Electronic Medical Records

10 October 2016

Thanks to my brother, Baboucar who encouraged me to pursue my Master’s degree and the never ending support I receive from him. Special thanks to my six year old son, Ebrima for his understanding that I’m at school when I’m not home to read him a bedtime story. I also want to thank all my EMGT instructors especially Professor Herb Tuttle, Dr Tom Bowlin and Ray Dick who worked with me recently, for the wonderful information and feedback they provided on this project. Thanks to Parveen Mozaffar for her extreme support and encouragement during the course of my studies.

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Thanks to the staff at Royal Victoria Teaching hospital for providing me with all the needed information for this project. Last but not least, my gratitude goes out to Dr Don Anthony Woods. It is because of his influence that brought me where I am today. He always had my best interest at heart and I want to thank him for that. May God bless you! Executive Summary Most countries in Europe and the USA are increasingly using an electronic medical record (EMR) system to help improve healthcare quality. Unfortunately, The Gambia government faces a series of health crises including but not limited to HIVIAIDS, malaria, diabetes and tuberculosis.

These diseases threaten the lives of thousands of people. Lack of infrastructure and trained, experienced staff are considered important barriers to scaling up treatment for these diseases. The contribution of this field proj ect outlines the benefits of an EMR system at Royal Victoria Teaching Hospital (RVTH) and how it will improve patient safety. This is a descriptive study using interview questionnaires from officials at the Royal Victoria Teaching Hospital. The study also looks into other facilities in similar developing countries with advanced systems, but not so advanced as to be at the level of state-of-the­ art facilities in the U.

S. Results from this study indicates the importance of an EMR system at RVTH to facilitate effective and efficient data collection, data entry, information retrieval and report generation. As a catalyst for development, the implementation of an EMR system at RVTH may make it one on the best hospitals in the West African region. 5 1. Introduction According to Dick and Steen, Electronic Medical Record (EMR) is the compilation of patient medical information in a computer-based format that allows the collection, storage, retrieval, and communication of this data.

An electronic medical record replicates a paper chart and contains both clinical information (diagnoses, allergies, drug resistance and treatments) and demographic information about a patient; it provides a comprehensive medical picture and can be used by clinicians as a tool to determine appropriate treatment for patients. EMR is not only being welcomed by healthcare providers as a way to improve care delivery but also serves as a catalyst and gold standard for development (porter, Kohane, & Goldman; Reifsteck, Swanson, & Dallas).

Unfortunately, Africa, a continent faced with many challenges ranging from epidemics, civil wars, and disasters, lacks robust healthcare infrastructure in the form of computerized health care systems. For instance, Ghana has one the best health institutions in the region, Korle-Bu Teaching Hospital. This Hospital, for example, is currently the only institution in the West African sub-region which performs surgery. Due to the quality of outcome, it now receives referrals from most parts of the continent namely the Gambia, Sierra Leone, Liberia, Togo Benin, Tanzania, Nigeria, Cameroon, Cote d’ Ivoire, and Ethiopia.

Despite its exemplary performance, the hospital has no computerized information system which can help improve care delivery in the region. Therefore, the purpose of this study is to examine the potential benefits of EMR and its ultimate contribution to improving healthcare delivery development in less developed countries like The Gambia. 6 1. 1. Background of Royal Victoria Teaching Hospital The Gambia is a small country in West Africa, with a population of approximately 1. 5 million. RVTH has been in existence for over 100 years in The Gambia’s capital, Banjul.

It used to be called Royal Victoria Hospital until in the late 1990s, when its name was changed to RVTH. The Gambian Government decided that it had to reduce its dependency on foreign doctors by establishing a medical school in the University of The Gambia (UTG). The UTG now uses RVTH to teach its clinical students. In recent years, The Gambia has been doing much on its own initiative to take to improve the healthcare of the nation. There are 540 beds in the hospital and the two largest Departments are Pediatrics and Maternity.

The biggest “killer” disease in The Gambia is malaria, with young children and pregnant women being particularly vulnerable to this disease. Diabetes, high blood pressure, pneumonia and eye problems such as trachoma and cataracts are also major health problems. The following table provides an estimation of how many patients were seen at RVTH in the year 2008. Procedure Inpatient Admissions Children admitted to Pediatrics Patients treated in the Eye Center Out-Patient Appointments Out-Patients in the ER Number of Patients 25,281 9,352 986 over 184,365 24,334 Table 1: Number of patients seen at RVTH in 2008 7

Unfortunately, RVTH does not have any EMR system in place to facilitate patient safety. As noted by participants, “EMR software is not used at RVTH because administration keeps complaining of money. It looks expensive to them and also they are more used to the paper folder”. Currently, information is very fragmented and therefore does very little to help patient safety and consistency in care. Another important issue here is that a large number of these patients are illiterates. To ensure they receive the appropriate treatment, they will have to explain to the physician current medications they are taking etc.

This can be a very challenging and fatal to the patient sometimes. The typical paper medical record contains sections including information on demographics, admissions, discharge summaries, progress notes, protocols, laboratory results, radiology results, surgical and pathology reports, orders for, treatment and nursing notes. Most documentation regarding treatment of a patient is written directly in the patient’s medical chart. On a given day a patient arrives at the hospital for care, sign in his name and waits anywhere from 30 minutes to six hours o get their records pulled depending on the day. Physicians, nurses, medical residents who need access the information in the medical record must wait till it’s available. Typically, medical records are transported to the outpatient clinic where the patient would be seen, and then returned to storage center to be filed again. It is necessary for the medical record to follow the patient throughout their visit. If the patient was seen in one clinic where orders were written, it was necessary to physically transport the record when the patient moved to the medicine room for treatment. The purpose of this field project is to examine the potential benefits of an EMR system and its ultimate contribution to improving patient safety at the Royal Victoria Teaching Hospital in The Gambia. 9 2. Literature Review The first generation of EMRs was extensions of medical billing systems in large US hospitals. Over the last four decades, they have been used as tools to organize and store medical data. EMRs are widely accepted as important tools to support high quality health care in the US, Europe and other developed countries.

Evidence shows that using EMRs that include decision support systems improves quality of care and both reduce medical errors and unnecessary medical investigations (Partners in Health), Experience with the use of EMRs in developing countries, if available, is much more limited than it is in the US and Europe. Now there is considerable interest in using medical information systems to support the treatment of HIV and TB in Africa, Latin America, and Asia. In most African countries, healthcare information systems have been driven mainly by the need to report aggregate statistics for government or funding agencies.

Such data collection can be performed with simple paper forms at the clinic level, with all electronic data entry done centrally, but that approach tends to be difficult and time­ consuming and may provide little or no feedback to the staff collecting data. Individual patient data that are collected and accessible at the point of care can support clinical management. Clinicians can easily access previous records, and simple tools can be incorporated to warn of potential problems such as incompatible drugs.

Physicians or nurses can check on the outcomes of individuals or groups of patients and perform research studies. Many of these functions will work well on paper or with simple spreadsheets for up to 100 patients but become very time-consuming and potentially unreliable with more than 1,000 records, and virtually impossible with 10,000 or more. 10 Experience with the use ofEMRs in developing countries is much more limited than it is in the US and Europe, but there is now considerable interest in using medical information systems to support the treatment of HIV and TB in Africa.

Some examples of EMR use in Africa include: • The Regenstrief Institute in collaboration with Moi University in Kenya developed an EMR for general patient visits to clinics in western Kenya. This system was subsequently modified to support the care of several thousand HIV patients. • Baobab Health Partnership in Malawi has developed an EMR system using innovative, low-power touch-screen PCs for data entry and display. This system is now used to support the care of more than 7,000 HIV patients in the Lighthouse clinic in Lilongwe and has been chosen by the national HIV program for use throughout the country. [email protected], an HIV medical information system developed for US patients, has now been deployed in Uganda and is planned for use in other African countries and in Latin America. (Partners In Health) A wide-ranging literature review of electronic medical record implementation over the past decade reveals that clinical, workflow, administrative, and revenue enhancement benefits of the EMR outweigh barriers and challenges. Among other key efforts, organizations must train and motivate users to navigate EMR systems, as well as develop a common structured language.

Clinicians who used CPRs found that electronic 11 access to clinical infonnation saves time and provides a thorough and efficient way to manage patient information To reap the full benefits of an EMR, organizations must redesign current workflows and practices to evolve into efficient providers of care. EMR systems are developed to meet the following goals: improve quality of care, reduce organizational expense, and produce a data stream for electronic billing. (Dassenko and Slowinski).

The EMR meets these goals through workflow automation, connectivity, and data mining. (Gaillour) The Computer-based Patient Record Institute’s (CPRI) definition concurred with the other researchers, but added that the EMR provides protection of patient and provider confidentiality, has a defined vocabulary and standardized coding, produces documentation as a by-product of patient care, connects local and remote systems and provides electronic support for secondary users (payers, policymakers, researchers). Fromberg and Arnatayakul) Unfortunately, most EMR systems are unable to offer all of the components defined by the CPRI because ”the technology is too complex and too expensive, doctors won’t use computers, and standards don’t exist. “(Gaillour) The advantages associated with implementing EMRs are well documented and are straightforward. The difficulty comes with placing a dollar figure to these advantages; consequently, few organizations have published studies describing the actual costs and benefits attained from implementing EMRs. Bingham) The benefits associated with CPRs are organized into four categories: clinical, workflow, administrative, and revenue enhancement. Renner, states that measuring all the benefits associated with EMRs is 12 virtually impossible, and that it is probably safe to select those that can make the greatest financial difference, and incorporate them into a financial model.

Clinical benefits seen after implementing an EMR include: better access to the chart, improved clinical decision making and disease management, enhanced documentation, simplified patient education, and increased free time to spend with patients, accompanied by improved perception of care and quality of work life. These benefits ultimately result in better delivery ofpatient care and safety. Despite all of these benefits, EMRs are not a standard in today’s healthcare systems. It is evident that EMR technology is still a hot topic for discussion when browsing through current healthcare technology and management journals.

The following barriers have kept healthcare leaders discussing EMR technology instead of adopting it: cost, leadership, ROI, vendors keeping up with users’ needs, and deficits in the following categories: public policy, standards, security, and a true definition. First of all, cost has kept organizations from implementing EMR systems. These costs can be organized into the following categories: software, hardware, infrastructure development and maintenance, implementation, education, planning, and administration.

Software costs include development or purchase, maintenance, and upgrades over time, while hardware costs include purchase of workstations. (Mohr) Infrastructure development and maintenance costs include servers, interfaces, workstations, network cables, network maintenance, and help desk operations. Planning costs include development of an implementation plan, identifying measurable outcomes, and choosing meaningful metrics and goals, while implementation costs include training, overtime 13 ssociated with entering patient data, business disruption during transition, employee resistance to change, and lost productivity. Drazen, suggested that leadership was probably a more significant barrier than cost because, in the past, healthcare leaders have raised capital for essential business initiatives such as major building programs, acquiring a physician network, or starting up a managed care organization. This amount of capital is on the same scale as an EMR. Next, Drazen stated that a lack of government support is a major issue holding up EMR implementation.

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