Focus of Interoperability: EMRs vs Aggregate systems

[Michael Edwards]

What are the advantages of interoperable systems vs integrated systems?
Do we need integrated EMRs, or are integrated aggregate systems enough?

[Michael Edwards]

I think that the development of interoperable aggregate systems (HMIS, LMIS, HRHIS….) should be the first priority for countries working towards a unified national health information system. To do this, countries need to establish a Master Facility List, with unique identifiers for not only health facilities, but also unique identifiers for the aggregate levels (regions, districts, communities) within the health system as well. This is not just a technical challenge, but also a management challenge as well. Strong leadership is required.

[Manish Kumar]

Hi Michael,
You have raised a very pertinent question. I think paper-based patient record systems exist in most of the countries though they may not be standardized or capture relevant data. These data are in general fed into the national information systems in aggregate form. So when a country decides to implement a electronic medical record system it can also provide required aggregate data provided there is an agreement on the data to be collected and reported in relation to the said health objective.Until then, the focus should remain on aggregate systems.

But before getting into the interoperability details, I think it is important to deliberate on the system design issues which is driven by the requirements of its users. An important component of the design is system architecture which should align with the health goals and offers standardization, flexibility and scale to meet evolving health care information needs.

Also interoperability should not be discussed strictly in its technical sense which refers to automated information exchange rather it should include relatively less resource intensive options such as data import/export.

[James Setzer]

I would say that since we are much further along with aggregate reporting systems that we should proceed to try and link them. The pace of development of EMRs and their wide roll is far behind that of routine aggregate systems. Build the interoperability of these systems and when EMRs are ready and they many issues around them resolved (unique patient identifier being just one) they can then be brought into the existing and operating framework. Don’t wait for the EMRs! let us beuild what we can and when other elements become operational/available then let us add them in.

[David Boone]

Agree with James – we are putting the cart before the horse when supporting wide-spread EMRs in places without the infrastructure to sustain them. And diverting precious resources that could be used to strengthen and integrate aggregate data systems!

[Vikas Dwivedi]

Hello all,

Great discussion, one that is difficult to stay away from.

Thank you all, there are some very important thoughts and resources that have been shared by the participants.

I think the question posed by the moderator was on advantage of interoperability. I will start with my thoughts on that. In the current scenario, where we have multiple platform for disease specific reporting or function specific (logistics, service delivery, etc.) for aggregate reporting and them EMRs or some mhealth applications for community reporting, interoperability is a tool to improve decision-making at multiple levels of the health system. i would strongly encourage that teams/countries thinking of interoperability should think of the USE CASES first i.e. what do we want to achieve. Use cases help in one, documenting the health systems vision and then breaking it down into bite size pieces or phases.

Here, i will connect with the other participants. Once we have the phased approach, mapping data exchange between existing aggregate or client level is a cake. if there are aggregate system (only) we start with that, if there are some EMRs we should definitely include them as well.

Manish talked about architecture and requirements. These (+standards) are, in my view, building blocks for interoperability. The architechture helps identify what goes where and how and requirements and use cases guide ‘why’. Another advantage of doing this early in the planning phase is that it helps in identifying the solution to support interoperability.

Dave, thanks for sharing all the great resources. These will be very helpful in keeping ourselves up-to-date.

So, getting back to the moderators question, i would be really interested in hearing ‘what are the advantages of interoperability that are out there/being implemented?

[Michael Edwards]

I believe that data exchange between existing aggregate systems is not the piece of “cake” that Vikas suggests. If it was, then why don’t we see that it has been done successfully in many of the countries that have implemented aggregate systems? I just haven’t seen it yet. First is the issue of just mapping the facilities between systems. As Dave pointed out, he finds the situation with multiple “master” lists, and I’m sure reconciling these lists hasn’t been done primarily because doing so isn’t that easy, because you probably need to do this manually, as the facility names are probably not standardized, and there is no common unique identifier in use. Large countries have a lot of facilities. For instance, Nigeria has over 30,000 facilities, Tanzania has around 7,000 and Kenya around 10,000. Mapping this many facilities is no piece of cake. Even for a smaller country, there are issues with how facilities are named across different systems. In Haiti, after the 2010 earthquake having a Master Facility List proved indispensable during the rescue, and an international collaboration was brought together to quickly to provide this list. Those efforts are described in this article:
http://www.ghspjournal.org/content/2/3/357.full
http://www.ghspjournal.org/content/2/3/357.full

Besides the mapping facilities, you also need to address the issue of mapping fields and indicators. This is not always “a piece of cake” either. For example, when PEPFAR started using DATIM for entry of HIV/AIDS data, there were attempts to set up data exchange between existing systems and national systems. In DATIM, indicators for ART and Counseling and Testing have age and sex breakdowns that are often more detailed than those found in many national systems. DATIM had for Male and Females these age groups: <1, 1-4, 5-9, 10-14, 15-19, 20-24, 24-49, 50+. The national system had only these age groups for males and females: <1, 1-14, 15+. So it was impossible to use data exchange from the national system into DATIM without using calculated percentages, or in other words, making the data up.

[Olusesan Makinde]

Dear All,

Great points have been raised and I am indeed happy I did not miss this thread.

Just like previous commenters, the vision for an interconnected EMR for developing countries is still some distance away. Even the most advanced countries have not achieved this for various reasons. From my observation, those that conceive some of these ideas have little knowledge about what it takes to deliver them. Developing a system is not just the software, we need to talk about the people and the processes as well.

The MEASURE Evaluation Phase III project in Nigeria provided technical support to the Health Records Officers Registration Board of Nigeria to review the curriculum for training health information management (HIM) professionals. It had been observed that the HIM professionals encountered in the field had inadequate information and Communication Technology skills. These professionals are supposed to be the “techies” in health records management in health facilities. Yet an assessment found that fewer than 10% of them were skilled in database administration (not development). This is further elaborated on here http://him.sagepub.com/content/early/2016/04/07/1833358316639447.abstract

I also agree with Michael that we first try to connect the aggregate systems before venturing to link EMRs and like he said it is no joke. We identified the need to have a Health Facility Registry which serves as a hub for linking these aggregate systems as far back as 2013 and we proposed the idea to the government of Nigeria. This is described in our paper published here http://www.ncbi.nlm.nih.gov/pubmed/25422720. However, those to drive the system did not agree that we needed another system to manage these records and link in others. In fact, those managing the LMIS and HRIS were all working independent of those managing the DHIS. It took several sessions of explaining over a long time and persistent inability to achieve their goals before they saw reason to consider this and attempt to bring other partners in. Next comes the availability of resources to get this done. We managed to map the health facilities across a couple of databases in Nigeria but the success rates upon completion were also not encouraging because of lack of standardization in names and several other issues such as incomplete lists and multiple parties across 37 registries. For some states only 40% of health facilities in one list were available in the other.

Our recent publication titled “Potential use cases for the development of an electronic health facility registry in Nigeria: Key informant’s perspectives” available at http://ojphi.org/ojs/index.php/ojphi/article/view/6350 is directed at identifying the most important use cases in the development of a health facility registry which will form the base of a Health Information Exchange in Nigeria.

From the discussion on another thread on enterprise architecture, the vision should be about building in standards that will allow you to grow your system over time. There is no country that can at one time identify all the processes that need to be built into the system at once.

My few cents.

Olusesan Makinde

[Author]

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