Covid-19 has glaringly exposed the shortcomings of our health care system. When the disease reached our shores in March, we had a two- month general holiday in which to prepare ourselves. However, the strategy of quarantining returnees in their homes, combined with inadequate testing abilities, stigma related to the disease, and our inability to scale up capacity did little to contain the spread.
Nine months into the pandemic, we have more information about the mode of transmission, better treatment protocols, and the hope of a vaccine. However, our health care system itself has remained the same and, in some cases, worsened: Chronic condition monitoring and communicable disease surveillance are disrupted, vaccination rates among children have dropped, and possibilities of environmental health hazards loom due to the excessive plastic and medical waste. The fundamental dilemma is that our medical surveillance system is fragmented.
Any eventual strategies or development processes must be built on a health care system interlinked with modern technologies. Governance and health information systems (HIS) are the two most important elements to strengthen health systems. The former regulates the access, delivery, financing, and supplies of health care; the latter is used to gather, compile, and analyze health data to study population health.
Our current system is ill-equipped for public and population health management. In order to build a robust HIS, it is imperative to collect what is known as disaggregated data. Disaggregated data are the detailed, categorical information about age, gender, ethnicity, socio-economic condition, area of residence, education, and related medical history. They are collected from multiple sources and identify the variables needed to study and design policies. They allow comparison between groups, which can identify trends and reduce health inequalities.
Aggregated data are traditionally a compilation of disaggregated data. In Bangladesh, aggregated data are used for public reporting or statistical analysis, but these are collected either from incomplete data or informal study. A well-regulated HIS dictates disaggregated patient data collection, integrates data from numerous sources, analyzes it for different audiences, and makes it meaningful through data visualization. It is a tool that connects the dots to build a story of a specific health outcome.
Security, transparency, and accuracy of the information enable decision-makers to take unbiased, timely, and high- priority decisions. Where do we begin? The most essential component of HIS is the Electronic Medical Records (EMR) system. EMRs are vital to overhauling our fragmented system. EMRs contain patient health histories, diagnoses, medications, drug allergies, immunizations, medical interventions, family history, new diseases, accidents, and treatment plans.
Health care facilities are the organizations that provide health services which includes public and private hospitals, private clinics, community health clinics, diagnostic centres, doctors’ chambers, NGO health centres, floating hospitals, etc. A national mandate to implement EMR systems in all health care facilities is a starting point that will have positive reverberations up the system.
Disease incidence data generated from the health facilities are transparent data sources for policy makers and health service industry to detect the existing gaps in service and emerging public health issues. This microlevel system implementation will ultimately produce aggregated data which will set the foundation of our healthcare system’s development.
What are the benefits for citizens and healthcare providers?
Once digitally recorded, patients can share their files with different providers, receive coordinated care without the hassle of consulting different specialists, have access to their prescriptions at all times, avoid medicine reconciliation errors, avoid duplication of testing, and have a legible document of their medical history at all times. Providers get accurate, up-to-date, and complete information about their patients from EMRs. It also helps them make correct diagnoses, set safe treatment protocols, coordinate with other specialists with minimal effort, and increase their overall productivity. Professionally, it helps enrich their own records by tracking their own successful interventions on patients.
How does it benefit the population health and policy makers?
When the government lifted the general holiday and imposed area- wise zonal lockdowns in June, they faced an unexpected challenge. According to a report published in Dhaka Tribune, IEDCR could only locate 55,909 out of a known total 94,481 Covid-19 cases. This was unanticipated, since a data management system was specifically developed to monitor all Covid-19 positive cases early in the pandemic. It was created to ease the burden of the Health Directorate to accurately detect and isolate positive cases and contact trace possible cases. Because disaggregated patient data were missing, hospitals and testing facilities could not establish the location of over half the cases. A similar problem was encountered when an attempt was made to study why men accounted for over 75% of the total deaths from Covid-19 in Bangladesh. Very limited patient specific data could be found relating to comorbidities or behavioral patterns to support this observation. EMRs consolidate disaggregated data, which can be used to identify disease prevalence and population health problems. They ensure that developments are measurable and tangible. Based on them, urgent health issues can be detected, preventative care programs can be designed, and healthier lifestyles can be promoted -- all of which will ultimately reduce the cost of health care for everyone.
Is EMR aligned with our national policies?
The Bangladesh government’s 4th Health, Population and Nutrition Sector Program is aligned with the health-related UN Sustainable Development Goals (SDG). Measuring SDG health indicators are dependent on generating data from all levels of health care facilities. To achieve that, the DGHS Management Information System plans to establish EMRs in all health care facilities from community health clinics upwards generate patient-level disaggregated data.
Do we require Health IDs?
“The Health Informatics Standards and Data Structure” is an eHealth guideline designed for Bangladesh by the Ministry of Health and Family Welfare. It provides the procedures on how health sector data will be coded, collected, structured, represented, and recorded through different registries. It even recommends ensuring Health ID of patients. In an ideal world, each citizen would have one specific Health ID linked to one EMR. In practice, this is next to impossible since throughout our lives we receive care from different health facilities that have their distinct operating systems. This is why advanced health information systems in developed countries are now moving towards interoperability. Disparate EMRs of the same patient from different hospitals or providers are standardized to a universal format, which can then be shared through electronic health information exchange by other providers and by the patients themselves. This kind of advanced system requires a massive infrastructure that can only be established when the payment for health care is done by either the government or employers or insurers. In welfare states, or countries with health insurance systems, all claims of reimbursement are linked to accountability, which requires HIS automation.
If telehealth providers and tertiary private hospitals can do it, then why not all health care facilities?
The unique challenges faced during this pandemic have compelled people to look for alternative modes of care. The rapid growth of telehealth is an impressive development during this period. Almost 28 exclusive telehealth services have been identified that are providing teleconsultation to people. For example, several hundred thousand Covid-related calls were answered through the 16263/Shastho Batayon call centre. Most of the telehealth platforms in Bangladesh maintain electronic health records of patients. We may end up seeing telehealth providers amassing high volume of health data within a short period of time since there are 162 million mobile phones users. Through apps and web portals, patients can always have access to their health record and prescriptions. Corporate hospitals in Bangladesh have advanced hospital information systems which includes EMRs, Laboratory Information Management System, registration, payment, outpatient, and inpatient data systems; and some of them have data of over a million patients. Professionals working in those hospitals swear by the convenience of this automation
I argue that providing access to safe, secure, up-to-date health care is the number one priority of this country. We cannot do it without investing in EMRs. If telemedicine centres and corporate hospitals can do it, then why not all the public and private hospitals?
EMR systems are intertwined with nationalized health systems in developed countries. The government, as the regulatory body, must understand the urgency and mandate the implementation of EMR systems -- even if they are based on a very simple system. When it is a mandate, it will hold everyone accountable to the service they provide. Few hospitals within the country have done it, there are thousands of systems available already; we need not reinvent the wheel, but we must enforce the execution.
Dr Maliha Mannan Ahmed is the Founder and Executive Director of Organikare. She has an MBBS, MBA, and a Masters in Healthcare Leadership.
