Director, WHO Collaborating Centre on eHealth, UNSW, Australia
Health Informatics Expert, Bangladesh University for Health Sciences, Bangladesh, India
The WHO Collaborating Centre on eHealth at UNSW-Australia is working towards in the development of EMRs allowing the developing countries easy access to universal interface to an EMR anytime, anywhere. In Bangladesh, the work involved Bangladesh University for Health Sciences (BUHS) and its partners. APuHC has been leading research in eHealth (Healthcare using Information and Communication Technologies) and mHealth (healthcare using mobile phones) sponsored by global bodies, such WHO, European Union, IEEE and ITU-D in Australia, Europe and Asia-Pacific including developing countries, such as Bangladesh, India, China, Vietnam, Philippines, PNG and Nepal.
It has been well documented that coordination among healthcare professionals (i.e Physician, nurses and other clinicians) helps to achieve desirable patient outcomes. Health Information Technology (HIT) such as EMR, when appropriately designed and implemented, can help to achieve this goal by timely, accurate, adequate information exchange among the parties involved. Bringing in the patient to actively engage in managing the health information is of greater value, particularly in the contexts of chronic care diseases and in cases where the patient takes active part in managing their own disease process.
However, achieving successful coordination has also been difficult given the challenges in synchronising activities of different parties involved and the varying need of information requirement. Moreover, depending on the availability of time and the patient load, managing EMR during care delivery has been a daunting process for the clinicians, particularly in the developing countries in South Asia where the doctor-patient ratio is much worse than in developed countries.
Unlike developed countries, developing countries often suffer from some additional issues in adopting HIT, apart from technical issues. There are also issues with the available infrastructure, resources and technical expertise both from the development and users perspective. For example, there are questions such as how can patients actively engage in their own health information management in view of low literacy levels? There is a need to supplement the traditional use of EMR through desktop or laptop devices (or in recent cases through tablets), where the availability of these systems is a problem. How can the Healthcare Professionals (HCPs) actively engage in such cooperative health information exchange where they are heavily time-constrained? How can we manage the information in one place where the healthcare delivery system is pluralistic and information exchange at intra- and inter-organisational levels do not exist, and where ‘One country, one EMR’ vision might not be available (or achievable) in near future?
Proliferation of mobile devices, especially the low-cost smartphones have bridged the digital divide among the rich and poor and have been ubiquitous in their use, particularly in the developing countries. In comparison to the personal computer, these mobile phones are substantially cheaper (decent Android handsets can be found under $50), small and portable, have good battery backup, and have voice communication, text, multimedia capabilities along with access to the internet. Feature phones are even cheaper. People around the globe are using phones successfully for a variety of purposes. Voice call remains at the top of the functionality with texting and taking pictures of their life events. Smart phones are now a part of the daily life of people of developing countries as a means to receive and make payments (mobile money), getting consumer and health information (mobile health / mHealth). Among young people the use of social media sites through their mobile phone is quite popular.
Healthcare professionals have varying needs or use of EMR. A physician, moving between hospitals, clinics and practices, can have great uses of mobile devices to transfer vital patient information, lab results, and images. Although smartphones offer the potential to support mobility of applications like EMR, the usability of the interface, particularly the screen size, limits the use of its full potential as an EMR interface.
From a patient’s perspective, getting the list of medication and providing data of home-based monitoring or procedures to clinicians (i.e. Blood pressure, blood glucose readings, weight) are important. From a developed area perspective, these may seem to be very basic and rudimentary. Using EMR interfaces on laptop, desktop, or through a tablet with sufficient screen size ease out the process, but in a resource-poor setting, providing fixed terminal to every workspace is not feasible and to consider everyone is capable of using a large screen tablet is not quite realistic. Porting the EMR interface to a mobile phone has been tried but the limited screen size makes it quite cumbersome and time-consuming for maintaining an effective EMR.
Although there are arguments in favour and against the use of an EMR, the use of EMR has positive impacts on patient care. Writing paper scripts is still the most favoured choice for documenting patient encounters among the healthcare professionals; and while transitioning to an EMR almost invariably leads to some sort of combination of paper and electronic chart. In a busy patient care scenario (where doctor-patient ratios are poor), physicians almost invariably have to work in a time-constrained fashion and to ask them to maintain an EMR in such a setting may result in mass resistance. We looked into the physician and patient’s common practice of care-related information, storage and uses in such a setup. Physicians write their scripts in SOAP (Subjective, objective, assessment and plan) protocol. However, not everything detailed in the protocol is used, rather physicians use information obviously pertaining to the disease process (and more often only the positive findings). In a country with provision of only paper records and no inter-organisational data sharing culture, visiting a doctor and undergoing procedures results in documents (i.e. medication scripts, investigation reports, log book), to be stored which are the responsibility of the patient. Maintaining all of these, particularly for a patient suffering from multi-morbid chronic diseases, is tedious and carrying all of them around for subsequent visits may not be possible.
There are strong evidences of the use of smartphones as an information retrieval and image capturing device. Taking an image through a mobile phone is quite straight forward and it is basic to have an email account to activate a smartphone feature. By using the intuitive features of a smartphone in an innovative way, it is possible to use the basic functionalities of an EMR (i.e. Storage and Retrieval of information) and thus to maintain (add/modify/delete) health records and access them during a visit or in an emergency.
Based on the above understanding, a task-oriented template based EMR was interlaced with a mobile phone. The EMR itself is capable of defining templates, based on the work practices and reuse it without further processing. It also enables to define the templates to retrieve records formatted in XML. We built an interface that links smart phones with the EMR in varying roles (i.e. patient, doctor, physician assistant). The information to be provided in the screen was based on use-cases of mobile phones analysed from a small group of potential users internally.
The basic strategy incorporated for the solution was to leverage the intuitive applications of the smart phones that we believed will make the solution usable for all streams of users. In particular, we wanted to put the patient at the forefront to update the health-record in a setting where physicians or healthcare organisations do not maintain patient health records and where it is the patient’s duty to maintain the paper-based care records that have been provided during the care or the end of a care episode (i.e. surgical note, discharge summary). This was done on the basis of the understanding that an effective, accessible and relatively complete set of health records in such situations can only be achieved when the physicians and other care providers, including patients themselves, get better at sharing information.