Design And Implementation Of Electronic Health Records Systems And Performance In Nigeria Teaching Hospitals
CHAPTER 1: INTRODUCTION
Many countries have acknowledged the importance of Information Communication Technology (ICT) in provision of healthcare services to improve patient safety, efficiency and quality. Kenya has acknowledged this and has set pace in establishing initiatives to achieve this noble goal.
Electronic Health Records Systems (EHRs) are part of the larger health management information systems having several roles including serving as an intermediary between various healthcare facilities (Hendy et al., 2005). They are an extensive record of a patient‟s health data resulting from visits in a healthcare facility. The records contain patient demographics, their progress, and medication history. Adoption of these systems automates the inefficient paper-based systems, thereby streamlining the workflow of the physician and thus improving the efficiency and effectiveness with which they provide care for the patient. They can generate complete records of patients‟ visits, produce evidence for clinical outcomes for management decision support (Hillestad et al., 2005). They are increasingly being deployed in healthcare facilities to achieve improvements in safety and care of patients, but there remains a challenge to this, they must be used by physicians effectively. EHRs hold promise in the improvement, efficiency and quality of care for patients, however, in terms of information technology, they are still decades behind other industries.
Health costs have spiraled upwards putting financial pressure to employers, governments and individuals as they continue to increase faster than incomes. Use of these systems can result in cost reductions gained through the reduction of duplicate services, improved decision making with the provision of timely and relevant information, reduced medical errors, patient confidentiality, and more reliable prescribing (Hoffman, et al., 2008).Unfortunately most physicians are poorly equipped with the tools to address this as most lack the essential information systems to keep up with the latest medical interventions to respond to various challenges posed in the provision of care.
Kenya has embarked on a mission to develop its electronic health management systems with the aim of migrating paper-based records to the electronic form of records management. The Ministry of Health (MoH) is putting efforts geared towards standardization of EHR systems in
healthcare settings under their control. This effort culminated in a document on standards and guidelines for electronic health records systems (Ministry of Health Report, 2011).
According to the Ministry of Health Report (2011), government run healthcare facilities have poor ICT making it difficult for adoption, and even though potential benefits for adoption and effective use of EHRs are known, documentation of its use and physicians‟ performance in healthcare settings in Kenya is limited.
Electronic Health Records Systems
Hillestad et al. (2005) define electronic health records (EHRs) as systems that organize and store medical records in electronic form. Unfortunately, most healthcare settings still rely on paper- based records, making it difficult to coordinate care for the patient and perform routine quality measurements, thereby leading to increase in medical errors. The use of EHRs provides the opportunity to improve medical decision making thus reducing medical errors, they also promote care coordination amongst healthcare professionals on patients in assessing problems, and also linking to other disparate systems for easy accessibility and accumulation of medical data. Paper- based records have certain shortcomings: expensive to maintain, easily destroyed, difficult to analyze, lack of security and confidentiality; and also their negative impact to environmental resources. According to Tang (2006), there are benefits to using EHRs which include secure health records, faster access of patient records and real time interaction with pharmacies and other specialists thereby reducing medical errors. Keying of data into the EHR is mostly recorded by various health care professionals and support staff ensuring a patient‟s health information and records are complete, accurate and secured.
The healthcare setting has complex processes according to Martin (2004), which extends from an individual presenting a health concern to a healthcare provider and continues through diagnosis, treatment and follow-up. Achieving efficiency of these processes is neither low-cost nor easy. These systems have the potential to improve health outcomes of patients through enhanced disease management, decision support and increased levels of preventive care (Bates et al., 2003). They are continuously being improved upon to increase efficiency in management of information to ensure the right information is at hand in support of making better clinical decisions.
In a study done by Zandieh et al (2008) looking at challenges of implementing electronic health records versus paper-based systems, found that transitioning from a paper-based to an electronic system can be challenging. They also note that paper-based systems are plagued with inefficiencies such as the need for large physical storage space, time-consuming retrieval methods, loss or damage to contents in a patient‟s file, unauthorized access, and medical errors caused by ineligible handwriting of physicians. Such inefficiencies affect performance, and as inherent as they are, can be minimized with the adoption of an EHR.
Ochieng and Herselman (2008) conducted a local study on eHealth in rural areas and found that infrastructural factors that includes availability of computer, internet, and ICT skills are important drivers towards the adoption of electronic health records system. Sahay and Walsham (2006) add that, training of physicians in ICT boosts their confidence in using these systems and hence improving on their performance. This also means the roles of physicians would have to be reengineered to effectively accommodate the technology as a result of the disruptive change in the workplace by the introduction of EHR systems. It is this phase that McIntyre (2008) notes that physicians will experience low patient encounters.
Despite the challenges coupled with high EHR systems implementation and continuous maintenance costs being high, the costs are likely to decrease over time, and adoption rates will likely improve, leading to overall improvement of healthcare management. The Ministry of Health has also noted of several initiatives that are geared towards reporting of healthcare information with the use of the District Health Information System (DHIS) and other electronic medical record systems. This study therefore seeks to investigate the use of these systems by physicians working within hospitals in Nairobi County.
Physician Performance in Hospitals
In the USA, the Health Information Technology and Clinical Health Act (HITECH) was enacted under the Obama administration to promote the meaningful use of these systems in achieving efficiency in healthcare (Blumenthal, 2010). As a result of this, a tool was developed by the American National Committee for Quality Assurance (NCQA) to measure the performance of care (www.ncqa.org). The Health Effectiveness and Data Information Set (HEDIS) tool was developed for the purpose of providing consumers reliable ways of comparing various healthcare plans.
There are circumstances where physicians are encountered with limited information with which to make clinical decisions and this has a danger to the safety of the patient (Kaelber et al., 2007). This leads to duplication of services such as laboratory testing and prescription of drugs (Frisse et al., 2007). Without the use of these systems, searching for missing information on patients has an impact on the scarce administrative resources spent on this task causing unnecessary delays in care and thereby having a negative impact on the efficiency of the physician (Smith et al., 2005). These systems have the capability of exchanging information between providers through Health Information Exchange (HIE). This solution allows timely and useful clinical information at the point of care, thereby aiding the physicians‟ clinical decision process with the aim of improving patient outcomes (Shapiro, 2007), thus leading to decreased costs, and reduction of medical errors as a result of the improved decision process (Kaelber et al., 2007). Physicians that make meaningful use of EHRs are likely to improve on their performance and that of the health facility.
The Ministry of Health Report (2011) key output from the review process on electronic health records was to recommend some criteria for monitoring their usage. They acknowledge from their findings that implementing of EHRs is different from its‟ meaningful use, and that well used EHRs results in improvement of clinical care and as such the evaluation of their usage can take the form of either quantitative or qualitative depending on indicators set.
Hospitals in Nairobi County
The World Health Organization (WHO) recognizes the importance of the role played by healthcare institutions such as hospitals since they host various cadres of medical personnel, and the fact that they are also equipped with inpatient and ambulatory facilities that offer various medical services around the clock (www.who.int); they are also a source of essential information for medical research and education since a lot of data is collected on health related conditions arising from disease and injuries.
There is a popular dictum that “health is wealth” and it‟s in order to say that the wealth of a nation can be measured by the health status of its citizens. According to the World Bank (2005), amongst the drivers to a poor economic performance of a country is attributable to ill-health and low life expectancy. In other words, health is a fundamental driver for economic growth and development, therefore a high percentage of the Gross Domestic Product (GDP) is apportioned
for public healthcare by developed nations since they believe health is a great driver for economic growth. A better healthcare should not wait for the economy to improve but ensures that measures are put in place to reduce the high burden of disease, thereby increasing life expectancy leading to creation of a healthier and richer economy. Therefore, hospitals are valuable and should be well equipped to offer essential health services for individuals seeking medical attention for an improved health outcome.