Topics

Background of TIER.Net & Guiding Principles

1. TB/HIV system

THIS Integration: The processes to integrate the HIV/ART and DS-TB data management and reporting processes into a single in-facility data management system and a single data flow. In addition, the TB/HIV information system integration term refers to the technical working group team responsible for the transition project.

2. TIER.Net:

Three Interlinked Electronic register TIER.Net is a non-networked electronic programme containing TB/HIV patient information. It is a tool used to support patient management and provides data used to report routine programme performance data into the webDHIS.

TIER.Net is the software application that is part of the wider TB/HIV information system initiative
The TIER.Net application supports clinical governance, service delivery and programme management
TIER.Net is only as good as the extent to which it is managed, curated and maintained
As defined in the SOP and other critical guidance materials
Software application updates based on evidence-based feedback, policy and guideline updates/changes
Software application evolves to align with programme and policy updates

Guiding Principles

Action taken by the facility on the TIER.Net line lists support patient management, retentionefforts, and data cleaning activities.
Robust, comprehensive and accurate clinical recording keeping practices are a critical component of the TB/HIV information system.
All information (clinical stationery, results etc) are to be filed together in a single patient folder in accordance with the Ideal Clinic prescript of ’one patient, one folder, one folder number’2.
Facilities are to maintain printed and signed copies of submitted reports for reference and auditing purposes. In the event that a facility is unable to print the reports, an electronic file containing the reports is to be maintained for reference and audit purposes.
Integration of TB/HIV data into a single data flow process (via clinical recording, data capturing, and patient folder flow) facilitates data use at the facility and the reporting of data from facility to (sub)district, province, and national levels.
The line lists and programmatic reports are to be used at the facility-level to support clinical, patient, operational and programme management
Access to data (electronic or paper) is granted only to those authorised employees of the Department of Health. Anyone outside of the DOH requiring access to patients records (electronic or paper), must receive written approval by the district office and facility manager.

Scenario 1

You have appointment with AG in your facility and he/she identifies gaps in TB/HIV data management. One of the recommendations is to provide capacity building of staff on the identified gaps.

What are the guiding documents/Guidelines( including the versions) that you can use to prepare your capacity building exercise.

https://www.tbhivinfosys.org.za/doc/integrated-tb-hiv-data-management-sop-part-1-facility-level/

https://www.tbhivinfosys.org.za/doc/2019-art-clinical-guidelines-updated-2020/

https://www.tbhivinfosys.org.za/doc/2020_06_tier-net-user-account-management-guidance_v-3_signed/

Data flow &Timelines

Quiz
1. Choose correct Monthly TIER.NET reporting timelines from facility level - Sub District level – District level according to THIS SOP.

A. 3rd -6th – 10th
B. 4th – 8th – 12th
C. 6th – 12th – 16th
D. 5th – 10th -15th

2.How frequently should a Dispatch be generated at facility level and send to the next level (Sub District)?

A. Weekly
B. Bi weekly
C. Monthly
D. Quarterly

Cohort Report

The cohort report is different from the monthly report

It reports on program outcomes to measure Cohort outcomes

Program quality
Monitor changes over time
Measure changes in the HIV/ART program over time
Assess what changes should be made to the programme

Quarterly cohort data are collated within the DHIS to provide a country overview of ART program outcomes

It is a group of people that are followed over time – they all have something in common. What is the common link for our patients? The date the patient started ART

Quarterly report ‘cohorts’ are those who started ART in:

Jan, Feb, March – Quarter 1
April, May, June – Quarter 2
July, August, September – Quarter 3
Oct, Nov, December – Quarter 4

Cohort Reporting Timelines

Data Sources and Stationery

Scenario 2

Sister X has received lab results through NHLS Lab track or SMS
How would the clinician handle these lab results?

Possible Answers
The “Management of normal laboratory results in TIER.Net”
- The SOP states “any results not yet recorded must be transcribed by the clinician into the clinical stationery”
- If result was received from SMS printer, write “SMS” next to result
- If result was received via phone, write “telephonic” next to result
- If result was obtained from NHLS TrakCare, write “electronic” next to result
- Download electronic results and save in a folder
- encourage OPMs to have access to NHLS Lab Track
- N.B follow up on electronic results

-Once the results have been triaged by the clinician, they are to be returned to the AC for capturing.
- The AC must use the ‘Tests Awaiting Results’ functionality in the TB/HIV information system to capture all normal lab results that are triaged by a clinician (Note: Results can only be captured against test requests captured in TIER.Net.
-AC to initial and date on the returned test result once captured in the TB/HIV information system.
-All lab results that have been captured must then be returned to the patient folder and filed

Management on Abnormal Results
- AC must first prioritize the processing of abnormal results. - The AC to retrieve patient folders for those patients with abnormal results. - AC to place the results in the patient folder. - AC to give the folder to the clinician for intervention.

Once intervention is completed and documented by clinician,

Folder will be returned to the AC for capturing.
AC to capture abnormal result into the TB/HIV Information System and initial on clinical stationery next to the result.
AC to capture intervention activities of important information such as changes to next appointment date, outcomes etc

Approved Stationery & Source Documents

Standardised Clinical Records

Structured care

Irrespective of HIV or TB information system used the information is retrieved from the standardised clinical record

The standardised HIV and TB Clinical Records serve as the: *

Clinical record
Source for capture into TIER.Net

Stationery must be inserted in clients folder at first point of care Stationery should be fully completed

Example HIV/ART clinical stationery

Reminder of the stationery as a data source

Visit summary: source data for the data

Example OF TB Folder

Roles & Responsibilities

Quiz 1. Who should ensure that TIER.NET backup is generated and stored safely at facility level?

A. Facility Data Capturer
B. Operational Manager
C. Local Area Manager
D. HAST Coordinator

Who should ensure that TIER.NET line lists are generated and actioned accordingly?

A. Data Capturer
B. Professional Nurse
C. HAST Coordinator
D. Operational Manager

Who is Admin Clerk

Admin Clerk (AC) roles and responsibilities

ACs are responsible for administrative, reception and data management activities
Key activities include
- Pulling, filing, archiving, ensuring file complete with stationery and overall folder hygiene
- Capturing NHLS results that have been reviewed and signed-off by a clinician
- Capturing into the monitoring system on a daily basis
- Generating line lists and reports for routine data submission and reporting

Not responsible for

‘Managing’ the broader THIS strategy
Overseeing daily data management from all service points
Collating and verifying facility data
Providing reports to clinicians and FMs for review and discussion during weekly/monthly facility meetings

Facility Manager (FM) roles and responsibilities

Responsible for ensuring the processes for all data produced at a health facility are completed
Overseeing staff responsible for those processes
Facilitating routine and consistent interrogation and utilisation of data available at the facility-level to improve patient management and outcomes
Providing overall management of:
Data security
Audits
Stock control (related to data management)

Line Lists and Reports

Scenario 3

As the Operational Manager Using the ART quarterly report from TIER.Net, you have identified that the VL done rate at 6 and 12 months is below 50%.

Discuss the line lists that you would use and what actions would you do to improve the situation?

Possible Answers

FM should work closely with the Admin Clerk to pull out the VL due list and Tests awaiting results
Pull out the patient folders
Confirm in the patient folder if the VL was done or not If viral load was done, follow-up to locate the results & Update results in TIER. Net
If VL was not done, attach a note outside the patient folder as a reminder to clinicians to take VL on the next patient visit OR recall patients take Viral load as soon as possible, use of CHW to trace
FM should be made aware of these patients
Educate patients on importance of Viral load & viral load due dates
OPM should audit files, hold clinician responsible to collecting of bloods for patients who honored appointment

Line lists and reports

It is Important for line lists and reports to be generated at stipulated timeframes
Admin clerk is responsible for generating the line lists and reports
Facility Manager is responsible for ensuring appropriate action is taken

Demonstration/Practical Exercise of TIER.NET

Generate and interpret the below line lists & reports for your facility and explain what actions & interventions you would take:

Missed appointment report (addressing LOST TO FOLLOW UP)
7-28 days missed appointments
29-90 days missed appointment
U(LTF) report
Viral Load Overdue list = (Addressing viral load completion)
TB Outcome report = (addressing clinical program performance or MOVs) focus on recent quarter reported (Q3 2022/23 FY)
ART Outcomes cohort report – (addressing clinical program performance or MOVs) Focus on 12 Months Cohort - recent quarter reported (Q3 2022/23 FY)
Waiting for ART/TB line list

Weekly Line Lists

Monthly Activities

Monthly – Facility and system reports

Monthly programmatic reports to meetNDOH reporting requirements

TIER.Net: available reports

https://www.tbhivinfosys.org.za/doc/tier-v1-13_ndoh-key-line-lists-and-reports/

Data Demand & Use

Scenario 4

Some of the objectives of Data Demand and use are:
Improved data demand, utilization and Improved patient management. One of the key responsibilities of the Operational Manager is to come up with quality improvement plan.

Please use TIER Facility Management report to address red flag or problems (Using below template)

Example Of Facility Management Report

Objectives of Data Demand & use

Improved Data Quality

With increased utilisation, data quality will improve
The more you use it, the more likely you are to find critical issues
Specific tools designed to support interrogation

Improved Patient Management

Improved utilisation and adherence to SOP will result in better managed patients - Institutionalisation and accountability are critical
Analysis of routine performance data will help to prioritise patient management issues

Dialogue link between Programme Management & Information

Active dialogue between programme and information colleagues about data and its impact on programme activities - Data largely produced by information and used by programmes

Informed Decision Making

Management must be able to make decisions using the information routinely produced
Focus on existing data sources (TIER.Net and webDHIS) – use what we have

Improved Data Demand & Utilisation

Overall purpose of the training is to build skills, provide tools, and link these with existing requirements and job functions
Working smarter, not harder

User Accounts Management

Quiz

Who is permitted to merge patient records in TIER.NET according to THIS user account management SOP?.

Facility data Capturer
Operational Manager
Hast Coordinator
Local Area Manager

What can a User Role Account do on TIER.NET?

Add patient information and delete patients
Generate line list and deactivate users
Modify his/her user details and passwords
None of the above

Who should create new user accounts on TIER.NET at facilities

Provincial Information Manager
Supporting Partner Officials
Data Capturer
Operational Manager

Where should user Account control form be filed?

Sub district Office
TIER.Net lever arch file
District Office
Desktop (Computer)

How often should TIER.NET user access be monitored

Weekly
Monthly
Annually
Quarterly

After how long must an inactive user be deleted

1 Month
2 Month
3 Month
4 Month

When is it permissible to share TIER.NET password

When the colleague with access is absent/sick
Not permissible at all
When requested by AGSA.
When requested by managers

Scenario 5

Auditor General visit the facility for Information system audit, then he/she notice that TIER. Net system is having 3 different user accounts roles. Please explain below user accounts to AG:

Implementer
Administrator
User

Please list methods/storage devices that are used at the facility to store TIER.NET Backups.

Possible answers

Implementer- Account management

TIER.Net has 3 types of user accounts, all of which offer differing functionality depending on the profile of the user. These include:

Implementer
This role is equivalent to a super user. The implementer role has been created only for those who implement TIER.Net at facility, sub-district, district, or provincial level. The Implementer can change user details, including passwords, and can create exports with patient identifiers included. The implementer can also perform all the activities of the user and administrator.

What can an Implementer account user do regarding TIER.Net?
- Add, activate, deactivate all level of users (Implementer, Administrator, User) - Modify user details (usernames, passwords, facility access) This is tracked in the Implementer/Administrator Log Report - Perform all the activities of the user and administrator
- Restore back up files if on the same computer.
- Merge patients that have been verified and documented

Administrator- Account management

Administrator
This is the middle-level access role. The administrator role is principally assigned to the Operational or Facility Manager, or anyone in a management role other than the Implementer. The Administrator is not able to export patient identifiers in MS Excel.

Responsibilities & Functions

The OPM should be the Administrator of TIER. Net
Add, activate, deactivate level of users (administrator and user)
Perform limited access on system settings
Modify user details (usernames, passwords, facility access)
Merge patients.
Monitor and keep track of user access via the User Access Report and the Implementer/Administrator Log Report.

User- Account management

User
Facility Admin Clerk (AC) responsible for entering data into TIER. Net. The purpose of this user account level is to enable routine data capturing and reporting, whilst limiting the number of system settings that can be changed.

Responsibilities & Functions
- Add patient information to TIER. Net - Generate line lists and reports
- Modify own user details and passwords
- Create dispatches and back up files
- Ensure accurate capturing of patient information into TIER. Net from the clinical stationery. - Generate line list and reports (refer to the Integrated TB/HIV Data Management Standard Operating Procedure).

Monitoring User Activity There are two reports which monitor user access in TIER.Net
User access should be monitored on monthly basis, Print report and file it accordingly.

User Access Report

This report provides a breakdown of when each user has accessed TIER.Net, including the login date, activation status, and both login and log-off time.

All users (user, administrator and implementer) have access to this report.
This report determines which users have been active or inactive for a given period of time.
As part of the review process, the FM/OM must review the active accounts to ensure alignment with the person’s job responsibilities and If a user is misaligned, the user must be re-assigned to a role that reflects their assigned responsibilities.

Implementer/Admin Log Report

This report includes a list of time-stamped transactions (that is, actions performed and the user responsible for each action), including when a user account has been amended in any way by an Implementer or Administrator.

Generate and provide interventions were required If the facility does not have a functional printer,

Task

Create NEW User into TIER.Net = (Account Management)

Backup

Frequency of Backups
Dispatch vs Backup
Tier.net Facility Management report on Backups

Data Cleanup