• Disappointing findings from a US EHR survey

    The US may not be too good at EHRs. Peer 60 has released its survey results in Physicians' Take on EHRs. Its coverage includes:

    Ambulatory EHR adoptionMain EHR suppliers for acute care participantsPrimary EHR suppliers for ambulatory care participantsDamage control - the replacement marketTop physician priorities.

    The survey’s revealed some unsatisfactory findings. For 26% acute and 74% ambulatory healthcare, they include:

    Most physicians are highly dissatisfied with their EHRFrustrations are driven by poor usability and lack of desired functionalityThe EHR market for acute care facilities is consolidating quicklyFragmented Epic keeps making inroads in the ambulatory EHR market.

    Most ambulatory organisations, 85%, have ERHs. Most of the other 15% are small clinics.  Measured by the number of doctors in the organisation, the vast majority of ambulatory organisations, between 75% to 100%, have EHRs. With fewer than eleven, 25% don’t have EHRs. The rest are between 95% and 1005, with 201 to 500 doctors the only one at 100%. Ambulatory organisations are more likely to have EHRs when they’ve links to larger hospitals.

    About 89% of ambulatory organisations are not planning to replace their EHRs. For acute services, 91% are not planning to replace them. Acute healthcare doctors priorities for EHRs are:

    Patient satisfaction data: 30%Accountable care: 25%Alternative payment models: 22%Patient portal 15%No priorities: about 8%.

    Cost’s the biggest inhibitor for adopting EHRs for 47% of ambulatory services. About 28% see them as inefficient. The report has a Net Promoter Score (NPS), % Promoters minus % Detractors.  Only one supplier out of nine had a positive NPS. It was 5%. The other NPS scores ranged from -24% to -73%. As a group, doctors are extremely unhappy with their EHRs.

    For EHRs in acute healthcare, the range for four suppliers is 0% to -65%. The other two are -38% and -64%, so plenty of unimpressed doctors here too.

    Peer 60’s overview’s that frontline user satisfaction is rare, but they have few expectations of anything better coming soon, hence the low replacement rate. The EHR supplier that cracks it will have unparalleled competitive advantage. It seems that Africa’s health systems may have three main choices: endure the dissatisfaction until a better replacement comes along, adopt a slow implementation rate that can fix some dissatisfaction before stepping on, or wait, which may be interminable and deny benefits that EHRs can offer. These are not easy decisions.

  • Migrating to new EHRs has five myths

    Africa isn’t awash with EHRs. The WHO eHealth Survey identified fewer than 20% of 33 countries with national EHRs and average penetration into primary, secondary and tertiary facilities well below 50%. There are also numerous EHRs in local and groups of GPs. For each of these, migrating to new EHRs can have important implications.

    A white paper, Eliminate the Migration Chaos: Five Myths to Avoid in Your EHR Migration from Boston Software Systems, a data automation provider, and available from Health IT Interoperability, set out five myths to avoid. They are:

    Myth 1: don’t move the legacy data, start new in the next system, but the snag is, legacy systems contain valuable patient data that clinical staff rely onMyth 2: vendors will handle moving all of data with interfaces, but there’s always a core set of data that doesn’t fit pre-designed interfaces or new EHRsMyth 3: manual data entry’s good training for staff, but it has error rates between 2% to 27%, so never 100% data quality from manual dataMyth 4: all data moved will be accurate, but it’s only achieved if systems are built correctly and the data structured properlyMyth 5: eventually, there’ll be the advantage of a single system, but some of the legacy data structures don’t fit the new EHRs.

    Believing these can lead to eHealth chaos. Avoiding them needs an understanding the unintended misconceptions that lead to migration disorder, or at best, a messy migration. Challenges are understanding and overcoming the impacts of data migration from legacy systems when their vendors may not support the change, which needs to align several vendors, stakeholders and health workers.

    For Africa’s EHRs affordability is also a major constraint. Very limited eHealth resources can mean that comprehensive, high quality and total migrations don’t attract the resources they need. There’s always a crucial trade-off between new EHRs’ affordability and the resources for large-scale data migration. It’s a dilemma that requires Africa’s health systems to be realistic, which means distinguishing myths from facts.

  • Jordan makes progress with EHRs

    With a Gross Domestic Product (GDP) similar to Ghana and population similar to Chad and Guinea, Jordan’s challenges for EHRs seem less demanding. Hakeem, its eHealth programme, has connected about three million people, about 50% of its population, to EHRs in public and military health facilities.

    A report in the Jordan Times says Electronic Health Solutions (EHS), based on Jordan, is implementing the programme. It currently connects about 100 hospitals and primary healthcare centres. Two major hospitals, Al Bashir Hospital and King Hussein Medical Centre’ll be automated in the middle of 2017.

    Hakeem was launched in October 2009. Its vision’s to create a database of patients’ medical histories across the Kingdom. It’ll include data about patients‘ tests, procedures, surgeries, diseases, allergies, medications and demographics. Completion’s scheduled for 2020.

    Major clinical transformation’s one of the goals. It requires users to adopt significant changes in clinical and working practices, leading to benefits in patient safety.

    There are two other eHealth developments. EHS has developed an mHealth for doctors connected to the national programme so they can access patient’s data anytime and from anywhere. About 200 doctors already downloaded the app, which’s judged to be secure. EHS’s also working on the Electronic Library of Medicine to provide Jordan’s healthcare workers and medical students with electronic, up-to-date, evidence-based and free medical information. It also aims to close the rural and urban healthcare gap.

    EHS has also signed a Memoranda of Understanding (MoU) with several Jordanian universities. It includes provision of Hakeem labs for students to practise, so prepare them for future jobs.

    One of Hakeem’s challenges resonates with Africa’s eHealth. Over the seven years since Hakeem started, resource availability from beneficiaries and partners has been an issue. Staff turnover’s sometimes needs addressing. EHS trains staff who sometime leave, slowing implementation because of the time needed to train replacements. Part of the solution’s creating health information committees at health facilities with a role to train new staff.

    Having a national eHealth supplier like EHS with widening range of products’s an important feature of Jordan’s Hakeem. It shows the value of African countries cultivating an equivalent to help to advance their eHealth strategies and programmes.

  • Algorithms identify heart failure risk

    Lateral thinking was devised by Edward de Bono. Born in Malta, one of his opinions is “Dealing with complexity is an inefficient and unnecessary waste of time, attention and mental energy.” Cardiologists don’t see it quite that way. Africa’s health systems should follow the cardiologists lead.

    Algorithms using clinical data from EHRs offer opportunities for better healthcare. Cardiology services are taking advantage of these new analytic techniques, A study in the Journal of the American Medical Association (JAMA) Cardiology describes how cardiologists are develop algorithms that use readily available clinical data to identify hospital patients with heart failure. They’re diagnosing heart failure diagnosis based on discharge diagnosis and their review of sampled EHRs.

    It’s leading them to better, real-time case identification so they can target interventions to improve quality and outcomes for hospital patients with heart failure. Problem lists aren’t good enough for the task. They’re useful for case identification, but often inaccurate or incomplete. Machine-learning’s seen as a way to improve accuracy, but have drawbacks too, such as implementation complexities.

    The team completed a retrospective study of random 75% of hospital admissions of patients over 18 months at New York University Langone Medical Center. Data included demographics, laboratory results, vital signs, problem list diagnoses and medications to treat heart failure. Five algorithms for identifying heart failure were developed using data from EHRs.

    Heart failure on problem listsPresence of at least one of three characteristics: heart failure on problem list, inpatient loop diuretic or brain natriuretic peptide level of 500 pg/mL or higherLogistic regression of 30 clinically relevant structured data elementsMachine-learning, using unstructured notes with over 1,118 data items in the modelMachine-learning using structured and unstructured data, with 947 data items.

    The problem list algorithm identified about half the patients with heart failure. It’s insufficient for real-time identification. The next two had better results, but the machine-learning ones had the best predictive accuracy because they relied on free text notes and reports.

    However, it’s not a simple decision for Africa’s health systems to opt for machine learning algorithms. The research team says they’re difficult to implement because they rely on unstructured data and may need special expertise and resources. Instead, the researchers suggest that investment choices may depend on cardiologists’ clinical and operational needs. For Africa’s cardiology services, it may depend on the availability of data from EHRs too.

    De Bono went on to say “There is never any justification for things being complex when they could be simple.” Selecting an algorithm to identify heart failure may not be simple. The team says there may be a trade-off between costs benefits. Complex and simple aren’t binary choices. For Africa, the five methods may offer an investment ladder to eventually reach complexity and maximise benefits.

  • Widespread EHRs doesn’t mean doctors like them

    The US has achieved a considerable penetration of EHRs. A survey by Medscape of over 15,000 doctors across 25 specialties shows that over 91% use EHRs. It’s up from 74% in 2012. About 5% are either installing EHRs, or will install them within the next two years.

    Epic’s the biggest supplier to hospitals or health system networks. Cerner’s second. Despite the widespread use, doctor’s satisfaction doesn’t match it. They don’t like the erosion of their relationships with their patients that come with EHRs in consulting rooms.

    Overall satisfaction’s dropped too, down this year to 41% who’re somewhat to very satisfied from 45% in 2012. It’s matched by more very dissatisfied doctors, up from 7% percent in 2012 to 12% this year. It’s not too encouraging as a foundation from which to build wide eHealth.

    Despite US doctors’ unconvincing views of EHRs, they don’t seem disposed to do much about it. About 81% say they’ll keep their current system.

    In 2012, a large proportion of doctors, 77% had no patient privacy concerns. It’s crashed down to 8% this year. It seems that eHealth regulation and secure ICT and practices need rigorous attention. Alongside this concern, cutting and pasting in EHRs doesn’t help. Nearly one-third of doctors say they often use copy and paste functions. About 24% use it occasionally. Some 11% always use it. That’s a total of about two-thirds of doctors cutting and pasting.

    It’s a controversial practice, creating numerous risks. Malpractice risks increase when text in EHRs’s copied and pasted instead direct, specific input of comments about each patient. It also increases the risk of fraud easier and data inaccuracies.

    As Africa’s health systems expand their use of EHRs, it shouldn’t now be a surprise if there’s a lack of comprehensive enthusiasm. Findings from Medscape survey enable Africa’s health systems to incorporate these kind of results from doctors into their engagement, procurement benefit realisation plans.

  • Wella Health has a simple EHR solution

    eHealth start-ups in Africa can offer simple and effective EHRs for hospitals and clinics. As Africa expands its mHealth from its coverage of about 59% identified by WHO, mHealth offers options for specific healthcare activities such as prescribing and dispensing, for some of Africa’s health systems.  wellahealth, based in Abuja, Nigeria says it can help to automate healthcare and engage with patients too, especially for prescribing. Two features of its EHR are saving patient information easily and sending automatic SMS reminders to patients.

    When dispensing, entering patient and drug information in pointSystem saves the information and creates a secure patient record entry. It uses remindersPatient to send an SMS to patients with information about their medication and reminders about required future contacts and repeat prescriptions. Health providers already using bulk SMS sites and storing patient data in excel can use and import tool to set up existing patient list in wellahealth. 

    wellahealth’s claims for its benefits are better and easy patient management and follow-ups and efficient patient engagement using a patient hub to send bulk SMSs to patients. Users say its benefits their pharmacy practices. It enables better adherence and provides real-time intelligence on brand performance too.

    Africa’s mHealth has two parallel tracks. One supports health and healthcare. The other creates start-up opportunities. It’s good for Africa.

  • EHRs need contingency plans

    In the US, nearly 60% of hospitals experience unplanned EHR downtime. A report from the Health and Human Services Office of the Inspector General (HSS OIG) says 25% of health care providers that have had EHR downtimes said it delayed patient care. The effect has been that about:

    15% of hospitals have had a dysfunctional EHR negatively impacting their ability to treat patients 9% had to reroute patient care20% of the outages lasted more than eight hours.

    HSS OIG found the main causes of EHR downtime is due to hardware malfunctions, Internet connectivity problems, power failures and natural disasters. Hacking attacks and security breaches accounted for 1% of EHR downtime, but this data’s from 2014. Since then, cyber-security threats and attacks have increased and health ICT’s improved. A new concern’s the vulnerabilities in networked medical devices that may increase hospital networks and EHRs down time risks.

    Encouragingly, about 95% of healthcare organisations have contingency plans to deal with EHR disruptions.  However, there’s no room to relax. HSS OIG recommends that hospitals should continuously update these plans and institute a sustained and up to date cyber-security framework.

    While report’s data lags behind the USA’s EHR experiences its findings are crucial for African countries. EHRs in African countries face many of the same problems causing downtime in the USA. They may be more frequent and persistent than in the US, so the need for Africa’s health systems to have effective contingency plans are key in helping to minimising the downtime effect and continue to treat patients and save lives.

  • EHRs don’t mean an end to paper, and maybe not even paper light

    Potential’s wonderful. We all have it. So do EHRs, but they don’t seem to fulfil their potential. A study by a team in Texas, and published in Applied Clinical Informatics, found that many doctors who come-up against inappropriate EHR functionality use workarounds to manage test results. The team analysed data from a previous national survey on test result management. The results are valuable for Africa’s health systems by identifying functionality and usability constraints as issues that can occur in all types of eHealth, not just EHRs.

    The study examined the links between key socio-technical factors that could affect test result follow-ups. Socio- technical includes technology factors and those unrelated to technology, such as the level and type of organisational support for patient notification, and workaround use. From these perspectives, the team conducted a qualitative content analysis of free text survey data to identify the reasons for using workarounds.

    Out of 2,554 respondents, 1,104, 43%, said they used workarounds related to test results management. Of these, 1,028, 93%, and 40% of all respondents, described their workarounds:

    719, 70% and 28% of all respondents, use paper methods230, 22% and 9% of all respondents, use a combination of paper and computers for their workaroundsPrimary care practitioners who reported limited administrative support to help them notify patients of test results, or described an instance where they or a colleague missed results, are more likely to use workaroundsThree main reasons for workaround use are:A memory aidImproved efficiencyFacilitating internal and external care coordination.

    It seems that test results in EHRs don’t meet the needs of a substantial proportion of USA doctors. Consequently, future EHRs and their associated working practices and system need developing to overcome these limitations. As Africa’s health systems procure more eHealth, they need to set user requirements rigorously and evaluate eHealth’s scope of meeting them.

    While it’s rare for many types of eHealth to achieve 100% dependency, a 43% deficit’s too high and diminishes eHealth cost to benefit ratios and returns. The study identifies reduced patient safety as a concern that can drag benefits down and increase costs. Africa’s health systems need make sure they avoid these types of pitfalls when they move their EHRs ahead.

  • EHRs then HIE, or both at once?

    eHealth investment decisions are always tricky. Affordability determines how far health systems can go. In Africa, it’s always tight. Choosing EHRs may defer HIE decisions. Now, there’s an eHealth platform that offers both, Think!EHR.

    Health IT Central has a report that Tomaž Gornik, CEO of Marand, a Slovenia company, says “Postmodern EHR is the next stage in the development of EHRs”. It has a health data layer that connects all the apps and applications into one coherent system and it’s decoupled from applications, so independent of vendors. In this new health cyber-world, high-level interoperability’s paramount because all applications must capture, store, retrieve, analyse and use health data in a standardised, independent format.

    The report say Marand’s Think!EHR platform’s leading the way for health data platforms. It already has several major implementations already in use. One’s Moscow’s primary care eHealth system serving twelve million patients. Sweden and NHS England’s Open Source community are building a medication management solution on Think!EHR.

    It’s the first eHealth platform to combine Integrating the Healthcare Enterprise (IHE) document exchange standard with structured health data based on openEHR. It enables governments, healthcare providers, ecosystem enablers, vendors, Small and Medium-sized Enterprises (SME) and other healthcare providers to exchange and manage IHE and Health Level 7 (HL7) documents and simultaneously take advantage of fully structured health data.

    eHealth developments like this offer new possibilities for Africa’s health systems. They also require an investment strategy that expands eHealth skills to maximise the benefits.

  • Mayo Clinic finds some doctors at risk of EHR and CPOE burnout

    If you think EHRs and Computerised Physician Order Entry (CPOE) are good for your health, you might want to think again if you’re a doctor. A study by a Mayo Clinic and the American Medical Association (AMA) team, reported in Mayo Clinic Proceedings, has identified that EHRs, CPOE and their clerical burdens can result in dissatisfaction and a risk of burnout for some doctors. It introduces a new phenomenon into eHealth; a concept of eBurnout risk.

    The team had responses from 6,375 doctors, about 19%:

    5,389, nearly 85%, use EHRs5,892, over 92%, said CPOE’s relevant to their specialty, with 4,858, nearly 83%, using CPOEThe doctors represented 24 specialties.

    The findings are simultaneously fascinating, illuminating and alarming. It reveals some of the consequences of week ergonomics in large-scale eHealth. The International Ergonomics Association (IEA) sees these failings seemingly caused by an inadequate application of “theory, principles, data and methods to design in order to optimise human well-being and overall system performance.”

    Satisfaction with clerical burden varied by specialty, with the highest satisfaction among pathologists and radiologists and the lowest satisfaction among urologists, family medicine physicians, and otolaryngologists (Figure 2).

    Doctors in nine specialties had above average dissatisfaction. Pathology and radiology well ahead of the others. Doctors in eleven specialties ha above average dissatisfaction.

    Those who used EHRs and CPOE had higher rates of burnout.Self-entry of notes using voice recognition was associated with lower satisfaction with the clerical burden directly related to patient care and higher rates of burnoutPhysicians who used EHRs or CPOE were less likely to be satisfied with clerical burden directly related to patient care.

    Over a third, 36%, of doctors who use EHRs are satisfied or very satisfied with their EHRs. Nearly 44% are dissatisfied or very dissatisfied. This varied by specialty. Doctors in nine specialties had above average satisfaction, pathology, paediatrics, paediatric subspecialty, obstetrics and gynaecology, neurology, general internal medicine urology, radiology and family medicine. Pathologists had the highest levels, but less than 60%. The lowest satisfaction rate was below 30% for four specialties. Generally, “Physician satisfaction with their EHRs and CPOE was generally low.”

    There’s an age difference too. Almost 46% of doctors younger than 40, 396 of 863, were satisfied with their EHRs. Fewer aged 40 to 49 were satisfies, 367 of 971, so almost 39%. Satisfaction dropped to nearly 32% for doctors, 512 of 1,606 of doctors aged 50 to 59, and almost 34%, 1,752 of doctors who are older than. Satisfaction trends for CPOE and the clerical burden are similar.

    Doctors in eleven specialties were reported above average satisfaction with EHR and CPOE clerical burden. Pathology and radiology are the top two, both approaching 60%. Doctors in urology and family medicine have a satisfaction rate of less than 30%, and the bottom two. A chart showing the team’s assessed combined satisfaction and burnout scores reveals a wide range of impacts.

    Doctors in seven specialties, the bottom right quadrant, exhibit high burnout rates and low satisfaction with their EHR and CPOE clinic burdens. Doctors in radiology and general internal medicine have higher than average satisfaction scores, but also have above average risks of burnout.

    eBurnout risk has been identified by the study team arising from a range of unintended negative consequences of EHRs and CPOE. They can reduce efficiency, increase clerical burdens on doctors, and increase the risk of their burnout. For Africa, with an average of one doctor for more than 2,000 people, so a massive deficit, and an average annual population growth of about 2.5%, eHealth’s eBurnout risk could have a dramatic impact. Its health systems must be sure that they don’t suffer these outcomes.