For this study we found an error rate of 1.6% for primary data items, while in earlier studies in the same setting data could not be analysed because of the massive data loss and poor data quality. With this real time data monitoring and inbuilt checks we have realized acceptable levels of data quality. The CTDMS prevents us from missing data or ending up with poor quality data at the end of the study, which often at that point cannot be resolved anymore.
The presented analysis shows that after five months since the introduction of the CTDMS the error rates for both Primary and Secondary data items reflect acceptable levels of data quality. Furthermore these error rates were decreasing over time. The drop in errors per form with each form submission indicates that, while being prompted by the CTDMS, the data manager and responsible doctors are actively solving the errors. Online warning messages notify the data manager (entering data) when errors are detected, allowing them to immediately correct the data, rather than the usual delay associated with paper based CRFs.
Clearly, the CTDMS encourages local data managers to verify the entered data and, if necessary, ask the doctor whether the information is correct. It is also likely that the reason that data managers have to specify arguments before submitting the form in case the CTDMS detects erroneous data motivates them to verify whether the available data is actually correct. This may explain why our results show a significant increase of clean data and a self-learning curve of the data manager is to be expected. Moreover, the error logs provide valuable information about the bottlenecks in the treatment of the NPC patients.
In the past authors have pointed out that existing data collections in developing countries are often deficient [10, 11]. Eiseman and Fossum (2005) emphasize that existing data collections are insufficiently comprehensive, sometimes inaccurate, and often out of date by the time the data can be acted upon. All point out that without these data the required empirical knowledge to address the health problems in developing countries is insufficient. Especially on strategic planning, priority setting, monitoring and evaluation, advocacy, and general policymaking [12–14].
These comments supported us on introducing an online medical record system which could play an important role in improving data collection and data quality. Accordingly, during analysis we have also seen that treatment procedures are often unsatisfactory. The first analysis regarding the treatment of NPC has been presented and discussed with all members of the disciplinary team. The main concern was the duration of the radiotherapy. According to the protocol the duration for administering the 66 gray radiotherapy should take to the utmost 42 days, yet analysis showed that the treatment time takes in average 66 days, which will lead to inadequate treatment [15, 16]. Future analysis has to show if intervention by CTDMS system-based education of the doctors will eventually lead to better treatment outcome. The digital nature of the CTDMS, as well as the online availability of data, gives fast and easy insight in adherence to treatment protocols. As such, the CTDMS can serve as a tool to directly train and educate medical doctors. Therefore, a potential even bigger advantage of an online medical record system is the ability to monitor the data from the teaching hospitals especially in developing countries. Via this way the teachers can communicate directly or visit the participating hospitals with a custom fit teaching program, which will make such visits more effective.