The Tuberculosis (TB) pandemic, including its multidrug-resistant (MDR-TB) form, is a global health threaten. TB is one of the top 10 causes of death worldwide and the leading cause of death from a single infectious agent. An estimated 10 million people fell ill with TB in 2019 and 1.2 million people died (1).

The WHO End TB Strategy aims to end the global TB epidemic, with targets to reduce TB deaths by 95% and incidence by 90% between 2015 and 2035, and to ensure that no family is burdened with catastrophic expenses due to TB (2). In the years 2015–2019, TB incidence rate dropped by 9%, however this was less than halfway to reach the End TB Strategy milestone of 20% incidence reduction between 2015 and 2020 (3).

To achieve the End TB strategy goals and improve patients' management, effective surveillance systems are needed to measure and monitor the burden and the determinants of the disease. Implementing a functional TB surveillance system often remains challenging in many low- and middle-income countries (4). TB programs should promote the use of digital health platforms to collect patients' information, to reduce time and efforts to fill paper forms and to avoid common mistakes like data incompleteness and low accuracy. Digital health interventions can strengthen surveillance and monitoring, program management and ultimately patients' care (5).

Introducing a new digital health system needs an enabling environment and to deploy a formative stage to document bad and good practices, pivotal for the uptake of the new system (6). Therefore, a comprehensive approach is required, that starts with gaps and needs identification and the description of the patient's pathway for TB care (7).

Angola is among the 14 high burden countries for TB, TB/HIV and MDR-TB prevalence and is among the three countries, together with Congo and Liberia, that have never completed a drug-resistance survey so far (1). Moreover, according to the WHO country profile, Angola had a treatment success rate of 25% in 2017, much lower as compared to a pooled rate of 76.2% in sub-Saharan Africa countries in the last decade, according to a recent systematic review (8).

The Angola TB network is made of Sanatoriums, TB Dispensaries (DAT), Diagnostic and Treatment Units (UDT with smear laboratory), and Treatment Units (UT without smear laboratory). The TB surveillance system in Angola is weak, with main gaps regarding cases notification, data reporting and elaboration, and quality of data collected (9). The Angolan TB National Program (PNCT) uses a digital database to collect aggregated data from the network, however countrywide TB facilities continue to rely on paper-based tools leading to incompleteness, poor accuracy of data and delays in reporting. Therefore, it is imperative to enhance data collection and management in order to strengthen TB surveillance, programmatic decisions and patient's management. To this purpose, the implementation of user-friendly Electronic Medical Record (EMR) systems could improve data quality and strengthen the continuum of care by ensuring adherence to clinical guidelines and reducing errors in data recording and reporting. A study based in Malawi documented the positive outcomes of a point-of-care EMR system for HIV-TB patients in a public clinic (10). In Rwanda the use of EMR data for evidence-based clinical decisions improved HIV patients monitoring (11). A study in Kenya reported significant improvements in data quality through the implementation of a cloud-based EMR system for maternal and child health (12).

A systematic review showed that the factors that challenged the widespread use of EMR systems in Sub-Saharan Africa were the high costs of procurement and maintenance of the EMR system, poor implementation planning, issues with electricity supply and internet connectivity, and user's limited computer skills (13). Strategies such as phased implementation planning, financial sustainability, appropriate EMR system and training of users, showed positive results in EMR systems implementation.

Luanda is the capital city of Angola with one-third of the Angolan population living in conditions of overcrowding and poor sanitation. Luanda has the highest TB mortality rate in the country (13.9^*100.000 inhabitants) and 245 MDR-TB cases over 534 (46%) notified at country level in 2018 (14). A recent study also showed that in Luanda chronic diseases like diabetes are an important comorbidity for TB patients (15).

The Sanatorium Hospital of Luanda (HSL) and the Anti-Tuberculosis Dispensary (DAT) of Luanda are the two reference health facilities in Luanda dealing with most of the TB cases, and being also reference centers for the diagnosis and management of MDR-TB (HSL) and provincial reference center for the PNCT (DAT). These two health facilities collect clinical and surveillance data entirely on paper medical records and registries and this may result in poor quality of data and ultimately poor patients' care.

The project “Stop TB and TB/HIV in Angola: Improving Access to TB and HIV treatment by enhancing diagnostic quality and patient management in the Province of Luanda” funded by the Italian Cooperation Agency (AICS—Agenzia Italiana per la Cooperazione allo Sviluppo) and implemented by the Italian non-governmental organization “Doctors with Africa CUAMM” with the technical support of the “Italian National Institute of Health” (ISS) aimed at improving the quality of diagnosis and management of TB and TB/HIV patients at the HSL and the DAT of Luanda. The project, among other activities, included the development of a TB EMR system, based on an enhanced TB medical record and the setting up of software and hardware features, to be piloted in the two health facilities. The EMR system development was a three-stage process and included first a situation analysis, second the development of an enhanced medical record and finally the development of the EMR system. The situation analysis supported the identification of the patients' flow and actual gaps and needs in data recording and reporting at the HSL and the DAT of Luanda. The results of the situation analysis were used to develop an enhanced medical record that aimed at filling the gaps and needs identified, and finally in the development of the EMR system. The process was consolidated through a workshop for the staff of the two health facilities (around 40 people) involved in the data collection with the double aim of promoting awareness about the importance of data quality and getting acquainted with the TB EMR system.

The aim of this paper is to describe the three-stage process for the development of the EMR system and share the lessons learned. The description is focused on the activities that took place from March 2019 to January 2020.

The process could be replicated in other health facilities in Angola and other similar contexts to improve TB surveillance, control and quality of care, to boost the achievement of the WHO END TB strategy.

After discussing the gaps and needs of the current data collection system emerged during the situation analysis, the EMR expert team fed the results in the elaboration of an enhanced TB medical record. To this purpose, the two medical records and patients' forms in use at the two health facilities were used as a starting point. The DAT used the standard clinical record adopted by the National TB Program with essential information about diagnosis and treatment. The HSL medical record was based on the National TB Program standard record, but included more information, reflecting its role in the management of complex cases and MDR-TB cases.

A preliminary version of the enhanced TB medical record was discussed with key stakeholders to assess information clarity, content and sequencing, and compliance to national guidelines, and adjusted accordingly.

A formative workshop was arranged in January 2020 in the two health facilities to introduce the HCWs (around 40) to the enhanced medical record and to instruct them about their use for the digitalised data collection. The formative workshop allowed the HCWs to increase their awareness about the importance of data collection for TB surveillance, for the quality of the patient management and to enhance the accuracy of data reported to the National TB Programme for programmatic decisions.

The enhanced medical record is divided into several sections that follow the patient's clinical pathway (Table 3).

The EMR expert team fed the results of the situation analysis and the contents of the enhanced medical record in the design of the EMR system. Software and hardware components were defined, according to the stakeholders' needs and recommendations. The EMR system has been designed as a real-time, point-of-care, internet-based system based on open-source software that employs C# and Java language and the MSSQL server 2017. The system is available in Portuguese and English. Although the system is web based, and it allows to work online and offline, so far it has been configured to be used on a LAN (Intranet) at the health facility level in offline modality only.

The system is accessible only to authorized staff that has been provided with username and password and keeps an audit trail by tracking users, locations, and time for all the accesses. Data is encrypted during offsite data back up using secure encryption protocols. The system owns the technical features needed to communicate with the District Health Information Software 2 (DHIS2) (16), the Health Management Information System that is increasingly being used by the TB National Program for aggregate data reporting. The system can produce internal and external reports according to formats and indicators in use in the two health facilities and within the TB National Program. Multiple testing sessions assessed the usability of the EMR system.

A print screen of the EMR system is shown in Figure 1.

The following lessons learned were collected during the project, through a continuous consultation process with the stakeholders involved.

The situation analysis was done only in two health facilities. Other relevant needs of other health facilities of the Angolan TB Network might not have been considered.

However, the enhanced medical record and the EMR system were developed considering comprehensive needs of all the stakeholders involved, related to the enhancement of data collection and management, in order to allow replicability in other TB services in Angola.

This study was a first attempt to promote a digital health intervention in the context of the TB National Program in Angola. The study was a three-stage process. The first stage allowed the identification of gaps and needs in the data collection systems of the two health facilities. The second stage included the development of the enhanced medical record, based on the findings of the situation analysis. The third stage supported the development of the EMR system. The EMR system developed in the two health facilities in Luanda owns all the features to improve data collection, data quality and finally patients' management and could be exported to the other health facilities across the country.

The main lessons learned in the process were to engage all the involved stakeholders since the beginning and during all the stages; to promote the “think digital” cultural revolution; to support the development of an M&E system through all the steps of the data collection flow; to include sustainability of the system among the priorities areas to be discussed before starting the process. The lessons learned were similar to other studies in similar context (10), thus reinforcing their relevance.

Covid-19 pandemic caused severe disruption in the planned activities for the piloting of the EMR system in the two health facilities. Nevertheless, once the health emergency situation will decrease, the system will be piloted, evaluated and refined. According to other similar studies, during the piloting stage of the EMR system, particular care needs to be focused on enhancing the accuracy of the data recorded (19, 20). The evaluation of the EMR system will target the actual impact of the system on data quality and quality of care. Weaknesses related to data collection that were highlighted during the situation analysis, and the compliance to the EMR system requirements, will be assessed. This will also include an analysis on how well the EMR system matches the actual workflow of patients, and if this could be improved to enhance patient's care.

The TB EMR system would be an important tool to be scaled up to other TB services of the Angolan network, allowing to improve data collection and management and finally to strengthen national TB surveillance, programmatic decision-making and patients' quality of care.

The data were retrieved from patients' registries. Requests to access these datasets should be directed to c.robbiati@cuamm.org.

CR, MD, MT, and GM contributed to conception and study design, data acquisition, and interpretation of results and drafting the manuscript. GP and FD contributed to study conception and interpretation of results and revised the manuscript critically for important intellectual content. PS, OL, and JN contributed to data acquisition and revised the manuscript critically for important intellectual content. MS contributed to study conception and revised the manuscript critically for important intellectual content. All authors read and approved the final manuscript.

This study was performed with the support of the Italian Cooperation Agency (AICS—Agenzia Italiana per la Cooperazione allo Sviluppo).

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

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