Improving Data Integrity in Public Health: A Case Study of an Outbreak Management System in Nigeria

BACKGROUND

Studies have shown that one of the most important factors in improving service delivery in health care is the quality of data.¹ Data are a fundamental part of health care delivery and can be used for government planning and resource management and allocation. Therefore, maintaining the integrity of health care data—the accuracy, completeness, and validity of health care data being collected and stored—is integral to quality health care provision.

Over the years, health care facilities in low- and middle-income countries like Nigeria have struggled to maintain complete, accurate, and valid patient data. This challenge can be attributed to factors such as inadequate manpower, lack of technical knowledge, and an increasing volume of patients.²

With the coronavirus disease (COVID-19) pandemic rapidly crossing borders and spreading across countries and continents, leading to the death of millions of people and hospitalization of more, health systems were overwhelmed across the globe. The novelty of COVID-19 drove an urgency in the process of collecting, assessing, and analyzing all available data to gather insight on the scope and scale of the pandemic while also providing insight into how the disease is spreading and the impact of interventions in place to manage the pandemic. Thus, the need for collecting and maintaining quality data has become even more important.

To support Nigeria’s COVID-19 testing capacity, the Nigerian Institute of Medical Research (NIMR) established a drive-through test center³ in Lagos, Nigeria, to conduct free testing. The test center can process sample collection at a quicker pace, thereby allowing a higher number of cases to be tested daily in addition to other local clinics. The data collected at the test center as well as from other sources were to be evaluated for research and to inform policies for managing the pandemic,⁴ therefore, the data had to be of high quality.

In April 2020, Co-creation Hub (CcHUB) embarked on a collaborative research and development project with NIMR and Lifebank, a health care technology and logistics company, to study the test center’s data collection system, identify gaps, and find ways to support or strengthen the test center’s data collection capacity with the use of design and technology. The team used a human-centered design (HCD) approach to understand the problem and co-create a viable solution to this challenge.

During the past decade, there has been an increasing adoption and integration of design thinking and practices in development initiatives, particularly in global health programming.⁵ The Design for Health⁶ community—launched by the Bill & Melinda Gates Foundation and the Center for Innovation and Impact in the United States Agency for International Development’s (USAID) Bureau for Global Health—defined 3 models by which design methods and mindsets can be applied to developing global health solutions: spark, ingredient, or end-to-end.

In this article, we discuss how we used design as a “spark” of inspiration to reframe the understanding of the existing data-related problems at the test center, develop new ideas and innovations, and push boundaries to think differently.

USING DESIGN AS THE SPARK

In Nigeria, health care processes have historically been using paper-based systems, and the mindset around rethinking the use of technology posed a big barrier when thinking about solving problems. COVID-19 presented an unprecedented challenge for data collection and its use in decision making due to the disease’s novel nature, the speed and scale of the necessary pandemic response, and the existing data integrity issues. Initially, the center was using a paper-based record system, which raised questions about the data integrity and quality.

The spark of inspiration for Co-creation Hub’s collaboration with the Nigerian Institute of Medical Research (NIMR) on improving data integrity came from NimCure, a project conducted in 2018 with NIMR³ to develop a digital tool to support TB data management and promote adherence to TB therapy.

Research findings showed that individuals were providing inaccurate data on paper forms, leading to the inability to track patients who tested positive for TB. The most troubling example of the TB’s system’s inefficiency was when 2 patients who had both tested positive for TB could not be contacted with their test results due to inaccurate contact information. These 2 confirmed and contagious TB cases could not be reached either for treatment or for isolation due to poor data collection at the registration point.

This observation inspired the team to further explore the challenges with data collection and management process for TB patients. The team engaged with key stakeholders in the design process, which allowed the value generated to convince the stakeholders to rethink the way they collected data and how to improve that process.

To avoid similar data integrity issues, especially as new patients were recruited for the Nimcure medical trial, the design process was expanded to accommodate a reconstruction of the directly observed treatment center’s data collection system, thereby strengthening the integrity of data collected.

This system would later become the basis for first developing digital form at the COVID-19 test center to improve data collection and data integrity and later the outbreak management system to improve sample collection and management.

OUR DESIGN APPROACH

THE OUTBREAK MANAGEMENT SYSTEM

The design approach inspired the deployment of an automated data collection and management system based on the one used for NimCure for TB management. Through the engagement of all the relevant stakeholders during multiple rounds of iteration, this simple solution evolved into a practical digitized data management system that promotes data integrity and helps test centers more efficiently manage data.

Unique value proposition: By automating and streamlining data collection, the outbreak management system makes it easier and faster to manage data. The system retrieves information on demography, symptoms, pre-existing conditions, recent contact, and travel history to identify and triage high-risk cases that require testing. Some of the system’s key features are described here.

1. Case reporting form: People who think that they might have the virus and want to get tested can communicate their symptoms and request to be tested by completing an online digital form. Prospective patients submit the form to allow necessary information to be gathered faster and recorded more accurately.

2. Triaging/eligibility indication: The system automates the screening and triaging process based on the Nigerian Center for Disease Control case criteria to ensure that test centers’ capacity and resources are directed first toward cases with the highest risk level.

3. Phone number verification: This feature runs every phone number submitted on the platform through a nationwide database to confirm existence and validity.

4. Address validation: Using Google maps application programming interface, the system can validate every address provided to confirm that they indeed exist on the map.

5. Access control: The classification of users with specific privileges helps maintain data protection by ensuring data can only be accessed and modified by appropriate and qualified users.

6. Privacy: A unique identification code ensures the privacy of patients’ data.

7. Contact tracing data: The system collects a list of persons that each case may have been in recent contact with in the past to understand how the individual contracted the virus as well as who they may have been in contact with since the possible contracting point. These data are collected to support contact tracing for positive patients.

8. Duplicate entry restriction: Repeat or duplicate entries are detected and restricted based on name, phone number, email, and date of birth. This helps to ensure that all submissions are unique to a specific individual and that patients cannot make multiple submissions.

Other features that were included during iteration were: test invitations, appointment scheduling, and result reporting.

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Screenshot of case reporting digital form co-created with Co-creation Hub and Lifebank in collaboration with the Nigerian Institute of Medical Research for the COVID-19 drive-through test center.

LESSONS LEARNED