Tuesday, 11 November 2014

The Differences in Development, Design and Deployment of Electronic Health Records (EHR) between USA and India

Background:-
With innovators and early adopters among Indian Healthcare Organizations deploying Electronic Health Records (EHR) and the ARRA/HITECH program in the US having a major influence on policies and guidelines on EHR deployments in other countries, this article attempts to point out the differences between the needs of the two countries and ensure adoption of appropriate policies for India.

It would be unwise to blindly follow the federally backed program of EHR implementation that is ongoing in the US with Meaningful Use (MU) certification and the associated gated funding, without observing, studying and analyzing what is applicable and more importantly recognizing and adapting for what is different for the Indian Healthcare scenario.

With experience in designing and implementing state-of-the-art EHRs in the US and presently working in Lifetrenz (formerly dWise ) that has designed and developed an ONC Meaningful Use 1 and 2 certified EHR product for the US which has been implemented across hospitals in the US, while simultaneously designing, developing and implementing a full featured EHR in India that has been implemented across hospitals in India, this article brings out differences in developing and implementing EHR’s between US and India.

To begin, bringing out some of the differences between USA and India with regards to healthcare processes and workflows is best.

In the US, healthcare and documentation of healthcare is driven by insurance and billing requirements as most patients are covered by health insurance. For example in the ambulatory (OPD) environment, in the US recording of the patient visit by a doctor is done by guidelines provided by Evaluation and Management codes (E&M codes) with corresponding structured documentation. The codes for an established patient are provided in the table below:-

Level
E/M code
History
Physical Exam
MDM
Time (minutes)
1
99211
None
None
None
5
2
99212
Problem focused
Problem focused
Straight-forward
10
3
99213
EPF
EPF
Low
15
4
99214
Detailed
Detailed
Moderate
25
5
99215
Comprehensive
Comprehensive
High
40

Legend:-
MDM- Medical Decision Making, EPF –Extended Problem Focused

 The higher the E&M code the more the payment for the consultation by insurance. On an average a US doctor sees about 20 patients per day, for established patients they spend about 15 minutes per patient visit and new patients between 30 to 45 minutes. They have a more holistic approach to patient care with doing Review of Systems (ROS) and such.

In India most patients are self-pay and only some are insurance covered. Due to the sheer numbers, Indian doctors see between 40 to 60 patients per day, for established patients they spend about 5 to 10 minutes and for new patients between 20 to 30 minutes per patient visit (the time may be considerably less per patient especially in busy government hospitals). Hence the patient care and the visit documentation have to be problem focused.

In the Inpatient (IP) environment, in the US the nursing and paramedical staff have to do much more documentation such as care plans and assessments, while roles such as the clinical pharmacists have much more responsibilities. These differences in healthcare processes and workflows thus renders into differences in developing and implementing EHRs between the US and India. 

Differences in Development Platforms:

In the US the EHRs are developed on licensed platforms such as MS SQL for the database and Dot net for the business logic layer. All servers hosting US healthcare data have to be located in the US. This results in the development platform with licensing and hosting in the US being expensive. 

 India is extremely price sensitive, thus EHRs need to be developed on open source platforms with no license fees such as PostgreSQL database and PHP for the business logic layer. Furthermore, providing EHRs as Software as a Service (SaaS) on the cloud, means healthcare organizations save on hardware such as servers and do not need a big IT team. 

 Differences in Designing EHRs:- 

The US - EHRs being insurance/billing driven, there are differences in the US requirements like the standard for diagnosis in the US is still ICD 9 (CM), because the insurance companies only accept that. Since doctors dictate and transcribe their clinical notes there, EHRs need to have these functionalities built in such as speech recognition and/or a dictation and transcribing process. Evidence based medicine and standardized protocols are prevalent and so EHRs need to have functionalities for order sets and protocols. The nursing staff and paramedical staff need functionalities like care-plans and assessments. The pharmacy processes are more complex with more points of validation. Privacy and security is taken very seriously with HIPAA rules in place, non-compliance of which lead to serious penalties. Also EHRs need to have the ability to send a patient’s data across to another EHR system (inter-operability) using standards such as C-CDA and HL7. Meaningful Use (MU) certification primarily tests the functionality of the EHRs and not the usability. This has led to blow-back from the end users such as doctors and nurses in the US about the difficulty in using MU certified EHRs.

India- Because of the high number and turnover of patients which results in problem focused care; the EHRs have to be designed with usability and speed being of prime importance, with quick access to needed functionality. In India it is more expertise care rather than evidence based care and ICD 10 is the standard for diagnosis. While trying to keep to the principals of privacy and security, it is not as stringent as it is in the US. Also sending across patient data to another EHR (inter-operability) has not yet come into play. 

Differences in Deployment of EHRs:- 

US -In the US the ongoing ARRA/HITECH program gives financial and other incentives to doctors and hospitals to deploy MU certified EHRs. However, the MU implementation timelines have been aggressive, without adequate clinical process redesign and workflow oriented set up being done, adding to the usability difficulties. In the US, the hospital management can give directives to the clinical staff in their organizations and so can reduce the schedule during Go-Live and ramp up after the users have learnt the EHR. However it is difficult to give one on one elbow support during Go-Live for lack of trained resources. 

India -In India there are no incentives or programs for deploying EHRs, hence need to handle end users gingerly and coax them to switch over from paper to electronic with change management techniques. The EHRs have to be configured after adequate clinical process redesign and workflow optimization is done, to ensure the ability to handle high volume of patients with fast input and output of data. Most healthcare organizations and clinicians in India do not allow reduction of their schedule and so the challenge is to get them to learn the EHR, which can be a steep learning curve, while simultaneously keeping up their patient volume at Go-Live. However, it is possible and important to give them one on one elbow support at Go-Live, as there can be enough trained resources available. 

 In conclusion if India does go through a Meaningful Use like program, it is important to first ensure “Meaningful Usability” and then meaningful functionality, to ensure the handling of the high patient load. There will have to be widespread implementation of the approved Indian EHR standards. The program should ensure that enough time is given during EHR deployment in a healthcare organization for clinical process redesign, workflow optimization and change management, leading to acceptance and buy in of the EHR by the end users. 

 This article featured in ET Healthworld.com :- http://health.economictimes.indiatimes.com/news/health-it/differences-in-designing-developing-and-implementing-ehrs-between-the-us-and-india/45110831

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