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									                            ZEPRS
The Experience of the Zambian Electronic
        Medical Record System
                             29 May 2007




        RTI International is a trade name of Research Triangle Institute




                                                                           1
                      ZEPRS
The Experience of the Zambian Electronic Medical Record
                        System
1.   Context
2.   Objectives
3.   Inputs
4.   Outputs
5.   Impact on Patient Care
6.   Making it Open
7.   Making it Scale           Chawama clinic MCH waiting room,
                               Lusaka, Zambia
8.   Questions & Comments


                                                                  2
                          Context
 Maternal mortality rate 940/1000
 Lifetime risk of death in pregnancy
  1/25
 Disability Adjusted Life Years
  (DALY) at birth 30.7
 Nearly 1/3 women infected with HIV
 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       Children outside Chainda Clinic,
  cases (2002)                           Lusaka




                                                                            3
                           Context
 All medical records on paper
 Protocol and records in reasonable
  order, but significant problems in
  operation
 Frequent failure to follow up patients
  diagnosed with STDs
 Failure in some cases to test for
  STDs
 Patients may move among clinics,
  but limited sharing of patient records
 No central database for monitoring
  patient population or quality of care
                                           Patient files at University
                                           Teaching Hospital, Lusaka




                                                                         4
                                 Context
Telecommunications
     Weak landline infrastructure
     Congested 2.4GHz wireless
      segment
Clinics
     Dusty, congested
     7 of 23 clinics had telephone lines
     All clinics with VHF radio for voice
Personnel
     No computer literacy
     Very stressed due to patient load
     High medical staff turn-over (40%)
Electrical                                   Clinician at the door of the
     Inadequate electrical systems at all   Prisons Kamwala Clinic in 2002.
      points, no backup power, No
      lightening protection
     Poorly regulated grid (Frequent
      power outages)



                                                                               5
                      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
                                         Patient files at University
      health administrators              Teaching Hospital, Lusaka, 2004




                                                                           6
 Key Requirements & Assumptions
 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.


                                                                          7
                                 Inputs
Money
   US$ 2.7 million (Bill & Melinda Gates
       Foundation through University of Alabama
       at Birmingham)
People
   UAB executive team
   RTI development team
   Lusaka-based technical support
    team
   Zambian medical advisory team                 ZEPRS and CIDRZ team at
Time                                              launch of electronic referral
                                                  application in Lusaka.
   4 years (1 Jan 2002 – 30 Sep 2006)




                                                                                  8
                                   Inputs: Money
                                 $ 2.7 Million total over four years*

  Cost by Component           Materials,
                                                Consultants,
                                                                              Subcontract costs
                              $76,559
                                                 $138,953                      include wireless
       Subcontracts,
                                                                               network equipment
         $797,506                                        Equipment,           ODC includes STTA
                                                          $499,140
                                                                               travel
                                                                              Includes operating
                                                                               costs for the period
                                                                               of performance


                                                       ODC, $556,528

                 RTI Labor,
                 $660,212




* RTI International accounting system. All costs include indirect costs.


                                                                                                      9
                                   Inputs: Money
                    $ 1 Million in computer and networking equipment*

 Hardware Costs                                                              134 desktop computers, 5 laptop
                                   Customs &                                  computers
                                   Shipping,                                 29 Printers
                          MoH       $13,127                                  130 computer carts
                                               VoIP, $29,591 UTH
                       LAN/WLAN,                                             Data center servers, storage,
                         $6,601                           LAN/WLAN,           backup, UPS units, generator
                                                           $51,619           One 15m radio tower
                                                                             Wireless high speed backbone
                                                          Data Center,        network
                                                            $72,729          Wireless base stations and
                                                                              subscriber units
                                                          Clinic WLANs,      Wireless repeaters
                                                             $74,433         Wireless access points
                                                                             Connections to multiple buildings
  PCs & Printers,                                                             in clinic compounds
    $514,799                                                                 UTH fiber optic and wireless
                                                                              network
                                                                             VoIP network equipment and
                                                                              handsets
                                                                             UPS battery backup units
                                                                             Lightening protection
                                                      WAN, $246,869



* Costs based on RTI estimates


                                                                                                                  10
                      Inputs: People
                                                                                                                                  Dr. Robert L, Goldenberg,
                                                  Gordon M. Cressman
                                                                                                                                             MD
                                                  Senor Project Advisor
                                                                                                                                    Principal Investigator


•   UAB executive team
    (5)                                              Eileen Reynolds
                                                     Project Manager
                                                                                                                Dr. Dwight Rouse, MD
                                                                                                                    Co-Investigator
                                                                                                                                                    Dr. Sten Vermund, MD
                                                                                                                                                        Co-Invesigator


•   CIDRZ management                     Consultants
                                                                 Chris Kelley                        Dr. Francis
                                                                                                                                                                        Dr. Alan Tita

    and advisory team (4)
                                        Scott Herman                                                Nuthalpathy
                                                                Senor Software                                                                                        Health Informatics
                                          Giddens                                                 Health Informatics
                                                                  Developer                                                                                                Advisor
                                        Dave Peckham                                                   Advisor


•   Zambian medical          Niamh Darcy
                            Senor Technical
                               Advisor
                                                                          Pablo Destefanis
                                                                          Senior Networking
                                                                            and Telecom
                                                                                                                            UAB Executive Team

    advisory team (10+)                                                       Specialist

                                                                                                                                  Dr. Jeffry Stringer, MD
                                                                                                                                     Director, CIDRZ
                                         RTI Development Team
•   RTI development
    team (4)                                         Dennis Nkula
                                                    Zambia Project
                                                                                                      Chafye Siulata
                                                                                                     Project Assistant
                                                                                                                                     Harmony Fusco
                                                                                                                                     Project Manager
                                                                                                                                                              Dr. Perry Killam MD
                                                                                                                                                                Project Advisor


•   Consultant (1)                                    Coordinator



                                                                                                                                        CIDRZ
•   Zambian technical                 Francis Banda
                                     Technical Support
                                                               Jamie Mwanza
                                                              Technical Support
                                        Specialist               Specialist

    support staff (3)                                                                         Dr. Moses Sinkala, MD
                                                                                                ZEPRS Executive
                                                                                                                                 Dr. Elwyn Chomba, MD
                                                                                                                                    ZEPRS Executive
                                                                                                                                                                     Dr. Ben Chirwa, MD
                                                                                                                                                                      ZEPRS Executive
                                                                                               Committee, LDHMT                      Committee, UTH                   Committee, MoH

•
                                Lusaka-based Technical Support
    Other Zambian testers                   Staff
                                                                                                        Ethel Mangani                                       Dr. Chipepo

    and trainers
                                                                                                                                   Dr. Chris Ngandwe
                                                                                                        Lyuba                                               Kankasa, MD
                                                                                                                                    Medical Advisor
                                                                                                        Nurse Liaison                                       Medical Advisor
                                                                                                                                                                        Dr. Mpundu
                                                                                                                       Dr. Henry Phiri, MD      Dr. Macha, MD
                                                                                              Emeldah Kabwe                                                             Makasa, MD
                                                                                                                       Medical Advisor          Medical Advisor
                                                                                              Nurse Liaison                                                             Medical Advisor


                                                                                                         Senior Zambian Medical Advisory Team




                                                                                                                                                                                           11
                                    Inputs: Time
                                           1/14/2004
                                           RTI begins
                                       ZEPRS Development
                         4/1/2003                               7/22/2004
                       First Version                        Referral Application
                      Medical Record        1/5/2004            Launched
    4/17/2002          Specification     Referral System                       7/1/2005               11/21/2006
Site Assessment                            Completed                          ZEPRS beta              ZEPRS v1.0




                       1/1/2003                1/1/2004                1/1/2005            1/1/2006

1/1/2002                                                                                                  9/30/2006

        7/1/2002                   10/1/2003       1/5/2004                5/1/2004
      WAN Completed               Software RFQ ZEPRS Prototype 1       RTI uses ZEPRS
                                    Released                             to Produce
                                                                          ART/PTS




                                                                                                                      12
                Outputs
Wireless network
Patient referral system
Perinatal patient record
 system
Clinicians trained
Clinicians using system

                            Cellular telephone tower with
                            ZEPRS co-located equipment


                                                            13
                 Outputs: Wireless Network
       Line of sight
       Hub and spoke
       45Mbps backbone
       20Mbps subscriber links
       10Mbps within buildings
       Connects 24 clinics, 1
        hospital, 2 administrative
        offices, 1 data center                                                          27km diameter
       Internet access for all                                                         hub and spoke
        facilities
                                                                                        line of sight
       Voice communication
        (VoIP) for all facilities                                                       network
       Data center maintained
        by NGO with research
        funding
       Availability at 88.3% (26
        Nov – 2 Dec 2006)
ZEPRS - Zambia Electronic Perinatal Record System.kmz   Map of Lusaka showing wireless links

                                                                                                        14
                 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




ZEPRS - Zambia Electronic Perinatal Record System.kmz   Map showing wireless links from TELECEL 1 hub


                                                                                                        15
       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.


                                                                                             16
                       Outputs: Wireless Network
                                   Connecting multiple buildings at clinics
                                            Kalingalinga
                                               2 X Lightning Arrestors
MCH                                                4 X Ntype Male
                                                  2 X Earth Spike                             3m Antenna Pole
                                                  20m Earth Cable                                & WM45
                                                                                                8dBi Plannar
                                                                                     SMA
                                                                                                  Antenna

                                                          Labour Ward                  10m
                                                                                      RG214

                                                                                      Reverse
 Client PC with                                                                        TNC       Client PC
2.2dBi antennas




 Client PC with
2.2dBi antennas                                                                                 Laboritory       Wired and wireless
                                                                                                                  connections used to
 Client PC with
2.2dBi antennas
                                                                                                                  extend network to
                                                             Client PC with
                                                            2.2dBi antennas
                                                                                                                  multiple buildings.

                  120º Sector


                                               8dBi Plannar
                                                 Antenna


                                                                      Reverse
                                                                       TNC
                                                                                AP

                                                           2-Way        20m ½”
                      13dBi Sectorial                                  Succofeed
                         Antenna                           Splitter
                                                                         5m
                                                       3 X N-Type
                                                                        RG214
                                                          Male
                                                       1 X SMA
                                        Mast with SU




                                                                                                                                        17
                                           Outputs: Wireless Network
                                                                                  Networking wards at UTH

Stairs




                                                         BO3
                                                                                                                                                                                                                          Fiber optic cable,
           FTP
                                                                        RF                                                                                                                                                 copper cable, and
         PC                           PC        PC                     PC               PC                                                                                                                                 wireless equipment
                      BO3 Ward

         60m FTP Cable & Trunking
         1 X Cisco AP350
         1 X TNC Male Connector
                                                                                                                                                                                                                           connects wards at UTH
         15m RG214 Cable & Trunking
         1 X N-Type Male Connector
         1 X 8dBi Roofmount Antenna




                                                                                                                                                                                                                         Ground Floor




                                                                                                                                      Corridor
                                                     Radio Signal from Rooftop : 120º




                                                                                                                                                                                               Consultation Ward

                                                                                                                                                                                        1 X 6U Cabinet
                                                                                                                                                                                        1 X UPS                                                   “Examination Hall”
                                                                                                Window Below Nursery                                                                    1 X Switch
                                                                                                                                                                                        1 X Cisco AP350 Full Set                             1 X Cisco AP350
                                                                                             1 X SMA Male Connector                                                                     1 X Cisco AP350 Power Injector                       1 X TNC Male Connectors
                                                                                             1 X 8dBi Plannar Antenna                                                                   2 X TNC Male Connectors                              20m RG214 Cable & Trunking
                                                                                             15m RG214 Cable & Trunking                                                                 20m UTP Cable & Trunking                             1 X N-Type Male Connector
                                                                                                                                                                                        15m RG214 Cable & Trunking                           1 X 8dBi Roof-mount Antenna
                                                                                                                                                                                        1 X N-Type Male Connector
                                                                                                                                                                                        2 X 8dBi Roof-mount Antenna



                                                                                                                                                                      UPS

                                                                                                                          Elevators
                                                                                                                                                     RF

                 PC                        PC            PC                  PC              PC
                                                                                                                                                             Switch
                                                                                                                                                                       2nd AP
                                                                                                                              RF
                                                                                                                                                                       Power
                                                                                                                                                                      Injector
                                                                                                                                                                                                                                                            PC                        PC
                                                            BO1                                                                                                                  UTP




                                                                                                                                                                                                                           RF
                                                                                                                                                                                                                                                                 “Examination” Hall


                                                                                                                                                   PC
                                                                                                                                                   Main
                                                                                                                                                 Reception
                                                                                                                                                                 PC                PC        PC                    PC       PC
                                                                                                                                                                                                                                        RF
                                                                                                                                                                                                                                                            PC                        PC




                                                                                                                                                                                                                                                                                           18
   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         Clinicians launch referral system in
                                         July, 2004




                                                                                19
                  Outputs: Patient Referral System
                                        Number of Referrals by Week


                  140


                  120
                                                                  Launch of ZEPRS v1.0
                  100
Total Referrals




                      80


                      60


                      40


                      20


                  -
                           29   34 39 44 49   1   6   11 16   21 26 31 36 41 46 51       4   9 14 19
                                   2004                         2005                         2006
                                                              Week




                                                                                                       20
   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




                                     21
       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                ZEPRS helps remind and
   Data warehouse and XML data export facilitate            coach clinicians through an
    reporting in SAS, SPSS, etc.
   Standalone mode for remote clinics with occasional       extensible rules system.
    connectivity - can sync records automatically with the
    main system.




                                                                                           22
       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
      Referral system                 Initial training for referral
      Patient record system           application.



                                                                       23
Outputs: Clinicians Using System
                         Average 584 new patients each week*

                                                 New Patients by Week

                 1,400

                 1,200

                 1,000
  New Patients




                  800

                  600

                  400

                  200

                   -
                         6   9   12 15   18 21 24 27   30 33 36   39 42 45   48 51 54   3   6   9   12 15 18

                                                        2006                                    2007
                                                                  Week

  * 5 Feb 2006 – 16 May 2007. Weeks include one-day weeks at beginning and end of year,
  resulting in 54 weeks for 2006.


                                                                                                               24
Outputs: Clinicians Using System
                                     More than 39,000 patients

                                               Cummulative Patients by Week

                 45,000

                 40,000

                 35,000

                 30,000
  New Patients




                 25,000

                 20,000

                 15,000

                 10,000

                  5,000

                    -
                          6 8 10 12 14 16 18 20 22 24 26 28 30 32 34 36 38 40 42 44 46 48 50 52 54 2 4 6 8 10 12 14 16 18

                                                             2006                                          2007
                                                                      Week

  * 5 Feb 2006 – 16 May 2007. Weeks include one-day weeks at beginning and end of year,
  resulting in 54 weeks for 2006.


                                                                                                                            25
Outputs: Clinicians Using System
                       19 Clinics actively using system

                                           New Patients by Clinic

                8000
                7000                                                                         2007

                6000                                                                         2006
 New Patients




                5000
                4000
                3000
                2000
                1000
                  0




                            te e
                           Ka tr e
                             az a
                             aw a




                          Ng er e
                              Ce a
                           Ch a




                             el a




                         Ka ala




                           Ra be
                         lin ata
                            Ch je




                          Ka ng a




                                       y
                           Ch ne




                  at ter ma

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                                       k
                         H dge
                         Ch a m
                         Ch ind




                          M nc
                         Ch ng




                        a t ilw a
                                     m




                         vi ipat




                                    oc
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                                  m
                                    o




                                    n




                                  w
                                na




                      Ka bw




                                M
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                               nd
                     M nya



                                  e




                                bl
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                                 li
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                     UT Lo
                              `o
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                             er
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                             ai




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                            B
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                           c
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                         R
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                      Ci




                      St
                      o
                    er
                M


                                                      Clinic

       * Feb 2006 – 16 May 2007. Kanyama and State Lodge with only a few patients to date.


                                                                                                    26
Outputs: Clinicians Using System
                                    7,657 babies delivered

                                         Deliveries and Newborns by Month

                1,400

                1,200

                1,000
   Deliveries




                 800
                                                                                                    Deliveries
                                                                                                    Newborns
                 600

                 400

                 200

                  -
                        2   3   4    5     6    7     8   9   10   11   12   1   2   3      4   5

                                               2006                                  2007
                                                          Month

  * Feb 2006 – 16 May 2007.


                                                                                                                 27
          Major Correction Points 1
Problem                                       Correction

Congested 2.4GHz spectrum; 802.11b            Higher speed (40Mbps, 20Mbps) 5.8GHz
wireless bandwidth (4-6Mbps) may be           wireless and VoIP equipment added cost of
inadequate for applications and VoIP          USD 300,716
Time spent developing detailed medical        Discharged consultant and initiated agile
record structure                              development for patient record system

Quality failure of South African contractor   Cancelled subcontract and completed
developing referral software                  software in-house

Selection of client computer type (desktop    Industry standard desktop PCs selected for
PC, thin client, laptop PC, tablet PC)        usability, maintenance, sustainability
debated
Custom-designed prototype PC carts are        Switched to lower cost wire carts for full
expensive (USD 600) and attract rats          deployment



                                                                                           28
          Major Correction Points 2
Problem                                        Correction

Lead software developer diverted to ART        No-cost extensions
patient management system

Training of clinicians by IT specialists may   Redesigned training to be done by senior
not be effective                               clinicians

Lightening protection for wireless             Installed best available protective devices
equipment proves inadequate                    at all points. Increased on-site stock of
                                               spares.
Electrical outages at a few clinics much       Tested off-line version of software with
longer than predicted                          “opportunistic” synchronization with central
                                               database (not fully operationalized)
Failure of application and database servers    Used temporary PC application server as
in close succession 2 years after hand-over    quick fix, and then replaced failed servers



                                                                                              29
          Major Correction Points 3
Problem                                          Correction

Rand/USD exchange rate places software           RTI assumes responsibility for developing
development in South Africa out of reach         software in-house

Extended power outages (some caused by           Adjusted UPS battery backup for minimum
illegal tapping of transformers) at some         4 hour up-time. Set all UPS units to log grid
clinics                                          power data. Installed automated network
                                                 monitoring and alert system
Limited Internet bandwidth and increased         Controlled and limited Internet access by
use of Internet by clinicians                    clinics

Limited availability of clinicians for testing   Enlisted medical students for testing


Lusaka-based technical support staff lack        Strengthened capacity through close
capacity for efficient and effective support     mentoring



                                                                                                 30
                 Major Correction Points
     Prototype custom $585 rugged mobile enclosed carts

                                                                     Advantages
                                                                      Some protection
                                                                        against dust
                                                                      Good protection
                                                                        against theft
                                                                     Disadvantages
                                                                      Expensive
                                                                      Requires
                                                                        antenna
                                                                        extension
Custom enclosed cart                                                  Hiding place for
prototype, made in South                                                rodents
Africa.                    Prototype cart being used for launch of
                           referral System.


                                                                                          31
                 Major Correction Points
            Commercial < $165 rugged mobile wire carts

                                                   Advantages
                                                    Inexpensive
                                                    Readily available
                                                    No hiding places
                                                      for rodents
                                                    No antenna
                                                      extension
                                                      required
                                                   Disadvantages
In examination room.                                No protection
                                                      against dust
                                                    Weaker
                                                      protection
                       Being used by clinicians.      against theft


                                                                         32
                                              Sustaining It
                                                   Network availability

                               WhatsUp Gold Availability Report (Dates)                                  Availability October
           100                                                                                           1, 2005 - April 30,
           80
                                                                                                         2006 (16 months)
                                                                                                         Availability can be
percent




           60
                                                                                         Avg of @avail

           40
                                                                                                         higher than 90% on an
                                                                                                         extended basis...
           20


            0
                                                                    WhatsUp Gold Availability Report (Dates)

                                                   100


                                                   80
            Availability October 1,
                                         percent




                                                   60
           2005 - April 30, 2006 (7                                                                                     Avg of @avail


                            months)                40


                                                   20
          Availability suffers due to
           management inattention                   0


                 and contention for
                           resources.

                                                                                                                                        33
                                               Sustaining It
                                                   Network availability

                                                                                                            Overall Network Availability
Causes                                                                                                            Calendar 2006
 Lightening
                                             100
 Extended power                             90

   failures at some                          80

   clinics
                      Percent Availability


                                             70

 Equipment                                  60


   failure                                   50

                                             40
Other Factors                                30

 Management of                              20

   support staff                             10

 Inadequate on-                              0
                                                   01-10
                                                           01-22
                                                                   02-03
                                                                           02-15
                                                                                   02-27
                                                                                           03-11
                                                                                                   03-23
                                                                                                           04-04
                                                                                                                   04-16
                                                                                                                           04-28
                                                                                                                                   05-10
                                                                                                                                           05-23
                                                                                                                                                   06-04
                                                                                                                                                           06-16
                                                                                                                                                                   06-28
                                                                                                                                                                           07-16
                                                                                                                                                                                   07-28
                                                                                                                                                                                           08-09
                                                                                                                                                                                                   08-21
                                                                                                                                                                                                           09-02
                                                                                                                                                                                                                   09-14
                                                                                                                                                                                                                           09-26
                                                                                                                                                                                                                                   10-08
                                                                                                                                                                                                                                           10-20
                                                                                                                                                                                                                                                   11-02
                                                                                                                                                                                                                                                           11-14
                                                                                                                                                                                                                                                                   11-26
                                                                                                                                                                                                                                                                           12-08
                                                                                                                                                                                                                                                                                   12-20
   site spares
                                                                                                                                                             Days
 Aging equipment
                                                                                           Daily                           Weekly                                  2 per. Mov. Avg. (Weekly)



                                                                                                                                                                                                                                                                                           34
              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
                 www.idg-rti.org


                                                  35
      Collaborating and Combining
          Open Source Efforts
ZEPRS
    Problem-based care
    Electronic referrals
    Web-based forms
    Developed documentation
    Experience in large scale deployment
    Years of experience in operation
    Off-line mode
    Stand-alone version (Eclipse RCP)

OpenMRS
    Regenstrief data model and concept
     dictionary
    Broader development and support        General records at Kalingalinga
     community                              Clinic prior to ZEPRS.


                                                                              36
                     Making it Scale
            Expanding beyond a metropolitan area

Tested
    Offline version for clinics with multiple
     PCs
    Automated record synchronization with
     centralized database
Proof-of-concept
    Stand-alone packaged version (Zephyr)
Concept
    “Organic” scaling
    Aggregate data reporting via mobile
     phone network
    Automatic SMS reminders and                 Safe Motherhood form from
     notifications to patients                   Zephyr stand-alone version of
                                                 ZEPRS.




                                                                                 37
                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




                                                                          38
                 Making it Scale


                                Clinic          · One facility
                                                · Single PC
                                                · Stand-alone
                                         `        Installation
                                                · One database




ZEPRS can operate as an easy-to-install stand-alone application on a
single PC.

                                                                       39
                   Making it Scale

                                    Clinic
                 “Client” PCs           “Server” PC
                                                                ·   One facility
                                                                ·   Multiple PCs
                        `
                                             `            `     ·   Networked
                                                                ·   One database


                                                      `
                                `




Technologies such as Zeroconf can enable users with minimal technical support to
create a shared, networked database within a facility.


                                                                                   40
                              Making it Scale
             Clinic
                                  · Many facilities
                                  · Existing mobile          Clinic
     `           `            `     phone network
                                                                     `

         `                `
                                      Data Center




                 Clinic                                              Clinic

                                  · Aggregate reporting                  `        `
                      `                                      `
                                  · Centralized
                                    database
                                                                 `            `



Operating in “off-line” mode, installations of ZEPRS can report aggregate data and
synchronize patient records with centralized databases when telecommunication
links are available.

                                                                                      41
           Questions & Comments
RTI Development Team
Eileen Reynolds, Project Manager              UAB Team
Chris E. Kelley, Senior Software Developer    Dr. Robert L. Goldenberg, MD, Principal
Niamh Darcy, Senior Technical Advisor         Investigator
Pablo Destefanis, Senior Networking and       Dr. Dwight Rouse, MD, Co-Investigator
Telecommunications Specialist                 Dr. Sten Vermund, MD, Co-Invesigator
Gordon M. Cressman, Senior Project Advisor    Dr. Francis Nuthalpathy, Health Informatics
                                              Advisor
Lusaka Technical Support Staff                Dr. Alan Tita, Health Informatics Advisor
Dennis Nkula, Zambia Project Coordinator
Francis Banda, Technical Support Specialist   Zambian Medical Advisors
Jamie Mwanza, Technical Support Specialist    Dr. Moses Sinkala, MD
                                              Dr. Elwyn Chomba, MD
Center for Infectious Disease Research in     Dr. Ben Chirwa, MD
Zambia                                        Dr. Henri Phiri, MD
Dr. Jeffrey Stringer, MD, Director, Co-       Dr. Christopher Ngandwe, MD
Investigator                                  Dr. Chipepo Kankasa, MD
Dr. Perry Killam, MD, Project Advisor         Dr. Macha, MD
Harmony Fusco, Project Manager                Dr. Mpundu Makasa, MD
Chafye Siulata, Project Assistant




                                                                                            42
                Making it Open
    ZEPRS Open Source technologies and components
Platform Component      Selected Solution
Operating System        Red Hat Enterprise
Server Backup           Arkeia Backup
Wireless Authentication AEGIS Premium Server
Relational Database     MySQL
Application             Java, Struts, JDBC, Apache DBUtils, AJAX –
                        DWR and script.aculo.us, Quartz, Junit,
                        XStream
Web Application Server Apache (httpd) Tomcat (servlet container)

E-mail                  Cyrus IMAP, Squirrel Mail, Sendmail, Spam
                        Assassin
E-mail Server Anti-virus AMaVIS



                                                                     43
   Inputs: People

                    Gordon M. Cressman
                    Senor Project Advisor




                      Eileen Reynolds
                      Project Manager




             Consultants
                                   Chris Kelley
            Scott Herman
                                  Senor Software
              Giddens
                                    Developer
            Dave Peckham

                                            Pablo Destefanis
 Niamh Darcy
                                            Senior Networking
Senor Technical
                                              and Telecom
   Advisor
                                                Specialist



             RTI Development Team

                                                                44
 Inputs: People


                  Dennis Nkula
                 Zambia Project
                   Coordinator




   Francis Banda            Jamie Mwanza
  Technical Support        Technical Support
     Specialist               Specialist




Lusaka-based Technical Support
            Staff



                                               45
           Inputs: People

                             Dr. Robert L, Goldenberg,
                                        MD
                               Principal Investigator




              Dr. Dwight Rouse, MD           Dr. Sten Vermund, MD
                  Co-Investigator                Co-Invesigator



   Dr. Francis
                                                                Dr. Alan Tita
  Nuthalpathy
                                                              Health Informatics
Health Informatics
                                                                   Advisor
     Advisor


                       UAB Executive Team



                                                                                   46
                    Inputs: People


                       Dr. Jeffry Stringer, MD
                          Director, CIDRZ




 Chafye Siulata           Harmony Fusco          Dr. Perry Killam MD
Project Assistant         Project Manager          Project Advisor




                           CIDRZ


                                                                       47
                        Inputs: People


Dr. Moses Sinkala, MD             Dr. Elwyn Chomba, MD             Dr. Ben Chirwa, MD
  ZEPRS Executive                    ZEPRS Executive                ZEPRS Executive
 Committee, LDHMT                     Committee, UTH                Committee, MoH



          Ethel Mangani                                   Dr. Chipepo
                                    Dr. Chris Ngandwe
          Lyuba                                           Kankasa, MD
                                     Medical Advisor
          Nurse Liaison                                   Medical Advisor
                                                                      Dr. Mpundu
                        Dr. Henry Phiri, MD   Dr. Macha, MD
Emeldah Kabwe                                                         Makasa, MD
                        Medical Advisor       Medical Advisor
Nurse Liaison                                                         Medical Advisor


           Senior Zambian Medical Advisory Team




                                                                                        48

								
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