Improving Health Care Efficiency in Rural Areas - The Role of the Electronic Health Record

• Abstract
• Background
• Why an Electronic Health Record?
• Improving Health Care Safety and Communication
• Shared Decision-Making
• Improving the Health of Rural Residents
• Potential Benefits of Shared EHRs
• The Doctor Global Solution
• References

Abstract

Both health professionals and patients in rural areas are disadvantaged, health professionals through long hours and limited peer support and educational opportunities, and patients because they do not have the same level of access to health services as their urban counterparts. One key contributing factor to this incongruence in care for patients is the lack of a unique patient health record.

Doctor Global is an Australasian health services and clinical software provider, which supplies web-based health records. The organisation’s philosophy is based on the belief that online consultations and a web-based electronic health record (EHR) can increase access to health care, reduce errors, and create efficiency. Access to the health record via a secure database and the internet allows rural patients to remain informed and part of the process and assists with referral to specialists. No information is "sent"; it remains secure and available as a shared resource accessible to the consumer and all relevant health professionals.

Potential benefits of shared EHRs include improved outcomes for patients and increased patient knowledge of their own condition(s), and improved clinical decision-making processes, safety and accuracy for health professionals through ready access to timely, reliable, accurate, comprehensive and relevant patient information.

The opportunity exists via EHRs and the internet to enhance the quality of patient care in rural and remote locations and for transient population groups by:

• empowering consumers through greater access to their own information
• providing health care providers with an effective way of carrying out on-line patient consultations in a highly secure and private environment
• increasing consumer safety through availability of a complete medical record with reduced legibility problems and risk of transcription errors.

Rural communities are already online and trading and adding health care to the services available is a logical and necessary addition. Numerous people perceive rural life as having many advantages over city dwelling and the internet and EHRs may ensure that the quality of health care available to rural dwellers matches that of their urban counterparts.

Background

The problems that commonly occur when providing health care services in remote rural areas have been well documented. They include a wide range of issues that arise from:

• insufficient numbers of skilled rural health care providers, which makes it difficult to form a teams of high quality medical care experts
• a lack of access to specialist professional training in remote locations for rural GPs and nurses,
• high levels of burnout causing health care professionals to leave rural areas
• a lack of career pathway for rural nurses and rural hospital doctors
• insufficient pay to recompense health care workers for the long hours and added responsibility involved in providing services in a rural area.

Both health professionals and patients in rural areas are disadvantaged.

Primary health care professionals in the rural sector often work long hours, need to be multi-skilled and have little clinical peer support, ongoing medical education or time off. This is evident in the current rural doctor crisis in New Zealand.

Despite a range of high quality services, many rural consumers do not have the same level of access to health services as their urban counterparts. The extent of morbidity and mortality for chronic diseases in remote areas far exceeds that in major urban areas ^{[ 1 ]}. Contributing factors to this incongruence include high turnover rates in primary care providers, issues related to continuity of care and the lack of a unique patient health record.

In 1962, US President John F Kennedy outlined four fundamental consumer rights to the US Congress:
1. The right to safety
2. The right to be informed
3. The right to choose
4. The right to be heard.

The International Organisation of Consumers Unions subsequently adopted these rights and added four further rights: the right to a healthy environment, and the rights to satisfaction of basic needs, to redress and to education ^{[ 2 ]}.

In New Zealand, The Code of Health and Disability Services Consumers’ Rights was launched in 1996, having become law as a regulation under the Health and Disability Commissioner Act 1994. The Code confers a number of rights on all consumers of health and disability services in New Zealand and places corresponding obligations on providers of those services.

In the context of health care provision, it is the view of Doctor Global ^{[ 3 ]} that consumers’ access to these basic rights remains variable and unsatisfactory. A visit to the doctor requires the consumer to provide all information relating to their health, and to abandon that information in the consulting room when they leave. For a number of reasons, patients do not always have access to the results of the consultation or a record of the results. This situation may be amplified in the rural setting.

With this in mind the Doctor Global philosophy is based on the belief that online consultations and a web-based electronic health record can increase access to health care, reduce errors, create efficiency and reduce unnecessary road trips and phone calls to seek out medical advice and treatment. By having access to the medical record, consultation and results via a secure database and the internet, rural patients are informed and are part of the process. Referral of complex cases to specialists is made easy. The specialist is granted access to the record with the patient’s consent. A fundamental point is that no information is "sent"; it remains secure and different providers are granted full or partial access.

Why an Electronic Health Record?

According to the Ministry of Health Electronic Health Record Project Report, an Electronic Health Record (EHR) means an electronic longitudinal collection of health information, based on the individual or family, entered or accepted by health care professionals, which can be distributed over a number of sites and in a number of settings. An EHR must accurately report vital health care information and should be comprehensive, clinically useful, portable, meet ethical and legal requirements and be of an open standard.

Currently, the main methods of non-face-to-face doctor-patient relationships are telephone, fax and e-mail. All of these are insecure and generally do not result in the health professional getting paid.

The potential for an EHR to provide a means to address health consumer rights is increasingly being recognised. The potential for an EHR to make a discernible difference to that consumer’s health is, however, still unmeasured as almost all EHRs developed so far have been designed for health providers’ use, and have not been intended to be shared by and be accessible to health care consumers.

There is an important role for an EHR that is available as a shared resource accessible to the consumer and all relevant health professionals. The internet provides an important communication and collaboration technology for accessing information and data from such records.

There are many potential benefits of shared EHRs. Health consumers should gain improved knowledge of their own condition and this should result in positive changes in the attitudes and behaviours of consumers who would then participate more effectively in and take control of their own health care. Health providers should have improved clinical decision-making processes, safety and accuracy, and the health care organisation may have an improved practice culture, in that patients are part of the process and have a right to view their records.

While we all accept that health care is an information-based industry, it is fair to say that equitable access to consumer records has been difficult to achieve. This has been one important reason why New Zealand’s models of health care provision have not been, and will not be, able to deliver equitable health care outcomes to all New Zealanders. In particular, rural and isolated regions, where access to consumer information becomes of even greater importance, have been under-serviced with measurably poorer outcomes for the health of citizens in those isolated areas.

New Zealand’s current models of health care are historical, hospital-based, provider-centric, and they impede rather than enhance the exchange of information within the medical profession, and between health professionals and patients.

The providers of health care services have been unable to address all the needs of the communities they serve and now require more flexible and innovative approaches to service delivery and support. Networked health and community services and innovative models that take account of local conditions can provide new opportunities for accessible services across the care and support spectrum.

In New Zealand, Government and District Health Board agencies are exploring a range of clinical information systems, decision-making support tools and telehealth applications. They are making considerable investment but there is little co-ordination and sharing of information. In Australia, the Australian Defence Forces and a variety of private hospital systems are also investing in clinical information systems, mainly of a proprietary nature, and it is likely that the Australian Commonwealth Department of Health will recommend the development of a national health information network following the work of the National Electronic Healthcare Records Working Party. There is no doubt, that EHRs will be part of New Zealand’s future health care system. The Ministry of Health Electronic Health Record 2001 Project has highlighted the fact that New Zealand is moving into electronic health and medical records, albeit that progress has taken place in an uncoordinated and non-strategic manner.

New Zealand could be the world leader in remote medicine and provide highly sought after evidence to guide future health care investment.

There are few comparable health care systems that can combine expertise in health, information technology and analysis and theory across the public and private health care sectors, the industry and academia. E-health care is a very fragmented area of interest not only in New Zealand but in the world generally. Again, a great deal of work is going on, with consequent expenditure but with relatively little evaluation, forward planning or co-ordination.

New Zealand could successfully exploit this opportunity to gain and maintain international standing in e-health care because international competitors are few. In the US the military alone spends about $80 million per annum on this area, although relatively little of this money goes into formal research programmes, and the primary focus - of ensuring the safety of the soldier in the field - does not translate well to society generally.

The US Government’s computer-based patient record (G-CPR) is part of a scheme to develop a framework enabling the provision and protection of world-wide, life-long health records for current and past members of the armed forces (more than 15 million people). Similarly, NASA spends large amounts of money exploring the use of telehealth care during space flight, particularly with respect to future missions to Mars, but this has little impact on more traditional health care. There are major health informatics and telehealth research centres in Alberta (Canada), Tromsø (Norway) and an increasing interest in this area at the MIT labs in Boston (US).

If, by improving provider/patient communication in the context of the services provided by clinicians, it can be demonstrated that there will be improved health care outcomes in terms of reductions in morbidity and mortality, then health care providers will have a product that will have broad application across all fields of health care on an international basis.

While a large number of e-health Web-based dot.com companies are actively pursuing commercial opportunities, mainly in the business-to-business environment (ie, providing educational services to GPs and other primary health care providers), the operators of these web portals are essentially uninterested in clinical research and evaluation and are much more focused on commercial outcomes and market share.

Despite large expenditure from many different players, there has been little emphasis on the important cultural and change management issues required within the New Zealand health care system to move into a more advanced environment. Moreover, there has been even less emphasis on research to explore the benefits of these systems, particularly for consumers and their health and well-being.

Improving Health Care Safety and Communication

Communications between health care providers account for somewhere between 50 percent and 90 percent of all information transactions within the health care system, depending on which sector is being considered. While few studies have attempted to directly quantify what percentage of all clinician-to-clinician communications are direct interactions, those that do exist all paint a similar picture. About 50 percent of "information transactions" occur face-to-face between colleagues, with e-mail and voice-mail accounting for about another 25 percent of the total. Only about 10% of these exchanges occur through an EHR system ^{[ 4 ]}.

Most information exchanges occurring within the health care sector are informal and will not be captured in formal computer systems like the EHR one and, consequently, IT developers have little interest in supporting this type of communication. Yet communication failures within the health system contribute enormously to adverse clinical events and outcomes. In a retrospective review in Australia of 14,000 in-hospital deaths, communication errors were found to be the leading cause of such deaths, twice as high as errors made because of inadequate clinical skill. Further, about 50% of all adverse events detected in a study of primary care physicians were associated with communication difficulties ^{[ 5 ]}.

Shared Decision-Making

In Australia the National Electronic Health Records Taskforce (www.health.gov.au/healthonline) has recommended the introduction of Australia-wide shared patient summaries. Research into the content of such records clearly should be focused on the needs of both consumers and clinicians, as well as the delivery and style of such records and the process of shared decision-making. Such research would be expected to provide a mechanism to determine the best approach to developing shared health records that are valid, helpful, reliable and which are supported by appropriate privacy and security systems.

Improving the Health of Rural Residents

The continuing advances in telecommunications, information technology and information systems’ capabilities, offer significant opportunity to improve the effectiveness and efficiency of health services in regional, rural and remote regions. Technologies must be chosen that are both cost-effective and address high priority health needs. The provision of access to a shared EHR for both the consumer and the provider would be expected to improve the continuity of care and clinical decision-making. This is especially important for sufferers of chronic illness.

Doctor Global is currently running pilot projects in New Zealand that will contribute significantly to the international evidence and research base in the area of EHRs and will test the impact on a community of the introduction of EHRs. The outcomes could include:

• improved understanding of the critical success factors for the introduction of an enterprise-wide clinical information management tool
• new knowledge skills and capacities at consumer, community, clinician, organisational and research levels, for the integration of new technology and systems in health care
• improved understanding of the technical, ethical and professional questions surrounding the introduction of EHRs, including privacy, confidentiality, security, redundancy, reliability and quality
• reduced risk of adverse events from communication difficulties.

Potential Benefits of Shared EHRs

There are potential benefits of shared EHRs for health care consumers, health professionals and health care organisations or systems, as follow.

For health care consumers the potential benefits of shared EHRs would include:

• Improved health outcomes for patients with chronic diseases.
• Increased patient knowledge of their own condition(s), and the factors impacting on their health.
• Positive change in patients’ attitudes and behaviours regarding their participation and control in health care.
• Increased activity by patients in self-monitoring and management of their own condition(s).

For health professionals, benefits would include:

• Improved clinical decision-making processes, safety and accuracy.
• Increased access to timely, reliable, accurate, comprehensive and relevant patient information.
• Integrated information from other health care providers.
• Reduced risk of errors deriving from communication difficulties (and subsequent lessening in the legal costs of defending doctors in lawsuits).

For the health care organisation/system overall, benefits would include:

• Improved efficiencies.
• Improved accountability - record of all consultations achieved through centralisation of data (reduce and/or record phone calls and increase clinical notes).
• Improved information management and communication systems.
• Improved relationships with patients.

It is definitely time to promote a culture in which health care consumers will be better able to access information about themselves, including the state of their own health and the treatment they are receiving. Additionally, patients should be empowered to increase their willingness and ability to self-monitor and self-manage, so that they take a more active role in maintaining their own well-being.

There are few, published, empirical studies that provide information or commentary on the introduction of EHRs within an enterprise. This is especially true in relation to studies that focus on evaluation of health outcomes and patient self-management behaviours. There are no studies describing an enterprise-wide implementation of a system allowing both other clinicians and patients to share patients’ records.

Doctor Global believes an EHR system can enhance the quality of patient care, by offering doctor, patient and other health care providers online access to comprehensive, accurate and up-to-date patient health records. Access to patient histories is then always available when and where they are needed. Such a system provides a health care system with the ability to cope with a transient or highly mobile population.

New Zealand has the opportunity now to enhance the quality of patient care, especially in rural and remote locations and for transient population groups.

This can be achieved by:

• Empowering consumers by providing them with greater access to their own information. In time, as patients become used to the system and using it effectively a culture will develop "in which health consumers will be better able to access information about themselves, including the state of their own health, as well as about treatments or interventions and any side effects"^{[ 6 ]}.
• Give health care providers with an effective way of carrying out on-line patient consultations in a highly secure and private environment.
• Increase consumer safety through the contribution of the EHR. Typed, electronic notes reduce legibility problems and transcription errors. Providers potentially have access to the complete medical record. This is especially important when patients are travelling and when different care-givers are involved in the consultation process, for example in relation to allergies and adverse events.

Such a system could also assist the development of the New Zealand health care industry by:

• Assisting health care professionals, through the development of decision support technologies that are mobile and can both deliver timely information and facilitate a consultation with suitable professionals on a flexible basis.
• Developing a more sophisticated and responsive health care system.
• Developing systems to enhance health maintenance/prevention programmes rather than focusing entirely on disease treatment.

The Doctor Global Solution

When Doctor Global was launched, one of the key premises was that everyone benefits when patients takes charge of their own health care and that what is good for patients is good for business.

In addition to online consulting, the organisation has been focusing the introduction of shared web-based EHRs to allow patients to access their own health information. The result is a comprehensive EHR, which is shared with patients and provides a more patient-focused approach to health care (refer to the Doctor Global web site at www.doctorglobal.com to view a sample record).

Doctor Global provides a safe and efficient electronic system for patients and health care providers to exchange data via the Internet. A key feature of the Doctor Global EHR is that it allows stored patient data to be accessed from a secure computer server whenever and wherever it is required. Access to an EHR is dually controlled by both the patient and health care provider.

Doctor Global’s systems use the Internet to improve health care access, efficiency and service on a global basis. Access is via a standard web browser on an Internet-connected computer. Patients require no additional software or product support.

Doctor Global wants to improve the current health care model, to make a significant contribution to the evidence about and research base for EHRs and to improve understanding of the critical success factors in introducing enterprise-wide, clinical information management tools. Experienced clinical and IT teams at Doctor Global are contributing to the knowledge and skill base internationally for health care re-engineering and change management processes.

A current Doctor Global initiative is "adopting" the rural township of Mokau, which does not have a resident doctor, by providing free use of the basic e-consultation facility and the EHR system. For this initiative, Doctor Global is working with these patients’ remote primary medical provider.

One of the most commonly asked questions relates to security. Doctor Global uses the same security as that used for Internet banking. Instead of having a cheque account or savings account, a patient can now have a "health account" for "banking health data".

Doctor Global has been working to improve understanding of the social, technical, ethical and professional questions surrounding the introduction of EHRs, including privacy, confidentiality, security, redundancy, reliability and quality. The web-based, secure system, which is highly sophisticated, solves these problems. The development of a lifelong EHR will bring huge benefits to the health care industry and to patients. It was started in 1998 and in 10 years from now such technology will be part of everyday life. It will save time, lives and money. We are sure we will look back in another 10 years and think, "that was primitive!". As people do now looking back on black and white TVs, the Model T Ford or the Kittyhawk.

Rural households have embraced the Internet and undertake many of everyday activities efficiently online. Rural communities are already online and trading and adding health care to the services available is a logical and necessary addition. Numerous people perceive rural life as having many advantages over city dwelling and the Internet may enable and encourage many more to move to the country.

References

1. Healthy Horizons: A Framework for Improving the Health of Rural, Regional and Remote Australians, National Rural Health Policy Forum, 1999.
2. Lawson R, Tidwell P, Rainbird P, et al. Consumer Behaviour in Australia and New Zealand. Australia: McGraw-Hill; 1996.
3. Doctor Global is an Australasian health services and clinical software provider, offering secure, private and accessible internet health and wellness systems. The organisation supplies web-based health and emergency records, clinical consultations and supporting tools, and offers health care providers an efficient way of consulting with their patients. Doctor Global does not replace the traditional role of the health professional but rather augments and adds efficiency to the traditional health care model.
4. Coiera E. When Communication is Better than Computation, JAMIA 2000; 7: 277-286.
5. Coiera E. When Communication is Better than Computation, JAMIA 2000; 7: 277-286.
6. Health Online. A Health Information Action Plan for Australia