Performance and user acceptance of the Bhutan febrile and malaria information system: report from a pilot study

Background Over the last decade, Bhutan has made substantial progress in controlling malaria. The country is now in an elimination phase, aiming to achieve no locally transmitted malaria by 2018. However, challenges remain and innovative control strategies are needed to overcome these. The evaluation and user acceptance of a robust surveillance tool applicable for informing malaria elimination activities is reported here. Methods The Bhutan Febrile and Malaria Information System (BFMIS) is a combination of web-based and mobile technology that captures malariometric surveillance data and generates real time reports. The system was rolled out at six sites and data uploaded regularly for analysis. Data completeness, accuracy and data turnaround time were accessed by comparison to traditional paper based surveillance records. User acceptance and willingness for further roll out was assessed using qualitative and quantitative data. Results Data completeness was nearly 10 % higher using the electronic system than the paper logs, and accuracy and validity of both approaches was comparable (up to 0.05 % in valid data and up to 3.06 % inaccurate data). Data turnaround time was faster using the BFMIS. General user satisfaction with the BFMIS was high, with high willingness of health facilities to adopt the system. Qualitative interviews revealed several areas for improvement before scale up. Conclusions The BFMIS had numerous advantages over the paper-based system and based on the findings of the survey the Vector-Borne Disease Control Programme has taken the decision to incorporate the BMFIS and expand its use throughout all areas at risk for malaria as a key surveillance tool. Electronic supplementary material The online version of this article (doi:10.1186/s12936-016-1105-0) contains supplementary material, which is available to authorized users.


Log-in program
Getting started Bhutan Malaria System, users need to log-in into system via username and password by following steps below: To exit the system, users can click the exit menu at menu bar ( Figure 2) and then the system will show exit box for assuring to exit the system (Figure 3).
-Click "Yes" for exiting the system -Click "No" to return into the system 2.

HOME
This window shows the summary of patient's number by malaria infection status and type of patients ( Figure 4). Number of patients in HOME window will be showed depend on blood draw date. To see this window, user can click at HOME menu at menu bar then select blood draw date.

DATA ENTRY
This menu will be used to register new patients and also enter the data for each form of malaria cases include malaria case register form, notification form, investigation form and follow up form. This menu composes of 4 sub-functions include;

Case register
Case register menu is a menu for adding data of new patients by following electronic form in the system. The index shows summary table of all patients who is already registered. Users can edit data or delete patients by using the edit and delete key at the end of patient's row in this summary table ( Figure 5).
To register new patients, user can click at "ADD DATA" key ( Figure 6) then the program will open the window of "malaria case register form" (Figure 7). This malaria case register form in the program is same as the paper form in Bhutan malaria routine work. Fill the patient's data in each blank and then click "SAVE" to register patient into the system.

Case notification
After users register patients in the system, the system will exclude patients who are positive results for malaria infection diagnosis into the list of notification. In the case notification menu, patients who are positive results will be listed in summary table (Figure 8). To fill data in the malaria case notification form, users can do it one by one by click "ADD" key at the end of patient's row in the table then the window of electronic malaria case notification form will be opened ( Figure 10). Users fill the data in the fields include; patient information, history, and diagnosis and treatment, then click "SAVE" for completely form.
However, users can edit patients's form, cancle and delete patient's form by using function key at the end of patient's row in the table. To cancle patient's form, when users click "CANCLE" menu the system will ask you for reasons to cancle patient's form. The reasons to cancle patient's form include: lost form don't get form already investigate but form not found other Users need to choose one reason before cancle patient's form and then click "SAVE" for completely cancle patient's form ( Figure 9).  1-8 ( Figure 10)

Case investigation
This menu will be used to investigate patients by following the malaria case investigation form and this menu will be linked with follow-up application on mobile phone. List of patients in this menu are same as list of patients in the menu of case notification. Users can add the data for investigation one by one by click "ADD" key and also edit form, cancle and delete patient's form by using key at the end of patient's row (Figure 11). After users click "ADD" key to add investigation's data, the window of electronic malaria case investigation form will be opened ( Figure  13). Users can fill data for patient's investigation by following fields in the form include; history of malaria control measures at patient's home, geographical reconnaissance information, entomological investigation and then click "SAVE" for completely form.
To cancle patient's form, when users click "CANCLE" menu the system will ask you for reasons to cancle patient's form. The reasons to cancle patient's form include: lost form don't get form already investigate but form not found other Users need to choose one reason before cancle patient's form and then click "SAVE" for completely cancle patient's form ( Figure 12).  1-10 ( Figure 13)

Case follow-up
This menu will be used to enter data of malaria case follow-up, and this menu will be linked with follow-up application on mobile phone. Generally, malaria case in Bhutan will be followed up 3 times at day 3, day, 14 and day 28. However, users can directly enter data on malaria case follow-up form by click on date in column of appointment date ( Figure 14) and then the widow of malaria case followup form will be opened and users can enter follow-up's data by following each fields in the form include; clinical status, blood test for malaria parasites, medication administration (day 3 and day 14 only), and lost to follow-up ( Figure 15).

4.
REPORT This menu will be used to see and export report of all malaria case form. This menu composes of 5 report of malaria case form include; -Malaria case registration form -Malaria case notification form -Malaria case investigate form -Malaria case follow-up form -Fever report form

Malaria case registration form
In this menu, users can see and export report of malaria laboratory register. To print report in standard format, users have to choose the range of time that users want to know and then click "PRINT" 1 to print out report of summary malaria laboratory register during time which users selected ( Figure 16). Users also export report in excel format by click at "EXPORT to EXCEL" 2 and then choose destination to save this report.

Malaria case notification form
This menu will be used to see and export individual report of malaria case notification form. Firstly, users have to selected conditions for searching malaria cases then list of malaria case will be showed in table. Users can see report one by one by click "PREVIEW" key at the end of malaria case's row in table and print out report. Users also export report in excel format by click at "EXPORT to EXCEL" and then choose destination to save this report ( Figure 17).
( Figure 17) 1 2 The report of malaria case notification form is showed below;

Malaria case investigate form
This menu will be used to see and export individual report of malaria case investigation form. Firstly, users have to selected conditions for searching malaria cases then list of malaria case will be showed in table. Users can see report one by one by click "PREVIEW" key at the end of malaria case's row in table and print out report. Users also export report in excel format by click at "EXPORT to EXCEL" and then choose destination to save this report ( Figure 18).

Fever report form
This menu will be used to see and export report of fever report form. Firstly, users have to selected week for searching malaria fever cases. Then, users can see report by click "PRINT" key to print out report. Users also export report in excel format by click at "EXPORT to EXCEL" and then choose destination to save this report ( Figure 20).
( Figure 20) The malaria fever case report form is showed below;

SYNCHRONIZATION
After users entered data for each form into the program, this menu will be used to synchronize all data to the data center. To synchronize all data to the data center, users can click "SYNCHRONIZATION" menu at the menu bar ( Figure 21) then click "SYNCHRONIZE DATA" and all data will be synchronized to the data center. This process will take several minutes. When all data was already synchronized, the system will show warning message.

ABOUT
The menu will show detail of the "Bhutan Malaria System" (Figure 22).