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RTI International is a trade name of Research Triangle Institute

ZEPRSThe Experience of the Zambian Electronic

Medical Record System29 May 2007

Title Slide

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ZEPRSThe Experience of the Zambian Electronic Medical Record System

1. Context2. Objectives3. Inputs4. Outputs5. Impact on Patient Care6. Making it Open7. Making it Scale8. Questions & Comments

Chawama clinic MCH waiting room, Lusaka, Zambia

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Context Maternal mortality rate 940/100,000

live births 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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ContextTelecommunications

Weak landline infrastructure Congested 2.4GHz wireless

segmentClinics

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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Objectives1. 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

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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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InputsMoney

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*

* RTI International accounting system. All costs include indirect costs.

Subcontract costs include wireless network equipment

ODC includes STTA travel

Includes operating costs for the period of performance

Cost by Component

Equipment, $499,140

ODC, $556,528

RTI Labor, $660,212

Subcontracts, $797,506

Materials, $76,559 Consultants,

$138,953

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Inputs: Money$ 1 Million in computer and networking equipment*

* Costs based on RTI estimates

Hardware Costs

Clinic WLANs, $74,433

WAN, $246,869

PCs & Printers, $514,799

Data Center, $72,729

UTH LAN/WLAN,

$51,619

VoIP, $29,591 MoH LAN/WLAN,

$6,601

Customs & Shipping, $13,127

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

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Gordon M. CressmanSenor Project Advisor

Dr. Robert L, Goldenberg, MD

Principal Investigator

Eileen ReynoldsProject Manager Dr. Dwight Rouse, MD

Co-Investigator

ConsultantsScott Herman

GiddensDave Peckham

Chris KelleySenor Software

Developer

Niamh DarcySenor Technical

Advisor

Pablo DestefanisSenior Networking

and Telecom Specialist

Dennis NkulaZambia Project

Coordinator

Francis BandaTechnical Support

Specialist

Jamie MwanzaTechnical Support

Specialist

Dr. Jeffry Stringer, MDDirector, CIDRZ

Harmony FuscoProject Manager

Dr. Perry Killam MDProject Advisor

Chafye SiulataProject Assistant

Dr. Sten Vermund, MDCo-Invesigator

Dr. Moses Sinkala, MDZEPRS Executive

Committee, LDHMT

Dr. Ben Chirwa, MDZEPRS Executive Committee, MoH

Dr. Elwyn Chomba, MDZEPRS Executive Committee, UTH

RTI Development Team

Lusaka-based Technical Support Staff

CIDRZ

UAB Executive Team

Senior Zambian Medical Advisory Team

Dr. Alan TitaHealth Informatics

Advisor

Dr. Francis Nuthalpathy

Health Informatics Advisor

Emeldah Kabwe Nurse Liaison

Ethel Mangani LyubaNurse Liaison

Dr. Henry Phiri, MD Medical Advisor

Dr. Chris NgandweMedical Advisor

Dr. Macha, MDMedical Advisor

Dr. Chipepo Kankasa, MDMedical Advisor

Dr. Mpundu Makasa, MDMedical Advisor

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

1/1/2002 9/30/2006

1/1/2003 1/1/2004 1/1/2005 1/1/2006

4/17/2002Site Assessment

7/1/2002WAN Completed

10/1/2003Software RFQ

Released

1/5/2004ZEPRS Prototype 1

1/14/2004RTI begins

ZEPRS Development

1/5/2004Referral System

Completed

7/22/2004Referral Application

Launched

7/1/2005ZEPRS beta

11/21/2006ZEPRS v1.0

5/1/2004RTI uses ZEPRS

to Produce ART/PTS

4/1/2003First Version

Medical Record Specification

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Outputs

Wireless networkPatient referral systemPerinatal patient record

systemClinicians trainedClinicians using system

Cellular telephone tower with ZEPRS co-located equipment

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Outputs: Wireless Network

Map of Lusaka showing wireless links

Line of sight Hub and spoke 45Mbps 5.8GHz FD

backbone 20Mbps 5.8GHz FD

subscriber links 10Mbps 2.4GHz 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)

ZEPRS - Zambia Electronic Perinatal Record System.kmz

27km diameter hub and spoke line of sight network

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Outputs: Wireless Network

Map showing wireless links from TELECEL 1 hub

Co-location on cell telephone towers, commercial building, ZNBC tower

Repeaters used to reach some sights

No redundant links LEAP, RADIUS,

encryption for security

ZEPRS - Zambia Electronic Perinatal Record System.kmz

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Outputs: Wireless Network

Satellite photo indicating wireless link to existing Matero Main clinic VHF radio tower.

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.

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Outputs: Wireless NetworkConnecting multiple buildings at clinics

Labour Ward

MCH

Kalingalinga

Client PC

AP

Client PC with 2.2dBi antennas

20m ½” Succofeed

SMA

Reverse TNC

3 X N-Type Male

Reverse TNC

10m RG214

Client PC with 2.2dBi antennas

Client PC with 2.2dBi antennas

8dBi Plannar Antenna

Laboritory

Mast with SU

8dBi Plannar Antenna

13dBi Sectorial Antenna

2-Way Splitter

Client PC with 2.2dBi antennas

1 X SMA

5m RG214

3m Antenna Pole & WM45

2 X Lightning Arrestors4 X Ntype Male2 X Earth Spike

20m Earth Cable

120º Sector

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

Ground Floor

BO3

BO1

Cor

ridor

“Examination” Hall

MainReception

PC

PC

PC

PC PC PC PC PC

PC

Elevators

Window Below Nursery

1 X SMA Male Connector1 X 8dBi Plannar Antenna15m RG214 Cable & Trunking

Stairs

PC

PC PC

Consultation Ward

1 X 6U Cabinet1 X UPS1 X Switch1 X Cisco AP350 Full Set1 X Cisco AP350 Power Injector2 X TNC Male Connectors20m UTP Cable & Trunking15m RG214 Cable & Trunking1 X N-Type Male Connector2 X 8dBi Roof-mount Antenna

FTP

PC PCPCPC

BO3 Ward

60m FTP Cable & Trunking1 X Cisco AP350 1 X TNC Male Connector15m RG214 Cable & Trunking1 X N-Type Male Connector1 X 8dBi Roofmount Antenna

RF

Radio Signal from Rooftop : 120º

RF2nd AP Power Injector

Switch

UPS

UTP

RF

RF

“Examination Hall”

1 X Cisco AP350 1 X TNC Male Connectors20m RG214 Cable & Trunking1 X N-Type Male Connector1 X 8dBi Roof-mount Antenna

PCPCPC PCRF

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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

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Outputs: Patient Referral SystemNumber of Referrals by Week

-

20

40

60

80

100

120

140

29 34 39 44 49 1 6 11 16 21 26 31 36 41 46 51 4 9 14 19

Week

Tota

l Ref

erra

ls

20052004 2006

Launch of ZEPRS v1.0

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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

Initial training for referral application.

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

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Outputs: Clinicians Using System Average 584 new patients each week*

New Patients by Week

-

200

400

600

800

1,000

1,200

1,400

6 9 12 15 18 21 24 27 30 33 36 39 42 45 48 51 54 3 6 9 12 15 18

Week

New

Pat

ient

s

2006 2007

* 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.

Cummulative Patients by Week

-

5,000

10,000

15,000

20,000

25,000

30,000

35,000

40,000

45,000

6 8 10 12 14 16 18 20 22 24 26 28 30 32 34 36 38 40 42 44 46 48 50 52 54 2 4 6 8 10 12 14 16 18

Week

New

Pat

ient

s

2006 2007

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Outputs: Clinicians Using System19 Clinics actively using system

New Patients by Clinic

0

1000

2000

3000

4000

5000

6000

7000

8000

Clinic

New

Pat

ient

s

2007

2006

* Feb 2006 – 16 May 2007. Kanyama and State Lodge with only a few patients to date.

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Major Correction Points 1

Problem Correction

Congested 2.4GHz spectrum; 802.11b wireless bandwidth (4-6Mbps) may be inadequate for applications and VoIP

Higher speed (40Mbps, 20Mbps) 5.8GHz wireless and VoIP equipment added cost of USD 300,716

Time spent developing detailed medical record structure

Discharged consultant and initiated agile development for patient record system

Quality failure of South African contractor developing referral software

Cancelled subcontract and completed software in-house

Selection of client computer type (desktop PC, thin client, laptop PC, tablet PC) debated

Industry standard desktop PCs selected for usability, maintenance, sustainability

Custom-designed prototype PC carts are expensive (USD 600) and attract rats

Switched to lower cost wire carts for full deployment

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Major Correction Points 2

Problem Correction

Lead software developer diverted to ART patient management system

No-cost extensions

Training of clinicians by IT specialists may not be effective

Redesigned training to be done by senior clinicians

Lightening protection for wireless equipment proves inadequate

Installed best available protective devices at all points. Increased on-site stock of spares.

Electrical outages at a few clinics much longer than predicted

Tested off-line version of software with “opportunistic” synchronization with central database (not fully operationalized)

Failure of application and database servers in close succession 2 years after hand-over

Used temporary PC application server as quick fix, and then replaced failed servers

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Major Correction Points 3Problem Correction

Rand/USD exchange rate places software development in South Africa out of reach

RTI assumes responsibility for developing software in-house

Extended power outages (some caused by illegal tapping of transformers) at some clinics

Adjusted UPS battery backup for minimum 4 hour up-time. Set all UPS units to log grid power data. Installed automated network monitoring and alert system

Limited Internet bandwidth and increased use of Internet by clinicians

Controlled and limited Internet access by clinics

Limited availability of clinicians for testing Enlisted medical students for testing

Lusaka-based technical support staff lack capacity for efficient and effective support

Strengthened capacity through close mentoring

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Major Correction PointsPrototype custom $585 rugged mobile enclosed carts

Custom enclosed cart prototype, made in South Africa. Prototype cart being used for launch of

referral System.

Advantages Some protection

against dust Good protection

against theftDisadvantages Expensive Requires

antenna extension

Hiding place for rodents

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Major Correction PointsCommercial < $165 rugged mobile wire carts

In examination room.

Being used by clinicians.

Advantages Inexpensive Readily available No hiding places

for rodents No antenna

extension requiredDisadvantages No protection

against dust Weaker protection

against theft

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Sustaining ItNetwork availability

0

20

40

60

80

100

Avg of @avail

perc

ent

WhatsU p Gold Availabil ity Report (Dates)

0

20

40

60

80

100

Avg of @avail

perc

ent

WhatsUp Gold Availabi l ity Report (Dates)

Availability October 1, 2005 - April 30, 2006 (7

months)

Availability suffers due to management inattention

and contention for resources.

Availability October 1, 2005 - April 30, 2006 (16 months)

Availability can be higher than 90% on an extended basis...

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Sustaining ItNetwork availability

Overall Network AvailabilityCalendar 2006

0

10

20

30

40

50

60

70

80

90

100

01-1

0

01-2

2

02-0

3

02-1

5

02-2

7

03-1

1

03-2

3

04-0

4

04-1

6

04-2

8

05-1

0

05-2

3

06-0

4

06-1

6

06-2

8

07-1

6

07-2

8

08-0

9

08-2

1

09-0

2

09-1

4

09-2

6

10-0

8

10-2

0

11-0

2

11-1

4

11-2

6

12-0

8

12-2

0

Days

Perc

ent A

vaila

bilit

y

Daily Weekly 2 per. Mov. Avg. (Weekly)

Causes Lightening Extended power

failures at some clinics

Equipment failureOther 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

communityGeneral 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 databaseProof-of-concept

Stand-alone packaged version (Zephyr)Concept

“Organic” scaling Aggregate data reporting via mobile

phone network Automatic SMS reminders and

notifications to patientsSafe 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

`

Clinic · One facility· Single PC· Stand-alone

Installation· One database

ZEPRS can operate as an easy-to-install stand-alone application on a single PC.

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Making it Scale

· One facility· Multiple PCs· Networked· One database

Clinic

``

``

`

“Server” PC“Client” PCs

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· Many facilities· Existing mobile

phone network

`

Clinic

Clinic

``

``

`

Clinic

``

``

`

`

Clinic

Data Center

· Aggregate reporting· Centralized

database

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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The ZEPRS TeamRTI Development TeamEileen Reynolds, Project ManagerChris E. Kelley, Senior Software DeveloperNiamh Darcy, Senior Technical AdvisorPablo Destefanis, Senior Networking and Telecommunications SpecialistGordon M. Cressman, Senior Project Advisor

Lusaka Technical Support StaffDennis Nkula, Zambia Project CoordinatorFrancis Banda, Technical Support SpecialistJamie Mwanza, Technical Support Specialist

Center for Infectious Disease Research in ZambiaDr. Jeffrey Stringer, MD, Director, Co-InvestigatorDr. Perry Killam, MD, Project AdvisorHarmony Fusco, Project ManagerChafye Siulata, Project Assistant

UAB TeamDr. Robert L. Goldenberg, MD, Principal InvestigatorDr. Dwight Rouse, MD, Co-InvestigatorDr. Sten Vermund, MD, Co-InvesigatorDr. Francis Nuthalpathy, Health Informatics AdvisorDr. Alan Tita, Health Informatics Advisor

Zambian Medical AdvisorsDr. Moses Sinkala, MDDr. Elwyn Chomba, MDDr. Ben Chirwa, MDDr. Henri Phiri, MDDr. Christopher Ngandwe, MDDr. Chipepo Kankasa, MDDr. Macha, MDDr. Mpundu Makasa, MD

For more information visit www.rtidemo.org

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Making it OpenZEPRS Open Source technologies and components

Platform Component

Selected Solution

Operating System Red Hat EnterpriseServer Backup Arkeia BackupWireless Authentication

AEGIS Premium Server

Relational Database MySQLApplication Java, Struts, JDBC, Apache DBUtils,

AJAX – DWR and script.aculo.us, Quartz, Junit, XStream

Web Application Server

Apache (httpd) Tomcat (servlet container)

E-mail Cyrus IMAP, Squirrel Mail, Sendmail, Spam Assassin

E-mail Server Anti-virus

AMaVIS

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Inputs: People

Gordon M. CressmanSenor Project Advisor

Eileen ReynoldsProject Manager

ConsultantsScott Herman

GiddensDave Peckham

Chris KelleySenor Software

Developer

Niamh DarcySenor Technical

Advisor

Pablo DestefanisSenior Networking

and Telecom Specialist

RTI Development Team

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Inputs: People

Dennis NkulaZambia Project

Coordinator

Francis BandaTechnical Support

Specialist

Jamie MwanzaTechnical Support

Specialist

Lusaka-based Technical Support Staff

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Inputs: People

Dr. Robert L, Goldenberg, MD

Principal Investigator

Dr. Dwight Rouse, MDCo-Investigator

Dr. Sten Vermund, MDCo-Invesigator

UAB Executive Team

Dr. Alan TitaHealth Informatics

Advisor

Dr. Francis Nuthalpathy

Health Informatics Advisor

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Inputs: People

Dr. Jeffry Stringer, MDDirector, CIDRZ

Harmony FuscoProject Manager

Dr. Perry Killam MDProject Advisor

Chafye SiulataProject Assistant

CIDRZ

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Inputs: People

Dr. Moses Sinkala, MDZEPRS Executive

Committee, LDHMT

Dr. Ben Chirwa, MDZEPRS Executive Committee, MoH

Dr. Elwyn Chomba, MDZEPRS Executive Committee, UTH

Senior Zambian Medical Advisory Team

Emeldah Kabwe Nurse Liaison

Ethel Mangani LyubaNurse Liaison

Dr. Henry Phiri, MD Medical Advisor

Dr. Chris NgandweMedical Advisor

Dr. Macha, MDMedical Advisor

Dr. Chipepo Kankasa, MDMedical Advisor

Dr. Mpundu Makasa, MDMedical Advisor