• BCS provides doctors views on EHRs

    Is addictive texting especially annoying during meals? Some hospital doctors in the US think it is, and think it’s annoying for patients when they’re accessing EHRs during consultations. A study in the Journal of Innovation in Health Informatics, (JIHI) surveyed hospital doctors’ perceptions of EHRs’ impact on patient-doctor interactions. It compared these to perceptions to doctors working from offices. JIHI’s a publication of the BCS Chartered Institute for IT, the British Computer Society (BCS).

    Data for the survey came from the 2014 Rhode Island Health Information Technology Survey. It asks eHealth users about their practice settings and specialties, their EHR and ePrescribing functionalities and frequencies of use, and free-text questions. They include open-ended questions analysed by the BSC study.

    Five main themes emerged from the free texts:

    • Less time spent with patients, more time spent on computers documenting EHRs        
    • Lower quality of patient-doctor interactions and relationships
    • But, no effect because doctors change their workflows
    • Improves access to information and preparation
    • Frequent unintended negative consequences.

    Hospital doctors report benefits ranging from better information access to better patient education and communication. They also frequently say EHRs help them to feel more prepared for clinical encounters. Office-based doctors more frequently say they’ve changed their workflow, while have depersonalised relationships. 

    The study team says its findings have two uses. One’s to modify interventions to improve EHRs’ use in inpatient settings.  The other’s to develop interventions to specific specialties. Both contribute to improving doctors’ satisfaction and patients’ experiences. Africa’s eHealth projects can incorporate these. Will it help to avoid texting at the dinner table?

  • Strategies for EHRs have changed over the years

    Back in the 1990s, EHRs were seen as large-scale clinical databases bringing data from clinical information systems and providing patient data needed for clinical tasks. Their role in public health was acknowledged, but seldom fulfilled. Since then, their role’s extended to become an essential source of data for health analytics, information for patients and a link to numerous mHealth services. EHRs are now as important to public health as they are to clinical practices.

    Many African countries missed out on the initial phase of EHRs. They’re still lagging behind. The WHO global eHealth survey shows Africa’s national EHRs adoption at some 11%, with about 18% of hospitals using them. Investment in some related systems for EHRs is also at 7%, compared to about 24% globally. 

    Alongside these findings, Africa’s mHealth investments pulling well ahead.  Approaching 60% across a range of mHealth features, Africa’s mHealth offers a valuable route into its EHRs.

    mHealth investment alone doesn’t help to deal with the challenges of EHRs. Complex informatics, such as semantic interoperability and architecture, connectivity constraints, increasing cyber-security risks, eHealth skills and establishing sustainable costs and finance all combine to make EHRs challenging for Africa. There’s plenty of good practices that have accumulated since the 1990s to guide Africa’s programmes.

    There’s also evidence of bad practices that Africa’s health systems should avoid. Knowledge of these are extremely valuable. Examples are rushing EHRs through on an unrealistic, short timeline, not understanding or managing risks, not having rigorous business cases and not engaging regularly with the main stakeholders from the start of formulating strategies for EHRs. Avoiding these are prerequisites for success, but doesn’t guarantee it.

  • Which is best, national or regional eHealth platforms?

    India’s Union Government has a national eHospital platform. A report in The New Indian Express (NIE) says Kerala State wants its own. It’s a perspective that can be reflected in Africa’s health systems. Which approach is most appropriate?

    In Kerala, only two hospitals from Kerala - Malabar Cancer Centre in Thalassery and Vaidyaratnam P S Varier Ayurveda College Hospital in Kottakkal have enrolled in the national Online Registration System (ORS). It links hospitals across India to facilitate online appointments for patients by authenticating either through Aadhaar or a mobile number. Aadhaar provides each person with a unique, random 12-digit number issued by the Unique Identification Authority of India (UIDAI). 

    Hospitals can also use the e-Hospital platform to provide online services to patients. They include online outpatient appointments, viewing their laboratory reports and the status of blood availability in blood banks. The main objective’s to have an appointment system at government hospitals to avoid long queues that inconvenience patients when they register.

    NIE says Kerala State officers haven’t provided a precise reason for opting for its own platform. It is reported as referring to its own eHealth as state-of-the-art, implying it’s a better solution.

    The decisions raise important eHealth issues. If local eHealth’s better than a national service, why give it up. It’s not only Kerala or India where this issue surfaces. It’s been a challenge for many countries. Effective convergence strategies that build on existing good practice are excellent ideas. They’re not easy to achieve.

    Some of Africa’s health systems may face similar challenges as they move from legacy systems. Change can offer new benefits, but it can sometimes bring additional costs.

  • Telemedicine is as big a US priority as EHRs

    Telemedicine’s up with inpatient and outpatient EHRs for US eHealth investment priorities. A survey by Reaction Data found 33% of healthcare executive have it as their top priority, alongside 32 % who have EHRS for inpatients and outpatients as top. Nearly half the respondents work in standalone hospitals. About a third are ion Integrated Delivery Networks (IDN).

    About 20% have investment to support a payment initiative. The Medicare Access and CHIP Reauthorization Act 2015 (MACRA) is a new way to pay doctors who treat Medicare patients. CHIP’s the Children's Health Insurance Program.

  • Some F/OSS EHRs can have limitations

    Africa’s health systems often look to Free and/or Open Source Software (F/OSS) for their EHRs as a way to adopt low-cost solutions. F/OSS’s an expanding service. The 8th Annual Future of Open Source Survey found that F/OSS projects doubled between 2012 and 2014.

    A study in the Journal of Medical Internet Research (JMIR) found that there can be limitations in this strategy that need addressing. The team from California-Davis University in Sacramento reviewed 54 F/OSS EHRs and identified some weaknesses in functionality and usability, two essential components for benefits realisation. Only four EHRs in the study are certified by the US Office of the National Coordinator for Health IT.

    The State of Open Source Electronic Health Record Projects: A Software Anthropology Study sought information on the characteristics of prevailing F/OSS EHR systems to understand the motivation, knowledge background, and characteristics of developers:

    • Most, about two thirds participate in F/OSS projects as part of paid activities
    • About 26% have been healthcare providers in their careers
    • About 45% don’t work in healthcare.

    The study claims a potential F/OSS weakness for EHR projects where developers’ backgrounds and their abilities to understand nuances of healthcare workflows. It suggests a solution’s to provide developers with direct access to healthcare providers and facilities.

    • Most F/OSS EHR projects don’t have a support service for sale
    • Dependencies on volunteer developers may not guarantee technical support
    • Reliability challenges may be present, especially when original systems are customised by institutional programmers
    • Identifying reliable sources for version updates can be challenging
    • Many organisations fear that open source projects can become inactive anytime, creating an acute need for substantial in-house software development expertise
    • Most healthcare organisations don’t have infrastructure to support software development
    • They may not have ICT staff who can manage Software Development Life Cycles (SDLC) for complex systems
    • Interoperability may be challenging where software isn’t integrated and there are disparate systems or groups of systems, especially with interfaces with commercial systems that require personnel with numerous skill sets
    • Privacy and security may not be rigorously safeguarded with consent or privacy policies, leading to limited protection against unauthorised access and information release
    • The lack of a corporate entity in most F/OSS EHR projects creates a marginal capacity to market F/OSS systems and navigate certification, limiting adoption by the US health systems.

    The study’s findings provide a helpful checklist for Africa’s health systems when they choose to pursue options for F/OSS EHRs. Decisions on all types eHealth providers contain trade-offs. Africa’s health systems can use the results to compare their choices for F/OSS EHRs.

  • Medical schools can train students in EHRs

    eHealth skills needs to expand to match its steady spread across Africa’s health systems. Health workers need them. So do future generations of health workers who’ll be providing healthcare within a year or so, and beyond.

    The American Medical Association (AMA) has started to address the challenge. It already has an initiative to create the medical school of the future. It’s announced a new training platform to ensure doctors and other healthcare professionals learn how to use EHRs to deliver patient care. The goal’s to ensure more medical students and trainees gain direct experience using EHRs during their training. 

    In collaboration with the Regenstrief Institute and collaborating with Indiana University School of Medicine, the AMA produced the Regenstrief EHR Clinical Learning Platform. It uses real, de- and mis-identified patient data to help students to provide virtual healthcare for patients with several complex health conditions. By navigating EHRs, documenting encounters, and placing orders using application similar to real EHRs, it provides an immersive and modern way for educators to teach students how to use EHRs to address important issues for population health, quality improvement, patient safety and social determinants of health. Educators can use the platform’s tools to create customised content specific to their curriculum goals and to evaluate students.

    The platform’s currently rolling out to US medical schools. It’s an initiative that Africa’s medial associations, medical schools and health systems could replicate to prepare medical students for their countries emerging eHealth world. 

    Building their eHealth capacity and capability’s a reliable way of creating the next generations of clinical eHealth leaders and enhancing Africa’s eHealth sustainability. It’s taken the AMA several years to reach its eHealth learning goals, and there’s more to come. Africa’s equivalents should take adopt a steady, smooth trajectory.

  • Wiikwemkoong goes live with a bit of razzamatazz

    In eHealth, going live usually involves uploading software and starting it up. Canada’s First Nations have a much better idea. Manitoulin Expositer has a report about eHealth’s razzamatazz. First Nations health officials and a Telus Health team were at Wiikwemkoong Health Centre to launch an EHR programme that will extend to more First Nations.

    Manitoulin Island’s in Lake Huron in Ontario province. Its first nation routes go deep. Archeological discoveries found Paleo-Indian and archaic cultures dating from 10,000 BC.

    With Michael McGregor of Giiwednong Health Link (GHL) eHealth programme manager as master of ceremonies, the go live started with a song by local drum group High Eagle Singers. Rita Corbiere, a Wiikwemkoong elder provided an opening invocation.

    GHL’s a health and information management collaboration between Manitoulin Island and North Shore First Nation health organisations. It’s funded by Health Canada, with priorities for planning and implementing EMRs in GHL members’ health centres. Practice Solutions Suite (PSS) are part of the project too.

    The project started in 2006. The long timeline justifies the celebrations. Next, 14 First Nation member communities will have their EHRs by March 2018. No wonder High Eagle Singers concluded the proceedings with an honour song.

    This leaves two challenges for Africa’s communities. One is to start up their EHRs. The other’s to celebrate in a way that only Africans can do.

  • A checklist for EHRs can help

    Like eHealth, there’s more than one definition of EHRs. Consequently, when it comes to procurement, it’s important to be specific about your definition and requirements. Dr Chrono has provided a checklist that can help Africa’s health systems with their eHealth strategies, plans and procure their EHRs. It has twelve components:

    1. Intelligent time-saving charting tools for operational efficiency, such as customisable medical templates, medical speech-to-text, dynamic photo charting and macros
    2. Customisation and flexibility, to tailor EHRs to practices and specialties
    3. Fully functional on mobile devices
    4. Integrated with laboratories so test  and imaging requests, provide referrals and send prescriptions are seamless, minimise paperwork and streamline administrative tasks
    5. Real time eligibility verification and billing
    6. Patient portal that’s user-friendly
    7. Flexible and simple patient admissions and check-ins
    8. Sharable patient educational material
    9. Available training and support for EHRs
    10. Regulatory compliance
    11. Data flexibility and portability
    12. Application Programming Interface (API) and third party integrations.

    For Africa’s health systems, sustainable affordability’s a vital matter. Other sustainability requirements, such as connectivity, are essential too. With all these in place, they can concentrate on mitigating investment risks and benefits realisation. There’s always more work to follow on with eHealth.

  • A review of EHRs sets out taxonomy challenges and concerns

    Like the term eHealth, EHRs are not strictly and unambiguously defined. A study in the Journal of Medical Internet Research (JMIR) has researched the literature and set about the task. It also identified concerns and challenges. The findings are essential for Africa’s health systems as they move their EHRs on.

    Its Personal Health Record (PHR) taxonomy comprises three main categories:

    1. Structures, the main data types and standards used
    • Data types in PHRs
    • Standards that PHRs can adhere to
    1. Functions that depicts the main goals and features of PHRs
    • Users profiles and types that interact
    • Interactions of patient types with PHRs
    • Data sources and techniques for information input
    • Goals that represents PHRs’ aims
    1. Architectures types and scope
    • Descriptions of the main architecture models
    • Coverage as physical locations and divisions for data

    There’s a wide range of challenges and concerns that need addressing. There are four main categories:

    1. Collaboration and communication
    • Context-aware computing
    • Wearable computing and IoT
    • Artificial Intelligence (AI) for health
    • Personalisation, usability, familiarity and comfort
    • Managing medications
    • Data generated by patients
    1. Privacy, security and trust
    • Confidentiality and integrity
    • Data repository ownership
    • Authorisation and access control technologies
    • Secure transport protocols
    1. Infrastructure
    • Portability between devices, equipment and hardware
    • Efficiency and scalability
    1. Integration
    • Patterns in collecting medical data
    • Terminology
    • Interoperability.

    For Africa’s health systems, these range from long-standing eHealth challenges to new challenges coming with constant eHealth innovations. They’re demanding to deal with, and increase with complexity the longer they’re left.

    Three common requirements to progress are affordability, benefits realisation and health systems human eHealth capacity and capabilities. They need adding to the list.

  • Are Africa’s EHRs expanding?

    At the core of eHealth sits EHRs. The WHO Global Survey 2015 and Capter 5 of the  WHO and Global Observatory for eHealth (GOe) publication eHealth Report of the third global survey on eHealth Global diffusion of eHealth: Making universal health coverage achievable, say there’s been steady growth in adopting national EHRs over the last 15 years. It’s’ jumped by 46% in the last five years. Africa has much more to do.

    More than 50% of upper middle and high-income countries have adopted national EHRs. The rate in poorer countries is 15% and 35%. Africa’s average’s at the lower end.

    EHRs depend on other eHealth for much of their data. Most, over 70%, national EHRs integrate with laboratory and pharmacy information systems. About 56% integrate with Picture Archiving and Communications Systems (PACS). African countries trail the global average on these too. Their investment’s about a third of the global average. Catching up on EHRs needs investment in these systems too, so a considerable resource, affordability requirement and undertaking.

    WHO identified lack of funding, infrastructure, capacity and legal frameworks as investment barriers. eHNA has posted on numerous others. They’re mainly parallel investments needed to maximise benefits. Examples are cyber-security, ID management, an example in a recent post, and ferreting out and quelling undesirable “digital dystopia” of ineffective EHRs that doesn’t improve health, healthcare or make it more efficient, posted on the snake oil speech at the American Medical Association.

    Africa’s need for more investment in EHRs and related eHealth and overcoming the barriers points to the important role of rigorous eHealth business cases. These lead to better eHealth investment decisions, so better eHealth, including EHRs. Healthier Africans is the overarching goal. EHRs are an important part of achieving, but only a part, and a part with significant dependencies that need to be in place too.