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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
2
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
3
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
4
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
5
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.
6
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
7
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.
8
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.
9
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,
$138,953
10
Inputs: Money$ 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
11
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
12
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
13
Outputs
Wireless networkPatient referral systemPerinatal patient record
systemClinicians trainedClinicians using system
Cellular telephone tower with ZEPRS co-located equipment
14
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
15
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
16
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.
17
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.
18
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
19
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
20
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
21
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
22
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.
23
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
24
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.
25
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
26
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.
27
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
28
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
29
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
30
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
31
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
32
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...
33
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
34
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
35
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.
36
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.
37
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
38
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.
39
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.
40
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.
41
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
42
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
43
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
44
Inputs: People
Dennis NkulaZambia Project
Coordinator
Francis BandaTechnical Support
Specialist
Jamie MwanzaTechnical Support
Specialist
Lusaka-based Technical Support Staff
45
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
46
Inputs: People
Dr. Jeffry Stringer, MDDirector, CIDRZ
Harmony FuscoProject Manager
Dr. Perry Killam MDProject Advisor
Chafye SiulataProject Assistant
CIDRZ
47
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