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Samal Island, Davao
April 29 – May 1
Pearl Farm Beach Resort
Forgot the Tardis!
First of the year
Siem Reap, Cambodia
The Privilege Floor at Lotus Blanc
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:
How to address these issues and challenges? Some recommendations below.
The driving question for this week is: “In a multistakeholder, multicomponent health information system, how can you ensure that all the players are doing their part?” A question that follows is: “What enterprise architecture frameworks are available and which one is the best for the health sector?”
To answer the driving question, to ensure that all players are doing their part, there should be accountability. A good leader can act as the captain of the ship to ensure that everyone is doing his or her part. There should be a road map to follow to guide, not only the leader but also all participants as regards what direction to take and what their respective roles are.
With regard to information systems, this road map is, essentially captured in the concept of enterprise architecture (“EA”). Gorton (2006) defines architecture as a system’s structure, its components and their respective functions, and how these components communicate. Gorton also states that architecture must address non-functional requirement issues like quality, and technical and business constraints. Architecture can refer to a wide range of contexts in IT, from a macroscopic framework — the blueprint for the IT system as a whole organization — to a design for one particular application.
According to Stansfield, et al., “The enterprise architecture provides the missing link to guide development and implementation of national health information systems.” EA places software development against a larger context enterprise — the whole business organization and how each individual part works with others. When defining software features and requirements, EA always refers back to the needs of the whole enterprise, in the context of the core processes and key customers. Essentially, EA is the interplay between a business and the information system that supports the business.
In the paper entitled “Alignment in Enterprises Architecture: A comparative analysis of Four Architectural Approaches by Magoulas, Hadzic, Saarikko and Pessi“, the four enterprises architecture provided are the Zachman Framework, The Open Group Architecture Framework (TOGAF), the Extended Enterprise Architecture Framework (E2AF) and the Generalised Enterprise Reference Architecture and Methodology (GERAM). These are described generally below:
The Zachman Framework was originally developed by John Zachman and extended to its current scope with the aid of John Sowa. In its inception, tThe purpose of the framework was to steer organizations away from the widespread practice of viewing the enterprise through static and disconnected models.
The Open Group Architecture Framework (The Open Group, 2009) was originally released in 1995. At the time, it was based upon TAFIM, a framework for information management developed by the United States Department of Defense. Currently in its ninth revision, TOGAF has gradually expanded its scope from strict management of IT towards a broader business orientation.
The Generalised Enterprise Reference Architecture and Methodology is a product of the IFAC/IFIP Task Force on Architectures for Enterprise Integration, founded in 1990. GERAM is designed so that the practitioner is able to combine different frameworks or methodologies in order to customs design a new architecture. Consequently, it is an extensive standard that includes meticulous descriptions of reference architectures, modeling languages, techniques and tools.
The Extended Enterprises Architecture Framework was created by Jasper Schekkerman in 2001. Rather than any unified documentation, E2AF is documented in several separate documents that are incremented in a piecemeal fashion. E2AF assumes a holistic approach to architecture, stating that an enterprise that is to function as a whole must be designed as a whole. Strong emphasis is also placed on contextual awareness and stresses constant awareness of threats and opportunities in the environment.
The “broader business orientation” of TOGAF reflects that widespread applications of this enterprise architecture. It can be applied not only within the IT sector but can expand to other sectors as well including the health sector. In the website, The Open Group.Org describes TOGAF as a framework that “enables organizations to effectively address critical business needs by:
Magoulas, et al reflects on the strengths of TOGAF vis-à-vis functional alignment, structural alignment and contextual alignment. TOGAF, as an EA, ensures functional alignment “by operational contracts between customers and provides.” This can be transposed to the health sector space wherein we can put into place operational contracts between patients (i.e. customers) and health practitioners (i.e. providers). The other EAs do not appear to offer this advantage of functional alignment.
Structural alignment is promoted in TOGAF, which is “based on governance contracts, IT responsibility, data trustees and ownership of common applications.” These concepts are key in the health sector. Notably, none of the other three EAs appear to put much emphasis on these concepts. Lastly, contextual alignment, which provides for “harmony between the external and internal environments of the enterprise” is supported by TOGAF, which ensures alignment through “operational and governance contracts.” The TOFAF framework requires that enterprises comply with laws and regulations. The TOGAF framework is broad enough to apply to many sectors and industries, including health.
It is to be noted however that, while TOGAF is, among the four EAs discussed, the best EA for the health sector, a specific framework for the Philippine Health Information System can be developed and may find even better suitability. In the paper, PHIS: The Philippine Health Information System by Canlas RD Jr., the following were given as guidelines as based on a combination of principles from service-oriented architecture, software development methodology, public health and change management and intended to improve the success rate of PHIS implementation. Canlas, appears to have built on the general principles under popular EAs (including TOGAF) to set out a framework specific to the Philippine health information sector.
These recommended guidelines are significant because they frame the discussion beyond the popular EA principles and sets out a practical and relevant road map — one that is within the Philippine context.
How can patients access their data from different healthcare providers as they transfer care?
Establishing the Philippine Health Information Exchange
The partnership between the Department of Science and Technology (DOST), Philippine Health Insurance Corporation (PHIC) and Department of Health (DOH) created the Philippine Health Information Exchange (PHIE). The PHIE is a health informatics system that will allow the operation and accurate use of data from various institutions and health facilities around the country. This will provide access to accurate health information from barangay health centers up to the national level, to improve the health care delivery system of the country. The data gathered by the PHIE will not only be used by these 3 agencies, but can be used by other organizations as well for the improvement of their services.
In the HIMSS AsiaPac15 Conference & Exhibition held on September 2015 during the Digital Healthcare Week, an update on the PHIC for Improved Healthcare Outcomes was given. Among the national objectives for health is to provide guidance in attaining the strategic goals of the DOH for the health sector namely, ensuring financial risk protection, access to quality health facilities and attainment of the health-related Millennium Development Goals. According to the update: “The Health Support Systems will establish harmonized, quality, relevant and responsive e-health services, to provide the necessary tools, data, information and knowledge for evidence-based policy and program development towards the provision of accessible, quality, affordable, efficient and safe health services and attainment of better health outcomes for all Filipinos.”
The use of PHIE is not as simple as it may sound. Theoretically, the sharing of health information will be easy if you are pertaining to a single hospital setting, wherein all the departments are housed in one roof. The reality is that the full implementation of PHIE, which will span the entire country, will face certain hurdles along the way. The Philippines is an island country and not all of its citizens have easy accessibility to basic health centers within the archipelago. Even with the onset of good technology, internet access still does not reach 100% of the citizens needing access to health information. Issues about data security and data privacy in gathering health data are present. Some health care professionals are also hesitant in using eHealth as this is outside their norm and comfort zone. The limited human health resource knowledgeable in health informatics will hinder the training and education of other health professionals to fully implement the PHIE. These problems must be properly tackled first, so as the ensure the smooth use and operation of the PHIE in the country.
The collaboration between the private and public sectors as well as local and international health agencies will support the establishment of the PHIE. The sharing of information among and between agencies and experts sharing the same interests will promote a more efficient implementation of the PHIE. The problems faced by other countries that have already implemented their own respective Health Information Exchanges may be avoided and may be used as a learning tool to further improve the implementation of PHIE. Along with the sharing of information and technical advice, funding from local and international agencies will ensure that the PHIE will have the backbone to stand on its own. Without a proper budget to implement the PHIE, all the sharing of knowledge, training and education of users of PHIE will be wasted if there will be no fund to purchase the basic equipment needed for the implementation of PHIE.
A significant aspect of the PHIE is the improvement of the Electronic Medical Records (EMRs) system that will assist in the mobility of patients. The current setup in hospital settings is the referral system wherein a patient will be carrying a paper referring him or her to another hospital. This paper does not always contain the complete history of the patient for proper care. There is a chance that the patient might lose the referral form along the way. This is where EMRs come into play. With the use of EMRs, the history and data of the patient from one hospital will now be stored in a secured cloud database. This means that the patient will have access to his or her records just by accessing the database even if there is a transfer of care to another health provider.
Conceptually, the idea of having universal access to EMRs is straightforward. However, in reality, it may not be so. The EMRs being used by each hospital use different setups or formats and are simply not interchangeable or inter-operable. Thus, one set of EMRs from one hospital would not automatically work with the existing EMRs of another hospital. The PHIE seeks to address the problem. By having a central database for all EMRs in the country with a uniform setup or format, the patient will be assured that he or she will be able to avail of health services in any hospital using his or her history and data stored by the PHIE and that such information can be easily accessed by the chosen health care provider by the patient. This will ensure that there will be no gaps or oversight in healthcare due to lack of patient information.
Below is a flowchart on how PHIE will handle the shared health information among and between different health providers.
Part of the assignment for the week is to draw a flowchart that details information collected at every step for a patient with diabetes with a non-healing wound consulting at the outpatient clinic. He is subsequently admitted in the hospital. Below is the attached flowchart showing the path the patient will take until he is subsequently admitted in the hospital.