1. 1 RTI International is a trade name of Research Triangle Institute Can an Electronic Medical Record System Improve Health Care in Lusaka, Zambia? Funding for this work graciously provided by the Presenters: Gordon M. Cressman Niamh Darcy Date: Tuesday 10 July 2007 Time:14:00 – 15:00

2. 2 Lusaka, Zambia – 2001 Health Status  Maternal Mortality Ratio 750/100 000 live births (WHO 2000)  Neonatal mortality 40/1 000 live births (WHO 2000  Lifetime risk of death in pregnancy 1/25  Nearly 1/3 of pregnant women in Lusaka infected with HIV (Joint UAB-Zambian studies)  Nearly half will transmit HIV to their babies. (Joint UAB-Zambian studies) Health Care  Virtually all modern health care for more than 1 million people 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  All medical records on paper  Protocol and records in reasonable order, but significant problems in operation Children outside Chainda Clinic, Lusaka

3. 3 Key Problems & Proposed Solution Key Problems  Almost impossible to systematically assess care delivery  Surveillance data limited to simple cross- sectional statistics, such as how many stillbirths or pregnancy-attributable maternal deaths occur in a given month  Even available statistics were suspect  Occasional failure to test and frequent failure to follow up patients diagnosed with STDs  Limited sharing of patient records between facilities  No central database for monitoring patient population or quality of care Proposed solution  Electronic-first perinatal record system  Patient records shared among facilities  Centralized patient records database Patient file storage at University Teaching Hospital, Lusaka In 2005 only one-quarter of office-based physicians in the U.S. used a fully or partially electronic medical record system. (Burt, Catharine W., Hing, Esther, and Woodwell, David. U.S. National Center for Health Statistics, 2005.)

4. 4 Challenges 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.

5. 5 Solution: Wireless Network Satellite image of Lusaka showing ZEPRS wireless network links  27km diameter hub-and-spoke line-of-sight wireless network  3 – 9 PCs in each clinic  Voice (VoIP) and data communication for all facilities  27km diameter hub-and-spoke line-of-sight wireless network  3 – 9 PCs in each clinic  Voice (VoIP) and data communication for all facilities

6. 6 Solution: Electronic Perinatal Record System Electronic-first system with shared, central database Role based access control – (e.g. clerks have no access to medical data, only demographics) Alerts clinicians automatically to complete procedures, follow-up, and address critical-care issues Easy to add problems, populate automated system problem alerts, link problems from mother to child and vice versa Easy to add fields, forms, and form flows without programming Includes patient referrals Free and open source software Graphical partograph matches WHO partograph.

7. 7 Solution: Electronic Perinatal Record System Perinatal, 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 module for VCT, PMTCT Request labs (CD4, RPR, HB) and view lab results Routine follow-up visits can be flagged as problem visits Data used to coach medical teams Longitudinal data used for surveillance, and to prioritize, design, monitor, and evaluate interventions ZEPRS helps remind and coach clinicians through an extensible rules system.

8. 8 Solution: Clinicians Trained Initial training for referral application. 800 nurses, midwives and other health workers trained Basics skills (Windows, Word) ZEPRS mail system Referral system Patient record system All training conducted by Zambians Basic computer skills training conducted by IT specialists Referral and patient records training conducted by senior clinicians

9. 9 Pilot Testing of User Acceptance Sample  15 – 21 November 2005  3 Clinics  10 days  308 patients Results  More than 70% of respondents reported the automated system as fast or faster than the manual system.  More than 80% of respondents reported the automated system as easy or easier to complete (use) than the manual system.  57% of respondents reported that information was recorded more accurately in the automated system than in the manual system.  64% of respondents preferred the automated system over the manual system. No respondents preferred the manual system. Killam, Perry, & Ng’andwe, Christopher (2005). [Report on Pilot Clinical Testing of the Zambia Electronic Perinatal Records System, 23 November – 7 December, 2005]. Unpublished raw data. Movable wire cart with PC connected to wireless network.

10. 10 Results: Patient Records Managed 20 clinics and more than 45,000 patients (June 2007) System role-out at average rate of 1 new clinic/month. Average of 2,608 new antenatal patients/month

11. 11 Results: Clinic-level Data to Systematically Assess Care and Coach Clinicians Clinicians, supervisors, and administrators have access to reporting.

12. 12 Results: Central Database for Longitudinal Surveillance and Research Data warehouse and XML data export facilitate reporting in SAS, SPSS, etc.

13. 13 Results: Central Database for Longitudinal Surveillance and Research Data show significant variation among clinic catchments.

14. 14 Results: Central Database for Longitudinal Surveillance and Research Syphilis screening may be at least as cost-effective as PMTCT in terms of cost/DALY saved. Terris-Prestholt, F., et al. Is antenatal syphilis screening still cost effective in sub-Saharan Africa. bmj.com 2003

15. 15 Conclusions A municipal wireless wide-area network can be maintained at a high level of availability in a developing country With some training, clinicians with no prior computer experience may adopt computerized record systems readily Automated and human coaching of clinicians using a patient record database can improve the quality of health care The value of a patient record database for monitoring health status and interventions can help sustain an electronic patient record system Computerized systems at the facility level must continue functioning through communications and electrical failures Cellular telephone tower with ZEPRS co-located equipment

16. 16 Scaling Up Solutions Automated scaling from one to multiple computers within facility Shared patient record database within each facility Use existing commercial voice/data networks when possible ASAP transmission of patient referral data from referring to referral facility “Opportunistic” synchronization and reporting to central shared database Adherence to international and national coding standards International open source support community Sometimes clinicians are patients: entering data using a mobile cart- mounted PC.

17. 17 Making it Scale Easy-to-install “stand-alone” version on single PC ZEPRS can operate as an easy-to-install stand-alone application on a single PC.

18. 18 Making it Scale Automated scaling from one to multiple computers within facility Technologies such as Zeroconf can enable users with minimal technical support to create a shared, networked database within a facility.Zeroconf

19. 19 Making it Scale Existing network, asynchronous reporting, central 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.

20. 20 ZEPRS Team 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 For further information: www.idg-rti.orgwww.idg-rti.org

21. 21 Webinar Thursday, July 26, 2007 12:00–1:00 p.m. US EDT 4:00–5:00 p.m. GMT 16:00–17:00 UTC RTI International Shares Lessons Learned from Project to Implement Electronic Medical Record System in Zambia Join us from the convenience of your desk for a demonstration and discussion of the technical and medical features of the ZEPRS EMR system, and how such tools can help improve health care service delivery and scale to help meet critical strategic information needs. Presented by Niamh Darcy, RTI senior systems analyst for ZEPRS and Chris Kelley, RTI lead software developer for ZEPRS. The event is free and available on a first-come, first-served basis. For details on attending the webinar or bios on the presenters, go to www.rti.org/zeprswebinar.www.rti.org/zeprswebinar