Comprehensive training to support the national TBHIV Information

Comprehensive training to support the national TB/HIV Information System (THIS) integration initiative Change management processes to implement integrated TB and HIV data management in facilities, using TIER. Net

What’s new in TIER. Net Overview of new functionalities in software since version 1. 8. 3 2

What’s new in TIER. Net – key headlines § TB module § Correctional § HPRS integration § ETR. Net § Bulk Services module DS-TB export sub clinic capturing module § Pending results) tests functionality (Bulk capture of NHLS lab All already covered earlier this week 3

What’s new in TIER. Net – TB reports § TB case identification results outstanding list § Waiting list for TB treatment § DS-TB treatment initiation report § TB Gene. Xpert report § DS-TB Cases Requiring Action (Non-conversion) list § DS-TB Conversion Sputa Required list § DS-TB Discharge Sputa Required list § DS-TB smear conversion report § TB Missed Appointment and Unconfirmed LTF list § TB Outstanding Outcomes list § DS-TB outcome report All already covered earlier this week 4

What’s new in TIER. Net – TB reports § DR-TB Treatment initiation report § DR-TB Sputa Required list § DR-TB outcome report Digitisation of DR-TB data in TIER. Net is deferred – no guidance provided at this stage. 5

What’s new in TIER. Net New and updated ART reports and lists Viral Load Due list Viral Load Cascade list ART regimen line validation list ART Quarterly Cohort Report 6

Viral Loads Due list § Lists all ART patients requiring viral loads, based on patients’ duration on treatment and last viral load recorded. § To be generated: The last Friday of the month, for routine management. o If a facility has monthly clinical management meetings, this should be generated 1 week before this meeting. o § Clients who have an outcome of RIP, TFO/MVO or confirmed LTF entered will not appear on this list. Unconfirmed LTF clients will appear. 7

Viral Loads Due list (cont. ) 8

Viral Loads Due list (cont. ) § This list can be exported to Excel (PDF and Word) and the date columns manipulated to look for particular patients who may need more urgent follow up than others (e. g. those who have initiated ART 6 months ago and have not had an adherence viral load). 9

Viral load cascade list § This is a list of patients whose last VL was unsuppressed. § The 3 most recent viral loads of these patients are listed with test dates, test results, and the ART regimen at the most recent visit. § Generate 1 week prior to monthly clinical meeting. 10

Viral load cascade list (cont. ) 11

Viral load cascade list (cont. ) § The list can be used for different purposes, for example, identifying clients who: o Have only 1 viral load recorded. o Have changed from 1 st line to 2 nd line regimen after 2 viral loads were greater than 400 and to see if they have had a follow-up VL 6 months after switching regimens. o Need to switch regimen lines. 12

ART Regimen Line Validations List § A list of all patients with regimen captured that is inconsistent with expected regimen combination (1 st, 2 nd, 3 rd/salvage). § To be generated: The last Friday of the month, for routine management, or o If a facility has monthly clinical management meetings, this should be generated 1 week before this meeting. o § This assists with data clean-up, and replaces the data clean- up document (in conjunction with Data Validation List). 13

ART Regimen Line Validations List (cont. ) 14

ART Regimen Line Validations List – special instructions for first use § This list will produce a large number of errors the first time that it is generated. § Cleaning up these errors will improve the quality of data produced by TIER. Net, but will require management after first generation. § Following upgrade to TIER. Net v 1. 10, this report must be produced on the same day. § The data clerk(s) must be tasked with resolving the errors within 7 days. o Any errors that are not capture errors (transcription) must be escalated to a clinician confirmation. § All errors must be resolved before the next monthly report is produced. 15

Changes to ART Quarterly Cohort Report The ART quarterly cohort report has been revised to include: o Additional baseline CD 4 categories, including CD 4 350 – 500, and CD 4 >500. o Third line regimen at each duration - this assists to monitor the proportion of patients transitioning to third line treatment. 16

Changes to ART Quarterly Cohort Report (cont. ) 17

Changes to ART Quarterly Cohort Report (cont. ) 18

Questions 19

Refresher on Viral Load results management . 20

Reminder about laboratory results § As soon as laboratory results are received, they must first be reviewed and recorded by a clinician, and then captured into TIER. Net. o Urgent results should be identified and patients recalled. o Normal results should be filed in the patient file. § Timely capturing of all laboratory results will mean that push button reports have more complete information, and can thus better support patient management. § If results are not captured into TIER. Net, they will not be available in the management reports. 21

Calculations VLD and VLS § VLD refers to the number of viral loads done, of patients who are expected to have a viral load done according to the SA Clinical guidelines (active on ART). § VLS is the proportion of patients with a result entered, that was less than 400. 22

Calculations VLD and VLS For example, if there are 10 patients on FLR and 0 patients on SLR and 0 patients on TLR at 12 months on ART. And, if 8 patients had their viral loads done and 6 were suppressed this could be calculated as follows: 23

Reminder of Viral Load management in TIER. Net § § § The rules in TIER. Net are aligned with the National treatment guideline. These rules allocate laboratory results entered in line with the durations and corresponding grace periods. All viral load results captured in TIER. Net ARE included in the cohort report. No data is excluded from the reports (except where a result is entered between 0 – 3 months from ART start). Where they are included depends on when the tests were requested by the clinician (done). The grace periods to the rules are as follows: o +/- 3 months for 6 month bloods. o 3 months to + 6 months for 12 month bloods. o Thereafter, +/- 6 months for annual bloods. 24

Illustration of inclusion & exclusion criteria for Viral Load management in TIER. Net and allocation of results in ART cohort report Legend Milestone: Routine Viral load monitoring test required in line with SA National ART guidelines Grace period: Threshold rules allocate laboratory tests entered to the respective duration in ART Cohort report 12 month lab test 6 month lab test ART Start 36 month lab test Annual lab test 24 month lab test Grace period Mar 5 Sep 3 period Grace period Jun 2 Grace period Continued annually Grace periods to the rules: +/- 3 months for 6 month bloods - 3 months to + 6 months for 12 month bloods Thereafter, +/- 6 months for annual bloods Note: The rules in TIER. Net summarize data in alignment with the routine laboratory tests as outlined in the National treatment guidelines. The rules in TIER. Net will allocate laboratory results entered in line with the durations and corresponding grace periods listed above. No data will be excluded from the reports (except where a result is entered between 0 – 3 months from ART start). 25

Integration headlines – course correction § Many facility managers and (sub)district managers have not demonstrated ownership of the HIV programme, and not adequately engaged with associated data, i. e. o Not pulling / actioning missed appointment reports, o Inconsistent / incomplete / incorrect reporting on ART, o Not reviewing lists and reports to identify areas for improvement in patient care, etc. This compromises clinical patient care! § Before rolling out the expanded functionalities of the system - need to ensure that facilities are fully utilising the existing functionalities of the system. 26

Questions? 27

What’s new in TIER. Net New cross-cutting reports and lists Transfer out form Facility Management report (Sub)District TIER management report Data validation list 28

Transfer Letter / Patient Summary Report • Electronic transfer letter used for patients who are transferring out of the facility. • Click on Generate Patient Summary. 29

Transfer Letter / Patient Summary Report 30

Facility management report § This is a summary report listing proportion or values to highlight critical pieces of information from each report contained in the Clinical Governance and Patient and Facility Management Reports. § If the indicator has a RED X, this means the corresponding report must be produced to provide details to the problems. 31

Facility management report (cont. ) n i t x te e l b i Leg t slides nex 32

Report Data element HCT report Number of HCT tests this month compared to the previous year's average. Green tick if above previous facility average. Facility management report Monthly report / Patients on waiting for ART list for more than 2 waiting list for ART months. Green tick if = < 1. Monthly report This months ART enrolment compared to the previous year's average. Green tick if above previous facility average. Monthly report This month's ART remaining in care compared to previous month's. Green tick if RIC is increasing. HIV unconfirmed Percentage HIV u. LTF (of RIC). Green tick if = < lost to follow-up list 3%. 33

Report Data element Facility management report Viral load due list Percentage of clients on ART greater than 7 months but less than 9 months and no first VL available. Green tick if = < 1%. Viral load cascade Number of patients with VL >1000 and no follow list up VL after 5 months. Green tick if = < 1. TB case Percentage of presumptive TB cases with identification report bacteriological test done (>=5 years) / all presumptive TB cases (>=5 years). Green tick if > 98%. DS-TB discharge Percentage of PTB bacteriologically positive sputa required list overdue for discharge sputa / All PTB bacteriologically positive. Green tick if < 5%. Sputum conversion Number of clients with a positive 2 month report conversion that have not had a 3 month follow up test (2 month lag). Green tick if 0. 34

Report Data element Facility management report TB unconfirmed Percentage TB u. LTF (of RIC). Green tick if = < lost to follow-up list 5%. Data validations list Percentage of data validation failures / total patients ever at facility. Green tick if < 2%. Monthly club report. Number of clubs expected to meet last month - number of clubs captured for last month. Green tick if 0. Workload report Visits (both TB & HIV) captured last month / visits captured previous month. Green tick if above previous month. N/A Last backup date. Green tick if < 48 hours ago. 35

(Sub) District TIER. Net management report § This report is a list of facility summary data, within the level you select from the facility tree (sub-district / district). § The aim of this report is to assist sub-district or district managers to help them better monitor and manage HIV and TB data at facilities. § It summarises and highlights important indicators for each facility. 36

(Sub) District TIER. Net management report (cont. ) n i t x te e l b i Leg t slide nex 37

(Sub) District TIER. Net management report § Each row displays the following facility data: o o o o Dispatch creation date (at facility) Dispatch load date Last captured visit date Last backup create date (at facility) TIER. Net version (at facility) Back log mode active (at facility) First ART start date HIV defaulters - Proportion of HIV RIC Outstanding HIV lab results TB defaulters - Proportion of TB RIC First TB treatment start date Outstanding TB lab results Outstanding TB outcomes 38

Data validation list A list of fields with suspected incorrect values captured. This replaces the data clean-up document § List can be sorted by folder number or validation failure type. § Routine management: to be generated every Friday. o Clerk to generate report, pull patient folders & resolve errors. Clerk to record alongside each resolved error, give to FM for signature and file in the respective section in the lever arch file in the registry. 40

Data validation list 41

Data validation list - special instructions for first use § This list will produce a large number of errors the first time that it is generated. § Cleaning up these errors will improve the quality of data produced by TIER. Net, but will require management after first generation. § Following upgrade to TIER. Net v 1. 10, this report must be produced on the same day. § The data clerk(s) must be tasked with resolving the errors within 7 days. o Any errors that are not capture errors (transcription) must be escalated to a clinician confirmation. § All errors must be resolved before the next monthly report is produced. 42

Questions? 43

What’s new in TIER. Net Snapshot of miscellaneous new functionalities Duplicate folder merge Moving facility data Alternate episodes pane Admin and Implementer log 44

Duplicate Facility Folder Merge § Tool to merge duplicate folders. § The Duplicate Facility Folder Merge option can only be used by an administrator or implementer. 45

Duplicate Facility Folder Merge § Search for the Folder to Keep and the Folder to merge it with using the Patient Lookup. § Make sure this is correct before proceeding. 46

Duplicate Facility Folder Merge § Click on Merge. 47

Move Facility Data § This option is used to move ALL patient data from one facility to another facility. § Can only be used by an administrator or implementer. § To be used when a new facility is opened, and is not yet in the MFL in the system, and data may temporarily be captured under another name. § When facility is properly included in MFL on system, then move all data there. 48

Move Facility Data § Search for the Facility to move data from and the Facility to move data to using the Location Lookup button. § Then click on the Move button. 49

User Interface (alternate episode pane) Mantoux tests and IPT: appears on HCT, Pre. ART and ART screens. TB treatment, Comorbidities, Pap Smear and Cotrim: will show if enabled by Implementer in Options. 50

Mantoux tests and IPT Click on Add/Edit IPT record, to open the pop-up window. 51

Mantoux tests and IPT Click on New. Enter: -Skin Test Done (Yes/No) -Skin Test Date -Skin Test Result (Positive / Negative) Save. 52

Mantoux tests and IPT Click on New. Enter: -IPT start date. -IPT stop date. -IPT outcome. Save. 53

Mantoux tests and IPT When entering the IPT Stop Date, the IPT Outcome must be entered. Options are: - Completed IPT Treatment - Transferred Out - Treatment Interrupted - Developed TB. 54

Mantoux tests and IPT episode pane on the Patient Details screen will update based on what is entered. 55

Admin and implementer log This report lists transactions when logged in as an implementer or an administrator. 56

What’s new in TIER. Net Other miscellaneous . 57

What’s new in TIER. Net - user functionality § Integrated and simplified TB/HIV patient list as default view § "Fuzzy match" added to patient creation procedure to eliminate non-exact duplicates § Ability to store & search on folder number history § (Updated: ) Workload report now includes captured TB visits § (Updated: ) Combined TB/HIV Patient Appointment List § Ability to capture comorbidities § Outcome handler for patients who have an outcome captured and they have more than one open episode § Added outcomes to HCT sub-module § Options updated 58

What’s new in TIER. Net - System optimisations § Database optimizations, allowing twice as much data to be loaded in the same SQL Server express database § User interface changes at higher level stations, improving system performance § Optimized dispatches § Reworked DHIS export § Numerous security improvements § Several bug fixes § Maintenance file load for easier loading of maintenance patches from CIDER (for implementers only) § Data Exchange Standard: various refinements including XML soft cap removed § Automatic online updater (for facilities with connectivity) 59

Questions 60

Contact details of NIT members Nevilla Somnath – National TB Programme – RIMES – Nevilla. Somnath@health. gov. za Riona Govender – NDo. H M&E – Riona. Govender@health. gov. za Catherine White – M&E Technical Support to NDo. H - cwhite@clintonhealthaccess. org Barbara Franken – Project Manager for THIS integration - bfranken@clintonhealthaccess. org Ipeleng Mojaki – TIER Implementation Associate - imojaki@clintonhealthaccess. org Moeketsi Finger – TIER Implementation Associate - mfinger@clintonhealthaccess. org 61