Gmcressman

Gordon M. Cressman is Senior Director of the Information and Communication Technologies (ICT) program for RTI International's International Development Group. He has more than 20 years of experience in information and communications technologies, 19 of them as a professional in international development. He is experienced in every phase of ICT systems design and implementation, including assessment, strategic planning, operational planning, systems integration, procurement, installation, training, and operation. His ICT applications experience spans health, education, and governance. He has helped organizations in 14 developing countries to improve their ICT systems through sustainable strategies sensitive to local constraints. more...

The Zambia Electronic Perinatal Record System (ZEPRS) is an Electronic Medical Record (EMR) system used by public obstetric clinics and a hospital (the University Teaching Hospital) in Lusaka, Zambia.

Background

In early 2001 a team of physicians at the University of Alabama at Birmingham (UAB) and visiting Zambian physician Dr. Moses Sinkala conceived the idea based on a successful electronic perinatal record system that the UAB had developed an proven in clinics in Birmingham. in July 2001 the Bill & Melinda Gates Foundation had awarded a grant to the UAB to develop a similar system to serve public obstetric clinics in Lusaka. ^[1]

The UAB team solicited proposals for the technical design and implementation of the system from several private sector information technology firms, including Electronic Data Systems, before awarding a contract to RTI International (RTI), a large 501(c)3 not-for-profit research organization based in Research Triangle Park, North Carolina. Other project partners included the Center for Infectious Disease Research in Zambia (CIDRZ) and the Lusaka Urban Health District of the Zambian Central Board of Health.

Objectives

ZEPRS was designed to improve maternal and perinatal outcomes by:

Improving perinatal care to women and postnatal care to neonates by:
1. Promoting adherence to good standard of care practices
2. Identifying and document potential medical/ obstetrical problems so that effective therapies can be administered
3. Improving communication and referrals among providers
4. Enhancing monitoring and evaluation of outcomes, clinics, and providers
Improving efficiency, completeness, accuracy of documentation and reporting

Major Components

ZEPRS achieves these objectives by providing the following:

An electronic patient record system with patient record database shared among facilities
A system that guides clinicians through the Zambian standard of care
Intelligent rules that alert clinicians to problems and recommend patient referral when appropriate
Standard & ad hoc reporting for supportive supervision, surveillance, analysis
An electronic-first system use by clinicians during the course of patient care
An electronic referral system to improve the efficiency and effectiveness of referrals

ZEPRS components include a high-speed point-to-point voice and data wireless network that interconnects facilities; wired and wireless networks within facilities; a data center managed by CIDRZ; and an electronic perinatal record system with integrated patient referral system.

ZEPRS uses a tabbed user interface and role-based access control system to enable several clinicians to share the same computer to retrieve and enter data for different patients.

Software Architecture

ZEPRS has been developed using the Java programming language. Other technologies used include AJAX, Quartz , MySQL, and others. ZEPRS has it's own content management system called DynaSite, that make it easy to add forms, fields, form flows, and business rules without programming. RTI has developed a locally installable version of the software using the Eclipse Rich Client Platform (RCP) and the Apache Derby embedded database.

Development History

RTI worked with South African firm Communications Solutions (Comsol) to conduct a wireless site survey of all facilities, and to design a line-of-sight wireless network to connect them. By March 2003 this network was operational. Before the end of 2003 RTI had worked with Comsol to add Voice over Internet Protocol (VoIP) to provide voice communication between facilities, and had extended the network to connect multiple buildings in clinic compounds and to multiple wards of the University Teaching Hospital.

Three to nine networked PCs and one laser printer were installed in each clinic, as well as additional PCs and printers in the University Teaching Hospital and administrative offices. The ZEPRS data center was installed at CIDRZ, which housed the combined ZEPRS technical support team.

Approximately 800 clinicians, many of whom had never used a computer, were trained in basic computer literacy. Standard clinical protocol reference works and email were made available to clinicians electronically over the ZEPRS network.

By early May 2004 RTI had completed an open source electronic patient referral system. This was launched into production use in clinics on 22 June 2004. Clinicians adopted this component readily and the system was soon rolled out to all 24 clinics and the University Teaching Hospital.

Also in May 2004, CIDRZ asked RTI whether the ZEPRS software could be adapted to help in managing antiretroviral therapy (ART) to treat patients infected with the Human immunodeficiency virus (HIV). Version 1.0 of this software, the ART Patient Tracking System (ART/PTS), was launched into use at Kalingalinga Clinic on 1 June 2004.^[2]

RTI reviewed the completed Beta version of the fully integrated perinatal record system with the UAB team in July 2005, and released Version 1.0 on 21 November 2005. This version was pilot tested in a limited number of clinics in Lusaka from December 2005 through December 2006. ZEPRS was launched into production use in four clinics in two clinics in February 2006. The system was rolled out to all clinics at the average rate of one clinic each month until the roll out was completed in August 2007.

Current Status

Since the roll out was completed in August 2007, ZEPRS has been used by 24 public obstetrics clinics, as well as six wards (blocks A-D, adult ARV ward, and pediatric ARV ward) within the University Teaching Hospital in Lusaka. By the end of May 2008 there were more than 155,000 patient records in the system, with an average of over 5,000 new antenatal patients being registered in the system each month. ZEPRS links multiple pregnancies of the same mother to the mother's record. By the end of May 2008, ZEPRS had been used to manage multiple pregnancies for more than 240 mothers.

Ongoing Development

Since ZEPRS was launched in February 2006 it has been continually refined and enhanced based on input from clinicians and emerging needs. In 2008 RTI worked with CIDRZ to implement and interface with the Laboratory Information Management System (LMIS) at Kalingalinga Clinic, enabling lab test results such as CD4 counts to be transferred to patient records automatically twice daily. RTI is currently testing a version of the software that can be installed locally, be used within a facility in the absence of network connectivity, and can synchronize records automatically when connectivity is detected.

Adaptability

ZEPRS core software architecture has been adapted for use in managing antiretroviral (ARV) drug supplies, managing malaria indoor residual spraying operations, and post-exposure prophylaxis (PEP) for rape survivors.

Availability

ZEPRS has been released by RTI as free and open source software under the Apache Software License (Version 2.0)

Related Systems

Notes

^ 1 US-Zambian Collaboration Receives $4 Million To Establish Electronic Obstetric And Newborn Medical Record In Lusaka, Zambia
^ 2 Hubschman T, Mweetwa V, Fusco H, Chi B, Levy J, Sinkala M, Shields M, Stringer J. Electronic patient tracking supports rapid expansion of HIV care and treatment in Lusaka, Zambia. President’s Emergency Plan for AIDS Relief 2nd Annual Meeting, “Supporting National Strategies: Building on Success.” Addis Ababa, Ethiopia, May 22-27, 2005.

References

Ajita S., Dipsikha S., Sahajad A. (2006) "e-Health Perspective: Healing touch to health", i4D Magazine.
Cressman, G., Darcy, N., Destefanis, P., Kelley, C., Reynolds, E. (2007) "Can an Electronic Medical Record System Improve Health Care in Lusaka, Zambia?", AIDSIMPACT 2007.

[GatesPresRelease-1] 1 US-Zambian Collaboration Receives $4 Million To Establish Electronic Obstetric And Newborn Medical Record In Lusaka, Zambia

[art_pts_article_jama-2] 2 Hubschman T, Mweetwa V, Fusco H, Chi B, Levy J, Sinkala M, Shields M, Stringer J. Electronic patient tracking supports rapid expansion of HIV care and treatment in Lusaka, Zambia. President’s Emergency Plan for AIDS Relief 2nd Annual Meeting, “Supporting National Strategies: Building on Success.” Addis Ababa, Ethiopia, May 22-27, 2005.

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