Zambia’s Electronic Medical Record – Background

Post Sequence

1. Background
2. Initial Release
3. Patient Flow
4. Reporting Server
5. Version 2.0
6. Continuity of Care
7. (More on the way…)

These are a series of posts on the history of Zambia’s first national Electronic Medical Record or EMR. The EMR was known by a few names: PTS, PMRS, Continuity of Care and finally SmartCare. The EMR was originally targeted at supporting care and treatment of the estimated 17% of the adult Zambian population infected with HIV. The project was successful on a grand scale. It grew to serve the population of Zambia as a general EMR addressing other illnesses such as Tuberculosis, Malaria and general health. It is still in operation today has served millions of patients not just in Zambia but in other African nations as well.

Introduction

The project went though several name changes while I was part of it and so I have chosen to address it as the Electronic Medical Record itself. However for reference purposes, these projects have been referred to by the following names:

• Patient Tracking System (PTS)
• Patient Management & Reporting Server (PMRS)
• Continuity of Care
• SmartCare

One of our Zambian project members (who is shown in the photo at left) came up with the brilliant final name of SmartCare and that is how it is known to this day.

I was fortunate to have played a series of important roles in it’s development and for some time I have wanted document this outstanding project which is still living and breathing today.

In 2003 two things happened that were unrelated but had a great impact on my life. My wife and I moved to Lusaka, Zambia and George W. Bush launched the President’s Emergency Plan for AIDS Relief, or as everyone calls it, PEPFAR.

ZEHRP

My wife and I were both 29 at the time and planning to get married. At the same time we were looking to do something different. We were living in Northern Virginia and having both travelled in our youth, we were looking to find a way to do something meaningful and different. My wife came into contact with a scientific & volunteer organization out of Lusaka Zambia, ZEHRP (Zambia Emory HIV Research Project) lead by Dr. Susan Allen. She accepted us as interns in Public Health (my wife) and IT Support & web design (me).

While my wife did the important stuff I was fixing PCs and developing the website. In youthful exuberance I architected a complex backend using Java EE on JBoss. I also created a desktop client Java Swing based content authoring application (this state of the art at the time I promise!).

As is always the case we needed a catchy logo. However I did not (and do not) have tremendous design skills, but with a little effort and with the help of Macromedia (now Adobe) Fireworks I created the logo you see above. It honestly began as only a simple stick figure logo for the website, but as the organization lacked any general logo of its own it gained traction for its simplicity and ease of painting. It depicts the HIV virus and a couple inside a circle with a wall between them and the acronym of the organization, Zambia Emory HIV Research Project or ZEHRP at the bottom.

The website is long dead. The Swing and Java EE code is longer dead, but the logo lives on as the official emblem of the HIV Research Group in Zambia.

Teaching Java

ZEHRP employed a large number of data entry technicians to validate and correct data entered in the field recording the health and well being of our study participants. My “desk” was in the foyer of the building and the rest of my colleagues including the young Zambians had to pass by me on their way to their office. Over time these young Zambians watched me pull my hair out over such things as deciding whether to use the EJB 2.0 Remote Home Interface or the Remote Interface to interact with my client side JCompoentss and JContainers!

I digress. The point is that the Zambian Data Entry Technicians were very interested in what I was doing and kept asking questions. In one of my better moments I decided that I should just teach a class on Java. For the next six months I taught them the ways of objects, methods, interfaces and inheritance using the same book that I had used to teach myself Java, Dietel’s Java How to Program (current edition). Complete with a mid-term and a final!

Much later on the star student would go on to work with me on the the Zambia EMR, which is why this is mentioned here. So it is about time I discuss the other thing that happened in 2003, PEPFAR.

PEPFAR in Zambia

HIV and AIDS were devastating Africa and the rest of the world. President Bush in his 2003 state of the union address announced an intention to spend $15 billion on prevention, care and treatment of HIV and AIDS. Since PEPFAR started in Zambia in 2004 the country has received $1.7 billion for assorted programs.

CIDRZ & CDC

Another organization in Lusaka, CIDRZ (Center for Infectious Disease Research in Zambia) was selected to play the pivotal role in rolling out the PEPFAR program in Zambia, starting in the capital city, Lusaka. Led by a capable team headed by Dr. Jeffrey Stringer, CIDRZ was to play the critical founding and incubating role for the initial development and deployment of the HIV-focused half of Zambian Electronic Medical Record in collaboration with the district and national health organizations and ministries of Zambia as well as the US CDC.

Later (spoiler alert) we will combine forces and unify with another great team led by Dr. Mark Shields to add two key features to the system a SmartCard & a touchscreen based user interface as well as obtain the financial and technical support of the US Centers for Disease Control.

The story is about an Electronic Medical System or EMR, but the development of an EMR was not the original intention of either PEPFAR or CIDRZ (although it was of CDC). The goal of CIDRZ was heavily focused on the treatment side, to treat as many patients who were infected with the HIV virus as possible. That an Electronic Medical Record system emerged from it was a natural consequence of having to collect, collate and aggregate information from millions and millions of patient visits.

In the next several posts I will tell the story of that Electronic Medical Record system.

My wife and I had been in country for about 6 months working with ZEHRP above and through a fortunate encounter the program lead at CIDRZ and myself became acquainted. In early 2004 CIDRZ was rolling out the initial treatment program. I was invited to join the team to help to create and operationalize a patient data entry system to capture the data being collected in the field clinics and produce the critical reports at a public health level describing the efficacy of the PEPFAR program in Zambia.