Gp Capt (Dr) Sanjeev Sood, Hospital and Health Systems Administrator, Air Force Hospital, Chandigarh, has successfully managed several Air Force Hospitals (Station Medicare Centres) providing quality and comprehensive medical cover to a large dependent population.

With a special interest in ICT applications in healthcare, Gp Capt (Dr) Sanjeev Sood shares insights into the electronic medical records implementation status in India, in conversation with Divya Chawla

Please give an estimate of compliance on EHR/EMR in Indian hospitals. How has it been complying with the global scenario?

The adoption of meaningful IT and EMRs has been slow all over world including US hospitals. Though no survey has been carried out on adoption of EHR/EMRs in India, but of the 15,000 odd hospitals, there are only a few (less than 300) that may have migrated to some form of EMRs. The hospitals that have moved on to digital records are mainly private corporate hospitals; some trust run hospitals like SGRH, Delhi and AIMS, Kochi; and few progressive state government hospitals on funding from State Health Projects. Only a  fraction of  hospitals among these, have just begun to deep archive their EMR data into warehouses, so as to subsequently use it for research, data mining and analytics to facilitate smarter decisions and improve quality of care. Thus, though some Indian hospitals have commenced their odyssey to EMRs; not many have been successfully able to implement ICT solutions in their facilities, and those who have implemented, only a few have been able to fully incorporate and integrate in their work culture and achieve seamless, paperless, wireless and filmless environment so far. Since there are no standards prescribed by any Indian regulatory authority, issue of compliance does not arise.

In US, after the enactment of American Recovery and Reinvestment Act (ARRA) in 2009, an estimated US $19 billion are being infused into health IT. The level of US hospitals,  having meaningful use of IT is less than 17 percent (less than 5 percent at comprehensive level—generation V, as per Gartener classification i.e., present in all clinical units with all functionalities; and 17 percent at basic level). The adoption is higher in large, urban and teaching hospitals. It is estimated that 90 percent of all physicians and 70 percent of all hospitals in the US will adopt EHRs under the Health Information Technology for Economic and Clinical Health (HITECH) Act by 2019.

What are the barriers that limit the adoption of EMRs and EHRs?

According to UN MDGs, goals, especially target 18, the benefits of ICT should be made available to the healthcare sector. Most sectors in general and healthcare in particular lag behind in keeping pace with revolutionary changes occurring in ICT in the past one decade, due to various barriers, such as, lack of resources and initial capital costs involved in implementation of technology projects. Further, healthcare providers are generally perceived to be less techno savvy, resistant to EMR adoption due to cultural barriers. Once installed, HCWs have limited option for trial and to experiment with EMRs. Further, EMR innovation is inconsistent with adopters’ values and beliefs; physicians view guidelines and protocols as ‘cookbook’ medicine. The approach to project implementation is fragmented and piecemeal. There are 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 some unfounded concerns like dehumanization of patient care, loss of customer base by sharing patient EMRs, erosion of clinical acumen and unclear return on investment. Many problems associated with EHRs—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.

Other challenges are that healthcare delivery is incredibly complex and uniquely personal, making IT system designing a daunting task; and not like repetitive, factory chores in manufacturing where one size may fit all. The success of IT projects depends on successful marriage between people, processes and technologies from the stage of inception to competition. The US $31 million EMR at the Cedars-Sinai’s hospital had to be rolled back just after implementation because it was not user friendly. Sometimes, the process of EMR implementation may become so arduous and bogged down in the minutia of databases, software features, interoperability, ontologies, and codes that the intrepid HCOs may run out of wherewithal and capital, before getting anywhere near the Holy Nirvana that EHRs promise to deliver unto them. But the gains at the end of odyssey are worth the efforts.

Please give us the status EHR/EMR in your hospital. What are the criteria that you look upon while choosing particular software for EHR/EMR?

My HCO has initiated few IT projects and has taken major steps towards issue of smart health information cards for each individual with biometric authentication based access control. EMRs have to deliver on certain key parameters and criteria that include performance; security, privacy and confidentiality; high storage capacity of servers; ability to integrate and operate with legacy systems across various departments, hospitals and other systems and sources like biomedical equipment and devices; and finally integration with other EHR system functionalities, such as computerised provider order entry for prescription drugs and electronic reporting of performance measures.

In future, longitudinal medical records will allow tracking of patients’ conditions and medications so that providers in HCOs will have detailed information at their fingertips

How do you see the future of the implementation of EHR/EMR in Indian healthcare scenario extensively at per of the global standards?

According to NASSCOM report, the future IT growth will be driven by healthcare sectors in short and long term. Growth of IT in healthcare will be driven by increased usage of web for data warehousing, customer portals by health service providers, cloud computing, remote medical diagnostics, digitisation of medical records, drug research and clinical trials, billing systems and other front/back office services. 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.

In future, longitudinal medical records will allow tracking of patients’ conditions and medications so that providers in HCOs will have detailed information at their fingertips. Clinicians will document using structured tools that allow capture of patient symptoms, clinical findings, and the physician’s assessment. The interdisciplinary teams that manage patients with chronic conditions will be able to track their panels, and seamlessly exchange information. When patients are admitted to a hospital, they will be tracked from the instant they enter the hospital until they leave, and whether guidelines are being followed. Both patients and providers will have a better sense of what will occur and when, and this will result in higher satisfaction in all stakeholders. When patients leave the hospital, their discharge summary will go with them to the team responsible for follow up care. This system will include safety nets that are not present today.

The providers and patients are willing to provide conducive environment for this tremendous, complex, and sophisticated transformation. Many believe that it represents the dawn of a whole new era of medicine. The examples of the VA and Kaiser Permanente suggest that these hopes may come to fruition. Thus, I foresee a great holy nirvana waiting for health care sector at the end of this odyssey.

Do you think that there is a need for implementing standards, regulation to run an effective system of EHR/EMR in India? How can the government intervene in the scenario?

The government and regulatory agencies have a major role in how EMRs are developed and implemented by HCOs. They need to reward and incentivise HCOs that adopt IT and EMRs with ‘meaningful use’, as done in US under HITECH Act. Professional autonomous bodies can also institute competitive awards for excellence for hospitals on line of National Balridge Quality Criteria that are much coveted in USA. Further, government needs to enact suitable legislation and policies to encourage adoption of EMR, legally accept digital signatures, and provide guidelines to standardise records formats, nomenclature, and communication protocols to enhance interoperability of IT applications across healthcare spectrum. While in the U.S, Health Insurance Portability and Accessibility Act (HIPAA) addresses some of the relevant issues, much remains to be done in India. The Government may also educate care providers and public at large about benefits of EHR and may also mandate compliance. Thus, while additional legislation is needed, it must be crafted in ways that make a revolution in healthcare information possible, and do not paralyse this revolution with possible unintended consequences-such as implementation failures due to organizations’ inability to make the necessary cultural changes.   

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