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

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

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

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

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

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

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

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

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 license

ZEPRS documentation published under a Creative Commons Attribution-NonCommercial-ShareAlike 2.5 license

ZEPRS Home page

Patient Status

Demographics

Pregnancy Dating

Medical/Surgical History

Routine Ante-natal Visits

Chart: Routine Antenatal visits

Tracking PMTCT/VCT in Safe Motherhood

Counseling Visits

ARV Regimen

Regimen Results

Entering Lab results – CD4

Pregnancy Dating/Previous Pregnancies

Demo: Antenatal

Referrals

Referrals – Viewing the record that triggered the referral

Referrals: UTH perspective

System Generated Problems

Comments on Problems

Problem List

Partograph

Partograph: Complex data entry with simple user interface

Tracking Cervix/Decent plot

Entering data: Result:

Partograph Timing Alert

Partograph conclusion

Delivery

Delivery Summary

Links to Infant record

Correcting a patient record

Improvement: Highlights on key fields

Demo: Labor and Delivery

Reports

Report selection

ANC Monthly Report

Reflex Register

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

Software Platform

Platform Component Selected Solution

Operating System Red Hat Enterprise 3 (Currently CentOS 4.2)

Server Backup Arkeia Backup 5.2

Wireless Authentication

AEGIS Premium Server 1.1.4

Relational Database MySQL 3.23 (currently MySQL 5.0)

Web Application Server Apache (httpd) 2 Tomcat 5 (servlet container)

E-mail Cyrus IMAP, Postfix, Spam Assassin

E-mail Web Interface Squirrel Mail

Firewall SonicWALL

Client Anti-virus McAfee

E-mail Server Anti-virus AMaVIS

Sample Screen Flow

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.

Software DevelopmentDesign: 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.

ZEPRS Administration

Form-based Administration

Create Form

Editing Forms

Adding a new field

Editing a field

Generating Dynasite source

Application Updates

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.

Question 12. Which is easier to complete (use), the manual "blue book" or ZEPRS?

42.9%

35.7%

7.1%

14.3%

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

d. The ZEPRS systemwas easier

c. Both are about thesame

b. The blue book was alittle easier

a. The blue book wasmuch easier

n = 14

Question 12. Which is easier to complete (use), the manual "blue book" or ZEPRS?

42.9%

35.7%

7.1%

14.3%

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

d. The ZEPRS systemwas easier

c. Both are about thesame

b. The blue book was alittle easier

a. The blue book wasmuch easier

n = 14

ZEPRS Summary - User AcceptanceEase of Use

More than 80% of respondents reported the automated system as easy or easier to complete (use) than the manual system.

More than 80% of respondents reported the automated system as easy or easier to complete (use) than the manual system.

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.

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

ien

ts

2006 2007

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

ien

ts

2006 2007

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

ZEPRS Summary - Major Correction Points

Problem Correction

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

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

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