Basic components of the NETLAB system
The NETLAB system was developed during the last quarter of 2006 and was implemented and started collecting information on January 30, 2007. It has three main components: (1) a registration component for entering the data from the moment a sample is received until test results are complete; (2) a reporting component to communicate the test result to different users; and (3) an educational component.
The registration component of NETLAB gathers two types of information: one about the sample and one about the patient. Registration starts with the assignment of a barcode to each sample when it reaches the reception area of the laboratory and the use of the same barcode throughout the analysis and reporting process. The use of the barcode minimizes human error and also enables sample tracking. Basic information about the patient is also recorded using a unique identification code for each person. This number corresponds to the National Identification Document (DNI) that all Peruvians receive and keep until death. This number, which used to be assigned at age 18, is now given starting at birth. The DNI number allows the NETLAB system to maintain patient-specific information and search for historical information about patients in the database.
The NETLAB system also has the capacity to automatically detect duplicate or omitted patient data and request verification from the individual or establishment that sent the sample. Email messages are sent to the health provider, health establishment or laboratory that provided the sample in order to seek further information about the client and sample and if necessary, request a new sample, thus improving the quality of test results and information about each patient.
The system allows the registration of test results both manually and automatically, all of which are double-checked prior to publishing. Automatic registration is available for CD4 counts since the cytometer is connected to the NETLAB system database through a platform. Before any results are made accessible to the public, they are verified by the laboratory coordinator.
There is one additional function that has been very useful for follow-up of samples. This function is based on a module that marks pending results with green, yellow and red flags (like a traffic light) if the sample processing is on time (according to the on-line catalog times), delayed by one day after the expected time for results, or delayed two or more days longer than expected. This is quite helpful for monitoring laboratory performance and the quality of services provided by the laboratories and for improving patient care, since delayed results and health care decisions could jeopardize patients' treatment and health.
The reporting component of NETLAB makes the system accessible to all users over the Internet (Figures and ), including an expanded number of laboratory personnel, health providers, health administrators and PLHIV. The system assigns a unique profile to each group of users based on the type of information access that each group requires either as a human right, as is the case with PLHIV, or in order to carry out their professional responsibilities, as is the case with the other groups. Additionally, access to this information will further engage health service users in their own treatment and care and should also help them to become more adherent to treatment. Through NETLAB each PLHIV can access all of his or her test results carried out through the Ministry of Health, independent of the health establishment where the test was taken, and health providers in the HAART program can access the historical results of all of her or his HAART patients. Each individual user accesses the NETLAB system through a unique username and password that is known only to the individual. Users can enter the system through any computer that has Internet access, either at a health establishment, a public Internet cafe or at home.
Main NETLAB screen. Shows the primary NETLAB screen, including points of access for laboratory personnel, health providers and health administrators (left side) and for HAART patients (right side).
NETLAB access icon. Shows the NETLAB access icon, which is displayed on the main webpage of the Peruvian National Institute of Health and provides direct access to the main NETLAB screen shown in Figure 2.
NETLAB results are provided in a user-friendly, easy-to-understand format and users are able to access both current and historic test results (Figure ). Simple text is used to show the type of test, the establishment where it was taken, and the numeric result for all of the PLHIV's HIV-related tests. Simple graphs are also presented, showing the individual PLHIV's test results over time. In addition to obtaining test results, NETLAB users are able to provide constant feedback and report any problems or questions. The main NETLAB screen prominently displays a feedback form through which the user can describe difficulties and questions and send a message directly to NETLAB staff, who respond within 24 hours.
Figure 4 Presentation of individual CD4 count and viral load results over time. Shows historical test results for a HAART patient, including 10 CD4 counts and 10 viral loads, which are available to the patient and the patient's health provider through the NETLAB (more ...)
The educational component of the NETLAB system significantly expands its utility for all users. On the main user screens, prior to entering the username and password, all users and others who might be interested are able to access educational information. The screen for PLHIV explains CD4 cells, CD4 counts and viral loads in a simple-text format that includes graphics (Figure ). The screen also provides numerous links to high-quality, user-friendly webpages that might be of interest to PLHIV, about HIV/AIDS, opportunistic infections, treatment and advances, support, nutrition and PLHIV rights. Also, all results provided to PLHIV are accompanied by a message that encourages the user to discuss her or his test results with the health provider. The screen for health providers and administrators provides links to updated information about HIV/AIDS, resources on related clinical care and research, and scientific journals.
Figure 5 NETLAB educational material for people living with HIV. Shows the NETLAB screen of educational information for PLHIV, which includes an explanation of CD4 cells, CD4 counts and viral loads, as well as links to webpages that might be of interest to PLHIV. (more ...)
In Table we present a summary comparison of the way results were offered through the INS before NETLAB and with the NETLAB system.
Characteristics of the management of test results before NETLAB and with NETLAB
Achievements of the NETLAB system
In 2007, tests for diagnosing and monitoring HIV/AIDS represented 41.2 percent of the total production of the Peruvian National Institute of Health (INS). In Peru, CD4 counts are monitored at baseline in recently-diagnosed patients and then periodically, at least once per year, both for PLHIV who are currently taking HAART and for those who do not yet take HAART. Samples for CD4 counts are taken at health establishments throughout the country and then sent to the INS or one of ten regional laboratories for analysis. Viral loads for PLHIV are also taken at least once a year and sent to the INS for analysis.
The NETLAB system processed and registered 16,053 CD4 counts and 16,047 viral loads in 2007, a significant increase over an average of 6,516 CD4 counts and 6,744 viral loads per year between 2004 and 2006. The number of PLHIV with recorded CD4 counts and viral loads also increased, from 11,169 in early 2007 to 14,667 at the end of 2007 and 18,907 as of September 2008. NETLAB has greatly improved the efficiency of the process for reporting test results. Before NETLAB, laboratory results were paper-based and could take an average of 60 days [range 15-120 days] to reach the health provider. Through the NETLAB system, laboratory results are available on the NETLAB webpage to all users who should have access on the same day that results are ready. The average time from completion of testing to publication of results has decreased to 1 day [range 1-22 days].
The number of individuals who are able to access results has expanded significantly, from 66 users prior to the implementation of NETLAB in late-2006 to 2,037 users through NETLAB as of mid-2008. Current NETLAB users include 944 PLHIV and 1,093 health providers.
Evaluation and improvements in the NETLAB system
Since the start of NETLAB, two survey-driven evaluations were carried out with PLHIV and health providers, all of whom are involved in the HAART program but not necessarily in NETLAB. The first evaluation took place 5-6 months post NETLAB initiation and the second took place 14-15 months after NETLAB began operating.
People living with HIV (PLHIV)
As shown in Table , over half of the PLHIV interviewed in both surveys reported knowing how to use the Internet and a high proportion of interviewees used the Internet at least once a week. The most remarkable changes were seen in the awareness of NETLAB, which increased from 9.5 percent to 52.3 percent between the first and second surveys. Some questions about exposure to training on the use of NETLAB and possession of a NETLAB password were only asked in the second survey. Around 16 percent reported having received training on NETLAB use, 11 percent reported already having a password and 14 percent reported having requested a NETLAB password (data not shown in table).
Internet use and awareness of NETLAB among people living with HIV and health providers
During the later evaluation, 14-15 months post the start of NETLAB, twenty PLHIV who had experience with NETLAB also participated in focus groups. Participants made numerous recommendations, including the importance of making the link to the NETLAB system more accessible and visible and making the process for obtaining a username and password less bureaucratic and available on-line. All of their recommendations were acted on within a three-month period, demonstrating NETLAB's commitment to the population it serves. The NETLAB icon was moved to a prominent position on the INS web page and the process for gaining access to the creation of a username and password was changed from a paper-based to an on-line system, which still maintains strict ethical guidelines. The capacity to generate a new username and password in the case of a lost or forgotten username or password has also been included on-line. In terms of the NETLAB system itself, participants recommended the addition of educational information that is brief, with minimal text and in simple language. These recommendations were also integrated into the system and are now part of the educational component, described above.
Internet use was also very high among health providers, with 95.5 percent of respondents during the first survey and all respondents during the second survey reporting knowledge of how to use the Internet and almost everyone accessing the Internet at least two times a week. As with PLHIV, there was an increase in awareness of NETLAB among providers between the first and second surveys, with awareness nearly doubling from 50.4 percent to 96.5 percent of providers. The proportion of providers who had a NETLAB password more than doubled, from 35.4 percent to 76.8 percent. Of the 82 health providers who had heard about NETLAB in the second survey, 68 or 82.9 percent of health providers had received training in how to use NETLAB. All laboratory personnel had received training, compared to 8 in 10 non-laboratory health providers (80.7%) (data not shown in table).