CLAUDINE HENNESSEYU N I V E R S I T Y O F C A P E T O W N

&

THEUNIS HURTERA N O V A H E A L T H I N S T I T U T E

TIER.netHIV Electronic Register

Who is the TIER.net Implementation Family?

3

Collaborative Partners

Department of Health

National Implementation Team Provincial Implementation Team District Implementation Team Facilities

NGO partner – Right to Care

Assist and support implementation of 3 Tier system Provide support to sites

CHAI –

Responsible for TIER 1&2 ART Monitoring

UCT – technical support team

Provide technical support to NDoH & National Implementers, Master Trainers Developers of TIER.net (Tier 2) and eKapa (Tier 3)

What is TIER.net and what can it do?

5

Paper register

TIER.net*eKapa (EMR)

* Three Interlinked Electronic Registers

Middle Tier System

6

TIER.net

NDoH accepted middle tier monitoring system for the ART

program (ARV‟s, HIV & TB*)

Reports on longitudinal outcomes

Replaces paper monitoring with additional fields:

PreART TB information Detailed visit information Better tracking of outcomes Adherence club patients*

Digitises patient information for transition to EMR system

Non networked & stand alone system (can link)

7

TIER.net

What it IS

A facility reporting tool designed to facilitate the production of:

monthly and quarterly cohort reports

reports to enhance patient and facility management

An electronic implementation of a paper-based register system

What it is not

A watered-down, lightweight, or off-line EMR system

A patient registration system

An appointment system*

Where is TIER.net?

9

Going Global...

Western Cape

Provincial Department of Health and City of Cape Town health facilities

Supported by UCT, Anova Health Institute, Kheth‟Impilo, That‟s It, Right to Care

Northern Sudan

Piloted by WHO

Zimbabwe

Supported by Medecins Sans Frontiers

Mozambique

Supported by Medecins Sans Frontiers, UCT

10

TIER.net in all sites, UCT/That‟s IT supported

Rolling out September 2011UCT/RTC supported

TIER.net in all sites, Anova supported

Rolling out July 2011UCT supported

Rolling out, Supported by Anova

PGWC sites & COCT sites: Kheth‟Impilo & UCT supported

Why the transition to TIER.net?

Paper Based/simple spreadsheets Electronic

Unwieldy in large clinics Reports are time consuming

in large clinics As clinics grow greater room

for error in capturing data Monthly TB information is

not captured Monthly capturing/yearly

capturing

Appropriate for: Smaller start up sites Clinics without electricity

Computerized

Reports by „push of button‟

Additional reporting functionality

(PEPFAR/WHO)

Import functionality to eKapa

Data Clerk Accountability

More effective use of Data Clerks time

Specific day/month/year capturing

Paper & Electronic

13

Why the transition?

Burden of disease

37 percent of infected people were receiving treatment for HIV – WHO guidelines 2010

1.5 million on treatment* Change in starting threshold = increase in numbers of patients in clinics

HIV & AIDS NSP 2007-2011

Goal 6: Enabling PLWHA to lead healthy lives Have 80% of new AIDS cases on treatment by 2011

Priority Area 3: Research, Monitoring and Surveillance Goal 6.5: Strengthen the health system

Improving facility systems, thus improving patient care Work smarter, not harder-better use of data clerks time

Need for one M&E system

What does TIER.net provide?

15

Facility Level

Provide push button reporting:

defaulter lists (early, late, confirmed) monthly and quarterly reports

Number of patients ever started/TRIC

Can export to excel for additional non standard reports

Provides 2nd line regimen start date

Provide you with up to date accurate data about patient on ART or those HIV+ or those be worked up for treatment (PreART)

Provides TB, pregnancy information per visit

16

Facility Level

Provides appointment lists, next visit lists

Support Club Patients

Specific visit information:

Regimen, CD4, VL*, Pregnancy, TB

TFI/TFO site information

Enables accountability from Data Clerks

If the database is not up to date, it will be reflected in numbers

17

District Level

Provides up to date information of all patients in all facilities

Push button reporting on a monthly, quarterly basis

Allows managers to highlight “hotspot” facilities

Unsuppressed Viral Loads

High number of LTF‟s & TRIC

Allows managers to validate data, before it goes to the „next level‟

FACILITIES & DISTRICTS

IMPROVING SYSTEMS & DATA FLOW

Patient arrives at clinic w green card

pharmacy

Folder to ART clinic

Folder pulled

Clerk checks for new blood results or phones for results

Folder captured in paper register

Filing of blood results

Folder to general registry

Patient takes folder home

Delay as patient waits for folder to be found/pulled

Folder to nurse/clerk for triaging

Nurse visitDoctor visitCounselling

session

New blood results not always checked

for by clerk

Folders not separated and re-filed incorrectly =

missing files

7h 00

8h 00

9h 00

10h 00

11h 00

12h 00

13h 00

14h 00

15h 00

16h 00

Delay as patient waits for results to

be found

Lack of time for ongoing filing and

capturing

Patient sent back to clerk for

results

Lack of time for pulling defaulter

lists, reconciling of results with folders

Indicates data clerk /staff role

Indicates typical patient flow

Time line indicates usual highpatient burden times at facility

0h 00

Patient arrives at clinic with green

card, placed with prepped folder

Nurse visit

Pharmacy

Patient leaves clinic

Patient Flow at Facility

Folders of un-booked patients

pulled

Folders pulled for next day appointments

Folders collected from

pharmacy

Folder captured in TIER.net

Folder filed

Clinic traffic

control

Data clerk activities

Doctor

visit

Counselling

session

Appointment list generated from TIER.net

Checked for outstanding blood results

Folders set aside for next clinical appointment day

7h 00

8h 00

9h 00

10h 00

11h 00

12h 00

13h 00

14h 00

15h 00

16h 00

Indicates data clerk /staff role

Indicates typical patient flow

Time line indicates usual highpatient burden times at facility

0h 00

Multi disciplinary

team meeting

preparationMaintain clinic

organization

Generate appointment

lists (TIER.net)

Present data at

multidisciplinary team

meetings

Weekly

cle

rk

acti

vit

ies

File blood resultsFile patient

folders

Generate early

defaulter reports

(TIER.net

Generate late and

defaulter reports

Assist in recalling potential

defaulter patients

Generate monthly

reports

Mo

nth

ly c

lerk

acti

vit

ies Clean data (TIER.net)

Maintain clinic

organization

Generate and submit

cohort reports

Attend Quarterly training

workshops

Qu

art

erl

y c

lerk

acti

vit

ies

Clean data (TIER.net)

Generate unconfirmed

defaulter reports

Maintain clinic

organization

22

Data Flow

Facilities Sub-Districts Districts Province

NationalWHOEtc

NGO

NGO

Slide courtesy of Meg Osler, UCT

Data flow example

National DOH M&E Team

Provincial M&E Team

District HAST / IO‟s

Sub structure HAST Co‟s

Facility-

Data Clerks –MDT–Facility

Managers

•HAST Co‟s provide on going training and support to data clerks/facilities

•Information Officers can be used to help support HAST co‟s with cleaning of data/computer issues/updating of software/trouble shooting

•Idea that data flows through all channels

EDEN DISTRICT

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Data Flow example

Khayelitsha

Facility– Data Clerks –

MDT – Facility Managers

TB/HIV/STI Coordinators

SDM

Provincial M&E Team

National DOH M&E team

* eKapa data

25

Anova- Data Flow example

Winelands

Facility– Data Clerks –

MDT – Facility Managers

Province

Sub District HAST

Sub District IO

District HAST

District IODistrict Medical Officers

Sub district HAST Co’s Validate Data

Province

26

Patient arrives at clinic

Patient to clinician

Patient to Pharmacy

Patient goes home

Dc‟s pull „unbooked‟

folders

DC‟s check for new blood

results

Folders pulled for next day

appointments

Folders collected from

pharmacy

Next appointment

date recorded *

Folder captured in e-register

Folder filed

LTF reports

Tracking down missed

appointment patients

Monthly and quarterly stats to

province

Facility data (RMR)

MDT meeting

prep

Filing of blood results

Traffic control

Ongoing clinic

organization

TIER.net & the health facility

Implementing TIER.net

28

Process of Implementation

1. Informational meeting

2. Facility site visits & Evaluation

4. Preparations*

5. TIER.net training

6. Back capturing of data

7. TIER.net training part 2 - live

8. Hand over to clinic w/ support

9. Quarterly workshops for staff

S T E P 1

Informational Meeting

30

Purpose is to discuss the implementation process

Inform and dialogue with key persons

PIT‟s, DIT‟s, NGO/partners

HAST coordinators, Program managers

Clinic Staff

Facility Managers, Clinicians, Data Capturers*, pharmacists

Others

S T E P 2

Facility Site Visits & Evaluation

32

Review of paper registers or electronic systems

Registry Organization

Work flow Folder flow

Blood results

Patient Folders

Role of Data Clerks

Equipment needs

Space for Data Clerk/computer

Clinic support – HAST coordinator, facility manager, program manager, staff etc

S T E P 3

Preparation of facility

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Register prep by data clerks

Updating regimes Updating baseline bloods/regimes Verifying clinic numbers New/TFI patients Outcomes

Procurement of Equipment

Computer Back up flash Printer Extension cords Furniture Dedicated DC space Security measures

Is my facility ready for TIER.net?

Are registers up to date?

Where is the hard data?

Folders, registers, electronic systems?

Files filed according to Clinicom number - last 3 digits?

Blood results filed in patients folder?

Work space for data clerk?

Are all staff aware of implementation & „improvements to systems‟

Dedicated transition time for Data Clerks?

Does everyone have an open mind and patience?

Time allocation campaigns, audits?

Reorganization of clinic – if

needed

Streamlining patient/folder flow – if needed

Data Clerks & Additional Staff - if needed

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Are the paper registers ready?

2/10 HENNESSEY, Claudine TFO P 3 ldl123456 7 6 1 0 2 4 /12 56 1a 1a 1a 1a 1a S 1a 145 tfo

H O W T O U S E T I E R . N E T ( 2 P A R T S )

B A C K C A P T U R I N G O F D A T A

C L I N I C A L R E C O R D K E E P I N G

L I V E M O D E

Training‟s

38

Training – part 1

TIER.net

Overview of TIER.netBack capturing* of dataRole of Data ClerksOverview of HIV (targeted at Data Clerks)

Data Clerks & key staff

1-2 days of training

On site or group training

Facilitated by Master trainers & partners

39

Back Capturing Process

Transferring of data into TIER.net

Either during group training or at facility

Paper register to TIER.net group or facility

Import from other electronic system Updating of data on site

Capturing directly from folders On site

Time line dependent on:

What is being used: registers, folders, other e-systems Register are up to date Allocated/protected time given to Clerks

40

Clinical Record

Documentation Training

Ensures that all staff are documenting the same way & understand clinical stationery

Allows Data Clerks quick, simple and accurate entering of data

Training includes: Clinicians, Pharmacists, Counselors, Data Clerks

Either done in group training or at individual facilities

41

Training – Part two...

2-3 day training

Data Clerks

Live mode training continued...

Review of systems

Have recommendations been considered?

Cleaning of the data

Generating reports

HAST Co‟s, IT, IO‟s, managers or other key personnel

Using the data

Generating reports

Data Flow

Ongoing support

42

Live mode training revisited

Cleaning of data

Entering Data from folder

Generating reports

Monthly, quarterly, defaulter lists etc

Capturing PreART data

Trouble shooting – what‟s working what‟s not?

Hand over to clinic staff

Ongoing support

EXTRAS....

44

iDart

iDart pharmacy system

Dispensing of ARV‟s

Replaces ARK and other systems

Full reporting function

Full stock taking

Works with TIER.net and eKapa

Training and implementation simultaneous with TIER.net

Dependent on equipment and training staff Training by Cell Life – Cape Town

45

Support

Once the facilities are up to date and „live‟ what happens?

Quarterly workshops

Best practices

New additions

Revisiting „issues‟

Training of new and ongoing training of staff

Quarterly audits

Ongoing training of trainers

Updating of software & materials

L E T S T A K E A L O O K ! ! !

TIER.net HIV Electronic Register

47

View by country, province, district, sub-district, facility

48

Individual patient record

Patient details

Outcomes

Baseline data

Monthly treatment visit

info

49

Monthly treatment Visits

Visit date

Pregnancy & TB Status

Regimen

Months prescribed

Next appointment

CD4 & VL

50

Monthly Report

51

Standard Report

52

Interpreted Report

53

Early Missed Appts

54

Late Missed Appts

55

LTF‟s unconfirmed

Coming soon.......

57

In development

A few standard graphs

Retention in care over time, viral loads suppressed, etc

Facility management reports

Waiting list (Pre-ART) patients stratified by CD4 count categories Two consecutive viral loads >1000

Data quality reports

Missing baseline CD4 counts Missing 6 monthly CD4 or VL counts

TB module merged into this software

Will export to ETR.Net

Mother Child Health

ANC, labour and deliver, exposed infant register

T H A N K S F R O M T H E T I E R . N E T

I M P L E M E N T A T I O N T E A M !

Questions/Comments