1. RTI International is a trade name of Research Triangle Institute Using ICT to Improve Patient Care ZEPRS Gordon Cressman, Chris Kelley, Niamh Darcy June 22 2007

2. Context: 2002  Maternal mortality rate 940/1000  Lifetime risk of death in pregnancy 1/25  Disability Adjusted Life Years (DALY) at birth 30.7  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)  All medical records on paper  Patients may move among clinics, but limited sharing of patient records  No central database for monitoring patient population or quality of care Children outside Chainda Clinic, Lusaka

3. Scope, Funding, Client  Scope  Lusaka, Zambia  23 public health clinics –ZEPRS  University teaching hospital  Central Board of Health  Center for Infectious Disease Research in Zambia (CIDRZ)  Funding  Bill & Melinda Gates Foundation – ZEPRS  Elizabeth Glaser Foundation/PEPFAR - ART  Client  University of Alabama Birmingham

4. Project 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

5. RTI Component Objectives  A Local Area Network (LAN) of up to five workstations in each of 23 (became 24) public health care clinics selected by the UAB  A LAN of up to five workstations in the University Teaching Hospital  A LAN of up to five workstations in the Ministry of Health  A data center supporting the electronic perinatal records management system  A wireless Wide Area Network (WAN) connecting clinic LANs, UTH, CIDRZ, and MoH LAN into a single network with access to the perinatal records management system.  A Web-based perinatal records management system designed in conjunction with UAB to serve the needs of the Lusaka Urban Health District

6. ZEPRS Key Concepts  Guides medical personnel through Zambian standard of perinatal care  Concept of “flows” within the system and related data  Shared terminal usage  Usage of ZEPRS data for quality assurance and supervision  Patient confidentiality  Adaptability/Extensibility of ZEPRS system (HIV/ART, Safe Motherhood)  Using mini applications to build computing skills

7. ZEPRS Key medical features  Safe Motherhood  Pregnancies linked together  Convert typical visit to problem visit  Graphical Partograph (matches WHO partograph)  Patient Referral System  Use of EDD/EGA calculation and update in display (with options for manual over-ride) – very useful automation for nurses  Antenatal and Postnatal card generation (supports patient mobility)  Infants linked to mother for each separate pregnancy  Reports  Problem Management including problems across multiple pregnancies

8. ZEPRS Key Technical features  Data export facilitates reporting in Access, SAS, SPSS etc  Connected and disconnected mode  Standalone mode for remote clinics with occasional connectivity - can sync records automatically with the main system.  Open Source – Java J2EE – Tomcat/Struts/MySQL

9. ZEPRS Design Principles  User driven, collaborative and iterative  Software developed using open source tools (cost-effective) and best-of-breed web architecture  Software adapted easily to other contexts and applications  ZEPRS software released under ASL2 open source licenseASL2  ZEPRS documentation published under a Creative Commons Attribution-NonCommercial-ShareAlike 2.5 licenseCreative Commons

10. ZEPRS Home page

11. Patient Status

12. Demographics

13. Pregnancy Dating

14. Medical/Surgical History

15. Routine Ante-natal Visits

16. Chart: Routine Antenatal visits

17. Tracking PMTCT/VCT in Safe Motherhood

18. Counseling Visits

19. ARV Regimen

20. Regimen Results

21. Entering Lab results – CD4

22. Pregnancy Dating/Previous Pregnancies

23. Demo: Antenatal

24. Referrals

25. Referrals – Viewing the record that triggered the referral

26. Referrals: UTH perspective

27. System Generated Problems

28. Comments on Problems

29. Problem List

30. Partograph

31. Partograph: Complex data entry with simple user interface Tracking Cervix/Decent plot Entering data: Result:

32. Partograph Timing Alert

33. Partograph conclusion

34. Delivery

35. Delivery Summary

36. Links to Infant record

37. Correcting a patient record

38. Improvement: Highlights on key fields

39. Demo: Labor and Delivery

40. Reports

41. Report selection

42. ANC Monthly Report

43. Reflex Register

44. Software Development  Agile+ programming approach: iterative development (CMM Level II)  Referral application used to seed development approach, training, roll-out and support  RFP issued to South African/Indian firms – rand appreciation and responsiveness resulted in developing in-house  Multiple supporting applications developed (administration of users, training, web-based email, web-based PM, bugtracker)  User Manual drives training plans  Detailed test plans and testing, using local medical students who we trained in software testing

45. Software Platform Platform ComponentSelected Solution Operating SystemRed Hat Enterprise 3 (Currently CentOS 4.2) Server BackupArkeia Backup 5.2 Wireless AuthenticationAEGIS Premium Server 1.1.4 Relational DatabaseMySQL 3.23 (currently MySQL 5.0) Web Application ServerApache (httpd) 2 Tomcat 5 (servlet container) E-mailCyrus IMAP, Postfix, Spam Assassin E-mail Web InterfaceSquirrel Mail FirewallSonicWALL Client Anti-virusMcAfee E-mail Server Anti-virusAMaVIS

46. Sample Screen Flow

47. Software Development - IDE and Development  What skills does a developer need to work on ZEPRS?  Experienced Java developer for code changes  Basic pc skills to modiy ZEPRS forms.  ZEPRS Dev tools  Incremental development  Average 2 builds/month – usually simple field changes, reports  Process of installing new builds – application updates  Testing  Unit tests  Load tests – jMeter  Demo login  Documentation – used Drupal CMS for www.idg-rti.org website.www.idg-rti.org

48. Software Development Design: Enterprise Content Management  Authorized users may login to the Administration section of the ZEPRS application and create new forms, add/modify fields to a form, and add/modify enumerations to a field.  Systems administrators may query common values using the Report section Query interface. These ad-hoc reports may be useful for previewing data intended for a published standard report.  Rules: Rules may be added to the ZEPRS forms via the Administration section’s web interface. Values entered into a form field that has a rule can trigger the creation of a problem, which will be displayed in the Problem listing. These problems can prompt the user to refer the patient to UTH, complete a form, or provide information.

49. ZEPRS Administration  Form-based Administration  Create Form Create Form  Editing Forms Editing Forms  Adding a new field Adding a new field  Editing a field Editing a field  Generating Dynasite source Generating Dynasite source  Application Updates Application Updates

50. ZEPRS Administration – making changes  Open ZEPRS project source code in Eclipse or Idea  Launch local version of ZEPRS app via IDE’s Tomcat instance to browse app and make form modifications via web interface  After form editing is complete, click “Generate Dynasite Source” to generate java and xml files that manage form rendering and patient flow.  In IDE, use the Ant task “dist-zip” to create a distribution of the ZEPRS war file and other related sql and installation files.  SFTP files to the server.  Run batch file which installs new version and updates any db schema changes.

51. ZEPRS Summary - User Acceptance Ease of Use More than 80% of respondents reported the automated system as easy or easier to complete (use) than the manual system.

52. ZEPRS Summary - Patients in 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.

53. ZEPRS Summary - Conclusions  With some training, clinicians with no prior computer experience may adopt computerized record systems readily  The value of a patient record database for monitoring and improving health status can help sustain an electronic patient record system  The communications network is being used for several health programs  Local staff can maintain and manage the communications network

54. ZEPRS Summary - Major Correction Points ProblemCorrection Time spent developing detailed medical record structure Discharged consultant and initiated agile development for patient record system Lead software developer diverted to ART patient management system No-cost extensions Failure of application and database servers in close succession Used PC for temporary application server Replaced failed servers Quality failure of South African contractor developing referral software Cancelled subcontract and completed software in- house

55. ZEPRS Summary - Critical Success Factors  Close collaboration with health workers and UAB  Thorough testing  Effective user training  User acceptance and participation  Reliability and performance of network  Reliability of computers in facilities  Project management  Use of on-line tools, and IM for remote project support

56. Questions and Comments RTI ZEPRS 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 UAB ZEPRS team  Dr. Perry Killiam, Dr. Dwight Rouse, Dr. Francis Nuthalapaty RTI Website with full ZEPRS details  http://www.idg-rti.org