Outline of next two days

1. Change management processes to implement TIER at the facility to use TIER for the integrated TB and HIV data management Comprehensive Trainings to support the National Integrated TB/HIV Information System Implementation

2. Outline of next two days • Training session excludes DR-TB due to recent programmatic changes (short course regimen) & changes to EDRWeb that still require interoperability with TIER.Net • Guiding principles • Change management headlines • Data management • Preparatory steps for going live • Framed in the context of tracking the DS-TB treatment cascade – line lists & reports • TB identification & testing • Laboratory diagnosis & treatment initiation • Retention in care • Importing TB information into ETR.Net

3. Background • The National TB Programme maintained a simple yet robust TB recording & reporting system since late 1990s • Consisted of data collection tools, paper-based registers & electronic registers (ETR.Net & EDRWeb) • Key issues with the TB recording & reporting systems • Patients managed in vertical data management systems • Systems do not support the tracking of patients longitudinally with repeated TB episodes • Systems do not support the tracking and management of patients with co-morbidities • Ownership of data removed from health facilities as information is captured away from health facilities • TB data does not flow into DHIS

4. Background cont.. • TIER.Net: patient information management system that supports the capture of TB data at health facilities • Patient information captured directly from patient folders - retirement of paper registers • Extensive reporting functionality that supports retention of patients across the 90-90-90 treatment cascades • includes line lists that alert clinicians of leakages in care from one pillar to the next (e.g. laboratory results outstanding list, patients not yet on treatment list) • Management reports at various levels - support patient management & drive improved data quality • TB data from TIER.Net imports to webDHIS at sub district level • Alignment to DHIS includes review of TB reporting timelines • TIER.Net maintains interoperable functionality with ETR.Net/EDRWeb/DHIS/HPRS

5. Guiding Principles for integration • One patient one folder (several diseases) • 1 patient, 1 folder, 1 folder number • Integrated clinical stationery: the TB treatment record (blue card) & ART clinical stationery will be filed together • Active TB case: blue card remains on top of ART folder • Inactive TB case: blue card placed at bottom of ART folder • Patient held cards do not change • Re-organisation of filing room to accommodate integrated folders - merge all TB and HIV patient records and hold them in one filing room • Placing ownership of TB data back in the hands of facilities • Initial capture of active TB episodes takes 3 to 4 days; not months

6. Change management headlines • Anything new is uncomfortable but aligning TB/HIV integration with strategy towards the long term vision of a single networked EMR • Can expect performance indicators to decline temporarily for one or 2 quarters before seeing improvements • Report any concerns immediately to NIT (National/provincial teams on standby to help) • Changing roles and responsibilities – sub/district TB DCs and Coordinators not becoming obsolete, but free up time and tools to monitor quality of clinical services, drive improvements and improve clinical care of patients • Replacement of paper register with electronic register at facility level • Capturing directly from TB blue card into TIER.Net • Line lists & reports can be printed real time - to improve patient and facility management

7. Data management inextricably linked to clinical governance • Quality of source data • complete and correct clinical documentation - critically important for patient care and TB/HIV monitoring • Ongoing clinical trainings necessary as part of this process • Successful capture dependent on: • Good clinical record keeping • Dedicated time for capturing • No lab results are to be captured without the clinician actioning and signing • Reporting algorithms aligned across TIER.Net & ETR.Net

8. Preparing for initial capture of active TB episodes • Close off all episodes of TB patients who have not had a visit for >3 months in the paper register – assign LTF outcome • Decide with TB Nurse if paper TB register sufficiently completed and up to date to be used as source for capture • If no major gaps - capture can happen using TB register • Any page with an active patient - requires whole page to be captured (active and inactive) • If register not completed well – pull all TB blue cards to ascertain if all patients are in register and update patients and/or missing information • TKI to help during this process • Estimated that 120 blue cards per day can be captured into TIER if 2 people are working side by side from 1pm to 4pm

9. Preparing for initial capture of active TB episodes –Facilities capturing in ETR • Backup TB data from ETR.Net onto an external device • Create a dispatch file & submit to the (sub) district office • STOP capturing TB registers in ETR.Net & uninstall ETR.Net from the computer • From the paper register, close off all episodes of TB patients who have not had a visit for >3 months – assign LTF outcome • Decide with TB Nurse if paper TB register sufficiently completed & up to date to be used as source for capture • If no major gaps - capture can happen using TB register • Any page with an active patient - requires whole page to be captured (active and inactive) • If register not completed well – pull all TB blue cards to ascertain if all patients are in register and update patients and/or missing information • TKI to help during this process • All above steps must be done on the same day

10. Data verification Is the captured data accurate and complete? • Complete data verification guide (page 31 of the Implementation Guide) • Number of active patients in register or blue cards should equal number in TIER TB Module • Have elements (see data verification guide) in a few sample patients been captured accurately? • This should occur on same day as last day of this process • Should be quick and seamless • Done by TKI together with clinicians, FM and DC • Now paper TB register can be retired – put away in FM’s office

11. Data Verification Guide

12. Ongoing support • During the first month, the TKI should visit the facility on a weekly basis to perform the following: • Complete a Facility Site Visit Task List form • Supervise data capture and answer any questions that may arise • Speak to the FM to ensure patient management reports are being generated & used • Use audit tool to assess completion of stationery and capturing into TIER.Net • After the first month of intensive support, the TKI should visit the facilty quarterly to ensure the data is flowing to the (sub) district during the reporting periods, and all the above steps are maintained

13. Highlights of previous section • Programme management tool (vertical) vs patient management information system • Critical success factors – change management, clinical governance & guiding principles • Central role of TKIs in preparing facilities for roll out • 2-3 years to reach national vision • TB/HIV integration improves clinical care and patient management - saves time for both clinicians and patients • All information required for patient management available real time • Coordinators will have more time for mentoring at facility which will improve patient care

14. DS-TB Cascade: TB identification & testing

15. Discussion: TB Screening and Identification • What steps need to happen in a facility for TB screening & identification? (For new case, patient on ART) • When does screening happen? • Where in the facility does TB screening happen? • Who in the facility conducts TB screening? • Where is the TB screening information recorded? • Who and where is sputum collected from positive screened cases? • What tools are utilised for recording patient information? • Where in the facility are these tools located/kept? • Who records in them?

16. TB Screening & Identification: Patient & Register flow • 3. Consultation • sputum specimen collected for Gene Xpert testing • complete a laboratory request form • record patient details in TB Identification Register • Record return dates for TB test results in the patient’s carry card • 2. Vitals • screening for TB • Filling in (tick) the PHC Tick Register 2 3 3 3 1 4 1. Registration - Collection of or opening new file at main registry - • 4. Data capturing • All TB Case Identification Registers will be collected by the DC from consulting rooms • DC to capture presumptive TB cases tested for the day and update results of already captured cases • DC returns all the registers to the respective consulting room after capturing 3

17. TB screening and Identification flow • Symptomatic client arrives at the facility • Client presents at reception • If known, collects folder and goes to consultation • If new, reception to allocate folder number and open folder, and refer to screening • Client screened using TB symptom screen, and recorded in PHC tick register and clinic file • If screened positive, refer to sputum room/clinician • Bacteriological (GXP) test conducted • If GXP positive and Rif sensitive, smear taken and patient started on treatment • If GXP positive and Rif resistant, start DR treatment according to latest guidelines • If screened negative, patient counselled on HIV and TB

18. Integrated Clinical Stationery • TIER grounded in the ICSM - Ideal Clinic prescript • one patient, one folder, one folder number (irrespective of module used) • Prior to introduction of the standardised ART clinical stationery – large number of facilities had no facility-retained records • The folder number in ART clinical stationery thus informed the filing system in the facility • Need to avoid framing discussions as being about “TIER number” – all facilities must have a system for numbering folders (which contains all clinical stationery)

19. Integrated Clinical Stationery(2) • In TIER - single folder number establishes the link between the modules for an individual patient and links the patient through the cascade of care • TIER.Net searches on, and links on, this folder number (among other parameters) • Thus folder number is essential for: • patient linkage • linkage of laboratory results • linkage between different systems • patient filing

20. Folder number in TB/HIV clinical stationery • DCs are trained to capture the folder number from the front of HIV/ART clinical stationery • The TB Blue card does not have space for folder number/HPRN • The folder number/HPRN will have to be copied from the clinic folder onto the blue card

21. Recording TB Identification information • DCs capture TB Id information directly from this register into TIER on a daily basis • Lab requests to be captured into TIER • Only clients screened positive are recorded in this register with date and type of bacteriological test sent to the lab • According to the burden, one or more registers will need to be available • Facilities to devise means to ensure all information entered into this register and captured into TIER

22. Capturing Case Identification data in TIER.NetPatient Lookup • Search database for patient • always check to see if patient already exists to avoid entering the same patient twice (use folder #, surname)

23. Capturing Case Identification data in TIERPatient Demographics • Create a new patient record

24. Capturing Case Identification data in TIERPatient Demographics Source for: Surname, Name Source for: DOB and Gender Case Id register does not cater for folder numbers currently; use the ‘Remarks’ column in the interim Source for: Contact details

25. Capturing HIV status from Case Id register Source for: HCT details Case Id register does not cater for any of the variables needed for HCT capturing currently. In the interim, a row was added in the HIV status column to enable capture of HIV test date Use the HTS register in the facility to obtain these information

26. Guidance for capturing HIV status

27. Line lists & reports for TB Identification & testing

28. Discussion: Laboratory Results management • Who receives & sorts laboratory results on a daily basis in the facility? • Who reviews and signs laboratory results in the facility? • Who is responsible for following up of outstanding results? • Who records results in the Case Identification Register, including rifampicin-resistant (RR results)? • When (at what point in time) are the results recorded in the Case Id Register? • How are patients’ results filed? • Who ensures that all positive GXP cases have a second sputum specimen collected? • Who initiates patients on treatment?

29. Management of normal laboratory results • FM to identify dedicated person responsible for receiving lab results daily • Clinician must review all results • Normal results separated out from abnormal results Triaging of results Management of Normal results • Each normal lab result must be signed off by clinician (initial and date) • Signed off lab results submitted to DC for capture • DC will “bulk” capture results in TIER using Pending Tests functionality • Results can only be captured against tests already in TIER (from TB ID register, TB blue card or ART clinical stationery) • DC signs captured lab results • DC files each result in respective patient file

30. Management of normal laboratory results (2) • Clinician will have ticked in ART clinical stationery - tests requested at respective visit • Clinician will have indicated in TB ID register and TB blue card – tests requested at previous visit • During patient consultation visit: • Clinician must look for new results inside the patient folder • Transcribe any new lab results in clinical stationery (ART clinical stationery or TB ID register or blue card) from lab result form or SMS printer or telephonic/electronic medium • If result was received from SMS printer- record “SMS” next to result • If results were received via phone or looked up on the NHLS TrakCare - indicate “telephonic/electronic” in visit summary section • Ensure dailyflow of TB ID register and patient folders to the DC for capture into TIER

31. Management of abnormal laboratory results • FM to identify dedicated person responsible for receiving lab results daily • Clinician reviews results • Normal results separated out from abnormal results Management of abnormal laboratory results • Clinician must take the following actions: • Recall patients with abnormal lab results to the facility • Document the action of recall (i.e. telephone call or WBOT visit) as well as date of next visit/appointment in patient folder • Clinician signs off result (initial and date) • For initial TB diagnostic test: • Clinician records initial diagnostic test (GXP) result in the TB ID register • DC inserts the result into patient folder and the folder is returned to registry for refiling • Triaging of lab results

32. Management of abnormal laboratory results (2) • For all other abnormal lab results: • DC inserts lab result in patient folder and returns folder to registry for refiling • At next consultation visit, Clinician must look for new results inside the patient folder • Transcribe the new abnormal lab results in clinical stationery (ART clinical stationery or TB ID register or blue card) from lab result form or SMS printer or telephonic/electronic medium • If result was received from SMS printer- record “SMS” next to result • If results were received via phone or looked up on the NHLS TrakCare - indicate “telephonic/electronic” in visit summary section • Ensure daily flow of patient folders to the Data clerk for capture into TIER

33. Bulk NHLS Capture Tool (Pending Tests) • Designed to capture all outstanding results of requested HIV and TB tests

34. Bulk NHLS Capture Tool (Pending Tests) Click on the patient row to enter the result or Search for a particular Folder Number or Lab reference number

35. Bulk NHLS Capture Tool (Pending Tests) For TB test results For CD4 or VL test results

36. Searching for existing patient in TIER Click on Search from the patient list to search for an existing patient Click the Search button once you have entered the search string

37. Searching for existing patient in TIER Double click the patient to open the record Section for capturing the Case Identification tests

38. Capturing Sputum tests in TIER Click on New to capture the Sputum tests and results

39. TB Case identification results outstanding list • N.B: The record will no longer appear on this list if • Patient has been traced and assigned an outcome (initial LTF, Died) • DC ticks “Result Not Available” in the “Case Identification” when result has been lost or specimen leaked/contaminated

40. TB identification results outstanding list • TB identification results outstanding list • This lists identifies those tests which have been taken but no result has been entered (7 days for smears/GXP and 42 days for TB cultures) • Purpose of the list • To alert clinicians of outstanding laboratory results • NB: clerks to stay on top of sorting, capturing and filing results in a timely manner to ease workload and to potentially not endanger patients’ lives

41. How to use the TB identification results outstanding list • When to generate the list • DC to generate the list every Friday • Steps to be taken • DC to verify outstanding laboratory results • See Table of Reports in TB\HIV M&E SoP (page 5) • DC to give the list to the person responsible (identified by the Facility Manager) for further action • The client must be recalled to the facility to re-test if test not found or contaminated

42. Capturing Sputum tests results in TIER Click on Edit to capture the Sputum tests results

43. Capturing GXP results Source for: GXP sensitivity results

44. Waiting list for TB treatment • Patients who have not yet initiated TB treatment will appear on this list for 60 days or until a TB episode is created & linked to this test • A bacteriologically positive TB result does not automatically open the TB treatment episode, this needs to be manually captured

45. Waiting list for TB treatment • Waiting list for TB treatment • A list of patients with bacteriologically positive TB results that have not been started on TB treatment yet • Purpose of the list • To help clinicians identify patients who have not yet started treatment (reasons?) • Useful to reduce time between TB identification and treatment; facilitates the timeous tracing/recall of the TB patient to initiate treatment • Indication of the facility’s working relationship with its community support structures (CHWs, CCGs &/or WBOTs)

46. How to use the Waiting list for TB treatment • When to generate the list • DC to generate the list weekly • Steps to be taken • DC to give to the responsible clinician (identified by the Facility Manager) for patient recall • Clinician to document recall information, including appointment • DC to capture appointment into TIER

47. TB Identification Report • # of presumptive TB cases • # produced a sputum sample • # positive results, further disaggregated by test type • # positive started on TB treatment or reason for attrition (initial LTF or death) • DHIS indicators calculated according to latest NIDS

48. TB Identification Report • TB Identification Report • Aggregate report of all presumptive TB cases with bacteriological tests carried out in a month including contacts tested for TB • Purpose of the report • To monitor sputa sent to the lab, for evaluating case detection and determining the prevalence of presumptive TB cases at facilities

49. How to use the TB Identification Report • When to generate the report • DC to generate on the 7th working day of every month • Steps to be taken • DC to submit the report to FM • DC to present at monthly clinical or facility meetings • FM to verify and sign off on reports and file in the respective section in the lever arch file in the registry • A copy is submitted to the SD office by the 10th of each month

50. Monthly DHIS Indicators according to NIDS 2017 • Smear TAT (<48h) • TB bacteriological positive >=5 years • Treatment start >=5 years • Child contacts < 5 years started on IPT