This is already the 8th week blog for the subject HI201 Health Informatics. The driving question for this week is: “What are the issues and challenges in implementing electronic health records in primary care?”
Before we proceed to answer the driving question, we need to qualify and narrow down our focus on the electronic health records in primary care for developing countries. One main reason is that most developed countries have already tackled and surpassed issues and challenges in implementing their electronic health records in primary care. We need to focus on developing countries such as the Philippines to help tackle the pending issues and challenges in implementing electronic health records in primary care.
What are Electronic Health Records (EHR)? Other names of EHRs are Automated Health Records (AHR), Electronic Medical Records (EMR) and Computer-based Patient Record (CPR).
“Electronic Health Record includes all information contained in a traditional health record including a patients health profile, behavioral and environmental information. As well as content, the EHR also includes the dimension of time, which allows for the inclusion of information across multiple episodes and providers, which will ultimately evolve into a lifetime record. (Mon, 2004, Amatayakul, 2004)”
Automated Health Records (AHR) – this term has been used to describe a collection of computer-stored images of traditional health record documents. These documents are typically scanned into a computer and the images are stored on optical disks. ( Electronic Health Records: A Manual for Developing Countries. World Health Organization, 2006 )
Electronic Medical Records (EMR) – similar with Automated Health Records, this has been used to describe automated systems based on document imaging or systems which have been developed within a medical practice or community health center. These include patient identification details, medications and prescription generation, laboratory results and in some cases recorded by doctors during patient consultation. EMRs are normally used within a hospital setting as their means of recording data of all their patients. (Electronic Health Records: A Manual for Developing Countries. World Health Organization, 2006)
Computer-based Patient Record (CPR) – this was defined as a collection of health information for one patient linked by a patient identifier. The CPR could include as little as a single episode of care for a patient or healthcare information over an extended period of time. (Amatayakul, 2004)
Whether the term EHR,, AHR, EMR or CPR is used, it is important to recognize that the records must be organized primarily to support continuing, efficient and quality health care. The system must also continue to meet legal, confidentiality and retention requirements of the patient, the attending health professional and the healthcare institution.
There are a number of advantages in the move from a paper-based system to an electronic system. For one, there will be an improvement in the accuracy and quality of data recorded in a health record. Healthcare practitioners shall have enhanced access to a patient’s healthcare information enabling such information to be shared by relevant healthcare practitioners for the present and continuing care of the patient. Quality of care is expected to improve as a result of having health information immediately available at all times. There will be an improvement in the efficiency of the health care record service. There will also be lower healthcare costs for the patient as duplication of tests and procedures will be avoided.
What are the issues and challenges?
The following issues and challenges are listed by the World Health Organization:
- Unique patient identifier must be addressed before moving forward to automation
- Clinical data entry issues and lack of standard of terminology
- Resistance to computer technology and lack of computer literacy
- Strong resistance to change by many healthcare providers
- High cost of computers and computer systems and funding limitations
- Concern by providers as to whether information will be available on request
- Concerns raised by healthcare professionals, patients and the general community about privacy, confidentiality and the quality and accuracy of electronically generated information
- Quality of electronic healthcare information and accuracy of data entries
- Lack of staff with adequate knowledge of disease classification systems
- Manpower issues – lack of staff with adequate skills
- Environmental issues – electrical wiring and supply of electricity, amount and quality of space needed for computers, etc.
- Involvement of clinicians and hospital administrators
How to address these issues and challenges? Some recommendations below.
- Use of a unique patient identifier that will give accurate results in data collection. Double counting will be minimized in the collection of data for the use of the hospital or the government in assessing the needed health programs to improve healthcare of the patients. The government must assist in ensuring that a single patient identifier will be created for the citizens to guide in proper data collection in the healthcare system. Herein, we see the value of the implementation of a national ID system.
- The biggest error in clinical data entry is the absence of a common data dictionary that will be used in the implementation of the EMR. This will give different meanings and definitions on each entry that can cause confusion and disarray in the analysis of the healthcare record of the patient. An agreed data dictionary that will be common for every user of the EHR will address one of the biggest errors in clinical data entry.
- Resistance to computer technology and lack of computer literacy are issues that go hand in hand in preventing the use of computer technology in the healthcare environment. There are 2 sets of people involved here, one set is composed of those who are computer literate but knowingly choose not to make use of computers in the implementation of EHRs. The other group is composed of those who totally do not have computer literacy, preventing them the use of EHRs even if they want to. With the continuous evolution of computer technology and the internet, proper education and guidance will remove the apprehension of users and educate new users in the use of EHRs in the healthcare environment.
- Any change in a system will have automatic resistance and the same can be said for healthcare providers. Resistance to change usually comes from not being aware of the new system and the uncertainty of future that it might bring to them. The best way to answer this is the involvement of the healthcare providers from the outset of preparations for the implementation of EHRs. This way, there will be familiarity with the upcoming healthcare information system and it will not be a shock to the healthcare providers.
- The high cost of hardware and software has a significant effect on the implementation of EHRs. Without the hardware, then there is no medium for the software to run and implement EHRs in the healthcare environment. With the current trend of computers becoming less expensive, the administrators and implementers of the EHRs should focus more on prioritizing the hardware and software needed to fully implement the EHRs. This means that the purchase of multiple medium specs computers must be prioritized over the purchase of high spec computers. Medium specs computers are likely to perform as well as high spec computers in the implementation of the EHRs
- The establishment of an EHR will address the concern of the providers regarding access to healthcare information of the patients. Such information is generated or stored in the database for future access.
- Data privacy is a big issue not only in the health sector but also in relation to other uses of computer technology. At a minimum, existing laws and regulations that address data privacy in the general sphere of technology should, at a minimum, apply to the health sector. Because of the sensitive nature of medical information, greater fines and penalties should be imposed on those who violate data privacy in EHRs.
- As with paper based recording, the accuracy of data collection is a big factor in the use of EHRs. One may have the EHR implemented, but with wrong data input on the files of the patient, the EHR will be more of a burden than benefit to the healthcare providers. Some factors of data quality are the accuracy and validity of the original source data. Data should be reliable, complete and legible. The data must also be recorded at point of care and available to authorized persons when and where needed for patient care.
- The coding of the disease classification system is still continually growing. This means that continuous training and education must be provided in proper coding for this sector of the healthcare information system.
- A well-oiled machine will work more efficiently than one lacking in oil. The same can be said for a well trained workforce in the healthcare environment. It is vital to have a well trained staff in the implementation of the EHR as this will make or break the successful use of the EHRs. Without proper staff manning the system, the EHR will just be another software inside the hard drive of the computer.
- Environmental issues include the electricity and space requirements in the implementation of EHRs. As most EHRs will be implemented within an existing healthcare environment, the additional impact on electrical use should be minimal. If an EHR will be implemented alongside the construction of a new healthcare provider, then the issues of electricity and space availability must also be addressed. In any event, electricity and space requirements or restrictions should be considered in the design of the system.
- As mentioned earlier, the involvement of the providers at the outset of the planning of EHR is vital. Clinicians and hospital administrators should likewise be involved as they will have the authority to ensure that there is a smooth transition in the implementation of the EHRs in the healthcare environment.
- Electronic Health Records: A Manual for Developing Countries. World Health Organization, 2006
- Amatayakul, M.K. Electronic Health Records: A Practical Guide for Professionals and Organizations. AHIMA, Chicago
- Sood, Sanjay Prakash, et al. “Electronic medical records: a review comparing the challenges in developed and developing countries.” Hawaii International Conference on System Sciences, Proceedings of the 41st Annual. IEEE, 2008.
- Tierney, William M., et al. “Experience implementing electronic health records in three East African countries.” Stud Health Technol Inform 160.Pt 1 (2010): 371-5.