By Sangita Ghosh De

The application of Electronic Medical Record, if implemented at large in healthcare, will improve patient care, reduce expenses, and fundamentally change the way in which medicine is practised in the country

There has always been a debate on the subject. Electronic Health Record (EHR) and Electronic Medical Record (EMR) have been the centre point of discussion in almost all major medical issues in India. There is no doubt that it has to be implemented across all the verticals of the healthcare services sector but the debate regarding the timeline, the parameters and process of the implementation continues.

The Institute of Medicine (IOM) in USA in a 1999 document entitled “To err is human” had stated that 98000 deaths occur each year in USA alone due to medication errors. EMR/EHR for each individual throughout his life span is the essential first step. IOM urged that by 2010 all prescriptions should be written electronically as it eliminates errors and coordinates better. “Medication errors occur because the prescriber does not have immediate access to relevant information relating to the patient’s condition and drugs timely,” said Dr Ramchandra Lele, Director, Nuclear Medicine, Jaslok Hospital and Research Centre, Mumbai.

But the adoption of meaningful IT and EMRs has been slow all over world including US hospitals, commented Dr Sanjeev Sood, Hospital and Health Systems Administrator, SMC, Air Force Station Jodhpur. “Though no survey has been carried out on adoption of EHR/EMRs in India, but of the 15,000 hospitals, there are only a few (less than 300) that may have migrated to some form of EMRs,” he analysed.

The reason behind this is that the majority of softwares running in Indian hospitals do not have a useful EMR module. Either the EMR module is too rudimentary or is so user unfriendly that it is not practical to fill it for every patient. “The incentive for entering data in an EMR is also –very low. Its benefit to an organisation is low unless it also possesses means of extracting medical data in an analysable form. Very few EMRs have been designed to store data in a very granular fashion and very few organisations have the tools to extract the entered data in an analysable form,” reviewed Dr Karanvir Singh, Head, Medical Informatics, Sir Ganga Ram Hospital (SGRH), Delhi. At a national level, unless there are medical data interchange guidelines and incentives it is unlikely that hospitals will increase spending to achieve this objective.

The size of the pie

According to a recent study by Accenture, the growth rate of global EMR markets is ranging from 6.6 to 9.7% across US, Europe, Latin America and Asia Pacific. The market is slated to be worth US$ 19.7 billion in 2013. US will experience 9.7% growth in its EMR market – from US$ 7.4 billion in 2010 to US$ 9.8 billion in 2013. With 5,800 hospitals, EMR adoption is beginning to accelerate due to American Recovery and Reinvestment Act (ARRA) incentives and penalties in US.

Asia Pacific’s (APAC) EMR market is expected to grow at 7.6%, Europe, Africa and Latin America will grow at 6.6% through 2013. Emerging markets, such as India and China may be a primary growth driver globally and may have the potential to implement innovative technologies, such as cloud-based EMR solutions. Other projections predict much more rapid growth in Asia Pacific. According to Frost and Sullivan, although the APAC Health Information Technolgy (HIT) market represents currently only 2.1% of the total healthcare market, it is very likely that the figure could double if not triple that in the next 10 years.

Despite the massive size and potential of the markets represent, global players hesitate about entering these markets because of some critical shortcomings in care delivery models. In India and China the number of patient attended per physician counts at 1,700 and 950 respectively, while each physician in the US is responsible for supporting only 400 patients.

Advantages of EMR/EHR are more for clinicians than for hospital administrators. While implementing, the hospitals always look for user friendly and cost effectiveness


“The current market for Hospital Information System (HIS) in India is estimated around US$ 60 million. EHR/EMR is a key component of this segment and the major driver for growth in future. The market is expected to grow at 10% per annum in future,” estimated Rahul Chatterjee, Deputy General Manager and Head, Healthcare, Siemens Information Systems, India. Siemens has recently launched its Hospital Information System (HIS), Soarian MedSuite, at the SL Raheja Hospital in Mumbai – a first-of-its-kind in India. Soarian MedSuite has an integrated Electronic Patient Record and addresses the administrative, clinical and financial processes of the hospital. But there are some obstacles. The advantages of stored medical data are more for clinicians than for hospital administrators. Unfortunately in most hospitals it is not the clinicians who control the budget and hence clinically useful systems do not get purchased, depicted Dr Singh at SGRH.While implementing the system, the hospitals always look for user friendly and cost effectiveness, stated Dr Param Hans Mishra, Dean, Indian Spinal Injuries Centre.

International expansion remains a challenge for the companies where 71% view global markets as a growth opportunity in the short term and 100% view global markets as an opportunity in the long term, the study by Accenture depicted. Steady growth in EMR/EHR markets is expected across the US, Europe and Asia Pacific.

In the US, after the enactment of ARRA in 2009, an estimated US$ 19 billion is being infused into health IT. It is estimated that 90% of all physicians and 70% of all hospitals in the US will adopt EHRs under the Health Information Technology for Economic and Clinical Health (HITECH) Act by 2019, informed Dr Sood.

A prospective growth of EMR needs government incentives, urged the medical community. Australia allotted additional packages for EMR and HIT adoption for further adoption in EMR and related activities. Also there is a shortage of clinical IT specialists globally which is slowly pushing the system towards cloud-based solutions for support and maintenance that reduce costs, increase efficiency and enable redeployment of valuable resources and over one-third of global health organisations have started using it.

The Indian landscape

India is still in the early stage of EMR implementation, stated Dr Singh. In 2005 SGRH implemented a HIS software along with EMR component (TrakCare, owned by InterSystems, USA). “Currently just over 50% of the admitted patients are having their medical details entered in the EMR at SGRH. This works out to about 100 patients having EMR entries per day but not for outpatients because of heavy workload and complicated logistics issues,” he added.

But EMR implementation in India needs a concrete backbone structure. “We need faster network connectivity for easy accessibility of data and quick response time, strong security, privacy and confidentiality with a secured back up prevention of loss of data, high storage capacity of servers for archiving of large volumes of data, ability to integrate and operate with legacy systems across various departments, hospitals and other systems,” clearly defined Dr Sood.

The hospitals that have moved on to digital records are mainly private corporate hospitals, some trust run hospitals like SGRH, Delhi, AIMS, Kochi; and few progressive state govt hospitals on funding from State Health Projects. Since there are no standards prescribed by any Indian regulatory authority, issue of compliance of implementing EMR have not yet arose, Dr Sood informed. According to Dr Singh, compared to EMR compliance in other countries, India is behind many of the developed countries. The main difference is the availability of funding. While some medium and large hospitals fund EMR projects of their own, there is no nation-wide funding for a national EMR backbone.

Roadblocks to overcome

It is clear that any market is complex enough according to its own parameters and challenges to overcome for a trendy growth and EMR/EHR is no exception in that. However, a number of factors have an impact across the market.

According to Dr Singh, “When we selected the HIS software we looked at the flexibility of the EMR module so as to it allows the IT department staff to make configuration changes that meet requirements of different departments.”

Shortage of clinically trained IT resources will impact future markets of EMR, as digitising the preexisting medical records is a huge challenge


But shortage of clinically trained IT resources will impact future markets, apprehended Accenture. Government regulation and support in funding are also key drivers of EMR adoption. Health information exchange (HIE) is also expected to evolve with EMR. “One strong incentive for storing medical data in a computerised form is the interface with insurance companies. But in India, insurance companies have not yet started the movement of requiring medical data to be submitted to them electronically,” observed Dr Singh. He pointed out this could be a potential reason of spreading EMR in India. Digitising the preexisting medical records is a huge challenge, commented Dr Sood. “In the US and Canada, hospitals are experiencing very thin (or even negative) margins, making it a challenge to set aside funds for EMR. Recently, Australia announced a US$467 million national e-health initiative sponsored by the government to link EMR systems and HCIT applications. Conversely, in Japan many hospitals are struggling to afford ongoing EMR due to inadequate government support,” he informed.

But security and data sharing is a mater of concern now. This might prevent cloud solutions from being utilised, because transmitting and sharing data with various locations and institutions is at high risk, apprehended Dr Sood. “We have not imported legacy data into our new HIS. The old system continued to run on another parallel server in case we needed legacy data for any patient as the older system did not maintain a unique ID for a patient and was hence incompatible with the new system’s structure,” mentioned Dr Singh. But all these include high costs which sometimes become unbearble for some institutions. The implementation gives no added revenue to hospitals, voiced Dr Mishra.

There are also issues like interoperability and seamless connectivity, big-bang or incremental approach of implementation; and lack of overall policy and vision in EMR adoption in healthcare. “There are also concerns like loss of customer base by sharing patient EMRs, erosion of clinical acumen and unclear return on investment. But problems like tedious data entry, increasing of staff workloads, poor user interface, disrupted workflow, faulty connectivity, and inadequate software updates – have been gradually solved over the past decade by early adopters,” said a positive Dr Sood. But a US$ 31 million EMR at the Cedars-Sinai’s hospital, Los Angeles had to be rolled back just after implementation because it was not user friendly, he informed.

However, healthcare IT solutions have primarily focused on addressing the administrative and financial processes of hospitals, Chatterjee at Siemens addressed. “However, adoption of IT by physicians is a challenge in the healthcare sector. Healthcare providers are beginning to appreciate the role of IT in driving patient safety, quality of care and clinical outcomes,” he added. The market for EHR/EMR is already growing globally. Emerging markets have the potential for rapid growth by using innovative technologies like cloud-based solutions, Chatterjee reconfirmed.

Ensuring data security and confidentiality

As has already been discussed data integrity and confidentiality are very important issues for any hospital. “I have found in a few hospitals while importance has been given to strong protection on data confidentiality from the user interface very little importance has been given to integrity at the hard disk level. It was possible for any user with knowledge of SQL to fire an update query and update the data stored on the hard disk,” Dr Singh commented. SGRH has addressed this issue by implementing ‘Cache Direct,’ an application that prevents access to data stored at the server level itself. Since India does not have Health Insurance Portability and Accountability Act (HIPAA) or equivalent laws, stringent control of data confidentiality is missing. “But our HIS, which is customised, password protected and fully audited, does not allow anyone to extract patient data from system in text or any other form, except in the form of valid patient reports,” assured Dr Singh.

Digital medical records are more secure than the old paper records, ensuring patient safety, quality of care and clinical outcomes

But digital medical records are more secure than the old paper records, debated Dr Sood. Furthermore, access is easily tracked and audited if ensured with the right level of security and advanced encryption codes. “The EMR data analysis software can detect duplicate payments, overpayments to Health Care Organisations (HCOs), non-billing to health insurance companies, and miscoding of diseases and payments, thus preventing fraudulence,” he further pointed out. In the developed countries, patient owns data and decides who can see it and can even prevent it from his treating physician, which is not at all possible in India with low or no literacy to manage their own data and associated rights and therefore treating doctors can see medical data without requiring patient authorisation, exemplified Dr Singh.

Government as watchdog

But there is a very strong requirement for data interchange standards in India and it is only the government which can spearhead this, Dr Singh apprehended. “The reason is clear. Hospitals, by themselves do not have any incentive, and may even have a disincentive, to provide their own data outside their organisation where the partner hospitals need to adopt their software,” he clarified. “The government can reward and incentivise HCOs that adopt IT and EMRs with ‘meaningful use’, as done in US under HITECH Act. Further, government needs to enact suitable legislation and policies to encourage adoption of EMR, and provide guidelines to standardise the process,” added Dr Sood. While in the US, HIPAA address some of the relevant issues, much remains to be done in India.

“Government incentives are expected to be a key driver for the growth, a visible trend in the US, EU and in several other countries like Australia. The government needs to come out with a set of regulatory standards to address the needs of the market to drive adoption and HIT through funding packages for regional and national integration projects,” urged Chatterjee.

The already existing international standards can do the job fairly easy for the government, commented Dr Singh. Because those may be idealistic standards which can be slightly watered down to draw various models for the country.

For a healthier tomorrow

Nevertheless, cloud solutions is expected to have a significant impact, with an apprehension of increasing spending on clinical IT over the next five years.

Emerging markets includes Asia Pacific countries may experience rapid growth by learning from more developed nations and utilising innovative approaches. But the development will largely depend on regulatory standards, government support and future trends affecting domestic healthcare systems, analysed research reports. Research says that the Nordics, Spain and Australia will be the global leaders in overall EMR implementation in 2013, while France, Germany and Japan are expected to be market laggards with lower rates of adoption, where the US is expected to exhibit the highest projected growth rate.

According to NASSCOM, the future IT growth will be driven by healthcare sectors in short and long term. According to Dr Sood, as the volumes increase, and models like SaaS and cloud computing becomes available; the cost will come down further making IT applications affordable to all.

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Related October 2010