• Successful EMR switching lesson from Scotland’s Fife

    Implementing EHRs from scratch is challenging. Switching from one set of EHRs to another is more daunting. NHS Scotland has been developing its latest Patient Management System (PMS) version over several years. Marianne Campbell, eHealth senior programme manager at NHS Fife, a health board in Scotland, has described provided five essential lessons in Connected Care Watch. An overarching requirement’s “Grace under fire … keeping a cool head in times of stress.”

    They five are:

    Early stakeholder engagementFull dress rehearsalClear leadership and delegationStick to the scopeUnderstand priorities.

    An connecting thread running under these is the long timescales needed for success. PMS has been many years in development. Implementing it extends across several too. It’s consistent with finding from Acfee’s eHealth evaluation database 

    Switching needed intensive preparatory efforts lasting over a year. Over 700,000 records were transferred from the existing system to PMS, and change management introduced new processes and procedures across ten acute, mental health and community facilities. More than 3,000 health workers completed the training programme. It also needed teething problems addressing. 

    Fife’s PMS project is part of a broader initiative across Scotland, promoted by the devolved Scottish government. There are 14 regional and eight specialist Sottish Health Boards. Twelve, covering 92% of the population, now use PMS.

    Engagement focused on internal stakeholders, reflecting PMS’s change management requirements affecting almost all health workers. A Fife lesson’s that more engagement was needed, especially regular immersive workshops. These started five months before go live. 

    The full dress rehearsal enables a seamless go live. It revealed troubleshooting actions in a controlled test environment. They were addressed in advance.

    and iron out any kinks before the big day.

    Two leaders dealt with and technology and business in parallel. They weren’t the only ones, Decentralised leadership from each area were empowered to make effective decisions quickly. Two technical teams from of NHS Five and InterSystems worked as a cohesive unit. 

    Sustaining the scope required strict discipline. It had to deal with some robust debates to balance the requirements of services with the go live timeline goal. Being controlled and systematic was the only way to a project of PMS’s scope could succeed. 

    The numerous stakeholders had many competing priorities. Clarity about critical activities was a daily discipline. 

    Success’s attributed to careful planning by many people over a long period. As Ms Campbell points out successful implementation doesn’t preclude issues arising down the track.

    eHNA’s looking forward to her next report on  PMS’s realised benefits compared to the previous system. Lessons from the realisation timescales and activities are as valuable as implementation lessons.

  • Dell offers better access to imaging data

    Modern eHealth can provide mountains of clinical data. Storing and accessing it effortlessly in real-time’s an increasing challenge. A whitepaper from Dell EMC, available from EHR Intelligence, describes a way to do it. 

    Key Strategic Technolgies (sic) to Improve Access to Clinical Data promotes two principles for PACS. One’s that storage infrastructure shouldn’t need redesigning every time new data’s added. The other’s to have a Vendor Neutral Archive (VNA).

    Affording a fully-fledged solution can be a challenge for Africa’s tight eHealth finances. Dell EMC proposes a phased approach that supports future VNA deployment. It is flexible enough to support a wide range of performance demands such as data analytics, expansion into private, hybrid, or public clouds and changing clinical workflows.

    It’ll need Africa’s eHealth programmes to partner with infrastructure development vendors who can: 

    Scale local architecture without downtimeMaintain daily performanceReduce or eliminate future migration burden.

    These will help to achieve several objectives that improve healthcare quality:

    Integrate imaging with other eHealthEnable doctors to taking clinical decisions using the most pertinent, complete, accurate and timely patient data. 

    Can this find a place in Africa’s eHealth strategy? The principles fit all types of clinical data.

  • What's needed to help improve EHRs?

    Millennia ago, primitive people huddled in caves to keep warm and protect themselves from big, wild beasts, many now extinct. As people advanced, huddling became less important, but it’s emerged in healthcare, and EHRs are the catalyst. 

    Safety huddles to proactively identify and address electronic health record safety, a study in the Journal of the American Medical Informatics Association (JAMIA) identified 245 safety concerns related to EHRs. To be more precise, safety huddles found them. Four main types were: 

    42% EHRs’ technology working incorrectly26% EHRs’ technology not working at all17% EHRs’ technology missing or absent16% user errors.

    Huddling theory says the activity’s helpful in creating collective situational awareness, leading to increased organisations’ capacity to respond to concerns, limitations and weaknesses. The study shows it: 

    Promoted discussion of several technology issues in organisationsServed as a promising technique to identify and address EHRs’ safety concerns.

    The team recommends that healthcare organisations consider huddles as a strategy to promote understanding and improvement of EHR safety. If it works for safety, it could help with other weaknesses in EHRs. If it works for EHRS, it could work for some other eHealth services too.

    It seems that our ancient ancestors were on to a modern management technique, so announcement in waiting rooms could soon be saying “A doctor will see you shortly. At the moment, they’re all huddling for eHealth.”

  • Pocket mHealth's patient-centric and advances IOp

    Combining the synergy of patients, their mobiles and healthcare’s a growing ambition. Pocket mHealth likes the idea. It’s an app that brings EHRs to smartphones. The group is part of Atos Research & Innovation based in Atos Spain. It can fit Africa’s programmes for mHealth and EHRs.

    Validated by medical professionals, Pocket mHealth aims drives the paradigm shift needed for person-centric medical care. It provides access to EHRs so users can improve the way they take care of their health. An emphasis on Interoperability (IOp) and eHealth standards enabling integration of clinical data from heterogeneous Hospital Information Systems (HIS), it supports benefits such as better clinical efficiency, fewer medical errors and lower costs.

    Pocket mHealth’s underlying philosophies are:

    Clinical data belongs to appropriate citizensUsers supervised by corresponding, responsible health professionals.

    These are achieved by Pocket mHealth’s validation by medical professionals. Other features include:

    Improved diagnosesSuppressing unneeded paper or DVD reportsAvoiding duplicate and redundant testsEHRs are continuously updated and complete, enabling better health and quality of life decisionsSupporting patient mobility with accessible clinical data that enables better healthcare in rural or holidays locationsCyber-security mechanisms that guarantee the privacy and data security.

    Both the vision and type of solution fit Africa’s needs. Its strategies and programmes for EHRs can incorporate secure IOp links to citizens’ smartphones. 

  • Rothman Index predicts patients’ increasing risks

    It’s often reassuring to hear that hospital patients are in a stable condition.  When they’re deteriorating, it’s not so good. It’s even worse when the deterioration’s a set of marginal steps that are challenging to find, but lead to catastrophic states. This was the motivation for the Rothman Index (RI), a predictive health analytics tool.

    Florence Rothman was diagnosed with aortic stenosis, narrowing of the exit of her heart’s left ventricle. She had a low-risk surgical procedure and seemed to be recovering, then became weaker and started a slow, steady, subtle decline that detected when her condition became critical. Relevant data was recorded in her EHR, but the trends weren’t easy to see, so wasn’t used by the skilled and caring healthcare professionals. She was discharged, and four days later, collapsed and died in the ER.

    Michael and Steven, Florence’s sons, one an engineer, the other a scientist, both skilled in data analysis, were inspired reveal EHRs’ crucial insights to improve healthcare. They created the Rothman Index (RI), a statistically validated patient acuity score across all diseases and conditions. It presents patients’ real time conditions and can be trended and visualised, alerting doctors and nurses of deterioration before it’s critical.

    Pera Health, formerly Rothman Healthcare Corporation until 2012, provides RI. It includes graphical user interfaces so healthcare professionals can visualise trends in health status from patients’ data in their EHRs. Regularly updated health scores are derived from vital signs, nursing assessments and lab results. The model transforms each input into a common representation of univariate risk, enabling heterogeneous data to be summed, solving the data fusion problem. Outputs are continuous measures of patients’ conditions integrated into their EHRs. Trends enable deteriorating and vulnerable patients to be identified, often with less than24 hours warning, and with minimal false alerts.

    The company says RI correlates well with:

    24 hour mortalityUnplanned transfers to ICUsICU readmissionsCode Blue events to for cardiac or respiratory arrests.Readmissions within 30 days of dischargeLengths of stay.

    RI can be a part of Africa’s EHR programmes to build predictive health analytics into hospitals; routines. It’ll help to maximise their EHRs’ benefits.

  • Informatics and EHRs can prevent strokes and improve monitoring

    Increasing responses to strokes and their after effects are important health priorities. A report in the US National Library of Medicine has estimated that in 2015, strokes were the second-leading cause of death worldwide after ischaemic heart disease. In 2010, strokes caused 5.3 million deaths globally, 10% of all deaths. Trends include increasing stroke mortality and lost Disability Adjusted Life Years (DALYs) in low- and middle-income countries and a dire estimate of the global economic impact unless effective preventive measures are implemented.

    Another study identified the aged-standardised incidence of stroke in Africa as 316 per 100,000, 0.3% population, and age-standardised prevalence rates of up to 981 per 100,000, almost 1%. Stroke incidence’s increasing, but the study said the “peculiar factors responsible for the substantial disparities in incidence velocity, ischaemic stroke proportion, mean age and case fatality compared to high-income countries remain unknown.” This is despite the incidence being lower than higher-income countries. A study in Sage Journals estimated the incidence of stroke, adjusted to the WHO World standard population, in 51 countries. It ranges from 76 to 199 per 100,000 population.

    Atrial fibrillation (AF) an irregular and often very fast heart rate may cause symptoms like heart palpitations, fatigue and shortness of breath. Treating it’s important because it may cause a stroke, with resulting adverse DALYs. After a stroke, AF needs monitoring. A study in Cardiology, published by Karger, aimed to identify the characteristics of atrial fibrillation (AF) in post-cryptogenic stroke. It’s a stroke with an unknown origin.

    The US Stroke Association has an estimate that cryptogenic strokes (CS) may be between 25% and 45% of ischemic strokes, so about 30%. They are where blood supply to part of the brain is interrupted or severely reduced, depriving brain tissue of oxygen and nutrients. Within minutes, brain cells begin to die. Ischemic strokes are about 87% of all types.

    The team’s project included Transient Ischemic Attacks (TIA). Mayo Clinic has a simple description of a TIA. It produces similar symptoms to a stroke, but usually lasting only a few minutes and causing no permanent damage. Often called a mini-stroke, a TIA may be a warning of worse to come.

    The team of cardiologists and informatics researchers from the Department of Medicine and Division of Cardiology at Santa Clara Valley Medical Center, the Biomedical Informatics Training Program, Stanford University, the Center for Biomedical Informatics Research, Stanford University School of Medicine and the University of California San Francisco, stratified a cohort of stroke patients by risk factors. It used data from EHRs.

    These included obesity, congestive heart failure, hypertension, coronary artery disease, peripheral vascular disease and valve disease. A risk-scoring model applied seven clinical variables that assigned patients into three groups. The risk-score’s measures of AF risk and may be used to select patients who need extended AF monitoring, especially home monitoring.

    The study’s an example of the value of doctors, informaticians and analysts working together to exploit the value of data in EHRs. It’s a model for Africa’s health systems and universities to work towards.

  • EHRs aren’t enough, they need communications

    Communicating isn’t easy. In “Is Anybody Listening?” a 1950s article in Fortune Magazine, William H Whyte, a journalist and author, suggested that “The single biggest problem in communication is the illusion that it has taken place.” Across health systems and within healthcare organisations, it can be at the demanding end of the spectrum.

    An eBrief from Spok says EHRs don’t do enough for clinical communication and collaboration. It’s particularly prevalent for information needing acknowledgements and prompt action. Spok’s proposal’s a complementary system for messaging and collaboration among all healthcare team members and across whole healthcare organisations. In Picking Up Where EHRs Leave Off: 6 Ways to Bolster the Benefits of Your EHR by Improving Communications in Your Hospital, six requirements are:

    Support all clinical and other healthcare team membersProvide an enterprise-wide directory to serve  as the source of truthOn-call schedule integration and clinician statusIntegration with third-party systemsCapability to support many devicesDeliver emergency notification rapidly.

    These will combine to enhance EHRs’ benefits. It reflects the changing nature of EHRs since the 1990s when they were seen as a database for healthcare professionals. Now, they’re a vital data source for health analytics, and Spok’s communicating needs.

    The perspective offers Africa’s health systems a broader approach to moving towards their goals for EHRs. Anton Chekov, the Russian story-teller, had an illuminating view of the wider world when he wrote in his Note Book “Don’t tell me the moon is shining; show me the glint of light on broken glass.”

  • 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 relationshipsBut, no effect because doctors change their workflowsImproves access to information and preparationFrequent 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.