Zambia’s Electronic Medical Record – Continuity of Care

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.

Need to Scale

Circa 2005 we were in good shape but were reaching the limits of what a small targeted team of four software engineers and eight operations personnel could accomplish. We had gotten out two releases of the primary PTS product and one release of the PMRS product. Yet we were reaching the limits of our ability to build new features.

The current User Interface design had served us well for the initial stages of the project but it was now showing its age. Additionally the rapid growth in both patients and clinics (patients were now numbering in the tens of thousands and the clinic count was well into double digits) were pushing our limits operationally.

Due to the overall organizational structure (we were a clinical research and operations group not a software company) we had limited ability to grow our staff.

To put it in 2019 terminology, we needed to scale.

At the same time we had been working on the PTS software there was another US CDC sponsored group building a similar product called “Continuity of Care”. It was a very impressive system built by two US-based software shops Dimagi & Salar and led by a committed, passionate, and very prescient Dr. Mark Shields, the CDC Informatics Director for Zambia.

Continuity of Care

Continuity of Care had two blockbuster features that we lacked:

  • Touchscreen User Interface
  • SmartCard-based Patient Record

It was in the process of being beta-tested at the time that we began to consider a merger of the two systems. Their clinical focus was not HIV but rather Postnatal care.

Touch Screen User Interface

The user interface was based on assumption of the use of a touch screen. In 2005 a touch screen was novel. People were not walking around, as they do now, with a touch screen in their pocket. It was a conceived of as a way to ease adoption of the EMR for nurses and other clinical personnel. These personnel did not have pre-existing mouse and keyboard skills. However it was not purely a touchscreen user interface. It was a hybrid approach. By clicking one of the form fields you activated a widget on the bottom half of the screen as shown below.


The SmartCard component of the Continuity of Care system was similarly novel. At the time I first encountered the SmartCard in 2005 the only previous experience I had with microchip embedded cards was with the phone cards sold by France Telecom. As interesting as the miniaturization of a memory device was, even more so was the idea that we could compress, store and encrypt an entire patient’s record on an individual card. The patient could then take the card with them to ensure that they had “Continuity of Care” wherever they went.

Dimagi, Salar & ZMoH

Additionally with the Continuity of Care project came access to the two separate teams of developers at Dimagi and Salar as well as the developers, deployment specialists and operations team members from the Zambian Ministry of Health. The entire group was very strong technically and with passion for the mission. Over the course of the project many of them became good friends.

The MOU & Merger

For all the above reasons we decided we would be better together than apart. We worked out a Memorandum of Understanding (MOU) between the groups and we delegated responsibilities for development, data and other areas.

I must admit that I was deeply in love with the project at this time and allowed myself a certain vanity. I arranged for it to be signed on my birthday.

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