NCD Data Digitalization Initiative

1. Background & Purpose

Since the implementation of SystmOne (CCMS) in September 2023, the NCD Unit has transitioned from paper-based documentation to a fully digital record-keeping system. This digitalization effort aims to:

• Enhance data continuity and medical history accuracy
• Enable better clinical decision-making
• Support long-term reporting, screening eligibility, and resource planning
• Reduce double work: reduce medical practitioners workload where previously we need to update patients data into CCMS and patient's physical NCD book.

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2. Scope of Data Transcribed into SystmOne

Digitalization covers transcription of:

1. Disease diagnosis & date of diagnosis
2. Underlying comorbidities
3. Past lab records: HbA1c, TC, LDL, BP, BMI, waist circumference
4. Anthropometry and vitals
5. Medication history & adjustments
6. Past imaging investigations
7. Compliance and complication records
8. Follow-up visit summaries

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3. Patient Tagging System

To streamline recognition of digitalized records:

• In SystmOne, a custom status alert in the patient profile is set ✅ NCD Data Digitalized
• In physical NCD book, a Record Dismissed stamp is placed:
  • On the large patient folder NCD book
  • On the green NCD booklet

NCD Booklet after Digitalization

Patient record fully digitalized.

Dual Notification

This serves as a dual notification mechanism to prevent unnecessary reliance on physical NCD books. Registration staff does not need to search for patient's physical book anymore during registration.

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4. NCD Digitalization Progress

Condition	Start Date	Staff Involved	Progress (May 2025)	Progress
1. Hypertension	Jan 2024	1–2 dr/ week (PM session)	~1,500 patients digitalized ~200+ pending Halted since Dec 2024 due to staff limitation	Completed 80%
2. Diabetes Mellitus	Aug–Sep 2024	1–2 staff/week (1 day/week)	~150 patients digitalized ~1,500+ pending Halted since Jan 2025 due to staff limitation	In Progress 10%

This reflects a systematic approach to clinical data migration aligned with MOH EMR expectations, ISO 9001 data accuracy standards, supports care continuity, digital audits & better screening tracking.

Important Note

Due to limited staff allocated for the process, DM & HPT patient data has not yet been fully digitalized. However, it is important to note that current patient data is being fully recorded into CCMS. This means that while the digitalization of historical data is halted, new patient records are being consistently documented, ensuring the continuation of the digitalization process.

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5. Secondary NCD Data — NCARDIS

Before CCMS, PKD Muar utilized an Appsheet-based system to record NCD data, which was implemented across all Klinik Kesihatan in the district.

From the perspective of KK Maharani, the NCARDIS system serves as:

• A mechanism for backing up data and to visualize old patients data.
• A secondary reporting tool for the district and PKD Muar level.