Using ICT to Improve Patient Care

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Dec 7, 2013 (3 years and 9 months ago)

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RTI International is a trade name of Research Triangle Institute

Using ICT to Improve Patient Care

ZEPRS

Gordon Cressman, Chris Kelley, Niamh Darcy

June 22 2007

Context: 2002


Maternal mortality rate 940/1000


Lifetime risk of death in pregnancy 1/25


Disability Adjusted Life Years (DALY) at birth
30.7


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 cases (2002)


All medical records on paper


Patients may move among clinics, but limited
sharing of patient records


No central database for monitoring patient
population or quality of care

Children outside Chainda Clinic,
Lusaka

Scope, Funding, Client


Scope


Lusaka, Zambia


23 public health clinics

ZEPRS


University teaching hospital


Central Board of Health


Center for Infectious Disease Research in
Zambia (CIDRZ)


Funding

ƒ
Bill & Melinda Gates Foundation


ZEPRS


Elizabeth Glaser Foundation/PEPFAR
-

ART


Client

ƒ
University of Alabama Birmingham

Project 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
health
administrators


Patient files at University
Teaching Hospital, Lusaka, 2004

RTI Component Objectives



A Local Area Network (LAN) of up to five workstations in each of 23
(became 24) public health care clinics selected by the UAB


A LAN of up to five workstations in the University Teaching Hospital


A LAN of up to five workstations in the Ministry of Health


A data center supporting the electronic perinatal records management
system


A wireless Wide Area Network (WAN) connecting clinic LANs, UTH,
CIDRZ, and MoH LAN into a single network with access to the perinatal
records management system.


A Web
-
based perinatal records management system designed in
conjunction with UAB to serve the needs of the Lusaka Urban Health
District

ZEPRS Key Concepts


Guides medical personnel through Zambian standard of
perinatal care


Concept of “flows” within the system and related data


Shared terminal usage


Usage of ZEPRS data for quality assurance and supervision


Patient confidentiality


Adaptability/Extensibility of ZEPRS system (HIV/ART, Safe
Motherhood)


Using mini applications to build computing skills

ZEPRS Key medical features


Safe Motherhood


Pregnancies linked together


Convert typical visit to problem visit


Graphical Partograph (matches WHO partograph)


Patient Referral System


Use of EDD/EGA calculation and update in display (with options for
manual over
-
ride)


very useful automation for nurses


Antenatal and Postnatal card generation (supports patient mobility)


Infants linked to mother for each separate pregnancy


Reports


Problem Management including problems across multiple pregnancies


ZEPRS Key Technical features


Data export facilitates reporting in Access, SAS,
SPSS etc


Connected and disconnected mode


Standalone mode for remote clinics with occasional
connectivity
-

can sync records automatically with
the main system.


Open Source


Java J2EE


Tomcat/Struts/MySQL


ZEPRS Design Principles



User driven, collaborative and iterative


Software developed using open source tools (cost
-
effective) 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 Home page

Patient Status

Demographics

Pregnancy Dating

Medical/Surgical History

Routine Ante
-
natal Visits

Chart: Routine Antenatal visits

Tracking PMTCT/VCT in Safe Motherhood

Counseling Visits

ARV Regimen

Regimen Results

Entering Lab results


CD4

Pregnancy Dating/Previous Pregnancies

Demo: Antenatal

Referrals

Referrals


Viewing the record that triggered
the referral

Referrals: UTH perspective

System Generated Problems

Comments on Problems

Problem List

Partograph

Partograph: Complex data entry with simple
user interface

Tracking Cervix/Decent plot

Entering
data:

Result:

Partograph Timing Alert

Partograph conclusion

Delivery

Delivery Summary

Links to Infant record

Correcting a patient record

Improvement: Highlights on key fields

Demo: Labor and Delivery

Reports

Report selection

ANC Monthly Report

Reflex Register

Software Development



Agile+ programming approach: iterative development (CMM
Level II)


Referral application used to seed development approach,
training, roll
-
out and support


RFP issued to South African/Indian firms


rand appreciation
and responsiveness resulted in developing in
-
house


Multiple supporting applications developed (administration of
users, training, web
-
based email, web
-
based PM, bugtracker)


User Manual drives training plans


Detailed test plans and testing, using local medical students
who we trained in software testing


Software Platform

Platform Component

Selected Solution

Operating System

Red Hat Enterprise 3 (Currently CentOS 4.2)

Server Backup

Arkeia Backup 5.2

Wireless Authentication

AEGIS Premium Server 1.1.4

Relational Database

MySQL 3.23 (currently MySQL 5.0)

Web Application Server

Apache (httpd) 2 Tomcat 5 (servlet container)

E
-
mail

Cyrus IMAP, Postfix, Spam Assassin

E
-
mail Web Interface

Squirrel Mail

Firewall

SonicWALL

Client Anti
-
virus

McAfee

E
-
mail Server Anti
-
virus

AMaVIS

Sample Screen Flow

Software Development
-

IDE and
Development


What skills does a developer need to work on ZEPRS?


Experienced Java developer for code changes


Basic pc skills to modiy ZEPRS forms.


ZEPRS Dev tools


Incremental development


Average 2 builds/month


usually simple field changes, reports


Process of installing new builds


application updates


Testing


Unit tests


Load tests


jMeter


Demo login


Documentation


used Drupal CMS for
www.idg
-
rti.org

website.

Software Development

Design: Enterprise Content Management



Authorized users may login to the Administration section of the
ZEPRS application and create new forms, add/modify fields to a
form, and add/modify enumerations to a field.


Systems administrators may query common values using the
Report section Query interface. These ad
-
hoc reports may be
useful for previewing data intended for a published standard
report.


Rules
: Rules may be added to the ZEPRS forms via the
Administration section’s web interface. Values entered into a
form field that has a rule can trigger the creation of a problem,
which will be displayed in the Problem listing. These problems
can prompt the user to refer the patient to UTH, complete a
form, or provide information.

ZEPRS Administration


Form
-
based Administration


Create Form


Editing Forms



Adding a new field


Editing a field


Generating Dynasite source


Application Updates

ZEPRS Administration


making changes


Open ZEPRS project source code in Eclipse or Idea


Launch local version of ZEPRS app via IDE’s Tomcat instance
to browse app and make form modifications via web interface


After form editing is complete, click “Generate Dynasite Source”
to generate java and xml files that manage form rendering and
patient flow.


In IDE, use the Ant task “dist
-
zip” to create a distribution of the
ZEPRS war file and other related sql and installation files.



SFTP files to the server.


Run batch file which installs new version and updates any db
schema changes.

Question 12. Which is easier to complete (use), the manual "blue book"
or ZEPRS?
42.9%
35.7%
7.1%
14.3%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
d. The ZEPRS system
was easier
c. Both are about the
same
b. The blue book was a
little easier
a. The blue book was
much easier
n = 14
ZEPRS Summary
-

User Acceptance

Ease of Use

More than 80% of
respondents reported
the automated system
as easy or easier to
complete (use) than
the manual system.

ZEPRS Summary
-

Patients in 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.

Cummulative Patients by Week
-
5,000
10,000
15,000
20,000
25,000
30,000
35,000
40,000
45,000
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
Week
New Patients
2006
2007
ZEPRS Summary
-

Conclusions


With some training, clinicians with no prior computer experience
may adopt computerized record systems readily


The value of a patient record database for monitoring and
improving health status can help sustain an electronic patient
record system


The communications network is being used for several health
programs


Local staff can maintain and manage the communications
network


ZEPRS Summary
-

Major Correction Points

Problem

Correction

Time spent developing detailed medical record
structure

Discharged consultant and initiated agile development
for patient record system

Lead software developer diverted to ART patient
management system

No
-
cost extensions

Failure of application and database servers in close
succession

Used PC for temporary application server

Replaced failed servers

Quality failure of South African contractor developing
referral software

Cancelled subcontract and completed software in
-
house


ZEPRS Summary
-

Critical Success Factors


Close collaboration with health workers and UAB


Thorough testing


Effective user training


User acceptance and participation


Reliability and performance of network


Reliability of computers in facilities


Project management


Use of on
-
line tools, and IM for remote project support

Questions and Comments

RTI ZEPRS 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

UAB ZEPRS team


Dr. Perry Killiam, Dr. Dwight Rouse, Dr. Francis Nuthalapaty

RTI Website with full ZEPRS details


http://www.idg
-
rti.org