All posts by Dr Abdollah Salleh

I am a retired surgeon, currently offering consultancy services in Information Management in Health Care Services. My interests and experience have been in patient care, quality management, clinical governance, medical education and information management (among other things). I served as a doctor in primary, secondary and tertiary care with the Ministry of Health Malaysia from 1977 to 2011. I am a life member of the Malaysian Society for Quality in Health, Malaysia; a society I helped establish and served as a Hospital Accreditation surveyor for many years. I served as invited lecturer and taught undergraduate and postgraduate students at various medical faculties (UITM, UKM and USM) in Malaysia. At Hospital Selayang, Malaysia, I was Chairman of the Clinical Advisory Committee, the Clinical-IT Coordinator and Quality Coordinator, for close to 10 years. I helped implement computerized hospital information systems in several hospitals. I graduated with MBBS from University of Malaya in 1977. I was (but has since ceased to be) a fellow by examination of RCS Edinburgh and RCPS Glasgow. I am contactable by e-mail at: drdollah@gmail.com

Failure of EMR to Give Expected Benefits in USA

Audio of Article: FAILURE OF EMR TO GIVE EXPECTED BENEFITS IN USA

I have just read an article about EMR from Scientific American entitled ‘Can AI Fix Electronic Medical Records?’

Below are my comments.

In the article, there are statements like

  1. “Digitization of patient charts”,
  2. “Medical records suck”.
  3. “EHR, one that is not simply a digital file folder and “to transition from paper charts to EHRs”

These reflect the confusion that arise from the use, in the USA, of the term EMR for the information system used in clinics and hospitals. In other places, people call the system the Healthcare Information System. In my hospital we call it the Total Hospital Information System. The latter name gives it a different perspective. It is a system to facilitate work just like systems in a shop, manufacturing plant or an airport.
Identification of case types, instances of care (visits, encounters and tasks) and role of the care provider allow the system to provide data entry forms and views of data appropriate to them. This is done through planning based on deep thinking.
The article mentions that systems “varied widely from site to site and even between sites using the same system”.
This is probably not the fault of the system developer but on the choice on how to implement them. A major problem in US is the lack of desire to streamline and to standardize. This is obvious from the statement: “Blood sugar from patients at one hospital …. there were literally thousands of different ways they were entered in the EHR”.
Strict clinical governance will alleviate many of these problems.
There was also a finding mentioned in the article that “To prescribe medications, a doctor has to locate them. a simple search for Tylenol brings up a list of more than 80 options. a simple task has taken precious minutes”.
As early as 1999, there are systems that can be customized for each doctor called the ‘favourite list’ and specific lists for departments containing selected drugs used in each of them.
Another surprising finding mentioned was “The physicians often made dosage mistakes. At one site the error rate reached 50 percent. We’ve seen patients being harmed and even patients dying because of errors or issues that arise from usability of the system”.
A good pharmacy system is integrated with a drug decision support system (like MIMS or Multum) which will check prescriptions and warn doctors about wrong dosage, drug interaction, contraindications due to allergy or pregnancy. Errors should be reduced in a computerized system not increased.

The article says ‘Physicians complain about clunky interfaces and time-consuming data entry. Polls suggest that they spend more time interacting with a patient’s file than with the actual patient”.
The reality is that when paper records were used, doctors and nurses also spend a lot of time writing notes or charting and flipping through the pages to read notes. The difference is, on paper, they can write whatever they choose and often after the interaction with the patient. In a computerized system, there is a need for data to be structured. If what the doctor is supposed to enter is anticipated and the GUI is made intuitive, data entry will be faster. Again, there is undue emphasis on the difficulty to record data but not placing importance to provision of information or guidance by the system. In my hospital care providers are very grateful that laboratory results, X-ray reports and vital signs are readily available without hassle.

The article suggests that

  1. “EHRs turned physicians into data-entry clerks”.
  2. “Doctors have to type up their narrative of the visit”,
  3. “.. but they also enter much of the same information when they order lab tests, prescribe medications and enter billing codes”.

This obviously stemmed from a failure to understand the use of a database (maligned in this article). It is a fundamental dictum that data is entered only once and used repeatedly for various purposes. It is also typical in USA to think that the system (as a result of misleadingly called EMR) is for doctors rather than for all stakeholders. In the USA, it was difficult to introduce Computerized Physician Order Entry because doctors (physicians) are reluctant to place orders for tests, procedures supplies, and so on themselves. This is because, previously entries were made by clerks. In other countries, this not an issue since doctors has always filled up the order forms themselves. If charge codes are attached to orders, there is no need for clinical care providers to worry about charging at all.

Another statement in the article is that “Information still does not flow easily between providers”.
In reality, most patients are managed at a single facility. Within the facility itself there is no reason at all for inability to share data. When they are transferred to another facility only a referral letter with a summary is sufficient to ensure continuity of care. Indeed, a good healthcare information system should be able to generate summaries automatically. Patients can carry summaries with them on their handphone, a thumb drive, a flash card or as a printed document. It is not about using the most advanced technology (example a shared common cloud-based database or AI) but about using the most appropriate technology.

In Malaysia, we run into the same problems in the past and will continue to dos so because we do to learn from our mistakes and successes.

First of all the attitude. I hear statements from people high up. “I don’t know much about IT in health but I think it’s no good”. People don’t want to learn let alone study in depth.
When we had the Telemedicine program together with Hospital / Clinic information systems the leadership cannot see their congruence. We cannot have one without the other. Until now we have a Telemedicine unit when we should have an integrated Health IT and Information management unit. The importance of Telemedicine and a central database for patient care is highly exaggerated.
We should concentrate first at where data is generated and its use for operations i.e. help workers to do work. At the beginning we had it right by calling it THIS. Last year, some smart alack has called it EMR (I suppose to follow the USA).
Yes, for managerial use of data we need a data warehouse. But why don’t we think first of where the data is to come from and how. I remembered attending workshops regarding National Lifetime health record (LHR) and Data warehouse where I asked: “What do you want to do with the data” The answer they give me was: “We just collect it, for people to use for whatever purpose.”
We still have a long way to go.

Apa Ada Pada Nama – EMR atau HIS

Ketika sistem pengurusan maklumat berkomputer dimulakan di Malaysia dengan pelaksanaannya di Hospital Selayang (1999) nama yang digunakan ialah ‘Total Hospital Information System’ atau ‘Sistem Maklumat Hospital Lengkap’. Nama yang sama digunakan di Hospital Putra Jaya, Serdang, Ampang, Sugei Buloh dan banyak lagi hospital. Nama ini menekankan niat untuk menggunakan Teknologi Maklumat (Information Technology) secara menyeluruh iaitu memudahkan kerja untuk semua fungsi dan di semua unit, menggantikan sistem sebelum itu. Malah pemberi khimat di Hospital Selayang sangat sangat menghargai bagaimana sistem maklumat hospital memudahkan kerja kerja seharian mereka.

Namun baru baru ini, Kementrian Kesihatan telah mengutarakan cadangan untuk melaksanakan Rekod Perubatan Elektronik (Electronic Medical Record) di seluruh negara dengan kadar cepat  (“…fast-track EMR implementation across MOH hospitals and clinics nationwide..”). Bila saya merungut tentang penggunaan nama, yang saya anggap salah, ada orang menjawab “biarlah apa nama jua pun asal sistem merekod atas kertas digantikan”. Jawapan ini menunjukkan salah faham mengenai mengapa kita menggunakan sistem berkomputer. Tujuan Teknologi maklumat digunakan dalam bidang perkhidmatan penjagaan kesihatan (seperti juga yang digunakan dalam bidang lain) adalah untuk memudahkan kerja dan menoptimumkan penggunaan data sebagai sumber yang berharga.

Rekod perubatan adalah catatan apa yang dibuat dan apa yang berlaku keatas pesakit mengikut kronologi. Kalau komputer digunakan sekadar untuk tujuan itu, aplikasi paling sesuai adalah aplikasi pemproses perkataan (word processor) seperti Microsoft Word. Sebaliknya, tetapi jika kita hendak gunakan teknologi maklumat untuk membantu kita membuat kerja, kandungan sistem mengandungi sistem kecil atau modul untuk perkhidmatan klinikal, bantuan klinikal dan juga pengurusan. Struktur sistem juga menjadi kompleks dan memerlukan usaha, kepakaran dan belanja yang tinggi untuk mencipta dan melaksanakannya. 

Mereka yang menggunakan istilah “Sistem EMR” kerap berkata itu hanya nama, maksud sebenarnya ialah sistem yang komprehensif (nama ini digunakan ia popular). Namun oleh kerana nama yang dipakai, fikiran mereka menjadi celaru. Mereka membina dengan menukar borang kertas kepada borang elektronik, lalu menjadikan mencipta borang sebagai usaha utama (tanpa memikirkan bagaimana data diaturkan dalam pangkalan data. Kemudian mereka merungut “Kita ada begitu banyak data, kenapa tiada orang hendak mengalikannya?”.

Kerana masih terbawa bawa dengan konsep mencatat data (documentation), mereka berpendapat sistemnya sangat mudah dan harganya pun sepatutnya murah. Baru baru ini saya mendapat tahu, ada sebuah hospital universiti menganugerahkan tender sistem maklumat hospital lengkap (yang mereka panggil ‘EMR’) dengan harga RM12 juta. Harga termurah Sistem Maklumat Hospital adalah lebihkurang RM40 juta.

Bila berinterksi dengan pegawai di Kementerian Kesihatan mahu pun di universiti, pepatah Melayu “Hanya jauhari mengenal manikam’ terlintas dibenak hati saya. Satu ketika saya terdengar dari mulut seorang Ketua Pengarah Kementerian dan seorang Timbalan Ketua Pengarah ungkapan yang sama “Saya tidak tahu sangat tentang penggunaan IT untuk hospital, tapi pada pendapat saya, ia tidak baik”.

Saya rasa terpanggil untuk berkongsi ilmu dan pengalan saya dan dengan itu lahirlah artikel setrusnya dalam laman web ini bertajuk “Sistem Maklumat Penjagaan Keshatan“.

Penyediaan Rencana “Carta Masuk-Keluar Cecair” (Fluid Intake-Output Chart)

Setelah bebarapa lama berusaha menyediakannya rencana mengenai Carta Masuk-Keluar Cecair akhirnya siap. Walupun versi English (Fluid Intake-Output Chart ) lama siap, versi bahasa agak sukar disiapkan. Namun ada kelebihannya kerana saya memasukkan banyak kandungan tambahan.

Rencana ini diletakkan di menu sebelah kiri, dibawah topik Versi Bahasa Malaysia > Amalan Klinikal > Pemantauan Semakan dan Kajisemula > Carta Masuk-Keluar Cecair.

Juga boleh diakses dari di Menu utama Home > Menu Versi Bahasa Malaysia

Saya harap pembaca menilai dan meberi maklumbalas jika ada kesilapan atau keraguan. Terima kasih kerana membaca laman web saya.

Healthcare Data Retention and Migration

Retention of the Electronic Medical Record (EMR) needs to be differentiated from data migration. The latter is one method of retaining data. For a paper-based record, retention means keeping it for a desired period of time in its original structure. By ensuring that the structure is intact, the original content is also preserved.
Retaining the EMR poses peculiar problems. First of all, the structure and content of the EMR need to be more clearly defined if it is to be retained. Even though many software providers name their applications as EMR, they are actually providing a system to facilitate clinicians to perform clinical care activities i.e. an application more appropriately named the Clinical Information System (CIS). The CIS contains a lot more data that what constitutes the EMR. No software developers in their right mind would develop systems just for the recording of events or incidents.
There are 3 purposes for which data need to be retained:

  1. Business continuity
  2. Continuity of care
  3. Preservation of a historical record

The continuity of care problem that emerges when a changeover to new system occurs is similar to the situation that exists when a patient is referred to another institution (using a different system) where the care provider provides sufficient information to his/her counterpart to enable continuity of care. Such information consists of  a letter and a summary of all events, findings and results for all visits made in the referring facility. For most instances in an electronic system, it is adequate to provide a summary of historical data regarding all events, findings and results for all visits made rather than carrying over the entire data contained in the CIS or Medical Record. The summary is actually a report created by extracting historical data from the database. It is quite possible to extract the entire data making up the Medical Record but for continuity of care this is quite unnecessary.
Data migration is essential only in instances where the critical points in the clinical care process, i.e. the clarification of diagnosis and firming up of the treatment plan, has not been sorted out. In cases where the definite diagnosis has been made and the treatment plan has been decided on, a case summary would be sufficient to enable the subsequent care provider to gain an insight on what had transpired earlier.
On the other hand, preservation of Medical Record for a certain duration is required by law. It would be simple if it is already created for each patient at each visit. Unfortunately, very few if any HIS have a built in facility to extract and present the EMR at the end of a visit. Most CIS (or even the so called ‘Electronic Medical Record System’) do not have this capability. Most institutions or software developers think that in order to preserve the Medical Record, the entire CIS need to be retained. I am advocating here that the EMR being a record need only be preserved in the form of a readable document created from a report extracted from the CIS. So, efforts should be made to define the data elements that make up the EMR, standardize its structure (sequence and arrangement) and develop the means of constructing it.
Read more about this subject in my article

Use of HIS for Medical Education and Research

I have just completed an article on “Leveraging the Computerized Hospital Information System for Medical Education and Research“. It is a concept paper. I do not know if such a system has been implemented anywhere. In the hospital I worked in previously, domains have been created for Operations, Analytical function, Train and Build. However, despite being a hospital for training undergraduates and postgraduates, the benefits of HIS have not been optimized for teaching and learning.
I think there are extensive possibilities and would like to realize them if given the chance.

A PDF version is available.