• Johannesburg starts up eHealth for primary care

    For many Johannesburg residents, seeing a doctor means leaving home as early as 4am to have a place at, or near, the front of the queue at the City’s primary healthcare facilities. Many people can spend the whole day in a clinic queue.

    Reducing waiting times is the eHealth goal of The City of Joburg. A report says Executive Mayor, Clr Parks Tau, launched the Rand electronic patient processing system in the new Jabavu Clinic in Soweto. It’ll reduce long queues and piles of paper at the clinics. It should also reduce the time healthcare professionals spend on paperwork, so increase the time they can spend seeing patients. It’ll also keep records safe, minimise errors and avoid unnecessary mistakes.

    The Mayor said “It’s about delivering services where they are needed the most and dealing with the issues that matter the most. The new system meant Johannesburg residents had leapfrogged into the digital era. We as the City of Johannesburg are using technology to solve the problems that residents face.”

    The system will be rolled out to the rest of public clinics in Johannesburg in due course. eHNA looks forward to hearing about its progress.

  • How far ahead of Africa are the USA's EHRs?

    An eHNA post on Africa’s responses to WHO’s 2015 eHealth survey showed it lagging behind global performance. It wasn’t surprising. Its scores for EHRs shows 18% of countries have national EHRs with about a 7% penetration rate into healthcare facilities.  

    An article in FierceEMR says 96% of USA non-federal acute hospitals have adopted certified EHRs. It’s a significant increase. The information is based on the American Hospital Association's (AHA) Information Technology Survey. It shows:

    The 96% of EHRs’ users are up from 72% in 2011Small and rural hospitals increased adoption of basic EHRs by at least 14%Critical access hospitals increased their adoption of basic EHRs 18%, but its adoption rate still lags behind other hospitalsBasic EHR adoption was even lower among children's hospitals at 55%Psychiatric hospitals’ adoption rates were only 15%40% of hospitals that had adopted comprehensive EHRs with increased levels of functionality, up by less than 2%Interoperability increased, with 85% of hospitals sending clinical data electronically, up from 78%Organisations receiving electronic data increased from 56% to 65%Surprisingly, organisations using or integrating electronic data dipped slightly from 40% to 38%.

    This comparison gives Africa an estimated 93% deficit on EHRs. Catching up doesn’t mean an unaffordable dash that disrupts other priorities. eHealth projects for EHRs are neither easy nor cheap, so there are no simple solutions. WHO’s survey also showed that Africa also has to catch up on Big Data and Analytics. The survey didn’t ask about the Internet of Things (IoT), but a deficit’s likely there too.

    At more than 50%, Africa’s making progress on mHealth relative to the rest of the world. Good strategic goals maybe to sustains its mHealth performance while slowly and steadily advancing its EHRs to support its top health and healthcare priorities.

  • Changing EHRs can have unwelcome surprises

    Few African health systems have national EHRs. This’s a finding of the recent WHO survey posted on eHNA. For those that do, they may have some unwelcome surprises when the time comes to change them.

    A survey in the USA by Black Book found that 87% of hospitals that are threatened financially regret replacing their EHRs. Another finding’s that 14% of hospitals that replaced their EHRs since 2011 are losing inpatient revenue at a rate that exceeds the total cost of their replacement. It seems to have negative effects on direct patient care and too.

    62% of ICT operatives claim there’s a significant negative impact on healthcare delivery directly attributable to EHR replacements 90% of nurses say EHR process changes diminished their ability to deliver hands-on care at the same effectiveness 96% of nurses in the Black Book’s previous survey said they had no input or inclusion in hospital EHR replacement planning In contrast, 5% of hospital leaders say the EHR replacement affected care negatively 63% of executives said they or their peers felt their jobs were in jeopardy through EHR replacement 7% of managers or higher incumbents said they or their peers were fired or asked to resign directly because of EHR replacement cost or adverse performance 19% said intermittent or permanent staff layoffs were directly caused by implementation delays, cost overruns, underestimated budgets or unavailable trained staff. 

    Surprisingly, levels of Interoperability (IOp) decreased immediately after replacing EHRs. About two-thirds of system users said IoP and patient data exchange functionality declined, causing problematic connectivity. 

    Doctors’ and other clinicians’ buy-in for new EHRs was challenging:

    78% of non-medical executives said promised clinical buy-in never materialised after their replacement EHRs were launched 88% of hospitals with replacement EHRs couldn’t report any competitive advantages to attract doctors based on their new system 80% of ICT staff said they felt they had to coerce doctors to adopt replacement EHRs.

    These are very valuable indicators for Africa’s health systems. They can apply in principle to using the first set of EHRs, not just replacements. Black Book’s findings are a reminder to approach eHealth steadily and engagingly.

  • Successful EHRs need users to use them

    EHRs are a big investment. Acfee’s evaluation models look for high utilisation levels to increase the probability of securing sustainable benefits. Ancile, a training firm, sees user adoption, the equivalent to utilisation, as the key. It’s has published A Roadmap to Achieve Successful EHR Adoption, an eBook to show how. It applies to all types of eHealth, and is available through FierceHealthIT, a USA eHealth news site. 

    It’s based on the premise that organisations that see training as an investment, not a cost, have high user acceptance and better application productivity. It’s borne out from a survey finding that 72% of say user adoption’s essential for success. 

    There’s a long check list of activities needed to achieve this. They’re in three main phases: planning, implementation and sustainment, a performance emphasis on the operational phase, and vital for Africa’s eHealth initiatives.

    Ancile sees training as an enabling activity. In this context, it fits alongside user engagement, which should begin at the outset of eHealth projects before the business cases are started. Successful EHRs extend engagement well into the operational phases. It’s encouraging to see that Ancile does this with its adoption model. It’s sustainment phase includes lessons learned and debriefings where users are challenged by EHRs. Sustainment activities extend into upgrades of EHRs too.

    Seeing enablement as a recurring resource offers a more constructive model than training as a start-up activity that’s part of implementation. Acfee’s evaluations have found that a limited approach can lead to underutilisation of EHRs’ functionalities, so limiting benefits realisation. It’s something African health systems cannot afford.

  • Some EHRs may have medication benefit barriers

    EHRs can have a wide range of benefits. In Africa, medication adherence is often seen as a high eHealth and mHealth priority. A research team led by Duke University in the USA has found some persistent barriers in EHRs helping to improve patient’s medication adherence. 

    In the Journal for Medical Informatics Research, the team set out its study. There are four persistent eHealth barriers to medication adherence. They are:

    Underdeveloped of data reciprocity across clinical, community, and home settings, limiting the data capture needed for clinical care Inconsistent data definitions and lack of harmonised patient-focused data standards, making existing data difficult to use for patient-centred outcomes research Inability to use the national drug code information effectively from EHRs and claims datasets for adherence purposes Lack of data capture for medication management interventions in EHRs, such as medication management therapy.

    Limited semantic interoperability’s seen as an underlying constraint in removing or minimising these barriers. It’s been a longstanding issue.

    Poor medication adherence data reciprocity across systems has two characteristics:

    Data complexity, coding syntax, and the transmission infrastructure on which data resides Output, such as medication history, refill rates or patients’ experiences of side effects.

    Common to both features, data’s not accessible, timely, nor easily understood by healthcare systems. Consequently, providers, patients, family members, and community support often lack adequate communication about using medication. 

    The study highlights the role of mHealth in medication adherence, which is important for Africa’s health systems. Barriers identified for EHRs can apply to mHealth too, so all need assessing rigorously as part of mHealth medication adherence projects. Just having an app doesn’t seem to be enough.

  • EHRs are more than sharing, they help detect type 2 diabetes

    Until a few years ago, EHRs’ benefits were mainly about sharing data for quality and efficiency gains. With Big Data and analytics, it’s more. EHRs can now be used to detect undiagnosed type 2 diabetes.

    A report in the Journal of Biomedical Informatics by a research team from University of California, Los Angeles (UCLA) describes how it started mining thousands of EHRs in 2012 to find a cheaper and more accurate way to identify people with type 2 diabetes. The approach offers big benefits for Africa’s health systems.

    The study had five main stages:

    Extract features from EHRs to predict diagnosed type 2 diabetes Predicted patients’ diabetes diagnosis using 9,948 clinical-quality EHRs Show that EHR phenotyping out-performed conventional screening Show EHR phenotyping had superior overall predictive accuracy Show EHR phenotypes also improved predictions of new patients with type 2 diabetes.

    Its initial data was an estimate of 25% of type 2 diabetes patients undiagnosed, due to inadequate screening. A long string of EHR data was used for the predictions and analysis. It included commonly prescribed medications, diagnoses as ICD9 categories, and conventional predictors, Body Mass Index (BMI), age, sex, smoking status, hypertension, Migraines, depot medroxyprogesterone acetate and cardiac dysrhythmias had negative associations with type 2 diabetes. 

    EHR phenotyping resulted in markedly superior detection of type 2 diabetes, including patients with EHRs with missing and unsystematically recorded data. The improvement should enable an extra 400,000 patients to be identified with active, untreated type 2 diabetes compared to the conventional pre-screening models. 

    By using analytics to reach undiagnosed patients, the methodology offers big benefits for healthy Africans. It offers big benefits for Africa’s health systems too, when they step up their combined investments in EHRs and analytics.

  • Integrating information with EHRs can be cheaper

    As EHRs become routine, do you know how much it costs to run interfaces to integrate data? Are you spending too much on integration? iNTERFACEWARE, a Canadian company, says in its free eBook, 7 Tips for Faster HER Integration that you probably are. Healthcare organisations that've experienced downtime, or take months to set up interfaces with their EHRs, or miss deadlines for HIE integration, are either losing or wasting money. 

    The seven tips to improve performance are:

    Understand the actual workflow Put the specifications upfront Avoid customizations on the EHR end Standardise and normalise your data Use real data for testing and mapping Embrace the power of scripting Focus on the data, not the system or format.

    These are important perspectives for Africa’s health systems. As mHealth and IoT expand their impact, it’s vital that their data is incorporated in EHRs. In addition the seven tips, developing, using and sustaining reliable unique patient numbers has to improve too. For Africa, accurate and complete registration of births, deaths and marriages is tip number eight.

  • A good roadmap can improve EHR's benefits

    eHealth initiatives are full or risks, and EHRs probably contain the largest exposure. ANCILE, a leading solutions provider to drive technology benefits by using software to improve users’ adoption, says a good roadmap that secures users commitment and acceptance is a way to minimise risks and maximise benefits.

    Its White Paper, A Roadmap to Achieve Successful EHR Adoption, sets out five main stages:

    Evaluate, select, install Implement Enable Go-live Sustain. 

    The roadmap is a combination of questions and answers. Underlying themes are training and people’s eHealth capacity as core components of success.

    Findings from its survey says “72% said effective user adoption was the most important factor for realising values. Many a software deployment delivers 100% on the business requirements only to fail in the final phase of user adoption.” Acfee’s evaluations confirm that maximising benefits and investment returns is extensively dependent on high levels of utilisation achieved promptly after go-live.

    ANCILE’s time scales are ambitious. They include planning of three to four months before go-live and implementation of two to three months. These seem a bit short. Stage 1 can take years, with technical evaluations, business cases and supplier assessments and certification.

    With increasing cyber-threats, as eHNA has reported, users’ skills and knowledge about compliance to good security practices is an essential training need. Without it, users can be an unintentional security weakness.

    For sustainability, Africa’s eHealth initiatives depend extensively on affordability too. There’s not much that suppliers can do about this.

  • eHealth strategies take longer than eHealth exhortation

    Many eHealth strategies have horizons of fulfilled potential and Utopian healthcare. Eduardo Galeano, the Uruguayan journalist, summed it up as “Utopia is on the horizon. I move two steps closer; it moves two steps further away. I walk another ten steps and the horizon runs ten steps further away”. A challenge for Africa’s eHealth’s to deal with this as a normal.

    England’s NHS shows a harsh reality of horizons. It started its EHR journey in the late 1990s. The end’s still not it sight. After the Connecting for Health debacle, the Secretary of State set a new EHR goal in a speech to the Policy Exchange in January 2013.

    A five-year horizon was set for an extensively paperless NHS in England, and by 2018, included:

    Clear plans in place to enable secure linking of EHRs and care records wherever they’re held, so there’s as complete a record as possible of the care someone receives Clear plans in place for records to follow individuals, with their consent, to any part of the NHS or social care system By April 2018, digital information to be fully available across NHS and social care services, barring any individual opt outs A clear expectation that hospitals should plan to make information digitally and securely available by 2014/15.

    The benefits were summed up by the Minister as “Only with world class information systems will the NHS deliver world class care.” There was also a goal to “save billions.”

    Subsequently, the Minister set a longer timescale. The NHS Five Year Forward View said out “the overarching objective of harnessing the information revolution is to make the NHS paperless by 2020.” This vision is encompassed in the National Information Board’s Personalised Health and Care 2020 Framework.”

    With a budget of £4 billion for EHRs and online appointments, prescriptions and consultations, it’s now being reinforced as an achievable horizon two years further away, along with objectives of:

    Faster diagnoses At least 10% of patients use computers, tablets or smartphones to access GP services by March 2017 By 2020, 25% of patients with long-term conditions such as hypertension, diabetes and cancer, can monitor their health remotely Free Wi-Fi in all NHS buildings, but no deadline’s set.

    Africa’s eHealth strategies and programmes can learn from this. It’s more important to put in place the sustained resources and organisation needed for continuous eHealth investment priorities rather than set out a Utopian eHealth endpoint that inevitably slips further away.

    Eduardo Galeano went on to say “As much as I may walk, I'll never reach it. So what's the point of utopia? The point is this: to keep walking.”

  • EHR mess-ups are risky for doctors

    There is now another reason why doctors don’t like EHRs. A HIMSS16 speaker says EHR mistakes put doctors at risk for malpractice lawsuits. While EHRs have been shown to improve patient health, safety and care coordination in many ways, what is less documented is how EHRs can also cause harm, and even leave healthcare professionals open to malpractice suits, says Trish Lugtu, , in an article in Healthcare IT News. She’s associate director of research at Midwest Medical Insurance Co (MMIC), a medical liability insurance company based in Minneapolis. 

    She pointed to one case where an anesthesiologist didn’t have critical information available in his views of the EHR that would have told him a patient wasn’t a candidate for the type of anesthesia used for the planned procedure. The mistake ended up paralysing the patient from the waist down.

    “I’ve found that there is a pretty even split between what I’ll call ‘unsafe technology’ and ‘unsafe use,” she said of the contributing factors to EHR-related malpractice claims. “Unsafe technology,” she added, “encompasses those issues that the provider generally can’t control in the moment or at the point-of-care, such as the way templates and workflow are configured, adequacy of fields to document, or how lists appear in dropdowns.”

    Technical issues such as downed systems or broken interfaces also affect access to EHRs. Despite this, Lugtu warned that no blame falls on the vendors. While vendors obviously need to be involved to fix some issues, Lugtu says the healthcare organisations are responsible for its level of engagement during implementation of new systems or modules and the security safeguards put in place. 

    Unsafe use, including everything from insufficient education and training to human error, is also a factor. Heretoo, careful implementation is crucial. “For example, blanket decisions about what data to convert for a patient population can eliminate crucial information for a few patients,” Lugtu explained “or processes may be under-developed for accessing information in a hybrid [electronic and paper] environment.”

    To combat these blind-spots, Lugtu advocates stronger partnerships between health ICT and risk managers, and between health ICT professionals and care teams, and patients. “Health IT people typically do not consider themselves as part of the care team nor are they treated as part of the care team, so the perception that EHR risk factors are just IT issues rather than patient safety issues creates a lack of real urgency,” Lugtu said. “The crux of the matter is that a broken interface isn’t just an IT issue to the patient whose life depends on it.” With the rate of ehealth and EHR implementation on the rise, malpractice cases could be too.