RTI International is a trade name of Research Triangle Institute

1. 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

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

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

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.

48. 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.

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