Electronic health records approaches and challenges: a comparison ...

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Int. J. Electronic Healthcare, Vol. 4, No. 1, 2008

Electronic health records approaches and challenges: a comparison between Malaysia and four East Asian countries Mohd Khanapi Abd Ghani*, Rajeev K. Bali, Raouf N.G. Naguib and Ian M. Marshall Biomedical Computing and Engineering Technologies Applied Research Group (BIOCORE) Faculty of Computing and Engineering Coventry University Coventry, CV1 5FB, UK Fax: +44(0)24 7688 8080 E-mail: [email protected] E-mail: [email protected] E-mail: [email protected] E-mail: [email protected] *Corresponding author

Nilmini S. Wickramasinghe Center for the Management of Medical Technology (CMMT) Stuart School of Business Illinois Institute of Technology 565 W Adams St., Suite 406 Chicago, IL 60661, USA Fax: +1 312 906 6549 E-mail: [email protected] Abstract: An integrated Lifetime Health Record (LHR) is fundamental for achieving seamless and continuous access to patient medical information and for the continuum of care. However, the aim has not yet been fully realised. The efforts are actively progressing around the globe. Every stage of the development of the LHR initiatives had presented peculiar challenges. The best lessons in life are those of someone else’s experiences. This paper presents an overview of the development approaches undertaken by four East Asian countries in implementing a national Electronic Health Record (EHR) in the public health system. The major challenges elicited from the review including integration efforts, process reengineering, funding, people, and law and regulation will be presented, compared, discussed and used as lessons learned for the further development of the Malaysian integrated LHR. Keywords: Malaysian health system; health ICT; Electronic Health Record; EHR; Health Information System; HIS; seamless; challenges.

Copyright © 2008 Inderscience Enterprises Ltd.

Electronic health records approaches and challenges Reference to this paper should be made as follows: Abd Ghani, M.K., Bali, R.K., Naguib, R.N.G., Marshall, I.M. and Wickramasinghe, N.S. (2008) ‘Electronic health records approaches and challenges: a comparison between Malaysia and four East Asian countries’, Int. J. Electronic Healthcare, Vol. 4, No. 1, pp.78–104. Biographical notes: Mohd Khanapi Abd Ghani is a Senior Lecturer at Universiti Teknikal Malaysia Melaka (UTeM). He had 16 years of experience in implementing and managing commercial and national Information and Communication Technology (ICT) projects before changing his career path from industry to academia in 2003. He earned his MSc in Real-time Software Engineering from Malaysia Technology of University. His research areas of interest include electronic healthcare systems, telemedicine, ICTs, and system architecture and design. He is currently undertaking his PhD at Coventry University, UK, on formulating an integrative telemedicine framework for Malaysia. Dr. Rajeev K. Bali is a Reader in Healthcare Knowledge Management at Coventry University. His main research interests lie in clinical and healthcare knowledge management (from both technical and organisational perspectives). He founded and leads the Knowledge Management for Healthcare (KARMAH) research subgroup (working under BIOCORE). He is well published in peer-reviewed journals and conferences and has been invited to deliver presentations and speeches in the USA, Canada, Singapore and Finland, among other countries. He is a Visiting Professor in Knowledge and Healthcare Management at the Illinois Institute of Technology, Chicago, USA. He serves on various editorial boards and conference committees and is the Associate Editor for the International Journal of Networking and Virtual Organisations as well as the International Journal of Biomedical Engineering and Technology. He is listed in both Who’s Who in the World and Who’s Who in Finance and Business. Professor Raouf N.G. Naguib is a Professor of Biomedical Computing and Head of the Biomedical Computing and Engineering Technologies Applied Research Group (BIOCORE) at Coventry University. He has published over 200 journal and conference papers and reports on biomedical image processing and the applications of artificial intelligence and evolutionary computation in cancer research. He has also published a book on digital filtering, and coedited a second book on the applications of artificial neural networks in cancer diagnosis, prognosis and patient management, which is his main area of research interest. He was awarded the Fulbright Cancer Fellowship in 1995–1996. He is a member of several national and international research committees and boards. He has also recently been selected to join the UK EPSRC Peer Review College and is a reviewer for the EU Directorate-General Information Society, eHealth. He has recently been appointed as an Adjunct Research Professor at the University of Carleton, Ottawa, Canada. Professor Ian M. Marshall is a Pro-Vice Chancellor for Research at Coventry University. Professor Marshall’s applied research interests are focused on the use of games in education and training and on development effort estimation for multimedia and other interactive courseware. He has worked extensively as a computer and information systems consultant, flexible learning material developer and trainer. In addition, he has extensive experience working with small- to medium-sized enterprises as well as with city councils and regional development agencies.

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M.K. Abd Ghani et al. Professor Nilmini S. Wickramasinghe is an Associate Professor and the Associate Director of the Center for the Management of Medical Technologies (CMMT) at the Illinois Institute of Technology, Chicago, USA. She researches and teaches in several areas within information systems including IT for competitive advantage, knowledge management, e-commerce and m-commerce, and organisational impacts of technology. In addition, Dr. Wickramasinghe specialises in the impacts of technologies on the healthcare industry and various aspects of medical informatics. She is well published in all these areas, having written books, numerous refereed scholarly papers and encyclopaedia entries. Dr. Wickramasinghe regularly presents her work throughout North America as well as in Europe and Australasia. Currently, she is the US representative of the Health Care Technology Management Association (HCTM), an international organisation that focuses on critical healthcare issues and the role of technology within the domain of healthcare.

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Introduction

An integrated Lifetime Health Record (LHR) is fundamental for achieving seamless and continuous access to patient medical information and for the continuum of care. These can be achieved through the convergence of Information and Communication Technology (ICT), medical content and health knowledge. Through this convergence, the patient LHR can be shared among healthcare professionals and across healthcare facilities regardless of where the previous visit was. In contrast, the fragmented and paper-based medical records have significant limitations such as illegibility, unavailability, sheer physical volume (over time), difficult transferability and integration between providers and institutions, and the necessity to record the same data many times (duplication) on different documents (Roman et al., 2006; Coiera, 2003; Pories, 1990). These problems become worse in situations where patients are able to freely visit any healthcare facilities for the same medical problem, and where the patients can be referred to an appropriate hospital anywhere in the country. All countries in the globe, including four East Asian countries (Japan, Singapore, Taiwan and Hong Kong), had taken initiatives to implement an integrated Electronic Health Record (EHR) system in their public health system either locally or nationwide. However, the aim has not yet been fully realised. The efforts are actively progressing. Malaysia is also driving towards that aim and is still struggling to find the best approach in implementing integrated EHR systems (named LHR) on all levels of public healthcare facilities. Every stage of the development of the LHR initiatives had presented peculiar challenges. The best lessons are those of someone else’s experiences. This paper presents an overview of the development approaches undertaken by the four East Asian countries in implementing a national EHR in the public health system. The major challenges elicited from the review, including integration efforts, process reengineering, funding, people, and law and regulation, will be compared and discussed. If suitable, this paper could provide the lessons learned and best practices to develop the LHR of Malaysia.

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Methods

The review was done through a literature research on discourses, current initiatives and approaches of the four East Asian countries with regard to health ICT initiatives include EHR, telemedicine, e-health and Hospital Information System (HIS). A critical analysis of the Malaysian health system and health ICT initiative was done using a case study research approach at the Ministry of Health Malaysia (MOHM). The investigation was carried out with the collaboration of the ICT Division of MOHM. The research was conducted through open-ended interviews, virtual interviews and discussions, and through accessing archival documents.

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Electronic health records system and the evolution of medical services

There are great differences between the developing and the developed worlds on issues of health and healthcare services. The emphasis of the developing world is on basic survival (such as providing better access to healthcare and increasing the quality of health) whilst in the developed world, the emphasis is on reducing public funding for healthcare. Indeed, the rapid increases in healthcare costs and finding ways to control them have become the most important health policy issues for the developed world in the past few decades (Industry Canada, 2006). Table 1 shows an increasing total cost (% GDP) of health expenditure among the G-7 countries from 2000 to 2004. Table 1 Year 2000 2001 2002 2003 2004

Total health expenditure of the G-7 countries USA 13.1 13.9 14.6 15.2 15.4

Canada 8.9 9.4 9.6 9.7 9.8

France 9.3 9.4 9.7 10.4 10.5

Germany 10.6 10.8 10.9 10.8 10.6

Italy 8.1 8.3 8.5 8.4 8.7

UK 7.3 7.5 7.7 7.8 8.1

Source: WHOSIS (2006)

The increase in healthcare expenditures also took place in the East Asian countries; most of them also gradually increased their expenditures on health every year. Table 2 shows the total health expenditure between 2000 and 2004. Table 2 Year 2000 2001 2002 2003 2004

Total health expenditure of the East Asian countries Singapore 3.6 4.3 4.2 4.2 3.7 Sources:

South Korea 4.5 5.4 5.3 5.4 5.5

Japan 7.6 7.8 7.9 8.0 7.8

**Hong Kong 5.2 5.2 5.5 – –

WHOSIS (2006) * Department of Health Taiwan (2008) ** HKDHA (2005)

* Taiwan 4.9 5.2 5.3 5.3 5.3

Malaysia 3.3 3.7 3.7 4.2 3.8

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Many factors contribute to the rapid rise of healthcare costs. One is the demographic changes such as population ageing, with its associated increased rates of chronic diseases and disabling conditions, as well as changing disease patterns from communicable diseases to noncommunicable diseases. Noncommunicable diseases are also known as lifestyle diseases. These scenarios are happening in developing countries such as Singapore, Malaysia and Hong Kong, where the percentage of the population aged over 60 years has increased (WHOSIS, 2006; HKDHA, 2005). Chronic and lifestyle diseases are expensive to treat because they often require lifelong management. A study shows that, over a 30-year period, the disease burden has shifted from communicable diseases to mainly lifestyle-related diseases, of which ischemic heart problems have become the highest disease burden suffered globally, as depicted in Table 3. Table 3

Changes in the global disease burden

1990

2020 (Projection)

Lower respiratory infection Diarrhoeal diseases Perinatal conditions Depression Ischemic heart disease Stroke

Ischemic heart disease Depression Traffic accidents Cerebrovascular disease Chronic Obstructive Airways Disease (COPD)

Source: Adapted from Schutz et al. (2006)

Due to the new trend of diseases that would be suffered globally, governments, payers and national health financing authorities are seeking new and different ways to provide adequate levels of service at lower costs. This is where EHR initiatives through health information systems (HIS, telemedicine, telehealth and e-health) come into prominence. Studies have clearly demonstrated that telemedicine and telehealth initiatives can realise savings while at the same time broadening the reach of healthcare systems (Frances et al., 2007; Koch, 2006; Moehr et al., 2006).

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The roles of electronic health records for continuing care

In an typical episodic encounter, a substantial portion of the healthcare provider’s time is spent on obtaining the patient’s medical history and subsequently recording, dictating, transcribing and arranging the information in an organised manner before a diagnosis can be made or before an appropriate treatment can be prescribed and administered (Coiera, 2003). Furthermore, if the patient is required to be referred to another medical provider for an expert opinion or a second opinion, the entire procedure of information collection may have to be repeated; any necessary pathological (and perhaps radiological) data collection involves a laborious task, one which cannot be delegated to another professional (Maheu et al., 2001). What is crucial here is that the absence or incompleteness of such data may lead to an inappropriate diagnosis and treatment or one that contradicts with the person’s physiological condition, such as having allergies (Chaudhry et al., 2006).

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According to a study conducted by the Institute of Medicine (Williams and Moore, 1995), the situation is quite worrying as 30% of physicians find great difficulty in accessing patient records at the right time and 70% of hospital records are found to be incomplete. An integrated LHR is crucial for continuing care and these efforts are currently progressing in many countries such as Canada, the UK and those in mainland Europe. The government of Canada has committed to the development of an interoperable enterprise health records solution by integrating approximately 40 000 existing health information systems in use across the country (Canada Health Infoway, 2006). Similar efforts are also being undertaken in the UK’s NHS through its extensive health ICT project, Connecting for Health (National Health Services, 2007). The EHR services component (NHS-CRS) of the Connecting for Health project is the most integral component among the applications and a crucial backbone of the NHS health infostructure (National Health Services, 2006). Both Canada and the UK have acknowledged that disparate health information systems and independent EHRs will not be sustained in the long term. The healthcare services will not be improved if the services are still episodic and access to health records is always restricted within a healthcare facility and an application system. Good care is dependent on access to the previous medical records, which should be a feature of healthcare systems in the future.

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Electronic health record development in four East Asian countries

The initiative to develop an integrated and centralised EHR that could be accessed seamlessly and continuously by the healthcare professional and consumers was actively undertaken by stakeholders around the globe. The formal aspects of EHRs are largely contained within the patient records. However, the implementation approach to collect and generate the EHR repository across countries would be different due to different health systems and policies, and socio-economic, political and cultural identities. The implementation approach of EHR in a certain country could not be copied 100% but the issues and challenges through the implementation experiences could be used as lessons learned. This section reviews the implementation approach of EHRs in the four East Asian countries. The most suitable approaches, experiences and best practices therein could be used as part of the lessons learned for developing the integrated LHR in Malaysia or other countries.

5.1 Singaporean perspectives The objective of the EHR initiative in Singapore is to curb the ever-escalating healthcare costs, to increase efficiency in medical care, to promote health and to empower Singaporeans to manage their health (HPBonline, 2007). The use of ICT in Singapore’s health system is widely accepted. The implementation level of ICT is used not only in clinical and administrative functions, but also in logistics activities of the seven main hospitals in Singapore (Pan and Pokharel, 2007). This clearly shows a very good level of ICT penetration in Singapore’s health system.

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A store-and-forward method (through the internet) is the main approach in gathering and generating the EHR across healthcare providers in Singapore through the health information system (such as the HIS, telemedicine and e-health applications). By way of example, the OphthWeb telemedicine system is a pioneer in delivering optometric treatment services and a testing ground for generating the Electronic Medical Records (EMRs) for Singaporeans before being applied to other clinical specialties (Chew et al., 1998). The use of web-based health information applications reduces telecommunication costs and implementation (such as version updates and software installation) costs. The use of the internet in healthcare delivery provides people (healthcare professionals and consumers) with easy access to the medical history at low cost and in a convenient manner (Chew et al., 1998). There are specialist areas which utilise internet technologies, such as teleophthalmology (which is considered to have less risk compared to other specialties). Teleophthalmology does not require a high degree of computer literacy and there is less data entry needed for healthcare professionals to capture the diagnosis and medical findings and then to generate the EHRs. The majority of health information systems (HIS, telemedicine services and e-health applications) in Singapore use a high-speed broadband backbone (Singapore ONE) with a bandwidth range of up to 622 mbps (Tay-Yap and Al-Hawamdeh, 2001). As such, the internet is a suitable technology for implementing EHR applications in Singapore. It enables patient health records to be shared across and between healthcare stakeholders and to be accessible to patients anytime and anywhere via the internet. The telecommunications charges, service charges and integration with legacy systems are among the main challenges for long-term sustainability of EHR initiatives in Singapore.

5.2 Japanese perspectives The efforts to develop the EHR started when the first Japanese telemedicine system was experimented on in Wakayama Prefecture in 1971. The Wakayama Medical Association, with the collaboration of Osaka University and Wakayama Medical College, did a project to providing medical care to rural mountain areas via Close-Circuit Television (CCTV) (Holliday and Tam, 2004). This was the best connectivity at that time. The patient medical records, including images, sounds and documents, were transmitted via telephone circuit and facsimile. In 1994, Japan’s EHR aim through ‘Health Information Strategy 21’ was launched with the mission to provide quality and efficient healthcare services to the citizens (Toyoda, 1998). The implementation of EHR was delivered through multitude channels of health information applications. HISs, telemedicine systems, telehealth systems and decision support systems are among the common healthcare information applications used in the EHR efforts. The bottom-up approach of EHR development in Japan mainly come from higher medical institutions, medical associations and private sectors (Takahashi, 2001). Japan currently does not have a government-centred EHR. However, some local, regional and single hospitals have installed digital patient records sharing data between hospitals, clinics and patients (Arnold et al., 2007).

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The majority of the health information system development was initiated by the medical institutions and medical schools in universities. This approach serves to lessen the risks, such as inadequate buying-in from physicians to use the applications. The use of internet technologies is the most popular approach in delivering EHR services to consumers or healthcare professionals in Japan. The internet and broadband telecommunication are the main transports for veering the patient health records across different healthcare facilities and levels and across healthcare professionals and consumers (Tsuji et al., 2003). The challenges to the long-term sustainability of EHR initiatives in Japan include excessive regulation and issues of integration with the existing healthcare delivery. One example of excessive regulation is that physicians in Japan are prohibited from answering specific questions about healthcare or diseases by e-mail or telephone (Holliday and Tam, 2004). Although the health informatics standard and standards organisation have been established in Japan, the integration is still a critical issue that needs to be resolved and is in progress until now (Inamura and Lemke, 2007). It has to be noted that healthcare services deal with human beings and that is why change management becomes a critical challenge in implementing the EHR in Japan. The technologies and standards cannot guarantee the buy-in and the succession of EHR systems without considering the reengineering process of the existing business processes (Masuda et al., 2005).

5.3 Hong Kong perspectives The mission of EHR initiatives in Hong Kong is both to improve healthcare delivery and to make better health information available to healthcare professionals and to patients (Lun, 1999). The Hong Kong Hospital Authority (HKHA) has strongly supported the development and implementation of EHR initiatives through the deployment of health information systems in the healthcare facilities of Hong Kong (Holliday and Tam, 2004; Cheung et al., 2001). The approach of EHR initiatives in Hong Kong is to start with medical informatics initiatives where the computerisation of the Hospital Authority (HA) is a focus. By way of example, after the HA was established in 1991, there were three phases of the information system project to be developed. These were the establishment of a patients’ database, the development of clinical information systems for generating central Electronic Patient Records (EPRs) and integration of healthcare information systems (Hjelm et al., 2001). Hong Kong’s approach to the EHR initiative is slightly different from other countries. It starts with basic infrastructural elements that are laid down incrementally. To cite an example, in the first phase of HA’s information technology, it implemented the administrative and financial modules and databases as the foundation (Leung et al., 2001). Then, the establishment of a wide area network took place linking all hospitals and clinics together for information sharing. After that, a laboratory and radiology and pharmacy systems were installed. This integration provides seamless access to the results in the clinic workstations or wards (Hjelm et al., 2001). Nevertheless, the greatest challenges for implementing the EHR in Hong Kong are funding and integrating the existing disparate systems and legacy systems into one for sharing the EHRs across healthcare facilities and levels (Leung et al., 2003). The people

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is mind-set is another challenge faced by Hong Kong, especially with regards to getting buy-ins from the physician to use the computer system for capturing the clinical findings on patients. See some barriers that slow down the adoption of EHR system usage in Hong Kong in Table 4. Table 4

Relative ranking of barriers in the adoption of clinical computerisation in Hong Kong Mean score

Barriers Time costs associated with computerisation including planning, purchasing, training and maintenance (‘time costs’)

6.16

Lack of technical support in case of system failure (‘lack of technical support’)

5.82

Initial capital (monetary) cost of computerising a medical practice (‘capital costs’)

5.70

Maintenance costs (monetary) including computer and software upgrades and staff training (‘maintenance costs’)

5.46

Lack of knowledge and perceived difficulty in learning new technology (‘knowledge gap’)

4.97

Interference with the nature and pattern of doctor-patient communication ‘interference with communication’)

4.85

Increased potential for breach of confidentiality of patient data (‘confidentiality breach’)

4.72

Lack of perceived benefits from computerisation of clinical practice (‘lack of benefits’)

4.08

Recent amendment of the Intellectual Property Ordinance to prevent copyright piracy (‘intellectual property regulations’)

3.23

Source: Leung et al. (2003)

5.4 Taiwan perspectives The EHR initiative in Taiwan has proliferated since 1990 and was officially launched in 1995 under the National Information Infrastructure (NII) project (Hu et al., 2002) for managing the development and implementation of telemedicine services across healthcare facilities and levels. The incomplete and limited access to the medical information of patients led Taiwan’s government to embark on the EHR initiative nationwide. Enabling patient care records to be shared among hospitals is essential not only in delivering quality medical care services but also in saving on medical expenses for Taiwan’s government (Liu et al., 2001; Luh et al., 2005). The healthcare provision of Taiwan remains private sector driven. However, the state government still has authority for performing a chiefly regulatory role on health policy and strategy (Holliday and Tam, 2004). The EHR strategy development so far has started with bottom-up field projects followed by a realisation that a strategic EHR framework is needed to maximise benefits. Among the approaches for implementing the EHR in Taiwan’s healthcare facilities was the National Health Insurance Smart Cards, known as ‘NHI-IC’ cards (Liu et al., 2006). The NHI-IC replaced the existing paper-based health insurance cards with a card capable of updating patient’s critical health records. The implementation of NHI-IC cards in hospital medical services demands both information technology and financial support

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for building up the information infrastructure and enhancing the existing HISs in Taiwan (Tsai and Kuo, 2007). Telemedicine programmes such as Continuing Medical Education (CME) and teleconsultation service are also among the initiatives in Taiwan (Chen et al., 2001). Three-fourths of the land area of Taiwan is mountainous and there are several small isolated islands around the major island. The use of intranet and internet connections using Integrated Service Digital Network (ISDN) and broadband network is common in EHR applications and HISs with a bandwidth range of between 128 kbps to 2 mbps (Chen et al., 2001). A widespread telecommunications network infrastructure capability provides many advantages (infrastructure cost and implementation duration) for implementing EHR systems across healthcare facilities and levels in Taiwan. The greatest challenge to implementing the EHR systems in healthcare facilities and levels in Taiwan is to integrate the existing disparate systems and legacy health information systems for collecting and mining the centralised EMRs. To cite an example, the legacy computer system IBM/SNA (System Network Architecture) OS390 over 25 years ago is still in use at National Taiwan University Hospital (Hsieh et al., 2006). Other legacy systems, such as the HIS (laboratory, radiology, pharmacy, admit discharge and transfer information system) and other support systems, are new challenges to integrate with recent health information systems and technologies like telemedicine, telehealth and e-health systems. This needs further research in order to have a smooth integration and to maintain the asset of the legacy system in Taiwan.

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Electronic health record efforts in Malaysia

The above review illustrates the challenges and approaches undertaken by the four East Asian countries in developing and implementing the EHRs for the nations. What follows is Malaysian approach and challenges in developing and implementing integrated LHRs in the public health system.

6.1 Overview of the health system The future healthcare system of Malaysia emphasises quality, innovation, health promotion, respect for human dignity, the promotion of individual responsibility and the promotion of community participation (MOHM, 2006b). In other words, the Malaysian future healthcare system is focused on people and services, with technology playing a key enabling role. The vision is the inspiration for the development of health services in the nation and provides the framework for the development and the use of health ICT in delivering healthcare services. Malaysia has achieved remarkable advances in health. Its population currently stands at 26 million (Department of Statistics Malaysia, 2006) and the life expectancy for males and females currently stands at 70.6 years and 76.4 years, respectively. The infant mortality rate has also decreased from 6.6% in 2002 (MOHM, 2002) to 5.1% in 2005 (MOHM, 2005). The government has expanded the number of health facility centres and the scope of health services nationwide. For example, the rural, or primary care, clinics have expanded their services to general outpatient services or stand-alone polyclinics (MOHM, 2005).

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On the other hand, the health manpower population ratio shows that the workload and the shortage of human resources in healthcare services will become critical issues in the future. For example, it is estimated that one doctor will manage 1300 patients; even worse is the ratio of pharmacists to the population, which is 1:6512 (MOHM, 2005). The future plan regarding the healthcare system in Malaysia requires extensive changes by converging ICT, medical contents and health knowledge. By incorporating effective telemedicine, telehealth and e-health, it is envisaged that the demand for healthcare services in health facility centres would be reduced, the shortage of health manpower would be addressed accordingly and, finally, the cost of services provided through clinics and hospitals would be decreased.

6.2 Current healthcare delivery system and physical set-up The Malaysian public healthcare system is structured in a hierarchical pyramid-based concept. At the base of the pyramid is a broad array of primary healthcare services (such as health centres, polyclinics, mobile clinics, and maternal and child clinics) spread throughout the country. The next level is district hospitals in every one of the 120 districts, feeding into state general hospitals in each state capital. At the top of the pyramid lies the Hospital Kuala Lumpur, which is the national tertiary reference centre providing specialist and superspecialist services for the nation (Abu Bakar, 2007). In terms of the physical healthcare facility set-up, the healthcare premises are normally developed within the area where majority of the population are living. Since 1998, 95% of the population have been living within a 5 km radius of the nearest healthcare facility (Suleiman, 2001). This set-up enables patients from anywhere in the country to be referred to the appropriate hospital, to access and visit several healthcare facilities through a nationwide network of clinics, hospitals and other health programmes in a convenient manner.

6.3 Electronic health records initiatives The majority of Malaysian doctors (specialists and general practitioners) do not use computers in delivering healthcare services to the patients. The patient medical records are recorded in a paper-based medical record and kept in the records office at each health facility premises. Computer use is greatest for general administrative work, less for patient-oriented administration and least for clinical use. The results of a survey on computer use carried out with the ICT division of MOHM is depicted in Figure 1, which summarises the categories of information systems implemented in a public healthcare facility for 2006. Approximately, more than half (51%) of the applications that have been implemented in various health facilities are for facilitating the administrative functions of medical practice services and public health services. The management and financial support systems contribute around 29% of the total projects. Whilst the core clinical applications for generating the EMR and LHR, such as Teleprimary Care (TPC), HIS and telehealth (MOHM, 1997b), contribute around 18% of the total project, the majority of the systems are still under trial/pilot implementation in certain healthcare centres and hospitals in various states. This percentage shows that the EMR/clinical application system has been given less attention and focus for collecting and generating the LHR.

Electronic health records approaches and challenges Figure 1

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The categories of health ICT projects in a public health facility (see online version for colours)

Management support 17%

Financial support 12%

Medical support system 19%

Teleprimary care 2%

Hospital information system 8%

Telehealth 8%

Health support system 34%

Source: Adapted from MOHM (2006a) and MOHM (2007)

6.4 Issues and challenges Malaysia’s ICT initiative in healthcare is considered new and is still in its initial stages. The major challenges in implementing EHR systems in healthcare facilities in Malaysia include integration and interoperability, healthcare organisation, changing people’s mind-sets, business process reengineering, rapid changes in technology and ICT infrastructure.

6.4.1 Health informatics standard In order to enable the various information systems to accept each other’s data (and to share the patient medical information from one healthcare context to another), the information model, terminology, connectivity and policies need to be standardised (Nelson, 1997). The lack of standards in collecting and sharing the health information reduces efficiency and hinders collaboration as healthcare organisations expand. The standards form the framework for integration between the various healthcare systems in delivering the healthcare services. In the context of IS projects in a Malaysian healthcare facility, the health informatics standard, especially the health vocabulary standard, is still inadequate. The health vocabulary standards include clinical terminology, disease classification, drug classification code, procedure code, test classification code, national code standard, such as public sector data dictionary, and Ministry of Health code standards (Hisan, 2006). These standards are crucial for the various systems to exchange information, for the achievement of MOHM’s goal to have an integrated LHR, and for seamless and continuous access to the patient LHRs. The importance of standards for ensuring the interoperability of clinical information in the LHR is broadly recognised. Without standards, the initiatives and the efforts to integrate the heterogenous IS set-up and fragmented IS solutions into an integrated whole will not succeed. This is due to the fact that the standards are a key foundational element of the solution integrity and integrated LHRs.

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6.4.2 System integration The integration issues on health ICT are well known throughout the healthcare industry. In 2005, approximately 80% of healthcare providers in the USA were still using paper-based medical records in their day-to-day consultations and, from the systems that did exist, few were interoperable (IAB, 2006). The Malaysian Public Healthcare Facilities are also faced with the same situation: systems operate independently and are unable to share patient medical records with one another. Uncoordinated planning and legacy and proprietary systems with limited or no networking capabilities present major challenges to systems integration (Norris, 2002). The integration challenges include a health informatics standard (such as a clinical code set, e.g., clinical terminology, drug code, disease code classification, and administration code set, e.g., health facility code and demographic code), an information system architectural standard (such as software, hardware, operating system, middleware, network communication protocol, database system, data model and information communication protocol) and standard operating procedures (such as care pathways, clinical professional guidelines and operational policies). It is therefore of critical importance that existing systems are upgraded and the future IS adopts standard solutions and integrity models for interoperability, scalability and reusability. Malaysia’s telemedicine blueprint (MOHM, 1997a), consisting of four integrated application components, provides a comprehensive framework and a road map for the building and provision of a future healthcare information system. It is our contention that the MOHM should coordinate and enforce the existing and the future information system to adopt that framework. This is to ensure that medical information is synchronised between the systems and that LHRs can be accessed seamlessly and continuously.

6.4.3 Changing mind-sets Various individuals are involved in providing healthcare services delivery, including physicians, specialists, nurses, pharmacists, medical assistants, administrators and other related healthcare staff. They are the users who will use the ICT in their daily routine in dealing with patients. The majority of them still have limited computer-related skills. Many may well be set in their existing ways and existing work processes may well have been ingrained into their daily lives for decades. Thus, any purported change in their routine daily workflow is bound to be viewed with some degree of hostility and resistance. In addition, inadequate awareness about ICT projects has further compounded the problems and challenges for implementing information systems at healthcare facilities. Proactive initiatives, such as providing training and short courses on ICT and medical informatics knowledge, are critical. Healthcare professionals need to embrace ICT as a mainstream tool for the future evolution of the healthcare system, especially via the adoption of telehealth and telemedicine in improving healthcare delivery to citizens (Wootton and Craig, 1999; Maheu et al., 2001).

6.4.4 Telecommunications infrastructure Telehealth or e-health systems involve geographical information and the use of telecommunications technologies in providing healthcare services to the patients. Telehealth applications can be implemented in healthcare facilities or provide services directly to patients through the internet and the web. In Malaysia, the network

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infrastructure may not be consistent across the country and among healthcare facilities. For example, in 2005, the average internet penetration in Malaysia was around 14% (Malaysian Communications and Multimedia Commission, 2005). The penetration in big cities such as Kuala Lumpur is around 50%. Such issues and challenges need to be addressed once the telehealth or e-health system is fully implemented in healthcare facilities nationwide. Inadequate telecommunications infrastructure would jeopardise the availability, accessibility and continuous upkeep of the patient medical record.

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Discussion

When compared to the four East Asian countries, Malaysia seems to fall behind in a few and at par in many important approaches and challenges in implementing EHR systems. We summarised from the literature that there are five common major challenges in implementing EHR in the four East Asian countries. These include integration efforts, process reengineering, people, funding, and law and regulations. The integration efforts are categorised as a major challenge in implementing the EHR in all five East Asian countries. The criticality of the challenges differed from one country to another depending on its health policy, socioeconomics, culture and politics (refer to Figure 2). Figure 2

Five major challenges in implementing EHR (see online version for colours)

INTEGRATED EHR

INTEGRATION PROCESS REENGINEERING PEOPLE FUNDING

LAWS AND REGULATIONS

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7.1 Integration efforts Japan, Taiwan, Hong Kong and Malaysia faced the same issue of lack of system integration capability. This might also be happening in other countries around the globe. These countries invented the HIS and have been implementing it in healthcare facilities for more than 20 years. The application technologies are already obsolete and majority of the legacy systems are still implemented in ‘silos’ and, the integration efforts have significant challenges. Japan has faced critical challenges in integrating its existing EHR systems into one and in its inability to share the medical records across healthcare facilities and levels. By way of example, the data between hospitals and clinics in Japan are still not easily shared although the Computerised Practitioner Order Entry (CPOE) system has been implemented since the 1980s (Arnold et al., 2007). The variety of health information systems and technologies implemented previously contributes peculiar challenges for integration. For a further example, most of the telemedicine systems and services in Japan are implemented in a fragmented manner and these would also contribute significant challenges for integrating the telemedicine services into existing healthcare services where EHRs are used as a basis for diagnosing the patient’s problem (Takahashi, 2001; Varghese and Scott, 2004). The integration efforts in Taiwan are also complex. The many types of health information systems (HIS, telemedicine systems and e-health) deployed through bottom-up and research approaches and, mostly implemented in a fragmented manner, led to crucial issues in sharing the EHRs. To cite an example, there were major upgrades and integration efforts to the existing HISs when Taiwan’s Bureau National Health Insurance (TBNHI) introduced NHI-IC into Taiwan’s health system (Liu et al., 2006). The variety of HIS and technology platforms will require major amendments and maintenance to the existing systems for communicating with the NHI-IC card reader and NHI-IC data centre and for integration with telemedicine services. Hong Kong has fewer challenges in its integration efforts due to the fact that it is still at the beginning stage – a small geographical size, small number of healthcare facilities and small number of EHR systems deployed. According to a survey done by Leung et al. (2003), 70% of the community-based clinics have yet to computerise any clinical functions. This should give an advantage in implementing an integrated EHR system across healthcare facilities and levels from scratch, where data conversion and integration work with existing systems will not be involved during the implementation. Singapore is one of the leading countries in EHR initiatives where the geographical size and effective ICT implementation planning provide great advantages to implement standard EHR systems across healthcare facilities and levels. By way of example, the implementation of EMR Exchange (EMRX) at all levels of healthcare facilities enables the patient health records to be accessed by the patient and healthcare professional via the internet (Health-4-U, 2007). Where does Malaysia stand on this issue? It is likely similar to the other countries (Japan, Taiwan and Hong Kong), still finding a best solution to link all EHRs into an integrated one. Malaysia has many steps to go to achieve the vision since the establishment of the health informatics standards and healthcare infostructure is still in progress. Clinical standards such as clinical code sets, communication protocols and clinical document standards architecture are still under development and these are crucial for integration.

Electronic health records approaches and challenges Table 5

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Challenges faced by the five East Asian countries

Challenges

Singapore

Japan

Hong Kong

Taiwan

Malaysia

Integration efforts

Moderate

Complex

Moderate

Complex

Moderate

Process reengineering

Moderate

Complex

Moderate

Complex

Complex

People issues

Moderate

Complex

Complex

Complex

Moderate

Funding

Gov/Grants

Grant/Private

Gov/Grants/ Private

Gov/Grants/ Private

Gov

Laws and regulations

Moderate

Complex

Complex

Complex

Moderate

7.2 Process reengineering The integration issues cannot be resolved through technologies alone. A comprehensive change-management approach that integrates a number of enabling strategies and activities will be required at system, enterprise and project levels to ensure the effective implementation of EHR systems. This includes service model design and process reengineering. Service delivery models will need to be redesigned and processes reengineered to maximise the benefits of investments in health ICT and multimedia technologies (Al-Qirim, 2006). The EHR projects should utilise service models designed for achieving the best accepted practices in terms of access, quality and cost so that finally, healthcare delivery services would be improved. To cite an example, the Malaysia’s telehealth project, which aims to focus on the wellness approach in its services, requires much process reengineering on its existing healthcare services model shifting from the illness to the wellness paradigm (MOHM, 1997b). This also happened in Singapore, where the Health ONE project aims to empower the citizens to manage their health status and where, of course, the healthcare delivery process needs to be changed (HPBonline, 2007). To cite a further example, in Taiwan, with the introduction of NHI-IC cards, a healthcare provider is responsible for writing the specified data onto a card and transferring the data to TBNHI within 24 h. Therefore, hospitals are likely to face more obstacles in the adoption of the NHI-IC cards as an integral part of their HIS. The existing processes have to be reengineered to accommodate the functionality features of the NHI-IC. To summarise the complexity among the five countries, Singapore has fewer challenges compared to Japan, Taiwan, Hong Kong and Malaysia. This is due to the fact that the EHR implementation approach of the country (Singapore) is through standard platform applications with a centralised host that can be accessed by all healthcare facilities through the web. By way of example, the Singapore Health Service (SingHealth) had deployed a standard system – Eclipsys’ Sunrise (TM) suite of healthcare information solutions – in all SingHealth’s Healthcare Organisations (HCOs) for minimising changes on existing workflow and reducing change-management efforts during the implementation of EHRs (Business Wire, 2001).

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7.3 People issues People issues relate to change management, communication, training and development. Addressing the attitudes, habits and cultures or behaviours focused on present healthcare delivery practices and preparing the general population and healthcare professionals for the major changes linked to health ICT and EHR will require comprehensive communications and education/training strategies, particularly for people and healthcare professionals who will need to operate in the new environment (paper-based to computer-based medical records) (Bali and Wickramasinghe, 2008). Furthermore, this will entail training and developing personnel to operate effectively in a team-based, information-rich and multimedia-enabled working environment (Edward, 2005; Yang et al., 2007). As knowledge workers, health professionals will increasingly interact with each other and their patients through multimedia networks (electronic health information and e-workflow). This alone will require a significant investment in training and technology. By way of example, in Taiwan, on average there is approximately one physician per 800 people and the largest medical centre sometimes treats over 10 000 outpatients a day, and the number of inpatients is nearly 3000 (Chen et al., 2001). This situation (patient workload and consumption of time) may detract the physician from being involved in the technology-based efforts (using a computer system in providing healthcare services to the patients). To cite a further example, the survey carried out by Leung et al. (2003), a wide spectrum of potential barriers that may impede the adoption of computers in clinical practice in Hong Kong include the lack of physical skills to implement and use the technology and attitudinal or behavioural issues.

7.4 Funding The widespread reshaping of the healthcare services and the rollout of EHR systems must take into account the potential impact on the cost of services delivered. Malaysia is determined to extract the maximum value out of current and planned healthcare expenditures, including investments in health ICT and EHR initiatives. In this technologically expanding world, healthcare expenditure has been steadily increasing in both developed and developing nations. Major causes of death and morbidity such as heart diseases, cancer and trauma are caused by lifestyle changes (Schutz et al., 2006). Thus, a paradigm shift from an illness-focused health industry to a wellness-focused one through health information systems (telemedicine, telehealth and e-health) is of prime importance to cut down costs and improve the healthcare delivery system as well as improve the quality of life of the people (Harun, 2007). The EHR project has been envisaged to be the enabler in ensuring a cost-effective and improved healthcare delivery service for the nation. However, as this is a national project, and a complex one at that, challenges are to be anticipated, including the funding sources. The existing funding source for the EHR project depends largely on the government. This happened in Malaysia, Hong Kong, Singapore and Taiwan. Approximately 75% of the healthcare infrastructure expenditure in Singapore was provided by the government (HPBonline, 2007; Business Wire, 2001) and even more in Malaysia – approximately 90% (MOHM, 2005).

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Japan currently does not have a government-centred EHR although some local and regional hospitals have installed telemedicine and EMR systems and shared healthcare facilities (Tsuji et al., 2003). The healthcare services and infrastructure are largely contributed by private sectors. The widespread reshaping of the healthcare system and the rollout of the EHR system must take into account the potential impact on the cost of services delivered and the source of funding. The five East Asian countries faced similar challenges in providing continuous funding to the projects. The government has to balance its financial contribution to health ICT projects and evidently the private sectors are trying to maximise revenues from the investment they made. This might slow down the development of the EHR initiatives in the region and also in some other countries. Table 6 shows the health ICT initiatives in the five countries. Table 6

Health ICT and EHR initiatives in the five East Asian countries Ministry of health website

National ICT project for health

Electronic health record initiatives

Malaysia

moh.gov.my and dph.gov.my

Lifetime Health Record (LHR)

Singapore Taiwan

moh.gov.sg doh.gov.tw

Hong Kong

hwfb.gov.hk

Japan

mhlw.gov.jp

Integrated telehealth, teleprimary care, total hospital information system Health ONE, telemedicine Telemedicine, national health insurance Smart-Cards Telemedicine, patient-held medical record system e-Japan, telemedicine, telehealth

Country

EMR Exchange (EMRX) NHI-IC cards Patient card Computerised Patient Medical Records (CPRM)

7.5 Laws and regulations The appropriate laws, policy regulations and standards strategy will be required to ensure the effective operation of virtual healthcare delivery through the HER system while protecting the rights of individuals/patients (Sucurovic, 2007). In order for a patient’s healthcare provider to have an accurate diagnosis and proper care management of the disease, the patient will have to reveal his/her medical history. In this respect the healthcare providers will be bound by law and ethics to the duty of confidentiality. The code of ethics in a doctor-patient relationship shall apply in the EHR environment as it does to conventional practice (paper-based medical records). As far as the personal data are concerned, it is a private matter between the physician and the patient. It is only the medium upon which the medical data are kept which is different. In this respect the patient would be required to sign the consent form before the personal data can be incorporated into the database. In practice, people will think that is difficult. What if there is an emergency, does the patient need to sign the consent form? What if the patient is unconscious or is in grave need of medical attention? So what will happen in such a situation? Well, as far as the healthcare professionals are concerned, they may use their judgement and training and attend to the emergency based on the situation at hand (Harun, 2007). When the situation has been stabilised and when conditions permit, they may then procure their patient’s consent or the person needs to sign the consent form only once in his/her lifetime (National Health Services, 2007).

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The excessive policy regulation regarding the confidentiality and privacy of the patient medical record will hamper the implementation of the EHR nationwide. One example of excessive regulation is that the physicians in Japan are prohibited from answering specific questions about healthcare or diseases by e-mail or telephone (Holliday and Tam, 2004). In Singapore, the prescription can be repeated online without seeing the physician for six months. Taiwan and Hong Kong faced significant challenges in terms of data privacy and confidentiality. The Malaysian government had also taken the initiative to come up with a set of cyberlaws to govern EHR initiatives (MOHM, 2000). Finally, laws and regulations are crucial to keep the patient’s health records confidential and private. However, there is a need to balance the information revealed by the patient and a need to keep the medical information private. Table 7 depicts some of the EHRs captured through the clinical support systems that have a potential to affect the patient’s confidentiality and privacy. Table 7

Application, electronic health records and possible impact to person confidentiality and privacy

EHR application

Data captured

Implications

Hospital Information Systems (HIS)

Name:

This is personal and private information.

Age: Sex: Address:

Clinical Information Systems (CIS)

Chief complaint: penile discharge or vaginal discharge

This is potentially embarrassing data, which the patient will consider to be very private.

Medical history (examples)

Implications if this data is leaked – The patient will be embarrassed. It can also compromise the patient’s ability to get proper coverage from insurance companies.

Hypertension Epilepsy HIV Tuberculosis (TB)

Laboratory Information Systems (LIS)

Breast implants

The patient will not want to reveal having undergone surgery for breast implants either for cosmetic or psychological reasons.

Family history (examples) Leprosy TB, HIV, Epilepsy

These diseases may present a social stigma if the information is leaked out.

Social history (examples) Drug abuse, Alcohol abuse, smoker, Sexual orientation

Incidences of these activities may reveal the social life of the patient and if the data is disclosed inadvertently the person who accesses the data can draw negative conclusions about the patient.

• VDRL test – a test for syphilis, a type of sexually transmitted disease

Thus the person handling this data may be able to draw the conclusion that the patient may be having a promiscuous lifestyle, which poses a social stigma as well.

• HIV Test • TPHA (Treponema Pallidum) test – a test for diagnosis of syphilis

Electronic health records approaches and challenges Table 7

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Application, electronic health records and possible impact to person confidentiality and privacy (continued)

EHR application

Data captured

Implications

Radiology Information Systems (RIS)

• X-ray

PCP is a lung infection that is most common in people with impaired immune systems. It is often seen in people with HIV. People handling the information may deduce that the person is suffering from Acquired Immunodeficiency Syndrome (AIDS).

Pharmacy Information System (PHIS)

A.Z.T. (Zidovudine) Treatment/Therapy – a drug is prescribed routinely for HIV patients

• CT scan For example: may detect a form of disease called Pneumocystis carinii pneumonia, or PCP, a form of pneumonia in an immunocompromised state

A person may deduce that the patient is suffering from Human Immunodeficiency Virus (HIV).

Source: Harun (2001)

8

Recommendations

8.1 Establish an integrated solution for achieving seamless lifetime health record A sound technical infrastructure is an essential ingredient in the undertaking of e-health initiatives by any nation. Such infrastructures should also include telecommunications, electricity, access to computers, number of internet hosts, number of Internet Service Provider’s (ISP) and available bandwidth and broadband access. To offer a good multimedia content and thus provide a rich e-health experience, one would require a high bandwidth. ICT considerations are undoubtedly one of the most fundamental infrastructure requirements. In addition, it is imperative that the appropriate standards and protocols are used so that seamless transfer of information is supported (Wickramasinghe and Sharma, 2005; Wickramasinghe et al., 2005). The LHR is the integration of an individual’s timeline of his/her EMRs from all the healthcare centres (s)he has attended since birth (MOHM, 1997b). A principal target for the integrated solution is to create as many EMRs as possible so that many LHRs can be generated and mined. The creation of LHRs will be achieved by linking and integrating EMRs from the telemedicine applications, as well as from various HIS applications and from paper medical records converted to EMRs. Apart from generating a LHR repository, another main target is to provide access to LHRs from various HIS systems, thus providing a full set of integrated EMRs for a given patient, the data being independent of time and source location. The integrated and seamless LHR should help healthcare professionals towards making better diagnoses and treatment when compared to episodic EMRs, which are essentially restricted to data available at the same healthcare centre or at a different HIS (Mohan and Raja Yaacob, 2004). The LHR repository will play the role of a data warehouse for historical and prospective health indicators and statistics. Hence, statistical analyses, trend analyses and data mining can be used on the data to provide group data services to policymakers, and various healthcare institutions and to support medical research by universities or

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other research institutions. As such, it is critical that all HIS applications should synchronise their efforts and initiatives towards an integrated solution for achieving an integrated LHR.

8.2 Establish a flexible framework for the continuous upkeep of lifetime health record It is crucial to develop a flexible framework in order to integrate the LHR and to ensure that it can be accessed, viewed and stored seamlessly and continuously across healthcare premises. A flexible framework would provide distributed sites and multiple storage devices to keep and maintain the LHR of patients, and would incorporate high accessibility and availability across different healthcare service levels and premises. The framework will provide a mechanism to store, display and retrieve the LHR using portable storage devices during the possible downtime of computer systems or during inadequate coverage of the telecommunications network. This mechanism will allow for the continuous and seamless flow of patient information and knowledge, and timely access to the patient’s LHR during a patient-doctor encounter (anywhere in the country regardless of where the patient’s previous visit was). The possibility of using portable storage devices, such as smart cards (Liu et al., 2006) and mobile phones, would enable the LHR to be in the patients’ possession. A recent mobile phone users’ survey in Malaysia indicated that the penetration rate of the cellular phone for the second quarter of 2006 stood at 80.8% (Malaysian Communications and Multimedia Commission, 2006). This means that eight out of ten Malaysian people own and carry a mobile phone. The adoption of cellular phones among Malaysians and the success of wireless networks nationwide have led to an explosion of cell phones to be used as portable storage devices for storing, displaying and retrieving the electronic LHR. This technology has enabled the LHR to be located close to the patient, and the doctor may retrieve patient medical history seamlessly from these devices. Adequate care is dependent on flexible access to previous LHRs, which should be a feature of the health system of the future. Care should not be episodic or fragmented but should take into account the patient’s entire health history, taking a long-term outlook.

8.3 Training For any LHR to be successfully implemented and used to its full potential, it must be kept in mind that it does not merely automated the existing healthcare delivery functions, but also provides the opportunity to augment functions so that the final level of care is at all times superior. Integral to this is the effective and efficient use of information and knowledge, which in turn requires the grasp of the essential capabilities of KM techniques (Wickramasinghe and Schaffer, 2006; Wickramasinghe et al., 2006). To achieve this requires training of all personnel who interact with LHRs. Furthermore, this will entail training and developing personnel to operate effectively in a team-based, information-rich and multimedia-enabled working environment (Coiera, 2003). As knowledge workers, health professionals will increasingly interact with each other and their patients through multimedia networks. This alone will require a significant investment in training and technology as preparation for LHR implementation.

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8.4 Trust In any ‘e-initiative’, consumers are also concerned about a number of dimensions of trust: trust in the security of value passed during electronic transactions with organisations that are ‘virtual’ in a disconcertingly ineffable way and trust in the privacy of personal data arising from electronic transactions (Roquilly, 2002; Fjetland, 2002; Ghosh and Swaminatha, 2001; Von Lubitz and Wickramasinghe, 2006). This becomes even more of a concern in healthcare settings and measures must be taken to ensure that at all times trust is developed. With respect to the Malaysian LHR project, security issues had to deal with decisions made upfront by the Ministry of Health and the government. Health information is ‘sensitive information’ and classified as ‘highly confidential’, in view of the consequences and implications that such information can impact upon an individual’s life (Noseworthy, 2004). The integrated LHR project with its seamless flow of data across a spectrum of health premises and levels of care involving both medical as well as administrative records will require tight security in the computerisation process. With respect to the LHR project, there is therefore a need for ‘End-to-End’ security assurance. It was suggested that security issues related to five major areas should be addressed accordingly. These include: •

Administration issues – organisation and relevant policies and procedures.

•

Technical issues (application security) – e.g., software security breaches will be addressed, frequent updates of operating system, system software and application systems.

•

Infrastructure issues – encryption of sensitive information sent through the network.

•

Data centre – security of servers and database is addressed via physical means, firewalls and zoning systems.

•

Legal issues – the use of digital certification application for data transmission (MOHM, 2007; MOHM, 2000; Mohan and Raja Yaacob, 2004; Sucurovic, 2007; Blobel, 2007).

9

Conclusions

The approaches and challenges of other countries were compared and several major challenges were revealed, including integration issues, process reengineering, people, funding, and legal issues and regulation. It is noted that the Malaysian experience in that context is not so different. All countries including Malaysia are moving to implement a national health ICT infrastructure. Malaysia embarked on the EHR project through a top-down strategy as part of its intention to become a developed nation by 2020. The healthcare vision (through health ICT) is one of its roadmaps to achieve the vision. As in any health ICT project, many lessons were learned the hard way. Though we are far from done, we thought that this would be a good milestone to share with the world at large what we have accomplished thus far. Therefore, challenges, issues and several positive recommendations are highlighted in this paper from the early deployment and from other countries’ experience.

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There are varieties of approaches in implementing HER, including starting with a bottom-up approach, research and a field project followed by the realisation that a strategic framework is needed to maximise benefits. The government-centred EHR is one of the strategic advantages to sustain the EHR initiatives especially in the aspect of enforcement (to use the computer-based medical records system) and to continue funding the project cost. To conclude this paper, the national implementation of EHR is not easy. It is easy to implement a health information system but not necessarily an integrated one. Sharing the experiences and lessons learned from our experienced neighbours could be beneficial in the next steps of this research.

References Abu Bakar, M.A. (2007) ‘Malaysia healthcare delivery system’, Personal Interview. Al-Qirim, N. (2006) ‘The case of telepsychiatry adoption and diffusion in a healthcare organization in New Zealand’, Journal of Cases on Information Technology, Vol. 8, No. 1, pp.31–48. Arnold, S., Wagner, J., Susan, J.H. and Gary, M.K. (2007) ‘Electronic health records: a global perspective – overview’, http://www.himss.org/content/files/DrArnold20011207 EISPresentationWhitePaper.pdf (accessed 23 January 2008). Bali, R.K. and Wickramasinghe, N. (2008) ‘Achieving successful EPR implementation with the penta-stage model’, International Journal of Healthcare Technology and Management, Vol. 9, No. 1, pp.97–105. Blobel, B. (2007) ‘Comparing approaches for advanced e-health security infrastructures’, International Journal of Medical Informatics, Vol. 7, No. 6, pp.454–459. Business Wire (2001) ‘Singapore and eclipsys partner in major information initiative: SingHealth’s HCOs to be interconnected using eclipsys solutions’, Business Wire, http://www.allbusiness .com/health-care/health-care-overview/6062095-1.html (accessed 15 January 2008). Canada Health Infoway (2006) ‘E-health knowledge way: EHRS blueprint’, http://knowledge .infoway-inforoute.ca/CHIPortal/EHRSearch/EHRS+Blueprint/ (accessed 5 May 2006). Chaudhry, B., Wang, J., Wu, S., Maglione, M., Mojica, W., Roth, E., Morton, S.C. and Shekelle, P.G. (2006) ‘Systematic review: impact of health information technology on quality, efficiency, and costs of medical care’, Annals of Internal Medicine, Vol. 144, pp.742–752. Chen, H.S., Guo, F.R., Chen, C.Y., Chen, J.H. and Kuo, T.S. (2001) ‘Review of telemedicine projects in Taiwan’, International Journal of Medical Informatics, Vol. 61, pp.117–129. Cheung, N.T., Fung, K.W., Wong, K.C., Cheung, A., Ho, W., Cheung, C., Shung, E., Fung, V. and Fung, H. (2001) ‘Medical informatics – the state of the art in the hospital authority’, International Journal of Medical Informatics, Vol. 62, pp.113–119. Chew, S.J., Cheng, H.M., Lam, D.S.C., Cheng, A.C.K., Leung, A.T.S., Chua, J.K.H., Yu, C.P., Balakrishnan, V. and Chan, W.K. (1998) ‘OphthWeb-cost-effective telemedicine for ophthalmology’, Hong Kong Medical Journal, Vol. 4, No. 3. Coiera, E. (2003) Guide to Health Informatics, 2nd ed., Hodder Arnold. Department of Health Taiwan (2008) ‘General health statistics, 2006’, http://www.doh.gov.tw/ statistic/english/1-3/2006.rar (accessed 25 January 2008). Department of Statistics Malaysia (2006) ‘Key statistics’, http://www.statistics.gov.my (accessed 3 May 2006). Edward, I.H. (2005) Innovation Management in the ICT Sector: How Frontrunners Stay Ahead, Edward Elgar Publishing Ltd. Fjetland, M. (2002) ‘Global commerce and the privacy clash’, Information Management Journal, Vol. 36, No. 1, pp.54–58.

Electronic health records approaches and challenges

101

Frances, M., Tracy, F., Carl, M., Julia, H., Susan, B., Pauline, G. and Siobhann, M.Q. (2007) ‘Perceptions of risk as a barrier to the use of telemedicine’, Journal of Telemedicine and Telecare, Vol. 13, Suppl. 1, pp.38–39(2). Ghosh, A.K. and Swaminatha, T.M. (2001) ‘Software security and privacy risks in mobile e-commerce’, Communications of the ACM, Vol. 44, No. 2. Harun, M.H. (2001) Integrated Telehealth: The Malaysian Experience, DTP Enterprise Sdn Bhd. Harun, M.H. (2007) ‘Early experience of integrated telehealth – lessons learned’, Personal Interview. Health-4-U (2007) ‘The patient education of the Singapore General Hospital’, http://www .sghhealth4u.com.sg./health4u/Main/SGH_Patient_Education2.htm (accessed 10 February 2007). Hisan, A. (2006) ‘Malaysia’s health: transforming healthcare services through ICT’, http://www .un-gaid.org/kl06/docs/ (accessed 15 January 2007). Hjelm, N.M., Hazlett, C., Hsieh, R.K.C. and Lee, J.C.K. (2001) ‘Moving with the sun’, International Journal of Medical Informatics, Vol. 61, pp.97–101. Holliday, I. and Tam, W.K. (2004) ‘E-health in the East Asian tigers’, International Journal of Medical Informatics, Vol. 73, pp.759–769. Hong Kong’s Domestic Health Accounts (HKDHA) (2005) ‘Total health expenditure’, http://www .fhb.gov.hk/statistics/download/dha/en/tf1.pdf (accessed 30 January 2008). HPBonline (2007) ‘Singapore health promotion board online: vision, mission & values’, http://www.hpb.gov.sg/hpb/default.asp?pg_id=948 (accessed 5 January 2007). Hsieh, S.L., Lai, F., Cheng, P.H., Chen, J.L., Lee, H.H., Tsai, W.N., Weng, Y.C., et al. (2006) ‘An integrated healthcare enterprise information portal and healthcare information system framework’, Engineering in Medicine and Biology Society 2006 (EMBS ’06), 28th Annual International Conference of the IEEE, pp.4731–4734. Hu, P.J.H., Wei, C.P. and Cheng, T.H. (2002) ‘Investigating telemedicine developments in Taiwan: implications for telemedicine program management’, IEEE Proceedings of the 35th Hawaii International Conference on System Sciences, p.8. IAB (2006) ‘Health IT in government – transforming health care and empowering citizens’, Intergovernmental Advisory Board American Council for Technology, http://www.himss.org/ ASP/ContentRedirector.asp?ContentID=65657 (accessed 23 November 2006). Inamura, K. and Lemke, H. (2007) ‘Technology and its clinical application in the field of computer-assisted radiology and surgery’, Biomedical Imaging and Intervention Journal, Vol. 3, No. 3, p.e41. Industry Canada (2006) ‘Information & communication technologies: report on the 5th international conference on the medical aspects of telemedicine’, http://strategis.ic.gc.ca/epic/ internet/inict-tic.nsf/en/it07656e.html (accessed 8 May 2006). Koch, S. (2006) ‘Home telehealth – current state and future trends’, International Journal of Health Informatics, Vol. 75, pp.565–576. Leung, G.M., Johnston, J.M., Ho, L.M., Wong, F.K. and Cameo, S.C. (2001) ‘Computerization of clinical practice in Hong Kong’, International Journal of Medical Informatics, Vol. 62, pp.143–154. Leung, G.M., Yu, P.L.H., Wong, I.O.L., Johnston, J.M. and Tin, K.Y.K. (2003) ‘Incentives and barriers that influence clinical computerization in Hong Kong: a population-based physician survey’, Journal of the American Medical Informatics Association, Vol. 10, No. 2. Liu, C.T., Long, A-G., Li, Y-C., Tsai, K-C. and Kuo, H-S. (2001) ‘Sharing patient care records over the World Wide Web’, International Journal of Health Informatics, Vol. 61, pp.189–205. Liu, C.T., Yang, P.T., Yeh, Y.T. and Wang, B.L. (2006) ‘The impacts of smart cards on hospital information system – an investigation of the first phase of the national health insurance smart card project in Taiwan’, International Journal of Medical Informatics, Vol. 75, pp.173–181.

102

M.K. Abd Ghani et al.

Luh, J.J., Cheng, P.H., Chen, S.J., Lai, J.S., Chen, H.S. and Chung, H.C. (2005) ‘Evaluation of the low cost telemedicine system in Taiwan’, Enterprise Networking and Computing in Healthcare Industry, HEALTHCOM 2005, Proceedings of the 7th International Workshop on 23–25 June, pp.316–319. Lun, K.C. (1999) ‘Health informatics in the Asia Pacific Region’, International Journal of Medical Informatics, Vol. 55, pp.3–7. Maheu, M.M., Whitten, P. and Allen, A. (2001) E-health, Telehealth and Telemedicine: A Guide to Start-up and Success, San Francisco: Jossey-Bass A Wiley Company. Malaysian Communications and Multimedia Commission (2005) ‘Household use internet survey’, http://www.mcmc.gov.my/facts_figures/stats/pdf/Household_use_internet_survey2005.pdf (accessed 11 March 2006). Malaysian Communications and Multimedia Commission (2006) ‘Malaysian Communication and Multimedia Commission: roles and responsibilities’, http://www.mcmc.gov.my/about_us/ roles.asp (accessed 31 May 2006). Masuda, Y., Sekimoto, M., Nambu, M., Higashi, Y., Fujimoto, T., Chihara, K. and Tamura, Y. (2005) ‘An unconstrained monitoring system for home rehabilitation’, Engineering in Medicine and Biology Magazine, IEEE, Vol. 24, No. 4, pp.43–47. Ministry of Health Malaysia (MOHM) (1997a) Concept Request for Proposal for Lifetime Health Plan: Telemedicine Flagship Application, Copyright 1997, Government of Malaysia. Ministry of Health Malaysia (MOHM) (1997b) Telemedicine Blueprint: Telemedicine Flagship Application, Government of Malaysia. Ministry of Health Malaysia (MOHM) (2000) ‘National telehealth policies: telemedicine flagship application’, Unpublished Document, Government of Malaysia. Ministry of Health Malaysia (MOHM) (2002) ‘Health facts 2002’, http://pnd.moh.gov.my/ uploads/health_facts_2002.htm (accessed 3 May 2006). Ministry of Health Malaysia (MOHM) (2005) ‘Health facts’, http://pnd.moh.gov.my/uploads/ health_facts_2005.htsm (accessed 3 May 2006). Ministry of Health Malaysia (MOHM) (2006a) ‘Health ICT initiative project progress report’, Personal Interview. Ministry of Health Malaysia (MOHM) (2006b) ‘Vision and mission’, http://www.moh.gov.my/ opencms/opencms/moh/MOH_Eng/misi_kkm.html (accessed 10 November 2006). Ministry of Health Malaysia (MOHM) (2007) ‘ICT Strategic Plan (ISP): 2006–2010’, Unpublished Document, Government of Malaysia. Moehr, J.R., Schaafsma, J., Anglin, C., Pantazi, S.V., Grimm, N.A. and Anglin, S. (2006) ‘Success factors for telehealth – a case study’, International Journal of Medical Informatics, Vol. 75, pp.755–763. Mohan, J. and Raja Yaacob, R.R. (2004) ‘The Malaysian telehealth flagship application: a national approach to health data protection and utilisation and consumer rights’, International Journal of Medical Informatics, Vol. 73, pp.217–227. National Health Services (2006) ‘The national programme for IT implementation guide’, http://www.connectingforhealth.nhs.uk/all_images_and_docs/implementationdocs/national _programme_implementation_guide_v4.pdf (accessed 15 May 2006). National Health Services (2007) ‘The NHS care records service: better information for better, safer care’, http://www.nhscarerecords.nhs.uk/patients/what-do-i-need-to-do-now/how-can-i -find-out-more/nhs-crs-summary-leaflets/summary_leaflet_online.pdf (accessed 19 July 2007). Nelson, D.A. (1997) ‘Why does medicine need standards?’, http://www.medicalcomputing.org/ archives/0astandwhy.php (accessed 20 November 2006). Norris, A.C. (2002) Essentials of Telemedicine and Telecare, John Wiley & Sons, Ltd.

Electronic health records approaches and challenges

103

Noseworthy, T. (2004) ‘Advancing Electronic Health Records in Canada: Why, How and Key Learnings of Potential Value to China’, IEEE – Medical Information Systems: The Digital Hospital, 2004. IDEAS ‘04-DH. Proceedings. IDEAS Workshop on 1–3 September 2004, pp.129–132. Pan, Z.X. and Pokharel, S. (2007) ‘Logistics in hospitals: a case study of some Singapore hospitals’, Leadership in Health Services, Vol. 20, No. 3, pp.195–207. Pories, W.J. (1990) ‘Is the medical record dangerous to our health?’, North Carolina Medical Journal, Vol. 51, pp.47–55. Roman, I., Roa, L.M., Reina-Tosina, J. and Madinabeita, G. (2006) ‘Demographic management in a federated healthcare environment’, International Journal of Medical Informatics, Vol. 75, pp.671–682. Roquilly, C. (2002) ‘Closed distribution networks and e-commerce: antitrust issues’, Intl. Review of Law, Computers & Technology, Vol. 16, No. 1, pp.81–93. Schutz, H., Wiedemann, P.M., Hennings, W., Mertens, J. and Clauberg, M. (2006) Comparative Risk Assessment: Concepts, Problems & Applications, WILEY-VCH. Sucurovic, S. (2007) ‘Implementing security in a distributed web-based EHCR’, International Journal of Medical Informatics, Vol. 7, No. 6, pp.491–496. Suleiman, A.B. (2001) ‘The untapped potential of telehealth’, International Journal of Medical Informatics, Vol. 61, pp.103–112. Takahashi, T. (2001) ‘The present and future of telemedicine in Japan’, International Journal of Medical Informatics, Vol. 61, pp.131–137. Tay-Yap, J. and Al-Hawamdeh, S. (2001) ‘The impact of the internet on healthcare in Singapore’, Journal of Computer-Mediated Communication, Vol. 6, No. 4. Toyoda, K. (1998) ‘Standardization and security for the EMR’, International Journal of Medical Informatics, Vol. 48, Nos. 1–3, pp.57–60. Tsai, W-H. and Kuo, H-C. (2007) ‘The internet and healthcare in Taiwan: value-added applications on the medical network in the National Health Insurance smart card system’, Int. J. Electronic Healthcare, Vol. 3, No. 4, pp.417–432. Tsuji, M., Suzuki, W. and Taoka, F. (2003) ‘An economic evaluation of the Japanese telehealth system by CVM: comparison of four regions’, IEEE – Enterprise Networking and Computing in Healthcare Industry, 2003. Healthcom 2003. Proceedings. 5th International Workshop, pp.24–28. Varghese, S. and Scott, R.E. (2004) ‘Categorizing the telehealth policy response of countries and their implications for complementarity of telehealth policy’, Telemedicine Journal and e-Health, Vol. 10, No. 1, pp.61–69. Von Lubitz, D. and Wickramasinghe, N. (2006) ‘Key challenges and policy implications for governments and regulators in a network centric healthcare environment’, Int. J. Electronic Government, Vol. 3, No. 2, pp.204–224. WHO Statistical Information System (WHOSIS) (2006) ‘WHO Statistical Information System: core health indicators’, http://www.who.int/whosis/database/core/core_select.cfm (accessed 25 May 2006). Wickramasinghe, N. and Schaffer, J. (2006) ‘Creating knowledge driven healthcare processes with the intelligence continuum’, Int. J. Electronic Healthcare, Vol. 2, No. 2, pp.164–174. Wickramasinghe, N. and Sharma, S. (2005) ‘Key considerations for ensuring high quality HIPAA compliant e-health’, Int. J. Services and Standards, Vol. 1, No. 3, pp.319–335. Wickramasinghe, N., Fadlalla, A., Geisler, E. and Schaffer, J. (2005) ‘A framework for assessing e-health preparedness’, Int. J. Electronic Healthcare, Vol. 1, No. 3, pp.316–334. Wickramasinghe, N., Geisler, E. and Schaffer, J. (2006) ‘Realizing the value proposition for healthcare by incorporating KM strategies and data mining techniques with the use of information communication technologies’, Int. J. Healthcare Technology and Management, Vol. 7, Nos. 3–4, pp.303–318.

104

M.K. Abd Ghani et al.

Williams, F. and Moore, M. (1995) ‘Telemedicine: its place on the information highway’, http://www.csua.berkeley.edu/~utsai/Telemed.html (accessed 20 April 2005). Wootton, R. and Craig, J. (1999) Introduction to Telemedicine, The Royal Society of Medicine Press Limited. Yang, K.H., Lee, S.M. and Lee, S-G. (2007) ‘Adoption of information and communication technology: impact of technology types, organization resources and management style’, Industrial Management & Data Systems, Vol. 107, No. 9, pp.1257–1275.