ZEPRS Electronic Perinatal Record System: Results and Impact

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RTI International is a trade name of Research Triangle Institute The Zambian Electronic Perinatal Record System For more information contact Gordon Cressman, gmc@rti.org, +1 (919) 541-6363 gmc Built on zcore™ - Rich forms, flexible administration, easy networking Gordon M. Cressman Director, Center for Information, Communication and Technology Monday 27 October, 2008 Title Slide

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Zambia in 2001 Health Status High maternal mortality (750/100 000 live births) High neonatal mortality (40/1 000 live births) 1 in 25 lifetime risk of death in pregnancy Nearly 1 in 3 pregnant women infected with HIV in Lusaka Nearly half will transmit HIV to their babies. Health Care in Lusaka Health care for more than 1 million people 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 in 2001 Children outside Chainda Clinic, Lusaka, Zambia gmc

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Key Problems Unable to systematically assess care delivery Surveillance limited to simple cross-sectional statistics Occasional failure to test for STIs and frequent failure to follow up patients diagnosed positive Limited continuity of care across pregnancies of same mother Limited sharing of patient records between facilities Unable to monitor patient population or quality of care Patient file storage at University Teaching Hospital, Lusaka, 2001 gmc

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Project Goals and Proposed Solution Objective: Improve maternal and perinatal health outcomes nd

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Project Partners Bill & Melinda Gates Foundation US$ 4 million grant over five years University of Alabama Birmingham (UAB) / Center for Infectious Disease Research in Zambia (CIDZ) Original conception Project oversight Medical expertise Training of clinicians Quality assurance Lusaka Urban Health District, Central Board of Health Medical expertise Engagement in all project phases RTI International Technical strategy, planning, specification, Project management Software design, development, testing Developing local technical support capacity and ownership User training and roll-out strategy Cellular telephone tower with ZEPRS co-located equipment gmc

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Major Components High-speed wireless backbone network Connecting and networking within facilities Training of clinicians Capacity building for local technical support staff Electronic patient referral software Electronic perinatal record software Continuous monitoring of hardware & software infrastructure Training in electronic patient referrals, Lusaka, Zambia gmc

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High-speed Wireless Backbone Network Satellite image of Lusaka showing ZEPRS wireless network links 27km diameter hub-and-spoke line-of-sight wireless network Wireless networks in all facilities 3 – 9 PCs in each clinic Voice (VoIP) and data communication for all facilities gmc

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Electronic Patient Referral System One of several “mini applications” to build computing skills of clinicians Notifies referral clinic or hospital of incoming patients Provides critical information to prepare for patients Updates referring clinic on patient status Maintains records of all referrals Launched in July 2004 at 3 clinics and 2 areas in UTH Used by 24* clinics and hospital successfully for 2 years Replaced by ZEPRS patient record system in February 2006 * Clinic 24, Bauleni Clinic, was opened during the project. Clinicians launch referral system in July, 2004 nd

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Zambian Electronic Perinatal Record System (ZEPRS) Electronic-first Data entered during course of care Data immediately available Shared facility and/or central database Shared terminal usage via tabbed interface Protects patient confidentiality Designed for perinatal care Links mothers to infants and supports multiple pregnancies Safe Motherhood module Convert typical visit to problem visit Graphical Partograph matches WHO partograph EDD/EGA calculation, automatic update, and optional manual over-ride very useful for nurses Antenatal and postnatal card generation supports patient mobility Mothers and infants are connected, and clinicians are alerted to problems. nd

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ZEPRS (continued) Guides and alerts clinicians automatically Guides medical personnel through Zambian standard of perinatal care Alerts clinicians automatically to complete procedures, follow-up, and address critical-care issues Concept of “flows” within the system and related data Includes patient referrals Connects referring and referral facilities Rich source of data to improve care Used for quality assurance and supportive supervision of medical teams Used for surveillance and to prioritize, design, monitor, and evaluate interventions Clinicians have access to important information from previous routine antenatal visits. nd

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ZEPRS (continued) Standard and ad hoc reporting Integrated standard reports Ad hoc reporting via SAS, SPSS and other tools Can be modified without programming Changing and adding forms and fields Changing and adding form flows Changing and adding rules for alerting and advising clinicians Visit www.rtidemo.org for demonstration videos Free and open source license No recurring licensing costs Safe Motherhood module maintains critical information for Prevention of Mother to Child Transmission (PMTCT). nd

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Status, September 30, 2008 800 nurses, midwives and other health workers trained Roll-out started February 2006 Average of 1* new clinic a month during roll-out Roll-out completed August 2007 Used by 24 clinics Used by all 4 UTH blocks (A-D) + adult and pediatric ARV wards Source: *ZEPRS patient record database. gmc

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Status, September 30, 2008 Managed care for more than 190,000 patients 5,800* average new antenatal patients registered per month 11,418 new antenatal patients registered in September 2008 Managed 96%** of births in Lusaka Managed multiple pregnancies for 595 mothers 483 users in 2008 Sources: *ZEPRS patient record database.** Dr. Perry Killam, Center for Infectious Disease Research in Zambia gmc

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Impact on Healthcare HIV test rate for new antenatal patients at Chipata Clinic increased by 10 percentage points through supportive supervision Case study* of Matero Clinic attributed very low maternal mortality to training of clinicians and ZEPRS Real-time data by clinic helps target interventions Sources: *Department for International Development (DFID), United Kingdom nd

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Relevance to Health Research Research data management systems and patient record systems overlap and meet critical needs in developing countries Patient records database provides rich data source for longitudinal research Patient records database used for public health surveillance Value of database and patient records system generates continued research grant funding for operations Cressman, G., Darcy, N., Destefanis, P., Kelley, C., Reynolds, E. (2008) "Can an Electronic Medical Record System Improve Health Care in Lusaka, Zambia?", Poster Presentation, PHI2008 Conference, Seattle, Washington, USA. Torres, Pablo (2008) “Ensuring the Sustainability of Research Data Collection and Management Systems”, Poster Presentation, AIDS2008 Conference, Mexico City, Mexico Stergachis, A., Keene, D., Somani, S. (2008) "Informatics for Medicines Management Systems in Resource-Limited Settings" Making the eHealth Connection Conference, Bellagio, Italy. Cressman, G., Darcy, N., Destefanis, P., Kelley, C., Reynolds, E. (2007) "Can an Electronic Medical Record System Improve Health Care in Lusaka, Zambia?", Presentation, AIDSIMPACT 2007. Ajita S., Dipsikha S., Sahajad A. (2006) "e-Health Perspective: Healing touch to health", i4D Magazine. 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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What We Learned Clinicians in developing countries can and will use electronic-first patient record systems Intelligent systems and supportive supervision can improve the quality of care Good systems for care providers can address the root cause of HMIS data quality problems Wireless technologies can enable facilities to share patient records The value of data can be leveraged to generate sustaining funding Well designed software can be adapted easily to new requirements and applications Sometimes clinicians are patients: entering data using a mobile cart-mounted PC. gmc

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What We Would Change Network infrastructure Difficult and expensive to maintain Cannot scale reasonably beyond a metropolitan area Electrical stability and cost Extended electrical outages at some clinics force them offline Electricity costs are increasing Interoperability No standard for patient ID, registration No use of data exchange standard Sustainability No local institution supporting the software Lower infrastructure requirements Use new, lower cost wireless technology Use existing mobile phone networks Lower power requirements Enable facilities to operate offline Use new, lower power equipment Adopt open standards Adopt the OpenMRS data dictionary Use HL7 standards for data exchange Build an open source community Join the OpenMRS Developers Group Engage regional OSS groups Engage local universities as development partners

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Technical Vision Operate independent of telecommunications and the electrical grid Scale up from a one computer to multiple computers sharing the same database in the facility Interoperate with other eHealth applications via recognized standards Transmit patient referral information between facilities Send patient reminders via SMS text messaging Synchronize new patient registration data to a national patient registration database Synchronize patient records with a shared multi-facility patient record database Submit aggregate data reports to one or more specified remote databases Supported by an international open source development community zcore: Rich forms, flexible administration, easy networking www.rtidemo.org

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What We’re Doing Now Developed laboratory management information system (LIMS) interface for same-day lab results in patient records (Zambia) Developed off-line client for intermittent connectivity (Kenya, Zambia) Testing asynchronous data transfer system (Kenya, Zambia) Adapting to other needs, such as ARV pharmaceutical supply management (Kenya) Using mobile phone networks for data transmission (Kenya) Building support for migration to OpenMRS data model Proposing new adaptations at new sites Investigating interface to new laboratory diagnostic systems Example: Mobile phones connect rape survivors to zcore-based case management system in South Africa. gmc

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ZEPRS Team RTI Development 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 Lusaka Technical Support Staff Dennis Nkula, Zambia Project Coordinator Francis Banda, Technical Support Specialist Jamie Mwanza, Technical Support Specialist Center for Infectious Disease Research in Zambia Dr. Jeffrey Stringer, MD, Director, Co-Investigator Dr. Perry Killam, MD, Project Advisor Harmony Fusco, Project Manager Chafye Siulata, Project Assistant UAB Team Dr. Robert L. Goldenberg, MD, Principal Investigator Dr. Dwight Rouse, MD, Co-Investigator Dr. Sten Vermund, MD, Co-Invesigator Dr. Francis Nuthalpathy, Health Informatics Advisor Dr. Alan Tita, Health Informatics Advisor Zambian Medical Advisors Dr. Moses Sinkala, MD Dr. Elwyn Chomba, MD Dr. Ben Chirwa, MD Dr. Henri Phiri, MD Dr. Christopher Ngandwe, MD Dr. Chipepo Kankasa, MD Dr. Macha, MD Dr. Mpundu Makasa, MD team

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For More Information… For more information about ZEPRS, zcore, and other zcore applications visit: Wikipedia (search for “ZEPRS”) ZEPRS background, history, major components, current status, and references www.rtidemo.org ZEPRS presentations and network map Links to ZEPRS demos and the ZEPRS project site Information about zcore zcore feature demos zcore software releases Information about the zcore-powered malaria Indoor Residual Spraying Application

Summary: Background, description, and results of the Zambia Electronic Perinatal System (ZEPRS) project.

Tags: electronic medical patient record zambia rti research triangle institute zeprs

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