ATLAS network objective and rationale
The objective of the ATLAS network is to develop and implement an STI and BBV surveillance system representative of ACCHS nationally, to supplement the NNDSS and contribute to improved understanding of local, regional and national patterns of clinical care of STI and BBV.
Electronic medical records (EMR) generally do not have the capacity to extract and analyse population-level STI and BBV data internally, sufficient to evaluate clinical practice and inform CQI. The ATLAS network provides this capacity.
Participating research partners
We invited five peak Aboriginal health service organisations representing regional areas in four Australian jurisdictions to partner in this research. Each organisation represents the views of multiple ACCHS of Australia within their geographical remit and agreed to act as ‘clinical hubs’ for this research. The five clinical hubs are Apunipima Cape York Health Council; the Institute of Urban Indigenous Health; the Aboriginal Health and Medical Research Council of New South Wales; the Aboriginal Health Council of South Australia and the Kimberley Aboriginal Medical Services (Figure 1). These hubs were chosen based on convenience, geographic location and existing collaborative relationships with the research team. Each clinical hub is committed to oversight of the ATLAS network and other research generated as part of the study.
Figure 1 – Map of CRE-ASH /ATLAS clinical hubs
The ATLAS network aims to have recruited 40–50 ACCHS from within the five clinical hub regions by the end of its funding period in 2020. The research team has committed to an extensive and ongoing community and site engagement process, which commenced while the funding proposal was being developed. Executive staff, sexual health/population health specialist staff and other management from the five clinical hubs and individual ACCHS were consulted about their organisation’s participation in the ATLAS network. Executive staff were our links with ACCHS Boards for support and permission to undertake this work. Key contacts within each hub continue to support and strengthen our engagement with the ACCHS participating in the ATLAS network.
Research governance and ethics
Once support for the ATLAS project was secured from the peak organisations, regional and/or individual health services research governance and ethics committees were approached.
Formal approvals were sought and received from six research governance and Human Research Ethics Committee (HRECs) in total, including three Aboriginal-specific HRECs: the Aboriginal Health Research Ethics Committee in South Australia (EC00185, approval 04-17-732); the Aboriginal Health and Medical Research Ethics Committee (EC00342, approval 1300/17); and the Western Australian Aboriginal Health Ethics Committee (EC00292, approval 805, following approval from the Kimberley Aboriginal Health Planning Forum’s Research Subcommittee). Permissions were also obtained from the Far North Queensland Human Research Ethics Committee (as Queensland Health provides much of the primary care services in Aboriginal communities where the Apunipima Cape York Health Council is also active— EC00157, approval HREC/17/QCH/102–1173) and the Flinders University Social and Behavioural Research Ethics Committee (as the Lead Investigator’s affiliated institution— EC00194, approval OH-00142).
A critical component of the internal governance processes for the ATLAS project is a Clinical Hub Reference Group, providing critical oversight of and input to all research activities and is an important voice for the Aboriginal communities within which the participating hubs and ACCHS work.
Operation of the ATLAS network
The ATLAS network routinely collects clinical service delivery data from participating ACCHS via their EMR. ACCHS in the network contribute deidentified patient records relating to clinical care (testing, treatment and management) for in-scope STI and BBV either directly from the ACCHS’s EMR or via the third-party data extraction tool GRHANITEtm.
Most EMR require the use of third-party software to perform the extraction and delivery of relevant data in a standardised manner. We explored several different tools before opting for the University of Melbourne’s GRHANITE tool (28), software that has been successfully used in other sexual health research and surveillance projects (29-31) and which utilises best-practice approaches to patient deidentification and data encryption (16, 32). For our network, the hash-based deidentification process was a key feature as it is thought to be more secure than the Australian Government’s SLK581 (33), retaining no element of personal information in the hashed identifier, yet still facilitates person-based linkage across the ATLAS network irrespective of the EMR from which the data originate. Moreover, the GRHANITE hashed identifier also can facilitate linkage to other projects and/or health services using the same tool. Similarly, the highly automated and monitored data collection process substantially reduces workload for the ATLAS research team once the surveillance infrastructure is established, and enables further automation of the analysis and reporting system post-data delivery.
EMR data are transferred to the ATLAS project’s secure databank located at the South Australian Health and Medical Research Institute and cleaned and stored for analysis. The ATLAS data processes utilise a custom-built SQL server accessing R Studio and Stata scripts interfacing with MS Word to produce standardised analyses for all sites participating in the surveillance network.
The STI currently included in the ATLAS project are chlamydia, gonorrhoea, trichomonas, syphilis and HIV. The BBV currently included in ATLAS are hepatitis B and hepatitis C (in addition to HIV).
An initial suite of 12 STI and BBV performance indicators have been developed for the ATLAS network’s surveillance reports, reflective of national testing guidelines (13, 14) and having a strong basis in previous research in the sector (24, 26, 34)(see Table 1). Refinement of these performance indicators, including their fit with any current reporting and their application to clinical practice, was conducted in collaboration with the clinical hubs and the services contributing the initial datasets to the ATLAS project. Development of these performance indicators also incorporated input from related research projects involving members of the investigator group, to ensure that the needs of all projects working with the same ACCHS could be met by a singular data collection, analysis and reporting process.
Anticipated outcomes of the ATLAS network
The ATLAS network aims to increase understanding of local, regional and national patterns of clinical care of STI and BBV for the purpose of informing clinical practice, policy, and program-planning, and can be used to identify further research priorities for participating ACCHS. The ATLAS network returns data to health services on a regular basis, for use in evidence-based CQI processes applying a ‘plan-do-check-act’ cycle through which iterative improvements in service provision can be made (35).
The ATLAS data are also available for additional analyses addressing specific local priorities and other research activities undertaken within the broader Centre of Research Excellence in Aboriginal Sexual Health research program or by authorised collaborators once the appropriate review processes have been completed. For example, the ATLAS surveillance data could be used in the development of STI and BBV diagnosis and treatment cascades, or research examining the testing and treatment of STI and BBV in pregnancy.