Notifiable disease reporting starts in the patient folder

A large share of Nigerians who fall ill present first at a private hospital. That makes private practices part of the country's disease surveillance whether they think of themselves that way or not: the national picture of an outbreak is assembled from what facilities report, and a case that is seen but never notified is, for that purpose, a case that did not happen.

There is a careful piece of Nigerian research on how well that works, and its findings are not the ones people assume.

What the survey found

Makinde and Odimegwu surveyed 507 private health facilities across six South-West states (Ekiti, Lagos, Ogun, Ondo, Osun and Oyo) in a cross-sectional study run between November 2016 and November 2017. Lagos supplied the largest share of the sample at 235 facilities and Ekiti the smallest at 20.

• 201 of the 507 facilities, 40%, routinely reported notifiable diseases to the health authorities.
• The spread between states was wide: 17% in Ogun, 60% in Oyo.
• 34% of the facilities surveyed had the requisite data collection tools.
• 49% had personnel assigned to health records management at all.
• Of those 248 assigned officers, 13, or 5%, could properly identify the three data collection tools. Among clinicians the figure was 7%.

The survey is now some years old and the sample is one region, so read it as the best available description of a problem rather than as this year's measurement. But the internal consistency of it is what makes it useful: the facilities without the tools, without the assigned person and without the knowledge are largely the facilities that do not report.

The finding that reframes the problem

The sentence worth sitting with is not a percentage. Among the providers who said they had never seen a reportable case, over 90% had attended to at least one case of malaria in the year before the survey.

Malaria is notifiable. These were not facilities refusing to report. They were facilities that did not recognise what they were looking at as a thing to report, or had no route from recognising it to recording it in a form anyone could count.

That changes what a practice should do about it. Exhortation does not fix a recognition-and-recording gap. The record does.

Why it is a records problem before it is anything else

Notification asks a question a hospital's register has to be able to answer: how many of this thing did we see, in this period, among people living where?

A stack of paper folders holds every one of those facts and can answer none of them without someone reading every folder. That is why the 34% figure and the 40% figure sit so close together. A facility without the tools is not a facility that has decided not to comply; it is a facility that cannot produce the number without an afternoon of work nobody has.

Four things have to be true of the record before reporting is realistic:

1. The diagnosis is written somewhere consistent. If it lives in free-text prose in one clinician's notes and in an abbreviation in another's, no one can count it. This does not mean forcing structure onto every note. It means having one place where the conclusion goes.
2. The date is the date of the encounter, not the date somebody got round to writing it up.
3. Where the patient lives is recorded, at least to local government area. Surveillance is geographic; a case with no place attached is much less use.
4. The register can be read as a list, not only as folders. The question "how many of X since the first of the month" has to be answerable without opening anything.

None of that requires software. A well-kept paper tally does it, which is what the data collection tools in the survey are for. What software changes is that the answer stops depending on somebody having kept the tally.

What to check in your own practice

• Ask whoever writes your notes to name the last three notifiable conditions they saw. If the list comes slowly, the recognition gap in that study is your gap too.
• Ask who is responsible for health records by name. Half the facilities in the survey could not answer that.
• Ask for a count of one common condition over the last month, and time how long it takes to produce.
• Check that the diagnosis a clinician writes ends up somewhere a non-clinician can count without interpreting it.

What RizCare does about this, and what it does not

Be clear about the boundary first, because it changes what you would use us for. RizCare has no notifiable-disease module and does not submit anything to any surveillance system. It does not decide what is notifiable, and it does not file on your behalf. Notification remains the practice's duty and the practice's action.

What it does is make the underlying record capable of answering the question. One record per patient, carrying the paper folder number your practice already writes, with demographics recorded once rather than at every visit. Visits dated when they happened. Notes written from short templates or as free text, signed, and attributable to the person who wrote them. A register the whole team reads rather than a drawer one person can reach.

That is the part a practice can fix this year. The other half, knowing what is notifiable and to whom, is training, and it is worth doing at the same time.

If you are looking at the rules around the record more broadly, what Nigerian data-protection law asks of a hospital that keeps records covers the obligations that come with holding this data at all.