1. Considerations for Electronic Surveillance Systems
Bill Coggin
CDC South Africa

2. “Nothing has really happened until it has been recorded.”
Virginia Woolf

3. “Nothing has really happened until it has been recorded.”
Virginia Woolf
“….and validated, analyzed, reported and ACTED UPON.”

4. Overarching principle
Electronic systems facilitate analysis at sub-district, provincial and national levels but represent only one tool.
Timely and accurate completion of the patient card and register is paramount
Foster data use at facility-level, program evaluation and improvement.

5. Pre-2000: Aggregate system
Problems inherent in design of system (TBSYS)
Not based on cohort
Difficult to breakdown to implementation level, eg validate results back to paper register.
Prone to subjective interpretation, calculation errors (reporting only on known outcomes)
More useful at higher levels
No issue of patient-record confidentiality

6. Revised R&R Cohort-based District-based
WHO-IUATLD standard definitions
Management tool
Patient-based ETR since 2000 (Epi6, Dos-based)
6/9 provinces

7. Electronic tools ETR: Epi6 > Windows
NTCP mandate to have all provinces’ CF data on one system as of Qtr 1/2004
Platform: EpiInfo or other
Microsoft .Net Framework
Started December 2003
Emulates ETR (Botusa)
SA-based programming and support

8. Approach Project plan/specifications:
Stepwise addition of required functionality (CF, SCR, TO, FacRep, exports, checks, etc)
Prioritized task list, resource requirements (eg programming time, costing, testing, stakeholder consultation)
Delineation of monthly release/update schedule.
HIV/TB surveillance component – from April 2004

9. ETR.Net Features: Validations Add/edit facilities Standardized reports
User/admin setup
Application updater
Import from prior systems
Last three provinces, implemented since April 2004

10. Experience with ETR.Net
In-country expertise
Rapid development
Simplified application development for standalone and distributed systems
No DLL registration, no DLL version conflicts
Stability across various Win platforms (Win98+)
Excellent user interface (Windows user familiarity)
Multi-language support (isiZulu or Xhosa ETRs?)
Copy and paste deployment

11. HIV surveillance in ETR.Net
Implementation of Comprehensive Plan offers renewed impetus to accelerate VCT and access to HIV services for TB patients
ETR.Net process is opportune time to integrate HIV data elements into software
Challenge: HIV test data has not been part of routine collection
Technical and administrative approaches to address this issue

12. Administrative and technical approaches
Register “Annex”
No pt identifiers
Link to register via TB register number (?ID #)
Training in confidentiality
Built-in MS Access database security
Built-in MS.Net security
Custom developed security:
User names and PWs
Different user types and permissions
Administrators
Users
HIV allowed or not
Patient data only visible at lowest level
Aggregate reports available at all levels

13. ETR.Net HIV data elements

16. Limitations
TB recording and reporting system is a surveillance & program management tool for a priority program.
Is not a POS patient management system.
Address this with linkages:
Export aggregate data to national HIS
Collaborations for linkages with other systems (eg PIS for ART)
Use of .Net framework facilitates such linkages.

17. Plans TBHIV surveillance pilots in: Selected TB/HIV Training Districts
Selected districts implementing Comprehensive Plan
A 500-bed TB hospital funded for expanded TB/HIV services via Emergency Plan
Continued development/enhancements of overall ETR.Net.

18. Issues in Implementing Electronic Systems *
Need to build for the long term while still meeting short term needs
Must adjust to situations that vary considerably among countries
Infrastructure
Human capacity
Stage of electronic systems development
No one size fits all – need tailored solutions
* Meade Morgan, June meeting

19. Conclusions Let time determine scope of project.
Succeed via continual incremental improvements.
Require progress not perfection.
Recycle proven concepts.
Consult widely and often; integrate demonstrated best-practice based on operations research and field experience.
Importance of NTP/NACPs, donors, WHO to commit resources for TB/HIV surveillance.
Not number-crunching but prog evaluation > service improvement > improved quality-of-life

20. Acknowledgements South Africa Department of Health
NTCP: Lindiwe Mvusi, Carina Idema
TB/HIV Team: Kgomotso Vilakazi, V Tihon
Provincial TB Coordinators
WamTechnology: Paul Maree & team
CDC Botusa team