Using ICT to Improve Patient Care
ZEPRS
Gordon Cressman, Chris Kelley, Niamh Darcy
June 22 2007
RTI International is a trade name of Research Triangle Institute
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



Testing




Average 2 builds/month – usually simple field changes, reports
Process of installing new builds – application updates
Unit tests
Load tests – jMeter
Demo login
Documentation – used Drupal CMS for www.idg-rti.org website.
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.
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.
ZEPRS Summary - User Acceptance
Ease of Use
Question 12. Which is easier to complete (use), the manual "blue book"
or ZEPRS?
a. The blue book was
much easier
14.3%
b. The blue book was a
little easier
More than 80% of
respondents reported
the automated system
as easy or easier to
complete (use) than
the manual system.
7.1%
c. Both are about the
same
35.7%
d. The ZEPRS system
was easier
42.9%
n = 14
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
ZEPRS Summary - Patients in System
More than 39,000 patients
Cummulative Patients by Week
45,000
40,000
New Patients
35,000
30,000
25,000
20,000
15,000
10,000
5,000
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
2006
2007
Week
* 5 Feb 2006 – 16 May 2007. Weeks include one-day weeks at beginning and end of year,
resulting in 54 weeks for 2006.
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
Quality failure of South African contractor developing
referral software
Cancelled subcontract and completed software inhouse
Replaced failed servers
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