Category Archives: Hospital Information System

Subcategory containing blogs about both Patient Care Systems and Managerial Systems

Failure of EMR to Give Expected Benefits in USA


I have just read an article about EMR from Scientific American

.Below are my comments.

Statements in the article like Digitization of patient charts”, “Medical records suck”. “EHR, one that is not simply a digital file folder and “to transition from paper charts to EHRs” reflects the confusion that arise from the use in the USA of the term EMR for the information system. 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 patient types, instances of care (encounters and tasks) and role of the care provider allow the system to provide forms and views of data appropriate to them. This is done through planning based on deep thinking.
It states 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 but on the choice on how to implement them. A major problem in US is the lack of desire to streamline and to standardize. “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.
“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 customised for each doctor called the ‘favourite list’ and different lists containing selected drugs used in a department.
“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) which will warn doctors about wrong dosage, drug interaction, contraindications due to allergy or pregnancy. Errors should be reduced in a computerised system.

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”. When paper records were used, doctors and nurses also spend a lot of time writing notes or charting. The difference is they can write whatever they choose and often later. In a computerised system there is a need for data to be structured. If what the doctor is supposed to enter is anticipated and the GUI is 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 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.

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

“Information still does not flow easily between providers”. In reality, most patients are manged 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. Patient can carry summaries with them on their handphone, a thumb drive or as a printed document. It is not about using the most advanced technology 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 its 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 operational database 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 of where the data is to come from and how. I remembered attending workshops regarding 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.

Making Sense of Hospital Information System

There is a lot of confusion in concepts and terminology regarding HIS. In 1999-2000 when I was first introduced to the subject of Total Hospital Information System, my own exposure to it  was minimal and I wrote (and rewrite) various articles to clarify in my own mind what a hospital information system is meant to be.
I have been a user of HIS for more than twelve years because the hospital that I worked in as a clinician is computerized from the start. At the same time, I have worked with IT and Medical records personnel in various capacities including applications analyst, the Clinical-IT Coordinator and chairman of the hospital’s Medical Records Executive Committee. Also, I volunteered to provide help to other hospitals and their vendors in developing and implementing their HIS. I have also been invited to evaluate systems being proposed and also those already implemented.
The ideas and content of the current article has been used by some people as the basis for preparing the request for proposal (RFP) document for HIS as well as Operations and Maintenance contracts.  From time to time I revised my ideas and only now I consider them worth sharing with others through a website.
These set of articles is an exposition of HIS as it is known to-day together with some of my own ideas which may be considered as radical by some. Foremost, is the proposal for differentiating Patient Information Database from the Electronic Medical Record (EMR). The concept proposed, requires differentiation of the two not only in data content and structure but also in the system architecture and system administration. However, I belief that this approach will provide answers as to what the EMR should contain and how it is going to be made available without the necessity of accessing it through a Clinical Information System (CIS). It can be saved and read as a document or image (e.g. PDF).

This approach calls for defining the pertinent data, from the myriad of data that is collected in CIS that is required to be retained or migrated to a new system. I am putting forward suggestions for re-examining our policies and procedures  concerning data migration. Personally I belief, from a medico-legal perspective and for continuity of care, it is mandatory only to retain the EMR. The retention of other data is guided by epidemiological, research and business considerations.

I am sharing these articles with you in the hope of a better understanding, on my part, of the subject. If it helps you in any way I would be much elated.

Abdollah Salleh