• 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 activitiesAbout 26% have been healthcare providers in their careersAbout 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 saleDependencies on volunteer developers may not guarantee technical supportReliability challenges may be present, especially when original systems are customised by institutional programmersIdentifying reliable sources for version updates can be challengingMany organisations fear that open source projects can become inactive anytime, creating an acute need for substantial in-house software development expertiseMost healthcare organisations don’t have infrastructure to support software developmentThey may not have ICT staff who can manage Software Development Life Cycles (SDLC) for complex systemsInteroperability 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 setsPrivacy and security may not be rigorously safeguarded with consent or privacy policies, leading to limited protection against unauthorised access and information releaseThe 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:

    Intelligent time-saving charting tools for operational efficiency, such as customisable medical templates, medical speech-to-text, dynamic photo charting and macrosCustomisation and flexibility, to tailor EHRs to practices and specialtiesFully functional on mobile devicesIntegrated with laboratories so test  and imaging requests, provide referrals and send prescriptions are seamless, minimise paperwork and streamline administrative tasksReal time eligibility verification and billingPatient portal that’s user-friendlyFlexible and simple patient admissions and check-insSharable patient educational materialAvailable training and support for EHRsRegulatory complianceData flexibility and portabilityApplication 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:

    Structures, the main data types and standards usedData types in PHRsStandards that PHRs can adhere toFunctions that depicts the main goals and features of PHRsUsers profiles and types that interactInteractions of patient types with PHRsData sources and techniques for information inputGoals that represents PHRs’ aimsArchitectures types and scopeDescriptions of the main architecture modelsCoverage as physical locations and divisions for data

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

    Collaboration and communicationContext-aware computingWearable computing and IoTArtificial Intelligence (AI) for healthPersonalisation, usability, familiarity and comfortManaging medicationsData generated by patientsPrivacy, security and trustConfidentiality and integrityData repository ownershipAuthorisation and access control technologiesSecure transport protocolsInfrastructurePortability between devices, equipment and hardwareEfficiency and scalabilityIntegrationPatterns in collecting medical dataTerminologyInteroperability.

    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.

  • Africa’s EHRs are trailing – unpacking the 3rd Global Survey on eHealth

    EHRs are one of eHealth’s building blocks. WHO Global Survey 2015, the data source for 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, provides insights for Chapter 5.

    Key findings include:

    Steady growth in adopting national EHRs over the last 15 yearsAbout a 46% global increase in the past five years.Over 50% of upper middle and high income countries have adopted national EHRsMuch lower adoption rates in the lower middle and low-income countries at 35% and 15%Most national EHRs integrate with laboratory and pharmacy systems at 77% and 72%, with Picture Archiving and Communication Systems (PACS) at 56%.

    Africa’s national EHRs match the low-income rate. Their integration with other information systems is lower than the adoption rate, so well below the global position. While some of the shortfall may be due to the definition of countries’ EHRs not matching WHO’s survey definition, so possibly understated, as the report mentions, it’s still a big gap.

    Catching up needs African countries to step up their investments. It also needs investment barriers to EHRs removing. WHO says these include lack of funding, infrastructure, capacity and legal frameworks. For Africa, parallel investment’s also needed in laboratory, pharmacy and imaging services and cyber-security, eHealth governance, business cases and M&E.

    Catching up alone isn’t a good investment goal. Adopting EHRs at a sustainable, affordable pace that results in healthier Africans and enables health professionals to improve their contributions are best.

  • Doctors are divided on EHRs’ benefits

    eHealth can offer benefits, but new costs too. Even good eHealth can end up with limited potential due to inept or unfulfilled implementation and operation. In the British Medical Journal (BMJ), two teams of doctors in the USA offer their opposing views on EHRs’ benefits. They’re not a representative sample, but the divergent views provide insights that Africa’s health systems can expect to encounter and deal with as they pursue EHRs’ and other eHealth goals.

    The team from Christus Health in Texas refers to studies showing EHRs reduce prescribing errors, shorten hospital stays and reduce mortality. This is despite its EHRs being immature, so containing some flaws. An encouraging theme’s that the team sees EHRs on an improving trajectory.

    Another benefit’s helping to reduce iatrogenic harm, illnesses caused by medical examinations or treatments. Progress’s seen as avoiding the eHealth trap and delay of pursuing a perfect EHRs delay instead good and developing EHRs sooner. Preventable iatrogenic errors cause 200,000 to 400,000 deaths a year in the US, so a leading cause of death.

    Related eHealth also provides benefits. Computerised Physician Order Entry (CPOE) accelerates healthcare delivery, improves efficiency, reduces the number of professionals in clinical workflows, and decreases delays, adverse events, and errors from illegible handwriting and miscommunication.

    These seem valuable benefits, so what’s the problem with EHRs. The team from Yale School of Medicine and the University of California, San Francisco (UCSF) says EHRs are detrimental to physician and patient relationships. Physicians can spend twice as much time staring into a computer compared to face time with patients. He team isn’t against EHRs and eHealth. They’re more against the position where EHRs aren’t yet ingrained in physician workflows. This may be due to approaches to EHRs that have inadequate needs assessment and adjustments for end user needs.

    The teams describe their views on a BMJ podcast. It seems that the maturity of EHRs’s a common thread. Choices extend across a continuum of go for EHRs now to improve them or wait until they’ve improved. At is simplest, a choice depends on the balance between the value and timing of EHRs’ probable costs and benefits. Probable’s more important than potential benefits, which are considerable, but rarely achieved, if ever.

  • Does Africa need a blueprint for migrating EHRs?

    All healthcare organisations need and rely on mass movement of patient and clinical data. Once eHealth’s used, information systems are updated and eventually replaced. Neither activity’s pain free, so the goal should be to find the least painful way to migrate data. Manual migration’s an option, but can compromise data quality, increase costs and jeopardise project timelines. Boston Software Systems recommends an electronic approach in its white paper EHR Migration Guide - Ensuring Patient Safety, Satisfaction and Clinical Adoption. It deals with:

    Data migration, moving data from old to new systemsData availability, providing access to patient data during and after migrationArchiving to support the process of shutting down legacy systemsHow automation technology worksHandling large volumesOvercoming automation objections.

    Migration where old systems are shut down needs data to be completely extracted, validated and moved to new systems. It often encounters legacy data that doesn’t fit its new environment. Manual solutions are time-consuming and costly. Automation may be a better option.

    During the switch and after, healthcare professionals need to access accurate, accessible and reliable patient data. Continuous availability’s vital for both uninterrupted healthcare and securing adoption of the new system. It’s rare for universal, simultaneous deployment across all departments and units, so there’s usually a period of double running when users access data in legacy systems, but documenting in new EHRs. The reverse may happen too, where users access new EHRs, but still documenting in the old one. A third scenario’s where some interfaces aren’t developed to pull data from legacy systems or new EHRs for secondary users.

    New information systems bring several changes to some clinical practices and workflow. Accessing both legacy and new systems is disruptive and inefficient. Supplier’s streamlining solutions can be expensive and need significant time and resources to deploy. A second enterprise deployment for legacy systems heading for decommissioning isn’t financially viable either.

    After go-live, decisions are needed on the systems to be decommissioned and the data to be archived. There’ll be a mix of records that need scanning into an archive solution and those to be added to new EHRs. Scanning documents or manually entering information can take months, needs significant resources and is costly. Automation can offer a better solution.

    Objections to using an automation platform can arise between its suppliers and EHRs’ vendors. It’s important that healthcare organisations define and manage these relationships. They should be set at the start of procurement and sustained throughout implementation and the early stages of operation.

    As Africa’s health systems move their eHealth on, they’ll have to deal increasingly with migration. It’s a good strategy to begin to develop the skills early.