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CARDIOVASCULAR JOURNAL OF AFRICA • Volume 26, No 6, November/December 2015
AFRICA
231
We compared attributes of the eRegister and traditional
paper-based systems. Benefits of the use of the eRegister system
are likely to include:
•
Electronic data entry. Data are entered in electronic format
directly at the point of capture, which obviates the need to
manage paper forms, reduces the risk of data error associated
with manual transcription of data from paper to electronic
sources, and improves the ease of updating data.
•
Flexible, real-time system. Data collected through mobile
devices populate the eRegister as soon as the device synchro-
nises with the CommCare platform. Conversely, changes or
local adaptions to data-collection forms to suit local needs
can be made in real-time in the CommCare application and
then distributed automatically to all mobile devices in the
field. The next time the device is synchronised, the newly
updated form will automatically be loaded onto the device,
offering a level of flexibility in data collection that would be
largely unworkable using paper forms.
•
Improving clinical operations. The eRegister system can be
used to track and manage treatment of individual patients.
Follow-up workflow plans can be created, penicillin allergies
can be tracked and alternative prophylactic treatment can be
prescribed, and custom reports and worklists can be created
to help health workers manage a cohort of patients (for exam-
ple, reports can be automatically generated that list patients
who missed their last appointment). The system can also be
utilised to distribute multimedia-format training modules to
field workers.
•
Improving clinical outcomes
.
It is known that delivery of
secondary prophylaxis within a registry-based programme
increases the success of control programmes.
19
The eRegister
system can provide an integrated method to organise ongoing
medical care of patients with RHD, minimising the loss to
follow up, and maximising the likelihood of compliance with
therapeutic regimens. This simple method also enables the
monitoring of patient outcomes, and planning of advocacy
and awareness activities in low-resource settings.
•
Improving treatment adherence
.
A particularly important
example of improving clinical operations is the ease of imple-
menting SMS reminders to the phones of patients, parents
and health workers in advance of patient appointments, or
in follow up to missed patient appointments. Adherence to
prophylactic treatment for RHD has been shown to be low in
many populations where RHD is endemic,
20,21
and the use of
register-based reminder systems can be an important tool to
help support and improve adherence.
22-24
•
Field team management. In addition to patient data, data
relating to data-collection processes is automatically captured
through the CommCare platform including, for example, the
time taken to fill in an individual data-collection form or the
number of forms submitted by each user. Data that describe
patterns of data collection can be used to identify training
needs and opportunities for productivity gains. Data collected
by field teams can also be anonymised and reviewed by
remote teams to analyse the quality of decision making and
identify training needs. Multimedia training materials can be
delivered to the field teams through the platform as well.
•
Research. A key feature of the system is the ability to rapidly
generate de-identified data reports that can be used for
research purposes. Furthermore, even though such data are
currently not captured in the WHF register, the platform’s
real-time data-collection features and workflow support can
also be used to effectively support other processes critical to
the conduct of clinical research studies, such as adverse event
reporting.
Preliminary lessons learned from early field testing of the
eRegister in Zambia include demonstration that the tool was
overall easy to use, and that local programme staff were able to be
trained to use the eRegister in a relatively short time and without
specific prior technical knowledge or experience. The field team
iteratively modified its work practices after the programme was
underway in order to increase efficiency in its task of screening
large numbers of children, for example, some data elements
were collected in a different order and at a different location
than was originally planned. It was straightforward to adapt the
content and flow of forms in the eRegister to reflect changes in
local work practices, and this was achieved in real-time without
interruptions to the screening programme.
The study team reported several immediate benefits of the
eRegister to programme operations. In particular, the eRegister’s
actual and up-to-date status reports that could be generated at
any time (including total number of children screened, where
the screenings had taken place, how many children had screened
positive for RHD, etc.), played important roles for programme
monitoring and planning purposes. Another significant benefit
was remote access to the eRegister by team members based
in different locations, and functionality, which was applied to
support data quality-assurance mechanisms.
There were also a number of challenges associated with the
eRegister. Insufficient use was made of the available features to
adapt the eRegister to evolving local work practices. Changes
in work practices were not always reflected in corresponding
changes in forms and workflows in the eRegister, leading to
sub-optimal use of the tool. Poor internet connectivity at the
sites in Zambia where the eRegister was used led to another
intermittent problem; while the eRegister was always functional,
it did on occasion take a long time to update software and
upload large files to individual patient records (e.g. ultrasound
images).
Discussion
Rapid advances in technology over the past decade have made
electronic patient resources theoretically within the reach of users
in virtually every part of the world, including in low-resource
settings where RHD is endemic and where efficient disease-
control programmes are most needed. We have adopted the
WHF framework for patient register to develop an open-access,
mobile, compatible, electronic patient register system. Our aim
was not to attempt to develop a ‘one-size-fits-all’ RHD patient
register, but rather to develop a platform that could be readily
accessed by a wide range of stakeholders and adapted to their
individual needs.
The main benefit of using an RHD register is to support
longitudinal treatment programmes for patients diagnosed with
RHD. In our field test of the eRegister in Zambia, we found
that the tool could also be adapted to effectively support an
RHD field screening programme. In addition to providing an
efficient platform for managing data associated with screening