e Health Records: Proposed plan for Pakistan

 Modern day health care has touched new horizons via the introduction of Information and Computer Technology (ICT), over the last few decades. These ICT systems include Electronic Health Records (EHR), Laboratory Information System (LIS), Patient Administration System (PAS) etc., but in my opinion health systems around the world especially in developing countries can improve considerably via the implementation of electronic health records.

With the advent of information technology and computers, many institutions and organizations are going ‘paperless’, similar is the case with healthcare; but getting rid of papers and files is not the aim of Electronic Health Records, it is rather the accuracy of records, its accessibility and interoperability which makes it useful (WHO, 2006). Electronic Health Record is longitudinal health record of a patient which is universally accessible and is maintained real time throughout a person’s life, including in patient and ambulatory encounters, along with personal health information (Mon, 2004, Amatayakul, 2004). This explains that the term Electronic Health Record (EHR), differs from other terms which are used alternatively, i.e. Automated Health Record (AHR), Electronic Medical Record (EMR) and Computer-based Patient Record (CPR). These terms differ from EHR as they contain scanned patient’s record and minimal inpatient information, with limited access (Amatayakul, 2004).

EHR exists in various forms in the health systems around the world, depending upon a country’s needs and priorities. WHO’s vision ‘health for all’, does not limit EHR to specialized health care only, but extends it to primary health care as well (WHO, 2006). Keeping in view the concepts of ‘meaningful use’ and ‘continuum of care’, which are associated with Health Information Exchange (Kansky, 2014) and offered by EHR, it is obvious that all of its objectives are difficult, if not impossible to achieve not only in developing countries but in developed countries as well. 2013 statistics show that the health professionals are unable to use the EHR systems to its full potential (Stone , 2014). Problems with interoperability either due to differences in interfaces or privacy concerns has limited the accessibility of electronic health records only to a hospital, a group of care providers or a certain locality, but this may no longer be the case. The General Data Protection Regulation (GDPR), a movement in European countries ensuring the protection of users’ privacy is a big step towards making interoperability possible (GDPR, 2016).

Electronic Health Records improve health care by reducing prescribing mistakes due to adherence to medical guidelines and increasing eligibility(Wolfstadt et al, 2007), assistance in monitoring and reduced cost by avoiding unnecessary investigations (WHO, 2012). It has also increased patients’ contact with the health providers (Pagliari et al, 2007). Public health has benefitted from electronic records as well, by improving influenza and pneumococcal vaccination and screening for stool occult blood (Dexter et al, 2008). With the advent of electronic health record the reporting of deaths and births statistics will become automated, as it will be done in real time, avoiding all the paper work and administrative tiers. Secondly, it will also solve the issue of filing of medical records, keeping in view the space limitation and the difficulty it offers with file retrieval when required for medico legal and insurance purpose (WHO, 2006).

The electronic records system in Malawi has registered 650,000 patients with HIV and 50,000 of them received treatment (Douglas, 2010). Open source free software was used for this purpose which guided health workers in diagnosis and treatment of diseases via touch screen clinical work stations at the point of care and was useful in radiology, laboratory and pharmacy as well (McKey & Douglas, 2008). Australia initiated a nationwide electronic health system called ‘HealthConnect’ in 2000, which was modified and renamed as ‘Shared Electronic Health Record’ (SEHR), after trials held in 2005, 2007 and a 2008 review revealed very satisfying results from its users especially due to its qualities of record sharing, privacy and an estimated 90% uptake by distant communities (HealthConnect, 2017). Kenya started the Mosoriot Medical Record System (MMRS) in 2001 (later renamed to AMRS) which served 60,000 patients and reduced patient visit duration by 22% and shortened consultation time by 58% (Kalogriopoulos et al, 2008). In a district in Indonesia, near Java, the primary health care centers are linked together in the computer systems via Local Area Network, which shows the number of patients being treated with a specific disease e.g. Tuberculosis etc; hence improving efficiency (WHO, 2006).

Pakistan is a developing country in South Asia, with a population of  207,774,520 (not including Azad Kashmir and Gilgit Baltistan), making it the fifth most populous country in the world (Pakistan Bureau of Statistics, 2017). It has total health expenditure 2.5% of GDP (which is quite low) and a partial coverage of electronic information system since 2006 for the collection and reporting of births, mortality and its causes (WHO, 2013). Pakistan has an ICT development index rank of 129 and only 10% of the individuals are internet users, although 67. 06% of individuals are mobile cellular subscribers (WHO, 2013). There is a District Health Information System (DHIS) in Pakistan, which is open source system developed by Eycon Pvt. Ltd, for the collection and reporting of health statistics in each district (DHIS, 2017) but there is no electronic health record system in the public sector hospitals, except for a few hospitals in the private sector. Hence, Pakistan is on stage ‘0’ according to the HIMSS Electronic Medical Record Adoption Model (HIMSS, 2017).

The reason for the success of EHR systems in the European and Scandinavian countries is the presence of a sound national policy regarding health IT along with provision of incentives and technical support to the providers adopting the electronic health system (Keirkegaard, 2013). WHO, 2013 has identified some of the barriers in the implementation of eHealth services in Pakistan, which include lack of leadership, governance and policy, lack of legal framework and standards (e.g. ICD, DICOM, HL7, SNOMED) for eHealth and budget restraint. Similarly, there are no ICT training programs for health professional and students to overcome the behavioral and technical challenges for eHealth adoption (WHO, 2013).

District Head Quarters Hospitals provide secondary health care in each district of Pakistan. A steering committee should be formed including policy makers, health professionals/service providers and administrative staff for the purpose of implementing electronic health records system in district hospitals, with the goal to make healthcare more efficient and cost effective. The aims and objectives of this project would be providing paper free environment, training the health professionals/clerical staff in information and computer technology, providing access to the patients to their health records and sharing of health records amongst the district headquarters hospitals within a specified time period, while ensuring privacy.

For the implementation of electronic health records system in a developing country like Pakistan, Amayatakul framework, 2004 can prove very useful. The first step in this framework is to review the existing health system for its preparedness for transition. That includes the presence of patient identification, complete/credible health records using standard language, coding and filing of health records and a functional legal policy for health record retrieval and patient privacy (WHO, 2016). In Pakistan the inpatient, outpatient, accident and emergency record is maintained on paper and for identification patient’s name; father or husband’s name is used. Each time a patient is received at the health facility a new serial number is issued, producing multiple records of the same patient. In many countries either name, date of birth or social security number are used for recognition, but the best alternative is national identification number (WHO, 2006) which is unique to each adult in Pakistan registered with the National Database Regulatory Authority (NADRA). Children can be identified by using parent’s identity card. Hence, Master Patient Index (MPI) which is hospital’s index of patients including the demographic information, hospital medical record number and national identification number, for the exclusive identification of the patient, is mandatory for health records, for the single identification of the patient across all databases (Health Informatics, 2017). Problems encountered in developing such an index in Pakistan are clerical mistakes in data entry. This problem can be addressed by the induction of qualified staff and training them accordingly.  

Patient’s record quality is determined by its completeness, accuracy and the use of standard language (WHO, 2006). The Health Information Standards, 2009 has identified several guidelines for medical record keeping which include mentioning patient identification number on each sheet, making daily admission/discharge lists, data entry in a sequence and immediately at the point of contact. Unfortunately in Pakistan medical records lack most of these components, which asks for training of health professionals in good record keeping practices.

The second step in the Amayatakul, 2004 framework is planning the transition pathway, which requires an internationally recognized standard for data management and interoperability e.g. Health Level 7 (HL7, 2017). It should be accompanied by the provider’s electronic signature which can be either the automatic signature of the software being used by the provider, verified by the provider’s password or a cryptographical digital signature (Amayatakul, 2004). The records should be stored initially in the Central Processing Unit (CPU), with online availability and the secondary storage can be in hard disks, which can serve as system back up (WHO, 2006). Policies for authorized access and duration of storage, along with sufficient finances, skilled human resource, equipment and promotion of the usefulness of electronic health records are very important for ensuring its success (WHO, 2006). In order to provide access to the patient, a ‘health card’, must be issued to the patient containing all his/her personal medical information and photograph for identification (Hebda et al, 2001). 

 

                         Fig.    A simple Electronic Health Record System (WHO, 2006)

The third step in the Amayatakul, 2004 framework is the selection of a suitable EHR system. The pre requisites for implementing EHR system are an Electronic Master Patient Index (MPI), an Automated Patient Administration System (PAS), Clinical Systems, automated clinical coding and disease and procedure indexing (WHO, 2006). In district hospitals Pakistan, where none of these systems exist, it would be better to adopt the implementation of EHR in phases, where units are developed electronically one by one, in a specified time frame, followed by connecting them online (WHO, 2006). Scanning of old record will not be cost effective and beneficial; hence it would be better instead to add a summary of the patient’s health record when he/she attends the new system for the first time. A thin client system will suit better in low income settings due to its affordability, security, flexibility and manageability (Velancia, 2013). Due to similar reasons open source electronic health record systems e.g. OpenMRS, are best for hospitals in Pakistan, as evident from its successful implementation in developing countries of Sub Saharan Africa and South America (Aminpour, 2014).

 

The fourth step for implementing electronic health records is to ‘install, design and test the system’ (Amayatakul, 2004). It requires a technological infrastructure including Central Processing Unit (CPU), Input/output devices, network (e.g. LAN, WAN, WLAN), supporting software/applications and space for installing/accessing the system i.e. terminals in each ward, outpatient departments etc (WHO, 2006). The Wireless Local Area Network (WLAN) is a good choice when it comes to the ease in communication and information exchange, but it has its own security risks which can be addressed by developing strong passwords for authorized access and putting guest users/patients on a separate network (Johnston, 2013). Health professionals can benefit from different ways of data entry in the EHR, which includes using templates, handwriting and voice recognition, hence restriction to a single format is not advisable (Connor, 2016). The fifth and sixth stage in the Amayatakul, 2004 framework is regarding enthusiastic training of the staff and continuous modification in the system via feedback received, so that it better suits the users and achieves its goals.

 

For the implementation of EHR in Pakistan, we have to adopt a ‘revolutionary’ approach (Amayatakul, 2004) as the whole process will be started from scratch and there will be many disappointments and drawbacks during the whole process. But persistence and modification of the system for better adoptability is the key to success to get better patient care.

 

 

 

References

 

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