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1. Zambian Electronic Medical Record System Results and Impact Gordon Cressman, Niamh Darcy, Chris Kelley, Eileen Reynolds May 9, 2008 RTI International is a trade name of Research Triangle Institute For more information contact Gordon Cressman, gmc@rti.org, +1 (919) 541-6363 gmc

2. 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

3. 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

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

5. 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

6. Major Components • High-speed wireless backbone network • Connecting and networking within facilities • Supported training of clinicians • Capacity building for clinicians and 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

7. Wireless Backbone Site Wireless Repeater Site Admin Office Clinic High-speed Wireless Backbone Network • 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 Satellite image of Lusaka showing ZEPRS wireless network links gmc

8. 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 Clinicians launch referral system in July, 2004 nd * Clinic 24, Bauleni Clinic, was opened during the project.

9. 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 Zambian Electronic Perinatal Record System (ZEPRS) Mothers and infants are connected, and clinicians are alerted to problems. nd

10. 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 ZEPRS (continued) Clinicians have access to important information from previous routine antenatal visits. nd

11. 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 Free and open source license No recurring licensing costs ZEPRS (continued) Safe Motherhood module maintains critical information for Prevention of Mother to Child Transmission (PMTCT). nd

12. Current Status, May 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

13. Current Status, May 2008 • >5K* average new antenatal patients registered per month to date • Used to managed care for nearly 140K patients to date • Used to manage roughly 96%** of births in Lusaka • Used to manage multiple pregnancies for >240 mothers to date Sources: *ZEPRS patient record database.** Dr. Perry Killam, Center for Infectious Disease Research in Zambia gmc

14. 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

15. Conclusions • 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 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

16. Ongoing Work • Laboratory management information system (LIMS) interface for same-day lab results in patient records • Off-line mode client for intermittent connectivity (e.g. Kenya, TCC South Africa) • Interfaces to other systems, such as a human resource information system • Adapting to other needs, such as ARV pharmaceutical supply management • Mobile phone networks for data transmission Example: Mobile phones connect rape survivors to ZEPRS-based case management system in South Africa.. gmc

17. AdaptabilityExample:Kenya ARV Pharmaceutical Supplies Key factors: • Public health centers in Nairobi manage all records on paper • Patient referral and feedback system is weak • Management of pharmaceutical supplies is hampered by manual reporting to supply points • Many pharmacists, pharmaceutical technicians, and nurses in Nairobi have some computer literacy • Electrical power is reasonably stable • Mobile phone operators offer 2.5-3G coverage nationwide now Medical supplies and patient records in health centers in Nairobi. gmc

18. 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 For further information:www.idg-rti.org team