Februaury 2007

MIRTS: Malaysia’s Answer to National Health Record : Dr. Zaitun A.B. and Dr. M.S. Termanini

“He who has health has hope; and he who has hope has everything” – Proverb.”When health is absent, wisdom cannot reveal itself, art cannot manifest, strength cannot fight, wealth becomes useless, and intelligence cannot be applied” – Herophilus. “The first wealth is health” -R.W. Emerson.

With the advent of Internet technologies, governments across   the globe are trying to provide efficient and effective e-service to its citizens. We see the implementation of e-governments with various flagship applications. One of them is health and wellness, which should be the top priority agenda of every government and citizen of the world.  In Malaysia, one of these flagship applications of e-governments is e-Health. In order to keep Malaysians healthy and fit, we need information systems that are accessible 24/7, with complete longitudinal health records. One such proposed pragmatic system is the Malaysian Immunization Registry and Tracking System (MIRTS), which can maintain a repository of immunization records of all Malaysians.

MIRTS is conceived as a computerized registry of preschool-aged children and their immunization records. The purpose of the registry is to assure that children remain up-to-date with their immunizations and that their vaccination records are available when they are needed – when changing doctors and at the time of daycare/preschool and school entry. More specifically, to allow the Ministry of Health to manage better the immunization data, to generate factual data on the progress of immunization in the country, forecast the wellness of children in Malaysia, manage the operations better and optimize its cost.

The term e-Health covers all forms of electronic healthcare delivered over the Internet, ranging from informational, educational and commercial ‘products’ to direct services offered by professionals, non-professionals, businesses or consumers themselves. It also includes a wide variety of clinical activities that have traditionally characterized telehealth, but delivered through the Internet. Simply stated, e-Health is making healthcare more efficient, while allowing patients and professionals to do the previously impossible.

While other industries have captured the value of the Internet early on, the scale and scope of the Malaysian healthcare system perhaps presents the greatest potential in Internet-based applications.

Access, cost, quality, and portability have been concerns in the healthcare arena. Evidence suggests that both health consumers and doctors are frustrated with the maze involved in the healthcare delivery. Fortunately, e-Health appears to be helping to resolve many of the challenges confronting the healthcare industry. Looking at the practice of industrialized countries, just in the past few years, the following e-Health services have emerged:

1. Health portals or health information sites, which empower consumers and physicians through customized education and online community experience.

2. Connectivity and communications solutions, which streamline administrative workflow, thereby reducing waste and inefficiencies.

3. e-commerce, including online health insurance and drug prescriptions.

As the technology evolves, we could see even greater value-added Internet applications, including sophisticated chronic disease management tools. And as the market matures, a consolidation of all the online services will become likely. We could have a truly ‘Integrated Delivery System,’ with attendant quality, access, and low cost. The Internet could serve as a panacea to all of the complicated challenges confronting healthcare. Technology can never displace the expertise and personal care that only healthcare practitioners can deliver, but we believe that the Internet can go a long way in facilitating communication, and streamlining tedious and time-consuming administrative work, that often curtails the time of the doctor with patients, and education of both physicians and patients.

Here we attempt to discuss how Internet technologies and ICT can be deployed to look after the well being of the citizens and residents of Malaysia as part of the e-health program.

The Problem Statement

It is not uncommon to meet citizens who visit the hospitals and clinics only when they are unwell. The general awareness on the efficacy of preventive medicine needs to be reinforced through campaigns, especially in developing countries. Statistics from the UNICEF states the fact that deaths are averted by immunization. The estimated number of deaths averted by immunization in 2003 was more than 2 million, as well as an additional 600,000 hepatitis-B-related deaths, that would otherwise have occurred in the adulthood from liver cirrhosis and cancer.

MIRTS is conceived as a computerized registry of preschool-aged children and their immunization records. The purpose of the registry is to assure that children remain up-to-date with their immunizations and that their vaccination records are available when they are needed – when changing doctors and at the time of daycare/preschool and school entry. More specifically, to allow the Ministry of Health to manage better the immunization data, to generate factual data on the progress of immunization in the country,  forecast the wellness of children in Malaysia, manage the operations better and  optimize its cost.

Immunization helps the body to develop protection against a particular disease, so that if at a later stage the body comes into contact with that disease, it will be able to fight it off. A person needs immunization for each disease that he/she wants to develop protection against. Fortunately, childhood immunizations in Malaysia are free. If we look at the present challenges facing immunization in Malaysia, we find that there is no systematic nationwide immunization plan, the process of immunization is getting more complex as new vaccines are developed, hospitals have home-grown systems for immunization, hospitals do not regularly share or transfer medical patient records, and physicians have no access to a child’s complete immunization history. Neither do most parents are aware of the immunization status of their children. Scattered records, created by mobile citizens, non-use of interoperability standards by the hospitals and the absence of tracking system to remind parents compounds the problem.

MIRTS as a Solution

The solution proposed is in the form of a web-based system named MIRTS, which is conceived as a centralized repository of immunization records of all Malaysians using Standardized Healthcare Level 7 (HL7) interoperability protocol. This centralized repository is capable of simple data aggregation and delivery and saves all records. It also ensures smooth interoperability and facilitates easy integration with other systems.

MIRTS will be beneficial to both parents and children. Research has shown that both parents and physicians overestimate the rates at which children are fully immunized. Parents are often unaware of immunization schedule; physicians often overlook 1-2 vaccinations. This is becoming a huge problem with the rapid changes in vaccination recommendations for children.

MIRTS can:

� Give parents easy access to a permanent record of their children’s shots even if they relocate or their children’s’ doctor retires.

� Allows the doctor to find a child’s history in a computerized database

� Give parents the official reports about their children’s immunizations for daycare, school or camp.

The visible benefits of MIRTS

� Better management of immunization records.

� Guaranteed privacy and confidentiality

� Data Quality

� Encouraging hospitals to participate

� Extending the model to other areas of healthcare

� Easier to integrate with other systems

� Electronically determining what immunizations are needed at each encounter

� Providing calculations of actual coverage levels and producing immunization status reports for parents during child care visits

� Automating the sending of reminder notices to parents

� Bringing together fragmented records to produce one complete immunization history.

Information in MIRTS will be kept confidential. Only a citizen, his/her doctor, or healthcare workers who can assist him/her with missed appointments or missed immunizations will have access to MIRTS. The information will not be shared with any other people or any other agency. By calling the Ministry of Health, Malaysia and with proper identification, parents can receive a free copy of their child’s immunization history at any time. Figure 1 and Figure 2 illustrate how all public and private hospitals in Malaysia will be connected to the MIRTS database and be accessible 24/7 through
the Internet.

However, the MIRTS project can achieve its desired success only when pediatric practitioner who administers vaccines to children will be required to report to MIRTS. Each month, MIRTS would send a report to each pediatric doctor, asking for immunization histories of children who have turned 7 and 19 months of age. These are two key times when immunization status should be reviewed. Similarly, a 2-year-old clean up report, known as the ‘Goldenrod’ report, would also be sent each year as a last effort to try to bring a 2-year-old population up-to-date with their immunizations.

Immunization coverage reports are generated for all Malaysian practices, based on children’s immunization status on their 2nd birthday. Up-to-date coverage is defined as 4 DTaP, 3 polio, 1 MMR on or after the first birthday, 3 hepatitis B (with the 3rd dose given after 24 weeks of age), Hib given age appropriately, and Varicella, on or after the first birthday.

Sometimes children are up-to-date with their immunizations but were not up-to-date at the time they turned 2 years of age. MIRTS uses this age as a cut-off, as all children should be series complete by the time they turn 2 years of age. Invalid doses are also responsible for its lower rates.

The most commonly administered invalid doses of vaccine are:

� MMR not given on or after 12 months
of age

� Hib not on or after 12 months of age

� Hep B #3 not given on or after 6 months

All too often it is also found that the DTaP #4 and the IPV #3 are not given, suggesting that the older infant is not coming back to the office. MIRTS can provide parents with a more detailed explanation upon request. MIRTS can help pediatric practices to obtain immunization histories for patients who transfer to their practice from any other pediatric facility in the country, and have easy access to the first hepatitis B shot given in the birth hospital. For each pediatric practice the system is able to:

1. Print a list of children who are missing any vaccine at any time

2. Automatically generate recall notices to parents of those children who are behind and reminder notices for upcoming appointments

3. Print out official reports for children with all given immunizations documented

4. Determine immunization coverage levels for pediatric practice

5. Order vaccines and report doses administered electronically
Building MIRTS Repository

The Immunization Registry will follow the HL7 (Health Level 7, 2006) Reference Information Model (RIM), and the HL7 Meta-Model Framework. All interfaces with the registry are provided (free) by the HL7 organization, based on XML (XML, 2006). HL7 is also providing net and service oriented architecture documentation to help deploy the registry.

The next step comprises of indexing of all the immunization records (seen in figure 3),  which is followed by linking all records together and creating the Longitudinal Vaccination Record (seen in the figure 4).The fourth step is adding future records to the Longitudinal Immunization Record (seen in figure 5).

New records (chains) will be added to Longitudinal records automatically. A count of the chains will also be stored in the main HL7 registry.

Lastly, all current records should be transformed and transferred to HL-7 compliant format and stored in the registry.  It is not a surprise that the majority of medical records are paper-centric, or they are stored on a separate computer, or it can be part of the mainframe.

The consolidation process may be tedious, but it must be done. Paper records have to be scanned as image, or retyped. Mainframe records have to be transferred to the new registry through a bridging system,  which will convert them to HL-7 format as well. However, the real challenge for the success of this project is to get the commitment of all public and private hospitals and clinics to update immunization data to the repository. An even bigger challenge will be to transfer existing disparate paper based records to MIRTS repository. The proposed system’s benefits, both tangible and intangible, are immense and therefore worth the effort.

For a successful implementation of the system, we propose the following holistic approach;

� Get sponsorship for the development of the system. The most appropriate will be the Ministry of health.

� Carry out an Integration Awareness Campaign amongst hospitals and clinics to convince them and invite participation in this project.

� Approach potential technology partners to implement the system

� Approach medical schools to encourage contribution from the medical aspect.

� Select two hospitals to participate in
the project

� Conduct a wellness survey

� Build pilot to show benefits

� Help Ministry of Health to get hospitals and clinics on the registry.

We anticipate that the actual, programming and testing of the system, will not be as time consuming as getting the other human related aspects of the system. These include campaigning, user training and change management. Like any other huge IT projects, this proposal will also require a champion, and the political willpower to be implemented and succeed.


Immunization – The Childcare Pages, 2006. Available at http://www.ed-u.com/immunization.htm,
Wysocki, M. ” What is e-Health?” Available at http://www.suite101.com/article.cfm/9670/57010, http://www.immregistries.org/pdf/HIPAA_v2.pdf
Health Level 7. Available at http://www.hl7.org, XML, available at www.xml.org

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