In line with country’s vision outlined in the NSP 2017-21, Zambia has already piloted SmartCare electronic case-based TB notification system online version in 10 facilities, and prior to that, the country has already rolled out SmartCare services for HIV cases successfully. Leveraging on the existing infrastructure in terms of database and deployment for Smart Care can lay a strong foundation for executing the vision of creating a comprehensive and integrated real-time case-based TB surveillance and notification system.

For this, the SmartCare system is desired to be implemented across all TB facilities and customized in line with the national TB treatment guidelines. This case-based notification system must accommodate components of monitoring of entire continuum of care for both DS TB and DR TB patients, starting from presumptive screening, referral, testing, treatment initiation, treatment adherence, treatment outcome and contact tracing in real-time.

The solution architecture should support adding all the above components in phases supported with versioning to ensure seamless upgrades and continuity.

Tentative timeline: Month 0-12

As visioned by the national TB program with the concept of an integrated Health Information Management System (HMIS), leveraging the current platform and foundation, basic integration and data exchange mechanisms should be worked out to avoid duplication of efforts and complement the existing data systems.

The current SmartCare platform infrastructure needs to be extended to support integration with national DHIS2, DISA system (GeneXpert), TruNat, Digital X-Ray outputs, Pill boxes and other adherence tools which help in using the data effectively for the patient continuum of care as highlighted by the National program.

Recommended exchange / ETL tools like Talend , Informatica which include these features make the data management task much easier and simultaneously improve data warehousing. ^{[8.1] , [8.2]}

The DHIS2 platforms architecture is easily compatible with these standard tools and processes making this an effective solution. ^[9] The data exchange process should follow and comply with FHIR , GDPR standards for more secured and seamless data exchange.

Tentative timeline: Month 6-18

NTP also envisages the need to simplify the data collection processes to enable robust data analytics and data use. Some of the activities include:

Inconsistent internet connectivity/network issues majorly hinder the data reporting. One effective way to overcome this is to support the current data collection processes by introducing a mobile application which will make the data entry process easier and will have features to store data offline which can then later be synched with the central systems.

The advantages for a mobile application include better performance, effective use of device features like in house system updates, usage of location, security measures and tracking user patterns and issue log mechanisms and other analytics measures.

The mobile application should be easily extendable to the current framework to support and ensure that the data structures are consistent and there is minimum effort to support any updates / changes to the program.

Additionally, the mobile frameworks using open source and standard technologies like Java, Postgre, React and Android, that are easily ( java , react ) supported by country IT teams will also have the standard best practices of mobile development like version management, data encryption, etc and will make this a more robust solution. ^[10]

Apart from the standard mobile / web interface there would be other sources of data collection, which include spreadsheets , csv , other apps that would need to be standardized and integrated with the existing DHIS2 aggregate and smart care system.

To ensure that there is a seamless integration from multiple channels without any data loss, the DHIS2 data transformation API also offers creation of standard templates which can be easily mapped with external data collection tools, apart from this, it supports batch upload for large volumes to ensure minimum disruption to the live systems. ^{[11.1] , [11.2]}

Tentative timeline: Month 0-6

NTP clearly emphasizes on the importance and need to improve data use and improving the data collection practices. As part of standard practices, the application(s)/solutions should follow the data quality mechanisms or the Data Quality Assurance (DQA) framework which would help in improved data use.

Data access control is another DQA measure that will regulate user’s access to meta-data. It will involve the principle of least privilege (POLP), i.e., user’s access will be determined based on their role in the project. POLP will define and limit what data they have access to and who has that access.

The training component of the application will also come with an e-learning package that should have a module on DQA and will support routine annual and periodic independent assessments of reported data.

To address the challenges with periodic training of facility level staff to orient them on using DHIS2/Smart care system for direct data reporting, the MOH must engage in development of a comprehensive eLearning module for app training.

Any national scale roll-out will have its own capacity and training challenges which requires development of a comprehensive eLearning module allowing all health staffs involved in data collection process for training not only on the eTB manager application but also on the latest manual of procedure and continued medical education on TB care.

While DHIS2 offers standard training modules on the application , training tools like Moodle ^[12] built on standard LMS framework can be reviewed for application rollouts.

One of the limitations highlighted by NTP is the need to improve the data collection processes at the facility level. To streamline this, procurement, distribution and maintenance of the required data entry equipment like laptops, mobile/tablet devices should be done on an urgent basis. Improving the current infrastructure at the facilities is crucial for a complete transition to digital notification.

Tentative timeline: Month 0-6

One of the main challenges highlighted by the NTP is the ongoing maintenance and enhancements of the platform. Since the application requires regular updates and to ensure effective adaptation and scale up the system support team requires trained personnel on DHIS.

Strengthening the NTP team with trained system administrators will help in reducing costs (in seeking technical support) and improving and expediting the planned implementations.

Tentative timeline: Month 6-24

These would also include developing a framework which should outline policies in line with recommended standard policies like HIPAA ^{[15.1], [15.2]} to cover Patient Data Management and Server & Infra guidelines.

Apart from application measures offered by DHIS2 ^[16] for patient data security , hosting solutions offered from Azure also cover these as part of their deployment options which can be considered as part of systems hosting. ^[17]