Electronic Medical Records (EMR): A Practical Solution
Messaging, Social Networking, Photo Albums, Filing Taxes, Stock Market Investments, Banking, Paying Bills and many other activities are moving online and are being converted to an ‘electronic form’. The internet user base in India (especially in the Metros and Tier-1 cities) is growing at a very fast rate.
Yet, something that is very critical, something that is very personal – Medical Health Record, is still stuck with that ‘nearly 2000 year old ancient Chinese invention – Paper’! Why aren’t medical records being stored in an easy to use electronic format? As in any big change, there are multiple reasons ranging from the availability of appropriate technology, stakeholder education, standards, and process changes.
Today, core technology is not a bottleneck. Having appropriate technology systems for the Indian environment is important. Stakeholder education and requisite process changes at hospitals and clinics are more critical. Let us try and explore the advantages of Electronic Medical Records, and their adoption. Let us begin with the definition of Electronic Medical Records (also referred to as ‘EMRs’) – Wikipedia defines Electronic Medical Records as medical records in a digital format.
In the past, detailed medical records were often only generated during surgical/other critical procedures or during treatment of a serious illness. Advances in medical sciences have meant that today, we undergo a lot more preventive tests and procedures. There is a great deal of focus on improved diagnostics and preventive care. This has resulted in a dramatic increase in the number of medical records an individual would typically maintain.
Rapid and easy accessibility of these medical records can help save time and effort, and can potentially be a life-saving aid in case of an emergency. Paper records by their very nature are difficult to manage, copy, carry, and forward to others.
Benefits of Electronic Medical Records
Electronic Medical Records can deliver multiple benefits to the various stakeholders in the healthcare process. For patients, they simplify management of their medical history – across multiple doctors, hospitals and other facilities. They also enable quick access and retrieval in case of an emergency. Risk of loss of valuable data is greatly reduced. For hospitals and other healthcare providers – EMRs simplify the overall records management process. For doctors, EMRs enable quick review of past history of a patient and aid in rapid diagnosis. They also enable a doctor to quickly forward and discuss a patient’s condition with a colleague or a specialist.
Further benefits of Electronic Medical Records can be achieved if they are made available over the internet. This enables ‘pervasive’ accessibility of an individual’s complete health picture at anytime, anywhere in the world. Adequate processes need to be taken to provide a secure login and password to maintain privacy and confidentiality of the data. A comprehensive and user-friendly categorization, storage, search and retrieval workflow needs to be enabled.
Similarly, intelligent offline availability of these EMRs is also critical (especially in India) where internet adoption (especially amongst senior citizens) is not that high, and where internet availability is not reliable. Offline availability can be enabled through storage devices such as CDs, USB drives, etc. It is important that the offline usage scenario has the same user-friendly search and retrieval capability of the EMRs.
Stages of Electronic Medical Records Evolution
EMRs are evolving through the following 4 stages (as described in Wikipedia):
1. Non-Electronic Data (Paper Documents)
2. Machine Transportable Data (Email, Fax, Scanned Documents)
3. Machine Organizable Data (Scanned Documents with metadata descriptors)
4. Machine Interpretable Data (Fully digitized documents with metadata descriptors)
[Note – ‘Metadata’ is defined in the subsequent paragraph].
Presently a majority of the hospitals and clinics in India are still stuck at Stage-1.
Stage-2 can be easily implemented but has limited value when it comes to cataloging, organization and searching of records. Stage-3 has tremendous value and relatively low cost of implementation (we will discuss this further). Note, ‘metadata’ means the ‘description of data’ and can include various organization information around a medical record such as ‘Type of document’, ‘Doctor’, ‘Date’, ‘Category of document’, ‘Importance’, etc. Stage-4 can deliver the ultimate value, but is quite expensive and complicated to implement.
Adoption of Electronic Medical Records – A Roadmap
Clearly, Stage-4 signifies the ‘utopia’ of EMRs adoption. However, what is the cost-benefit scenario? Let us explore this further.
Stage-4 needs the complete data (i.e. each and every row, column and field in a document) to be stored as a computer interpretable entity. Essentially, this entails a computer model (or dictionary) of each and every conceivable field (health condition (e.g. ‘Blood Pressure’, diagnostic parameter (e.g. Systolic/Diastolic), their values (e.g. 120/80), acceptable ranges (High: 100-140, Low 60-100), etc.) in any type of medical record needs to be created and stored. This is easier said than done! Such a data dictionary could run into tens of thousands of items. Free form text, such as doctor notes are even more difficult for a computer to interpret. For many hospitals and other data sources, where data is not generated electronically at source – this entails an additional manual process for keying in the data into the data dictionary format. Even if data is available electronically, lack of standards implies that different doctors and hospitals maintain different formats (in other words, each hospital has its own data model/dictionary!) – And a big mapping and data conversion exercise is essential. This predicament is a big reality in US today where every major hospital chain has implemented their own versions of such data dictionaries. As a result, they are not interoperable. In the real world, a patient visits multiple doctors/hospitals across cities and hence electronic data in one hospital’s format is meaningless during his next visit!
Lack of standards is one of the biggest reasons why Stage-4 EMRs haven’t been successfully deployed in US and in many other developed countries.
In India, we are long way off from such a common standard. Stage-3 simplifies all the implementation issues in Stage-4 by directly storing a scanned the paper document, the diagnostic image, or an electronic document in its native format (e.g. ‘.pdf’, ‘.doc’). There is no conversion into a ‘standard format’. The only limitation here is that such records cannot be machine readable. However, that is a small price to pay to achieve comprehensive cataloging and archiving of medical information. As described earlier, these documents carry a complete digital description (metadata) and can be stored, cataloged, searched and retrieved electronically with ease.
As can be seen from above, a good medium balanced approach is Step-3; especially for a developing country like India. Quick benefits can be derived through a lower relative investment, and the time for implementation is also very fast.
‘Practical’ Solution for Electronic Medical Records
A practical solution for Electronic Medical Records in the Indian context can be based on ‘Stage-3’ described above. In future, this can be migrated to Stage-4. The basic building blocks of such a solution are described below. Pune based ‘ArogyaDarpan.Com’ offers such a practical approach to Electronic Medical Health Records.
1. Online Web-Service to Upload, Describe (add metadata), Save and Search/Retrieve Documents in different formats.
2. Offline software capability to search and retrieve previously saved EMRs
3. Offline service capability to collect, scan and process documents, obtain other electronic documents directly from legacy systems. This can be further extended to automatically source and integrate medical documents from various legacy systems at different doctors/hospitals.