Puzzled Over the Perfect EMR

Digitisation has become an integral part in almost every sphere of life, but is yet to make its presence in the world of medical records, finds out Nancy Singh.

On the face of it, the possibilities of using EMR seem endless and optimistic, but there are issues that need to be addressed for it to make an impact.

Not many healthcare facilities have been successful in implementing information technology in healthcare beyond the usual accounts, billing, inventory and occasional laboratory and diagnostic services. "I don't think an EMR is used in its true sense. As of now, they are mainly used for administration and billing processes," says Sunil Kapoor, Director-Central Buying, of Fortis Healthcare, New Delhi.

"As of now, EMR is mainly used for administration and billing processes" - Dr Sunil Kapoor Director - Central Buying Fortis Healthcare New Delhi

An ideal EMR should provide accurate and timely data, alerts, reminders, clinical decision supports, medical knowledge, communications and other aids at all points of care for all healthcare professionals, so that it helps to improve the quality of healthcare. The concern is whether the EMR actually caters to these requirements. It should also include old useful functions and overcome the known problems of paper-based records, provide new useful functions not available from paper based records and at the same time should not generate new problems associated with the electronic medium.

As no perfect EMR exists in the market, another aspect is the lack of standards among various EMRs. This is because data does not follow a standard structure. Such data cannot be transmitted across locations and facilities. Internationally, many standards have evolved, the most famous being Health Level 7 (HL7) from the US. "Since some aspects of HL7, the most notable being Social Security Number, are not applicable to India, under the aegis of Ministry of Health and previously Department of Information Technology, we have made some standards which hopefully will correct this problem," says Dr Shashi Gogia, President, Indian Association for Medical Informatics.

With software companies targeting the Western and Gulf market, the Indian healthcare industry is unable to attract major software players to sell at affordable rates. The market is fragmented with inadequate products. The few players in India include CDAC, Karishma Software, 21st Century Health Management Solutions, Amla Mediquip, Sona Software whereas actual big players like Siemens, TCS, GE Healthcare, I-Soft are more into Hospital Information Systems.

Sadly, most hospitals who decided to become IT-savvy are not satisfied with the outcome.

"I think the role of EMRs have been hyped. Functions of EMRs in healthcare are very similar to banking systems in retail and commercial banks, but no one discusses them even though the impact they make to your personal life is tremendous," says Dr Pushwaz Virk, Health care management Fellow, Harvard University Health Services, Cambridge, USA.

Unknown Fears

Another issue is that of security. From the perspective of system functionality, there are several issues. It's cognitive overload, the information overload of EMR and badly designed interfaces that demand extra cognitive resources. Blind acceptance of information and recommendations leads to averse outcomes due to lack of context or inappropriate knowledge representations in the decision support system.

One of the main reasons for lesser success rate is also inertia. Vinay Ranade, Product Manager, Bioanalytical Technologies, Pune, says, "Medical practitioners are sticking to the old concept of using pen and paper. They are reluctant to change their way of working."

Reportedly, when Wockhardt Hospital, Mumbai, faced a similar problem from a reluctant group who refused to give up the pen and paper, it came up with a solution. All records are now carbon-copied which then go to the transcriber who feeds in the data for digital storage.

"With ineligible handwriting and incomplete notes in paper format, computerised systems will increase the time but if you enter the same amount of data and train yourself well, the time required in entering and subsequently searching for information will substantially be reduced," clarifies Dr Virk.

Apart from cost issues - initial and recurrent, with increased time to deliver care, disruption of hospital systems, some hospitals fear it would make them vulnerable to lawsuits as data for evidence of malpractice can be obtained. There are also questions about the user-friendliness of EMR. What are the dimensions of usability problems? How much of back conversion of previous paper charts to digital form is required to make the EMR truly useful with respect to existing patient base?

Do the various clinical systems talk to the EMR interchangeably to ensure the digital chart is updated? This is an issue of interoperability as most Independent Software Vendors (ISVs)base pay lip service to interfacing, but actually do little towards true standardisation and interchangeability. Also, the costs of licensing and the difficulties in implementing such clinically-oriented systems makes it difficult for hospital administrations to force the health systems to change towards using EMR. "The Electronic Patient Record (EPR) database should not be the master or central repository, but must be able to perform within the larger information system to make it compatible with other popular systems for laboratory, registration and billing, among other things," says Dr R P Pareek, Member, IAMI.

When large amount of data is available online, breaches in Internet security is a concern. Smart cards could be a possible solution. The low cost of the cards, their storage capacity, and the fact that patients can carry their card, make it an attractive option. "The efficient way of making healthcare available to masses is when Government becomes a ‘health insurance’ provider and not just a ‘healthcare provider.’ Smart cards and biometric solutions will bring down fraud and misuse," believes Madhava Murthy, Executive Director, S N Informatics, Bangalore.

"Though a little hyped, anyone with a scanner can access your code and information about your health status from anywhere in the world," says Dr SeemGupta, Domian Consultant, Wipro Healthcare. It is a popular concept in Europe, and healthcare smart cards are in use in pilot or operational settings. "This card is my lifeline. It has all data about my medical history. So if I have a heart attack this is the card that will save me," says Hardy Sekhon, Group Director, Risk Management Canada Health Infoway, a $1.2 billion not-for-profit corporation accountable to 14 Federal/Provincial/ Territorial Governments, which plans to provide Interoperable EHR across half of Canada by 2009.

In India, the issues of privacy have yet to be raised. However, with the solution of digitisation of medical records and putting them online being considered, this issue is bound to come to the fore. If patients feel that they have no control over the fate of their medical information, they might fail to disclose important medical data or even avoid seeking medical care because of concern over denial of insurance, loss of employment or housing, or stigmatisation and embarrassment. Though hospitals in India believe in maintaining their own records and not issuing it to the patients, new judgments have made it mandatory that on demand, it is necessary for the hospital authorities, to provide copies of such case papers to the patient or his near relative.

Long Way to Go

Slowly but surely, healthcare is moving towards EMR. "There are only a few hospitals that have fully-implemented EMR. It requires customisation time and money," avers Dr Pushwaz Virk, Fellow, Harvard University of Health Sciences.

Though EMR has a long way to go, experts believe that with the focus shifting from illness to wellness, the concept of e-health and digitisation may not make EMR a distant dream after all.

"While an EMR itself will not be changing the healthcare scenario, the concept of e-health will, wherein we get the benefits of quicker diagnosis of impending healthcare problems and an efficient as well as appropriate response," states Dr Gogia.

Development of EMR should be an essential requirement for all healthcare facilities. The rise of the insurance sector is likely to hasten this process.

nancy.singh@expressindia.com