September 2006

Technology Review

ELECTRONIC
MEDICAL RECORD

HEALTH TECHNOLOGY ASSESSMENT UNIT

MEDICAL DEVELOPMENT DIVISION
MINISTRY OF HEALTH
011/06
1. INTRODUCTION

The quality of healthcare in Malaysia warrants concern. The problems have been
categorized as underused, overuse, or misuse of healthcare services and uncertainty in
decision making about individual patients plays a part in inappropriate use. [1- 2] (Level 9).

Uncertainty in clinical decision making can arise from unavailability or poor quality data
on the patient. Medical records are still predominantly paper-based despite well
documented shortcomings in terms of accuracy, completeness, availability and legibility.
Incomplete, illegible, or unavailable patient information may result in redundant or
marginally productive visits, diagnostic and screening tests, and interventions. Preventive
care and patient education may be overlooked if consultations have to focus on rebuilding
clinical data.

2. TECHNICAL FEATURES

Electronic records fall under the purview of medical informatics, a combination of

computation and computer science and medical record keeping. Electronic medical
record (EMR) is a term used to describe computer-based patient medical records. The
term EMR has become expanded to include systems which keep track of other relevant
medical information (such as registration, clinical laboratory results, pharmacy, nursing
and kitchen). An EMR facilitates:
• easy look up of patient data by clinical staff at any given location
• building automated checks for drug and allergy interactions
• Integration of documentation and reporting of clinical results and reporting,
including comprehensive recording of use of primary and specialty care,
telephone contact, urgent care, and emergency departments
• computerized entry of physician orders for tests and prescriptions
• scheduling
• sending and viewing laboratory investigations
• 24-hours availability of medical records at point of care
 • accurate and complete claims processing by insurance companies
• immediate availability for all potential users, for example, staff in telephone
centres, pharmacists, and staff reporting clinical results
The Practice Management System is a term used to describe the medical office functions
which support and surround the electronic medical record.

Although an EMR System has the potential to permit invasion of medical privacy, if
security policies are monitored effectively EMRs are as secure as banking records, as one
example. Electronic Medical Records / Electronic HealthCare Record (EHCR) can be
distinguished as:
• The Automated Medical Record which is a paper-based record with some
computer-generated documents such as printing of clinical results, prescriptions,
and billing.
• The Electronic Medical Record (EMR) which ensures inter-operability of all
documentation systems from various units (e.g. pharmacy, clinical laboratory etc.)
in the institution or hospital.
• The Electronic Patient Record (EPR) which is a patient-centred record with
information from multiple institutions.
• The Electronic Health Record (EHR) which adds general health-related
information to the EPR that is not necessarily related to a disease such as the
“lifetime Health Record”.

3. OBJECTIVE
To determine the effectiveness, safety (confidentiality /security), cost implications, legal
and organizational implications of Electronic Medical Record (EMR) in government
hospitals.

4. METHODOLOGY
Search engines such as OVID, PUBMED, EBSCO, Proquest, Medline and Google were
searched using the following keywords - electronic medical record, electronic health
record, health informatics, legal issues concerning health information etc. Cross
references were also carried out on the articles retrieved

5. RESULT AND DISCUSSION

5.1 Safety
An EHR / EMR system must satisfy its users regarding privacy, confidentiality, and
(level 9)
security [3-4] . In most cases, consent is required prior to collecting patient health
information. This consent should include disclosure of the purposes for which the
information is being collected. Further, the information collected should be limited to
what is necessary for the health service provider's functions and activities. A provider
should “only use or disclose personal information for the primary purpose for which it
was collected or for directly related secondary purposes if these fall within the reasonable
expectations of the individual”. Insufficient protection can lead to unauthorized use and
disclosure of data, subjecting individuals to possible embarrassment, social stigma and
(level 9)
discrimination [5-6] . Modern computer applications in the health care system
threaten individual privacy despite offering significant benefits to patients and
practitioners. Computerized databases of personally identifiable information may be
accessed, changed , viewed, copied, used, disclosed, or deleted more easily and by more
people (authorized and unauthorized) than paper-based records.

Privacy and confidentiality aside, providers already face legal costs with regard to their
records. Adequate legal protection of personally identifiable health data is necessary to
facilitate the transmission of electronic data through e-mail, telemedicine, and other
applications. Improper record keeping may also give rise to medical malpractice liability
[7] (level 9).

5.2 Effectiveness
Although EMR holds great potential for improving the quality of patient care in primary
setting, taking advantage of this requires planning and communication. Considerable
uncertainty exists regarding the costs associated with electronically mediated health
initiatives and their allocation. Equally, there are practical, economic, political, and
professional barriers that impede the acceptance of electronic records systems. Individual
physicians or small practice groups have particular concerns about the costs and learning
curves associated with electronic records systems

Relatively few primary care practices use EMR. Reasons for not adopting EMR include
(level 9)
the temporary loss of revenue associated with EMR implementation [8-9] ,
physician perception that EMR negatively affects workflow, and concerns about patient
privacy. Even in settings where clinicians are committed to EMR, implementation
requires skilled users and a commitment to making EMR an integral part of the
organisation. Without these personal and institutional commitments to full
implementation, EMR may actually represent a net financial drain on primary care
practices and offer little or no patient care benefits [8-9] (level 9).

A decline in productivity after implementation of an electronic health record seems

inevitable, and if a practice is already straining to meet patient demand, an absence of
reserves magnifies the stress of implementation. Patients want and expect their physician,
especially primary care physician, to have a comprehensive grasp of what is going on
with them medically [10] (level 9).

The e-Health is expected to improve various aspects of healthcare (quality, cost-

efficiency, access, etc.) by: Supporting the delivery of care tailored to individual patients,
where ICT enables more informed decision making based both on evidence and patient-
specific data; Improving transparency and accountability of care processes and
facilitating shared care across boundaries; aiding evidence-based practice and error
reduction; improving diagnostic accuracy and treatment appropriateness; improving
access to effective healthcare by reducing barriers created, for example, by physical
location or disability; facilitating patient empowerment for self-care and health decision
making; improving cost-efficiency by streamlining processes, reducing waiting times and
waste.
All manner of health-care providers can benefit from e-Health initiatives and the use of
ICT in clinical settings. e-Health can allow for access to patient records by pharmacists,
sharing of information between clinicians and even between same-site facilities. Desk-top
and live on-line access to patient records, information that supports clinical decision
making, and health-system information, such as on-line booking of specialists, along with
a host of other possible uses of the new technologies will improve the clinical bench-
strength of providers, patients and the consumer. e-Health technologies also allow for the
development continuing professional education for providers in isolated locales.

6. CONCLUSION
There is insufficient evidence to support the full implementation of the EMR at national
level to all hospitals throughout the country due to lack of rigorous and generalisable
evidence of the effectiveness and cost-effectiveness of e-Health applications and
technologies. Most of the evidence obtained shows some success only at some primary
settings, some institutional or departmental levels. R&D will need to address human and
organisational factors affecting implementation, from the perspectives of both health
service staff and consumers (patients and citizens). Evaluation studies equally will
require a multidisciplinary approach. Implementation and integration of e-Health systems
into care processes are constrained by insufficient levels of systems interoperability
(though moves to ensure standardisation in many current e-Health implementation
programmes will reduce this). The legal and ethical implications of using health
information technologies and clinical decision support systems which may result in
harmful effects in certain cases are not yet clear. The effects of e-Health tools on patient
behaviour and the patient-clinician relationship are unclear. Potential health inequalities
resulting from the ‘digital divide’, particularly affecting the disabled and the elderly, need
to be minimised.
The transition to electronic medical records (beyond the implementation of the hardware
and software) represents a significant change to the clinical processes in a medical
practice. These changes must be carefully considered to ensure patient safety and quality
of care through the transition period, primarily through the continued integrity of the
medical record and the clinical processes that are supported by the medical record. In
addition, changes that are inherent with the change to electronic records such as patient
privacy and information security must be managed.
The technologies themselves, as well as their deployment, are challenging matters. There
are questions about how to properly automate the health-system, and the desktops of
clinicians. Which technical standards are to be adopted? Is the current level of technology
and technological-sophistication of the providers and public sufficient to the task? What
proprietary products will the public sector invest tax dollars in? How do we integrate the
current system's data "silos"? Some of the technologies remain unproven in extremes of
climate. There are limitations imposed by the fragility and newness of certain
technologies and products in situations where ongoing technical maintenance and
operational services are next to non-existent.
Other challenges include the development of a national "infostructure" to support inter-
jurisdictional data-sharing; the establishment of data and technical standards and health
informatics systems; and, financial investments in technology and deployment. There are
challenges with the education of sufficient numbers of informatics specialists to
implement, operate, manage and continue the development and improvement of the
technologies and the system. These challenges in implementation include geographic
considerations, cost, demographics, service access, quality, accountability, and the
integration of ICT.
While many telehealth technologies and projects are relatively new, evaluations of early
results suggest significant promise. Recent systematic reviews of studies of patient
satisfaction with telemedicine indicated that under ideal circumstances patients and care
providers accept and are generally satisfied with the care they receive and can give using
e-Health.
The promise of e-health is yet to be realized but appears to be an inevitable part of
Malaysia's future reality.
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