sharing of patient records
• No central database for monitoring patient
  population or quality of care

Patient files at University Teaching Hospital,
Lusaka
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Context

• Telecommunications
• Weak landline infrastructure
• Congested 2.4GHz wireless segment
• Clinics
• Dusty, congested
• 7 of 23 clinics had telephone lines
• All clinics with VHF radio for voice
• Personnel
• No computer literacy
• Very stressed due to patient load
• High medical staff turn-over (40)
• Electrical
• Inadequate electrical systems at all points, no
  backup power, No lightening protection
• Poorly regulated grid (Frequent power outages)

Clinician at the door of the Prisons Kamwala
Clinic in 2002.
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Objectives

• 1. Improved health of patients
• 1.1 Improved access to patient records
• 1.2 Improved patient record quality
• 1.3 Improved patient follow-up drug adherence
• 1.4 Improved information for research and
  analyzing interventions
• 1.5 Useful information for Zambian health
  administrators

Patient files at University Teaching Hospital,
Lusaka, 2004
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Key Requirements Assumptions

• Electronic system to replace perinatal Blue
  Book
• Shared, centralized database of patient records
• Wireless network connecting clinics, hospital,
  administrative offices, data center
• Multiple workstations in each facility
• Ability to move workstations if necessary
• Ability to print summary cards in facilities
• Ability to function through 4 hour electrical
  grid failure
• Operating costs paid through research grants

Pre-existing VHF radio tower at clinic.
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Inputs

• Money
• US 2.7 million (Bill Melinda Gates Foundation
  through University of Alabama at Birmingham)
• People
• UAB executive team
• RTI development team
• Lusaka-based technical support team
• Zambian medical advisory team
• Time
• 4 years (1 Jan 2002 30 Sep 2006)

ZEPRS and CIDRZ team at launch of electronic
referral application in Lusaka.
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Inputs Money 2.7 Million total over four years

• Subcontract costs include wireless network
  equipment
• ODC includes STTA travel
• Includes operating costs for the period of
  performance

RTI International accounting system. All costs
include indirect costs.
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Inputs Money 1 Million in computer and
networking equipment

• 134 desktop computers, 5 laptop computers
• 29 Printers
• 130 computer carts
• Data center servers, storage, backup, UPS units,
  generator
• One 15m radio tower
• Wireless high speed backbone network
• Wireless base stations and subscriber units
• Wireless repeaters
• Wireless access points
• Connections to multiple buildings in clinic
  compounds
• UTH fiber optic and wireless network
• VoIP network equipment and handsets
• UPS battery backup units
• Lightening protection

Costs based on RTI estimates
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Inputs People

• UAB executive team (5)
• CIDRZ management and advisory team (4)
• Zambian medical advisory team (10)
• RTI development team (4)
• Consultant (1)
• Zambian technical support staff (3)
• Other Zambian testers and trainers

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Inputs Time
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Outputs

• Wireless network
• Patient referral system
• Perinatal patient record system
• Clinicians trained
• Clinicians using system

Cellular telephone tower with ZEPRS co-located
equipment
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Outputs Wireless Network

• Line of sight
• Hub and spoke
• 45Mbps backbone
• 20Mbps subscriber links
• 10Mbps within buildings
• Connects 24 clinics, 1 hospital, 2 administrative
  offices, 1 data center
• Internet access for all facilities
• Voice communication (VoIP) for all facilities
• Data center maintained by NGO with research
  funding
• Availability at 88.3 (26 Nov 2 Dec 2006)

27km diameter hub and spoke line of sight network
Map of Lusaka showing wireless links
ZEPRS - Zambia Electronic Perinatal Record
System.kmz
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Outputs Wireless Network

• Co-location on cell telephone towers, commercial
  building, ZNBC tower
• Repeaters used to reach some sights
• No redundant links
• LEAP, RADIUS, encryption for security

Map showing wireless links from TELECEL 1 hub
ZEPRS - Zambia Electronic Perinatal Record
System.kmz
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Outputs Wireless Network

• Existing VHF radio towers at most clinics used to
  mount wireless network equipment.
• Multiple buildings in many clinic compounds
  connected using wireless and wired links.

Satellite photo indicating wireless link to
existing Matero Main clinic VHF radio tower.
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Outputs Wireless NetworkConnecting multiple
buildings at clinics

• Wired and wireless connections used to extend
  network to multiple buildings.

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Outputs Wireless NetworkNetworking wards at UTH

• Fiber optic cable, copper cable, and wireless
  equipment connects wards at UTH

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Outputs Patient Referral System

• Notifies referral clinic or hospital of incoming
  patients
• Provides critical information to prepare for
  patients
• Updates referring clinic on patient status
• Maintains records of all referrals
• Used by 24 clinics and hospital successfully for
  2 years
• Replaced by ZEPRS patient record system in
  February 2006

Clinicians launch referral system in July, 2004
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Outputs Patient Referral SystemNumber of
Referrals by Week
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Outputs Patient Record System

• Provides clinicians access to patient records 24
  hours a day, seven days a week
• Alerts clinicians automatically to complete
  procedures, improve follow-up, and make sure
  critical-care issues are addressed
• Data used to coach medical teams
• Longitudinal data used to prioritize, design,
  monitor, and evaluate interventions

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Outputs Patient Record SystemPerinatal, VCT,
PMTCT, Delivery

• Pregnancy Dating - captured at first visit and
  automatically updated during pregnancy with
  EGA/EDD
• Pregnancies linked, with critical problems from
  one pregnancy pre-populating for the next
  pregnancy
• Safe Motherhood - request labs (CD4, RPR, HB) and
  view lab results, ARV counseling visits
• Ability to add problems, populate automated
  system problems, link problems from mother to
  child and vice versa
• Convert visits can be flagged as problem visits
• Role based access control - clerks have no access
  to medical data, only demographics
• Graphical partograph matches WHO partograph
• Infants linked for each pregnancy to mother
• Patient Referral system for easy tracking
• Data warehouse and XML data export facilitate
  reporting in SAS, SPSS, etc.
• Standalone mode for remote clinics with
  occasional connectivity - can sync records
  automatically with the main system.

ZEPRS helps remind and coach clinicians through
an extensible rules system.
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Outputs Clinicians Trained

• All training conducted by Zambians
• Basic computer skills training conducted by IT
  specialists
• Referral and patient records training conducted
  by senior clinicians
• 800 nurses, midwives and other health workers
  trained
• Basics skills (Windows, Word)
• ZEPRS mail system
• Referral system
• Patient record system

Initial training for referral application.
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Outputs Clinicians Using System Average 584 new
patients each week
5 Feb 2006 16 May 2007. Weeks include one-day
weeks at beginning and end of year, resulting in
54 weeks for 2006.
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Outputs Clinicians Using System More than
39,000 patients
5 Feb 2006 16 May 2007. Weeks include one-day
weeks at beginning and end of year, resulting in
54 weeks for 2006.
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Outputs Clinicians Using System19 Clinics
actively using system
Feb 2006 16 May 2007. Kanyama and State
Lodge with only a few patients to date.
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Outputs Clinicians Using System7,657 babies
delivered
Feb 2006 16 May 2007.
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Major Correction Points 1
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Major Correction Points 2
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Major Correction Points 3
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Major Correction PointsPrototype custom 585
rugged mobile enclosed carts

• Advantages
• Some protection against dust
• Good protection against theft
• Disadvantages
• Expensive
• Requires antenna extension
• Hiding place for rodents

Custom enclosed cart prototype, made in South
Africa.
Prototype cart being used for launch of referral
System.
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Major Correction PointsCommercial mobile wire carts

• Advantages
• Inexpensive
• Readily available
• No hiding places for rodents
• No antenna extension required
• Disadvantages
• No protection against dust
• Weaker protection against theft

In examination room.
Being used by clinicians.
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Sustaining ItNetwork availability
Availability October 1, 2005 - April 30, 2006
(16 months) Availability can be higher than 90
on an extended basis...
Availability October 1, 2005 - April 30, 2006 (7
months) Availability suffers due to management
inattention and contention for resources.
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Sustaining ItNetwork availability

• Causes
• Lightening
• Extended power failures at some clinics
• Equipment failure
• Other Factors
• Management of support staff
• Inadequate on-site spares
• Aging equipment

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Making it Open

• Software developed using open source tools and
  best-of-breed web architecture
• Software adapted easily to other contexts and
  applications
• ZEPRS software released under ASL2 open source
  license
• ZEPRS documentation published under a Creative
  Commons Attribution-NonCommercial-ShareAlike 2.5
  license
• ZEPRS demonstration and development websites open
  to all
• www.idg-rti.org

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Collaborating and Combining Open Source Efforts

• ZEPRS
• Problem-based care
• Electronic referrals
• Web-based forms
• Developed documentation
• Experience in large scale deployment
• Years of experience in operation
• Off-line mode
• Stand-alone version (Eclipse RCP)
• OpenMRS
• Regenstrief data model and concept dictionary
• Broader development and support community

General records at Kalingalinga Clinic prior to
ZEPRS.
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Making it ScaleExpanding beyond a metropolitan
area

• Tested
• Offline version for clinics with multiple PCs
• Automated record synchronization with centralized
  database
• Proof-of-concept
• Stand-alone packaged version (Zephyr)
• Concept
• Organic scaling
• Aggregate data reporting via mobile phone network
• Automatic SMS reminders and notifications to
  patients

Safe Motherhood form from Zephyr stand-alone
version of ZEPRS.
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Making it Scale
We are balancing local resources and remote
resources to provide a perception of continuous
connection to a central data source. When we
experienced some problems with ZEPRS network
availability, we attempted to bring server
resources closer to the clinics by building a
more distributed model placing mini-servers in
each clinic. Then we implemented a system to
enable these remote servers to phone home when
the network links were back up to fetch updated
records and synchronize with the master server.
- Chris E. Kelley, RTI Senior Software
Developer
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Making it Scale
ZEPRS can operate as an easy-to-install
stand-alone application on a single PC.
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Making it Scale
Technologies such as Zeroconf can enable users
with minimal technical support to create a
shared, networked database within a facility.
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Making it Scale
Operating in off-line mode, installations of
ZEPRS can report aggregate data and synchronize
patient records with centralized databases when
telecommunication links are available.
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Questions Comments
RTI Development Team Eileen Reynolds, Project
Manager Chris E. Kelley, Senior Software
Developer Niamh Darcy, Senior Technical
Advisor Pablo Destefanis, Senior Networking and
Telecommunications Specialist Gordon M. Cressman,
Senior Project Advisor Lusaka Technical Support
Staff Dennis Nkula, Zambia Project
Coordinator Francis Banda, Technical Support
Specialist Jamie Mwanza, Technical Support
Specialist Center for Infectious Disease
Research in Zambia Dr. Jeffrey Stringer, MD,
Director, Co-Investigator Dr. Perry Killam, MD,
Project Advisor Harmony Fusco, Project
Manager Chafye Siulata, Project Assistant
UAB Team Dr. Robert L. Goldenberg, MD, Principal
Investigator Dr. Dwight Rouse, MD,
Co-Investigator Dr. Sten Vermund, MD,
Co-Invesigator Dr. Francis Nuthalpathy, Health
Informatics Advisor Dr. Alan Tita, Health
Informatics Advisor Zambian Medical Advisors Dr.
Moses Sinkala, MD Dr. Elwyn Chomba, MD Dr. Ben
Chirwa, MD Dr. Henri Phiri, MD Dr. Christopher
Ngandwe, MD Dr. Chipepo Kankasa, MD Dr. Macha,
MD Dr. Mpundu Makasa, MD
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Making it OpenZEPRS Open Source technologies and
components
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Inputs People
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Inputs People
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Inputs People
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Inputs People
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Inputs People