Electronic system to replace perinatal “Blue Book”
Shared, centralized database of patient records
Wireless network connecting clinics, hospital, administrative offices, data center
Multiple workstations in each facility
Ability to move workstations if necessary
Ability to print summary cards in facilities
Ability to function through 4 hour electrical grid failure
Operating costs paid through research grants
Pre-existing VHF radio tower at clinic.
US$ 2.7 million (Bill & Melinda Gates Foundation through University of Alabama at Birmingham)
UAB executive team
RTI development team
Lusaka-based technical support team
Zambian medical advisory team
4 years (1 Jan 2002 – 30 Sep 2006)
ZEPRS and CIDRZ team at launch of electronic referral application in Lusaka.
Inputs: Money $ 2.7 Million total over four years*
Subcontract costs include wireless network equipment
ODC includes STTA travel
Includes operating costs for the period of performance
* RTI International accounting system. All costs include indirect costs.
Inputs: Money $ 1 Million in computer and networking equipment*
134 desktop computers, 5 laptop computers
130 computer carts
Data center servers, storage, backup, UPS units, generator
One 15m radio tower
Wireless high speed backbone network
Wireless base stations and subscriber units
Wireless access points
Connections to multiple buildings in clinic compounds
UTH fiber optic and wireless network
VoIP network equipment and handsets
UPS battery backup units
* Costs based on RTI estimates
UAB executive team (5)
CIDRZ management and advisory team (4)
Zambian medical advisory team (10+)
RTI development team (4)
Zambian technical support staff (3)
Other Zambian testers and trainers
Patient referral system
Perinatal patient record system
Clinicians using system
Cellular telephone tower with ZEPRS co-located equipment
Outputs: Wireless Network
Line of sight
Hub and spoke
45Mbps 5.8GHz FD backbone
20Mbps 5.8GHz FD subscriber links
10Mbps 2.4GHz within buildings
Connects 24 clinics, 1 hospital, 2 administrative offices, 1 data center
Internet access for all facilities
Voice communication (VoIP) for all facilities
Data center maintained by NGO with research funding
Availability at 88.3% (26 Nov – 2 Dec 2006)
Map of Lusaka showing wireless links ZEPRS - Zambia Electronic Perinatal Record System.kmz 27km diameter hub and spoke line of sight network
Outputs: Wireless Network
Co-location on cell telephone towers, commercial building, ZNBC tower
Repeaters used to reach some sights
No redundant links
LEAP, RADIUS, encryption for security
Map showing wireless links from TELECEL 1 hub ZEPRS - Zambia Electronic Perinatal Record System.kmz
Outputs: Wireless Network
Existing VHF radio towers at most clinics used to mount wireless network equipment.
Multiple buildings in many clinic compounds connected using wireless and wired links.
Satellite photo indicating wireless link to existing Matero Main clinic VHF radio tower.
Outputs: Wireless Network Connecting multiple buildings at clinics
Wired and wireless connections used to extend network to multiple buildings.
Outputs: Wireless Network Networking wards at UTH
Fiber optic cable, copper cable, and wireless equipment connects wards at UTH
Outputs: Patient Referral System
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
Used by 24 clinics and hospital successfully for 2 years
Replaced by ZEPRS patient record system in February 2006
Outputs: Patient Referral System Number of Referrals by Week
Outputs: Patient Record System
Provides clinicians access to patient records 24 hours a day, seven days a week
Alerts clinicians automatically to complete procedures, improve follow-up, and make sure critical-care issues are addressed
Data used to coach medical teams
Longitudinal data used to prioritize, design, monitor, and evaluate interventions
Outputs: Patient Record System Perinatal, VCT, PMTCT, Delivery
Pregnancy Dating - captured at first visit and automatically updated during pregnancy with EGA/EDD
Pregnancies linked, with critical problems from one pregnancy pre-populating for the next pregnancy
Safe Motherhood - request labs (CD4, RPR, HB) and view lab results, ARV counseling visits
Ability to add problems, populate automated system problems, link problems from mother to child and vice versa
Convert visits can be flagged as problem visits
Role based access control - clerks have no access to medical data, only demographics
Graphical partograph matches WHO partograph
Infants linked for each pregnancy to mother
Patient Referral system for easy tracking
Data warehouse and XML data export facilitate reporting in SAS, SPSS, etc.
Standalone mode for remote clinics with occasional connectivity - can sync records automatically with the main system.
ZEPRS helps remind and coach clinicians through an extensible rules system.
Outputs: Clinicians Trained
All training conducted by Zambians
Basic computer skills training conducted by IT specialists
Referral and patient records training conducted by senior clinicians
800 nurses, midwives and other health workers trained
Basics skills (Windows, Word)
ZEPRS mail system
Patient record system
Initial training for referral application.
Outputs: Clinicians Using System Average 584 new patients each week* * 5 Feb 2006 – 16 May 2007. Weeks include one-day weeks at beginning and end of year, resulting in 54 weeks for 2006.
Outputs: Clinicians Using System More than 39,000 patients * 5 Feb 2006 – 16 May 2007. Weeks include one-day weeks at beginning and end of year, resulting in 54 weeks for 2006.
Outputs: Clinicians Using System 19 Clinics actively using system * Feb 2006 – 16 May 2007. Kanyama and State Lodge with only a few patients to date.
Major Correction Points 1 Industry standard desktop PCs selected for usability, maintenance, sustainability Selection of client computer type (desktop PC, thin client, laptop PC, tablet PC) debated Cancelled subcontract and completed software in-house Quality failure of South African contractor developing referral software Switched to lower cost wire carts for full deployment Custom-designed prototype PC carts are expensive (USD 600) and attract rats Discharged consultant and initiated agile development for patient record system Time spent developing detailed medical record structure Higher speed (40Mbps, 20Mbps) 5.8GHz wireless and VoIP equipment added cost of USD 300,716 Congested 2.4GHz spectrum; 802.11b wireless bandwidth (4-6Mbps) may be inadequate for applications and VoIP Correction Problem
Major Correction Points 2 Tested off-line version of software with “opportunistic” synchronization with central database (not fully operationalized) Electrical outages at a few clinics much longer than predicted Redesigned training to be done by senior clinicians Training of clinicians by IT specialists may not be effective Installed best available protective devices at all points. Increased on-site stock of spares. Lightening protection for wireless equipment proves inadequate Used temporary PC application server as quick fix, and then replaced failed servers Failure of application and database servers in close succession 2 years after hand-over No-cost extensions Lead software developer diverted to ART patient management system Correction Problem
Major Correction Points 3 RTI assumes responsibility for developing software in-house Rand/USD exchange rate places software development in South Africa out of reach Strengthened capacity through close mentoring Lusaka-based technical support staff lack capacity for efficient and effective support Controlled and limited Internet access by clinics Limited Internet bandwidth and increased use of Internet by clinicians Enlisted medical students for testing Limited availability of clinicians for testing Adjusted UPS battery backup for minimum 4 hour up-time. Set all UPS units to log grid power data. Installed automated network monitoring and alert system Extended power outages (some caused by illegal tapping of transformers) at some clinics Correction Problem
Major Correction Points Prototype custom $585 rugged mobile enclosed carts Custom enclosed cart prototype, made in South Africa. Prototype cart being used for launch of referral System.
Some protection against dust
Good protection against theft
Requires antenna extension
Hiding place for rodents
Major Correction Points Commercial < $165 rugged mobile wire carts In examination room. Being used by clinicians.
No hiding places for rodents
No antenna extension required
No protection against dust
Weaker protection against theft
Sustaining It Network availability Availability October 1, 2005 - April 30, 2006 (7 months) Availability suffers due to management inattention and contention for resources. Availability October 1, 2005 - April 30, 2006 (16 months) Availability can be higher than 90% on an extended basis...
Sustaining It Network availability
Extended power failures at some clinics
Management of support staff
Inadequate on-site spares
Making it Open
Software developed using open source tools 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 demonstration and development websites open to all
Collaborating and Combining Open Source Efforts
Experience in large scale deployment
Years of experience in operation
Stand-alone version (Eclipse RCP)
Regenstrief data model and concept dictionary
Broader development and support community
General records at Kalingalinga Clinic prior to ZEPRS.
Making it Scale Expanding beyond a metropolitan area
Offline version for clinics with multiple PCs
Automated record synchronization with centralized database
Stand-alone packaged version (Zephyr)
“ Organic” scaling
Aggregate data reporting via mobile phone network
Automatic SMS reminders and notifications to patients
Safe Motherhood form from Zephyr stand-alone version of ZEPRS.
Making it Scale “ We are balancing local resources and remote resources to provide a perception of continuous connection to a central data source. When we experienced some problems with ZEPRS network availability, we attempted to bring server resources closer to the clinics by building a more distributed model – placing mini-servers in each clinic. Then we implemented a system to enable these remote servers to “phone home” when the network links were back up to fetch updated records and synchronize with the master server.” - Chris E. Kelley, RTI Senior Software Developer
Making it Scale ZEPRS can operate as an easy-to-install stand-alone application on a single PC.
Making it Scale Technologies such as Zeroconf can enable users with minimal technical support to create a shared, networked database within a facility.
Making it Scale Operating in “off-line” mode, installations of ZEPRS can report aggregate data and synchronize patient records with centralized databases when telecommunication links are available.
The 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 more information visit www.rtidemo.org
Making it Open ZEPRS Open Source technologies and components Java, Struts, JDBC, Apache DBUtils, AJAX – DWR and script.aculo.us, Quartz, Junit, XStream Application AMaVIS E-mail Server Anti-virus Cyrus IMAP, Squirrel Mail, Sendmail, Spam Assassin E-mail Apache (httpd) Tomcat (servlet container) Web Application Server MySQL Relational Database AEGIS Premium Server Wireless Authentication Arkeia Backup Server Backup Red Hat Enterprise Operating System Selected Solution Platform Component