1. Brief overview of TIER.Net ART functionality for new users

2. Summary overview
The following slides aim to provide a taster of TIER.Net for new users (experienced users, don’t fall asleep  )
This focus is on TIER ART functionality as this was the primary use prior to the TB/HIV Integration.
This is not a sufficient training but rather to highlight key information and principles
Data sources and data input
Available reports
Please note, the user guide and reports manual are essential reference manuals for new users of TIER.
This is a summary overview only.

3. Confidentiality clause
First time logging in, there is a Confidentiality Agreement that the user must agree to/accept
If the user selects decline, they will not be allowed to log into the system
This can be reviewed again by clicking on the log-in screen

4. ART Treatment Visit Details
Includes standard regimen as well as the following drugs:
DRV (Darunivir or Prezista)
RAL (Raltegravir or Isentress)
ETR (Etravirine or Intelence)
DTG (Dolutegravir or Tivicay)
Restart ART
Only use if a patient stopped ART and is restarted ART after an interruption of more than 3 months

5. 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
Assists nurse driven services and decentralisation to PHC

6. Principles of the TB and HIV Stationery
Provides a ‘quick review’ of a patients history for clinicians in a short amount of time
Serves as the patient record allowing for continuity of pt care
Designed for the treatment and care of TB and ART patients in PHC context
Provides the source for data captured in to the Health Information System [HIS] (TIER.Net, TB register, ART register)
A well entrenched tool
provides easy reference for clinicians and
And well understood by data capturers for capture of data into the HIS
This stationery is a legal record

7. HIV/ART clinical stationery
ART monitoring: using the data
2/8/2020

8. Reminder of the stationery as a data source
Page 1

9. Page 1 and 3 provides baseline ART information

10. Visit summary: source data for the data capturer
Reminder: this is where the data capturer retrieves the results for capture into TIER.Net.
If the results aren’t filed the clinician doesn’t have the result and the data capurer doesn’t have a value to capture.
In turn, the programme can’t monitor the impact of treatment.
2/8/2020

12. The Visit summary provides source for all data captured into TIER
29/7/2016
Date of visit
Regimen, number of months’ regimen prescribed
Next clinical appointment
Laboratory information
Outcome information, including documentation of evidence for patient tracing
Other
Family planning and TB Screening and IPT
Laboratory Results
June ‘00
July ‘00 1a 1a
Regimen information
Next appointment date including visit type (facility or club)

13. A note on regimen codes: important to properly capture the regimen in TIER.Net
Regimen coding is per the SA Clinical Guidelines
NB: The regimen code is as defined by the SA clinical guidelines not by a patient moving from one drug to another. Thus, a patient moving from TDF, 3TC, EFV to - FDC- is still on a first line regimen but they are now on different drugs contained within the first line regimen.
Please correct incorrectly captured regimen codes.
TIER.Net produces the cohort report by categorising patient as being on first line or second line by the number captured next to the regimen (i.e. 1, 2 or 3).
Please ensure the number captured correctly describes the line of treatment; first-line , second- or third-line treatment
This is important to see the effectiveness of the ART treatment. The goal is to keep patients on first line regimen for as long as possible.
2/8/2020

14. A note on regimen codes: important to properly capture the regimen in TIER.Net
Regimen coding is per the SA Clinical Guidelines
NB: The regimen code is as defined by the SA clinical guidelines not by a patient moving from one drug to another. Thus, a patient moving from TDF, 3TC, EFV to - FDC- is still on a first line regimen but they are now on different drugs contained within the first line regimen.
Please correct incorrectly captured regimen codes.
TIER.Net produces the cohort report by categorising patient as being on first line or second line by the number captured next to the regimen (i.e. 1, 2 or 3).
Please ensure the number captured correctly describes the line of treatment; first-line , second- or third-line treatment
This is important to see the effectiveness of the ART treatment. The goal is to keep patients on first line regimen for as long as possible.
If patients are captured as e.g. 2T3E this is incorrect as this is a standard first line regimen, it should be 1T3E.
If an adult patient is captured with 1T3L this is incorrect as Lopinavir is typically* a 2nd line drug for adults.
Please refer to the data clean-up document and the SA clinical guidelines for further clarification.
*there are exceptions to every rule. If it is written in the notes that the patient is on 1T3L as first line due to other contraindications this should be clearly written in the clinical stationery and in notes section of TIER.Net. Thus, when conducting data cleaning activities, if the patient is picked up as having an incorrect regimen, when reviewing the clinical stationery it can be left ‘as is’ and further data cleaning can continue. This is meant to demonstrate the typical regimen codes.
2/8/2020

15. Correct capture of regimens
Upon review of some dispatches it has been identified regimen codes are not being captured correctly
In some cases regimens have been capture as:
Single drugs
Incorrect lines (1st line captured as 3rd line, or vice versa)
Very irregular
Data cleaning, each quarter, is imperative of ALL patients in TIER.Net
Once data has been cleaned, only the newly captured data will need to be cleaned. The workload will get easier.
ART monitoring: using the data
2/8/2020

16. All Reports All HIV Reports
Other new reports include the Work load and User Access reports

17. All reports All HIV Reports All TB Reports Other reports include:
Work load and User Access reports
(sub) District TIER.Net Management Report
Facility Management report
Data validation list
Implementer/Administrator Log report
Patient appointment list

18. Monthly ART Report (page 1)
The monthly ART report comprises
Data elements for national reporting
Additional data to assist with facility management. These include:
Clients started with prior ART exposure (HAART Experienced)
Transferred in (in this month)
Transferred out (in this month)
Waiting list (clients eligible for ART)
Clinical visits (in the month)
Total new clients ever started in this facility

19. Monthly ART report (page 1)
National data elements for reporting

20. Monthly report (page 2)
Information on this page is to support management
Number of restarts on ART
Number of pregnant women started on ART (in the month)
With CD4 strata
Rolling calendar of enrolment (new) and remaining on ART (TROA)

21. Quarterly Cohort Reports
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
Refer people to the ART M&E SOP

22. What is a cohort – what does it mean?
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

23. Data elements (Quarterly)
Quarterly data elements
What this data tells us
Baseline
Demographics of clients starting ART (adults and children separately)
Their immunologic status at ART start
Over time
11 data elements over time (adults and children separately)
outcomes of clients on ART
programme quality indicators at different time points
Cumulative retention in care (or the reverse, cumulative LTF/RIP)
Immunologic responses to treatment
Clinical outcomes can be compared between sites, sub-districts, districts and, with the standardisation of monitoring tools, between provinces

24. Quarterly Reports Demonstration of VL data
Interpreted Quarterly Cohort Report

25. Our reports can be a reflection of how well the system is functioning?
Therefore it is essential the quality of the data is good in order to adequately interrogate the program.

26. How is it captured in TIER.Net?

27. Data clerks get this information from clinical stationery
Data clerks get this information from clinical stationery X
345
LDL
cmh

28. Viral load journey: making it to the Quarterly Reports.....
Patient comes to clinic on appt day
Clinician requests bloods on stationery
Pt goes to blood room
NHLS form completed and blood drawn
Bloods sent to NHLS
NHLS processes blood
NHLS sends results to facility
Results sorted
Pts w abnormal results recalled
Blood filed in folder
Patient comes for clinical visit and reading of results
Sister documents results on ART stationery
Results captured into TIER.Net (dc initials beside blood result)
Quarterly reports generated
Report data analyzed; clinical care/resource allocation
Improved patient outcomes
The red highlights the various points where the VL might not be done or captured. Data is retrieved from the clinical stationery. It must be filed in the patient folder.
The red blocks illustrate places problems where the results aren’t effectively managed. Refer to ART M&E SOP.
2/8/2020
Thanks to Claudine Hennessey for this slide

29. The diagram on the previous screen illustrates the journey of the laboratory request and results
The red blocks highlight the key points where the VL might not be done or not captured, though all blocks are places where the results might drop off (i.e. not happen).
This also illustrates the integrated role everyone plays to ensure the results are returned to the patient file and captured into TIER.Net.
If the laboratory request is done (sticker in the clinical stationery), but the result is not filed in the patient file, the clinician does not have the information to effectively manage the patient.
If the result is not captured in the stationery the data capturer cannot capture the result. This results in low proportions of VLD. And unreliable VLS.
The implication of not filing the results is we are not effectively managing our patients but we are also spending a lot of money on laboratory tests that aren’t being acted on!
Additionally – results NOT captured into TIER.Net are not included in the push button management reports.
Refer to ART M&E SOP for further guidance.

30. Calculations VLD and VLS
𝑽𝑳𝑫 𝒙 𝒑𝒐𝒊𝒏𝒕 𝒊𝒏 𝒕𝒊𝒎𝒆 = # 𝑽𝒊𝒓𝒂𝒍 𝒍𝒐𝒂𝒅 𝒅𝒐𝒏𝒆 #𝑭𝑳𝑹+#𝑺𝑳𝑹 #𝑻𝑳𝑹 𝒙 𝟏𝟎𝟎
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 𝒙 𝒑𝒐𝒊𝒏𝒕 𝒊𝒏 𝒕𝒊𝒎𝒆 = # 𝑽𝒊𝒓𝒂𝒍 𝑳𝒐𝒂𝒅 𝑺𝒖𝒑𝒑𝒓𝒆𝒔𝒔𝒆𝒅 #𝑽𝒊𝒓𝒂𝒍 𝑳𝒐𝒂𝒅𝒔 𝑫𝒐𝒏𝒆 𝒙 𝟏𝟎𝟎
VLS is the proportion of patients with a result entered, that was less than 400
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:
The viral load done (VLD) data can be used as a proxy indicator for quality of care as this presents the number of viral loads that were done, filed into the patient folder, and the result captured into the clinical stationery as well as into the monitoring system. Therefore, this means the data was available for the clinician to act on and the data capturer had the data to capture.
VLD is represented by the blue line in the previous slide and the blue bar in next slide.
𝑽𝑳𝑫 𝒂𝒕 𝟏𝟐 𝒎𝒐𝒏𝒕𝒉𝒔 = 𝟖 𝟏𝟎+𝟎+𝟎 =𝟖𝟎%
𝑽𝑳𝑺 (𝒂𝒕 𝟏𝟐 𝒎𝒐𝒏𝒕𝒉𝒔 𝒐𝒏 𝑨𝑹𝑻) = 𝟔 𝟖 =𝟕𝟓%
2/8/2020

31. Reminder of the Viral Load and how it’s managed in TIER.Net
All viral load results captured in TIER.Net ARE included in the cohort report.
Where they are included depends on when the tests were requested by the clinician (done).
The grace periods to the rules are as follows:
+/- 3 months for 6 month bloods
3 months to + 6 months for 12 month bloods
Thereafter, +/- 6 months for annual bloods

32. Note: re rules in TIER.Net
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.
No data will be excluded from the reports (except where a result is entered between 0 – 3 months from ART start).

33. However, there are three caveats to the rules regarding the management of Viral Load results in TIER.Net
Caveat 1:
If a person is not on drugs when the annual Viral Load is captured then the bloods will be excluded.
This can be for 2 different reasons:
Data quality/completeness: if no visit is recorded (i.e. no regimen data) but a laboratory test is captured, the lab test will be excluded from the data as there is no corresponding visit to link to the requested test.
Reminder: the denominator for VLD is FLR+SLR+TLR. Thus, if no regimen is recorded then the laboratory result is excluded but this would also be excluded from the denominator. Data quality and completeness should be verified to ensure patient visits are captured.
Clinical management: Where a patient might be stopped treatment for clinical management reasons (i.e. this might happen if someone had hyperlactatameia and therefore had to stop drugs for their blood to normalise). This would be recorded as a patient visit with a 'stop' recorded and zero drugs issued. This too is excluded from the data collation. NB: Results are to be captured under the visit the bloods were drawn and not the date they were returned to the facility or the date they were filed.
[Interpretation: if a regimen is not captured but a blood result is captured in the corresponding visit the blood result won’t be included in the summary. Important to ascertain if this is a clinical management or data quality/completeness issue.]

34. Caveat 2
Caveat 2:
A patient with an outcome during the cohort summary duration being reported will be excluded from the summary data. Data is only reported on patients who are active on ART [defined as FLR+SLR+TLR in the duration the result is captured]
E.g. reporting for 24 months, those patients with a viral load captured and an outcome between 12 and 24 months will be excluded from the data collation. But, again, the patient would not be included in the denominator so this would not affect the VLD data.
[Interpretation: laboratory results are excluded where a patient has an outcome. Thus, this does not affect the data completeness due to the denominator definition for VLD which is FLR + SLR + TLR. The patient is removed from the active population and hence from the denominator]

35. Caveat 3
Caveat 3:  
Only one laboratory result per reporting duration is included. If more than one viral load is captured within the same duration (and grace period) only the latest result captured is included in the collated data per reporting duration.
[Interpretation: only 1 test is counted per person, per reporting duration. Any additional tests done and entered for patient management and monitoring purposes are important and comprise any other VL reports but they are not included in the aggregate cohort data in the cohort report]
Note: The rules in TIER.Net summarize data aligned to the National treatment guidelines and are not meant to prescribe patient or clinical management. TIER.Net collates the data that is captured to inform program monitoring.

36. Illustration of inclusion and 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
Annual lab test
36 month lab test
6 month lab test
ART Start
24 month lab test
Today
183 days
273 days
Grace period
Mar 5
Sep 3
Grace period
Jun 2
Grace period
Grace period
Continued annually
364 days
371 days
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
365 days
Jun 7 - Jun 6
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).

37. Reminder: cohort data is reported in arrears
The cohort data is reported 3 months in arrears. 
This means the data produced for the quarterly report (e.g. on October 10th) is current to end June. 
The delay allows for the return of and correct recording of patients, and
The filing and capturing of results. 
Detailed explanation:
Page 14 of the ART M&E SOP provides guidance to manage the laboratory results for optimal patient management from receipt at the facility to capture into the ART M&E system. Where this is followed, by the next clinical visit the patient results should have been:
returned to the facility,
sorted and reviewed by a clinician.
Urgent results identified and patients recalled.
Normal results filed in the patient file
recorded in the patient stationery by the clinician at the patient visit.
This would then be captured by the data capturer following the clinical visit*. 
Where the VL results are filed, and then captured at a subsequent visit, this data would then reflect in the data by the October submission period. 
* This needs to be thought through as it relates to patients enrolled in CCMDD as patients won’t be returning to the clinic and this potentially impact VLD. This requires operational consideration and should inform the development of the TB/HIV M&E SOP

38. Consecutive Unsuppressed Viral load Report
Lists patients whose two last Viral Loads were unsuppressed (>400 copies /ml)
Assists clinicians to identify patients who are on ART but their Viral Load is still not suppressed
This assists to:
Monitor patients more closely,
Target enhanced counselling, since the patient may be non-adherent to the treatment
Identify patients where further investigations need to be done (i.e. refer for resistance testing as the patient may be resistant to treatment)

39. Patient Appointment List
A list of all the patients who have an appointment on a particular day
Shows the ART start date, last visit date, months of ART prescribed, duration (months) on ART, duration (weeks) since the last visit, the appointment date, last CD4 count and last VL
Indicates whether patient is in a sub-clinic/chronic club

40. Patient Appointment List

41. Missed appointment lists
Early missed appointment list
Presents list of all patients that missed appointment between 2-3 weeks
Must be produced every Friday.
Late missed appointment list
Must be produced on the last Friday of every month
Unconfirmed lost to follow-up list
Presents a list of all patients without drug in hand for >90 days
Must be produced on the last Friday of every month
Further guidance on generating the reports and how they are actioned is available in the SOP (and SOP table)

42. What happens if clerks are not pulling reports?
What if the latest patient visit isn’t captured?
After 2 weeks patient will appear on the early missed appointment list
The clerk will have to pull the folder, confirm the patient did not attend, and forward all folders of non-attending patients to the Facility Manager.
If the patient did attend but the patient folder was not captured this creates unnecessary work.
What happens if the facility doesn’t pull the early missed appointment list?
Patient will appear on the late appointment list
The clerk will have to pull the folder and capture
What happens if the facility doesn’t pull the late missed appointment list?
Patient will appear on the defaulter list

43. What happens if the lists are not generated?
The facility doesn’t pull the missed appointment lists and unconfirmed lost to follow-up list?
The list just gets longer
The remaining in care number decreases
Money for the ART program (staffing, resources) reduced
Patients who are on treatment are being considered defaulters
CHW are sent out to the community to ‘check’ on the patient without needing to – taking away from those patients that DO need help
THIS is bringing the ART program to a halt!!

44. Additional reports available (not shown)
Illustrated reports
Workload report
User Access Report

45. Built in Help Functionality
Help document
Accessed from the Help tab
Explains how to use TIER.Net
i.e. searching for a patient, how to enter information, how to generate reports etc.

46. Built in Help Functionality
Click on Help > Help Contents

47. Built in Help Functionality

48. Help Function Select a topic from the contents list
Hyperlinks – click on a hyperlink (blue underlined text) to open the content