Electronic Health Records: Adoption and Overcoming the Challenges for India

Considering the massive amount of medical and healthcare records being generated across multiple institutions, the EHR plays an integral role in connecting all of them to provide real-time data of patients at a common platform.

Electronic Health Records ( EHR ) is the digitized collection of patients or populations' medical or health information. The vital health records of people are entered electronically by the healthcare providers throughout his/her lifetime. EHRs aim towards making the patient-centered records securely and instantly available to authorized users on demand. EHRs form an immensely vital part of health IT as it encompasses all advanced treatment histories of patients:

• Contains patient's medical diagnoses, history, radiology images, allergies, medications, lab test reports, and immunization dates
• Allow real-time access to evidence-based tools allowing providers to make decisions about a patient's health
• Automate and streamline the provider workflow
  
  

EHR for India

The Government of India aims to introduce a uniform maintenance system of Electronic Medical Records / Electronic Health Records (EMR / EHR ) by the healthcare providers and hospitals across the nation. The Ministry of Health & Family Welfare first initiated the standards for Electronic Health Record (EHR) for India back in September 2013. These pointers were on the basis of the recommendations made by the EMR Standards Committee constituted under the MoH&FW.

The draft of the EHR/ EMR Standards was hosted on the website of the Ministry initially, soliciting comments from the general public and stakeholders before implementation. After considering all the recommendations - the ‘EHR was finally passed by the Ministry of Health and Family Welfare.

Goals of EHR standards

With the rise of medical homecare devices and systems, meaningful healthcare data gets generated 24x7, which has long-term clinical relevance. This is where Electronic Health Record comes to the rescue as it collects all medical records generated during any clinical encounter or events.

Broadly, the goals of EHR can be defined as below:

• Promote interoperability and be specific about certain vocabulary standards and content exchange to establish a path forward towards semantic interoperability

• Promote all possible scope of technical innovation using adopted standards

• Support the evolution and real-time maintenance of the adopted standards

• Encourage adoption and participation by all stakeholders and vendors

• Keep implementation costs at a minimum

• Consider experiences, policies, best practices, and frameworks

• To the extent possible, adopting standards that are modular and not interdependent

Benefits of EHR

The benefits of EHR can be defined as below:

• Managing EHRs requires comparatively fewer staff members, limiting the need to have large spaces for record-keeping. Therefore, it costs much less to maintain and manage records with this approach.

• As the number of patients multiplies, the preservation of records becomes an even more significant challenge. EHRs, on the other hand, do not require to be printed on papers, hence no need to be backed by sizable physical storage spaces.

• EHR improves work efficiency and helps healthcare providers to reach their goals

• Provides quick access to critical patient records for efficient and coordinated patient care

• Offers a favorable environment for healthcare providers to enhance their productivity & work-life balance

• Reduces diagnostic and medical errors to improve overall patient care

• Improves interaction between providers and patients under a stable and secure environment improving convenience

• Makes medical prescriptions even safer and reliable

• EHRs ensures easily accessible of patients records from anywhere and at any time, and also the data can be stored for an indefinite time

• Being in electronic format, it minimizes the number of records lost

• EHRs help track patient's clinical progress and also improve patient compliance

• Provides a summarized report of the various clinical encounters in people's lifetime - avoiding unnecessary repeating tests

• EHRs are completely easy to update for real-time availability of data to multiple users at a single point of time

• EHRs facilitate advanced health care decisions, providing evidence-based care all the time

• EHRs are used for research purposes as well

Steps to a successful implementation of EHR

Implementing an electronic health record is not a very easy process, as it can get very challenging if not carefully undertaken using a step-by-step approach.

And this step by step approach is guided by six significant steps:

Assess the Organization's Readiness: The preliminary step towards EHR implementation is to rightly assess the organization's current needs, goals, along with its financial and technical readiness towards the change. And, only post having an accurate view of the preparedness can the organizations design an EHR implementation plan which matches the specific organizational needs.

Plan the Adoption Approach: In the planning phase, organizations need to draw on the information gathered by them during the assessment stage in order to elaborately outline their EHR implementation plan. It's essential to measure and view each minute aspect of the plan from an electronic point-of-view.

Upgrade to or Select a Certified EHR: Next, organizations should upgrade to or select a certified and trusted EHR. The EHR implementation team should leverage the information gathered in the planning and assessment phases to choose the perfect EHR matching the organization's needs and challenges.

Conduct Training for Effective Implementation of an EHR System: During this phase of EHR implementation, organizations need to focus on training to ensure the successful migration to electronic data maintenance. They will also need to assure that they prepare for EHR implementation go-live, including training, pre-go-live dress rehearsals, along with elaborate pilot testing in this step.

Achieve Meaningful Use: Next, organizations should work towards achieving meaningful use, focusing on the shift towards the Merit-based incentive payment system.

The introduction of MACRA (the Medicare Access and CHIP Reauthorization Act), brought in the Medicare EHR Incentive Program, which implies meaningful use. This later got transitioned to become one of the top four components of the latest Merit-Based Incentive Payment System (MIPS), which itself is part of MACRA.

MIPS harmonizes the existing CMS quality programs, the Physician Quality Reporting System, along with the Value-Based Payment Modifiers. MIPS combines multiple, quality programs into a single program to enhance quality care.

Continue Quality Improvement: Once enterprises have implemented an EHR and achieved its desired meaningful use, they should focus on continuous evaluation and improvement. It is critical to revisit the organization's goals and needs to refine the workflows and improve patient outcomes continuously.

Good read- Data Privacy and Security Risks In Healthcare Industry

Security challenges in EHRs

Compared to paper medical records, threats to electronic health records security will no doubt be a hurdle to the efficient sharing of medical records within organizations. But, to optimize its benefits, there are major issues in electronic health records that organizations need to consider and overcome:

Data Interoperability

The use of EHRs has multiple benefits to healthcare organizations. But, those advantages remain linked to the data interoperability of the systems. When medical records are retrieved or saved, various aspects of the records are involved. And, the lack of interoperability solutions and standards has been a significant obstacle in the exchange of healthcare data between multiple stakeholders.

The data must be compatible with all organizations to maximize the benefits of EHRs to serve patients or even for research purposes. When authorized organizations or people receive and send medical records, the records need to be compatible even though they use diverse systems.

Security

Organisations need to have a well-informed sense of assurance that the information risks and controls are balanced out. EHR systems may have multiple security vulnerabilities, and one of the biggest threats for EHR systems is malicious code. Software and hardware vulnerabilities removal is a must so that controls and risks are balanced to protect the system for effective business continuity.

EHRs involve sensitive, accurate, and confidential personal information of patients, like doctor's notes, prescription information, lab diagnosis, and personal and insurance-related information, which are too risky to be compromised. Medical records remain a lucrative target for hackers to commit cyber-crimes, including - identity thefts, phishing attacks, encryption blind spots, cloud threats, malware, and ransomware attacks. Hence, organisations need to prioritise cyber protection.

Business Continuity

Business continuity planning (BCP) is essential to create strategies for maintaining continuous business operations before, during, and after disaster events. Network failure, hardware failure, data loss, software failure, and attacks are some easy examples of disruptions on EHR availability.

For the business continuity, EHRs must always be available over the network. To ensure network availability, BCP needs to be in place. Using the electronic format of health records can be challenging without immediate technical support from the in house IT staff. Digital data is prone to damage by malicious code, and hospitals may lose access to EHRs, so having effective BCP in place is a must.

Digital Divide

This term defines the gap between people who have or who lack the access and know-how to technologies. The digital divide will leave many patients behind as they will not be able to derive the full benefits or services of the EHRs. This problem escalated in developing countries as EHRs are often not available.

Regardless of the availability of network infrastructure, few people are not familiar with computers and the Internet - the problem is grave in this case as well. Lack of skill, infrastructure, and knowledge remains the top hurdle behind the adoption of EHR.

Challenges faced by India for Implementation of EHR

The development and implementation of EHRs involve lots of challenges. And, especially considering the Indian healthcare industry, the top challenges are:

• Cost - EHR implementation is an expensive affair, taking away the lion's share of the planned capital budget investment. On a general note, the implementation process is classified into - hardware, software costs, implementation assistance, staff training, ongoing network fees, and maintenance.
  
  The organisations could also incur certain unplanned expenses as well during the implementation. Finding financial resources for EHR implementation remains one of the major hurdles, especially for smaller establishments.
  
  
• Data privacy - Data privacy concerns is another significant challenge for the patient community as well as the provider. The stakeholders often voice concerns regarding the risk of data leakage due to cyber attacks or natural disasters.
  
  In case of any security breach, organisations may get into a legal hassle, ending up spending millions of dollars to settle the disputes. Hence, the responsibility on the shoulder of the provider to ensure data security of the EHR is vast.
  
  
• Data migration - Exporting from paper-based documents to digital records is a mammoth task. There will be large chunks of copies to be transferred, making it a too tedious and time-consuming task for the staff. This is a significant EHR implementation challenge for hospital staff as the effort is more significant if there is no defined format of data management in the former system.
  
  
• Training - Before deploying the EHR system, the staff needs proper training about the new workflow. The physicians and the medical teams need to spend extra time and effort to understand the new system. Since this is a time-consuming process, small and mid-sized organizations fear the business loss during the training phase.
  
  
• Time - The migration to digitization is never easy - both training and data input will remain a too time-consuming process that is full of hassle.
  
  
• Infrastructure - Infrastructure is one of the EHR implementation challenges often faced by private health practitioners and small clinical establishments. They usually lack in house technical support or hardware to run the EHR systems smoothly. It is an expensive affair to build an in-house technical team and to buy hardware, which remains the main reason for small and mid-sized healthcare providers to delay the EHR implementation process.
  
  
• Incomplete coverage of Aadhar - The lack of complete coverage under the Aadhar has loosened up loopholes behind the implementation of EHR. Also, data breaches associated with Aadhar have fueled up the challenges further.
  
  

• Suitable vendors - Finding the relevant and trustworthy vendors who can assist in setting up the EHR with smooth migration and training process remains a challenge for most organisations.

Conclusion

To conclude, the implementation and development of Electronic Health Records in India are still at a very nascent but fragmented stage. It is crucial to focus on the following major issues in the electronic health record to succeed on the scale:

• Proper training of doctors and other healthcare professionals
• A much higher level of public-private partnerships
• Resolving the significant threats to electronic health record security
• Appropriate ICT infrastructure should be in place
• Working towards standardising EHRs
• General awareness towards the need and benefits of EHR

Once these primary issues get resolved, organisations will effectively move forward to a robust system of electronic health records available in real-time universally just a click away.