Review of the implementation of electronic health record in Hong Kong

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1 Title Review of the implementation of electronic health record in Hong Kong Author(s) Poon, Wai-yin.; 潘 慧 賢. Citation Issued Date 2012 URL Rights The author retains all proprietary rights, (such as patent rights) and the right to use in future works.

2 REVIEW OF THE IMPLEMENTATION OF ELECTRONIC HEALTH RECORD IN HONG KONG By POON Wai Yin Dissertation submitted in partial fulfillment of the requirements for the degree of Master of Public Administration Department of Politics and Public Administration The University of Hong Kong August, 2012

3 DECLARATION I hereby declare that this dissertation is your own work and has not been previously included for any degree, diploma or other qualification. POON Wai Yin 2

4 TABLE OF CONTENTS DECLARATION... 2 TABLE OF CONTENTS... 3 ABSTRACT... 4 LIST OF ABBREVIATIONS... 7 CHAPTER 1 - INTRODUCTION... 9 CHAPTER 2 - DEVELOPMENT OF ELECTRONIC HEALTH RECORDS IN HONG KONG CHAPTER 3 - LITERATURE REVIEW OF COST AND BENEFIT ANALYSIS IN ELECTRONIC HEALTH RECORDS CHAPTER 4 - FINDINGS AND WAY FORWARD BIBLIOGRAPHY

5 ABSTRACT ehr is one of the main development area in healthcare sector to ensure a high quality and effective healthcare service in Hong Kong is provided. However, the present development of ehr in Hong Kong is mainly focused on public sectors healthcare providers the hospitals and clinics under HA and DH. Most of the private hospitals and clinics are still using paper based health records. Although some of them may have implemented their own ehr systems, there is no interconnection among other healthcare providers. In this dissertation, the ehr system development in Hong Kong for both public and private sectors will be reviewed, to figure out the development of ehr and various clinical management systems, as well as the problems facing by the healthcare workers and patients. Also, HKSAR government shows supportive to the ehr development both in the governance and financial aspects. To facilitate the coordination of developing ehr sharing system among different healthcare providers, an ehr Office has been setup under Food and Health Bureau for this purpose. The ehr office will monitor the progress of the ehr development process. As HA has a well-developed 4

6 world-known Clinical Management System (CMS), which handles patient records in electronic forms in public hospitals daily. HA acts as one major advisor in ehr implementation for HKSAR. Data privacy and data security issues are the major concerns of healthcare workers and patients. The Personal Data Protection Ordinance (PDPO) provides protection on the data privacy in legal aspect. However, no legislation on data privacy has been specified for ehr currently. Meanwhile, various physical security protections have been adopted in the implementation of ehr in technology side, which provided a certain level of data security to the system. Chinese Medicine has been developed rapidly recently, it is expected the Chinese Medicine would become one of the core service area in healthcare sector in Hong Kong, sharing the healthcare service with the Western Medicine. However, there is no integration between Chinese Medicine and Western Medicine in current ehr sharing system development. ehr development involves huge investment, to evaluate the feasibility of developing the ehr system, a scientific tool is recommended, a Cost and Benefit 5

7 Analysis is hence conducted for the ehr in Hong Kong, to compare the effectiveness of ehr with the traditional paper-based health records in the healthcare setting. As recommended from the CBA, the ehr system will be developed with the consideration on the system flexibility and the adaptability from all the healthcare providers. On the other hand, the implementation of the ehr system will be a long and complex process and will require the contribution and participation from all parties. 6

8 LIST OF ABBREVIATIONS CBA Cost and Benefit Analysis CDIS Communicable Disease Information System CHP Center for Health Protection CMCTRs Chinese Medicine Center for Training and Research CMIS Chinese Medicine Information System CMS Clinical Management System CT Computed Tomography DH Department of Health ehr Electronic Health Record ehr Office ehealth Record Office emr Electronic Medical Record epr-id Electronic Patient Record Image Distribution esars Electronic Severe Acute Respiratory Distress Syndrome System FHB Food and Health Bureau HA Hospital Authority HAITS Hospital Authority Information Technology Services MIP Mentally Incapacitated Person 7

9 MR Magnetic resonance NGOs Non-government Organizations NSB Net Social Benefits PDPO Personal Data (Privacy) Ordinance PPI-ePR Public-Private-Interface Electronic Patient Record Sharing PPP Public-Private Partnership 8

10 CHAPTER 1 INTRODUCTION What is electronic health record? As defined by the Food and Health Bureau (FHB) An electronic health record (ehr) usually refers to a record in electronic format containing health-related data 1 of an individual (referred to as patient hereafter for simplicity though ehr is not confined to medical treatment for sickness) stored and retrieved by different healthcare providers including doctors and other healthcare professionals for healthcare-related purposes. 2 In Health Informatics of Hospital Authority, they defined an electronic health record is comprehensively includes details of patient episodes and visits; diagnoses; procedures; discharge summaries; allergies and alerts; all medications; laboratory and radiology results; nursing and allied health information; documents and letters; specialist clinical data; and radiological images 3. 1 Such data may encompass (i) personal particulars for identification and contact (e.g. name, identification, date of birth, contacts, etc.); (ii) health data (e.g. weight, height, blood type, vaccination records, drug allergies, etc.); and (iii) medical data (e.g. diagnosis, prescriptions, laboratory test results, radiological images and hospital discharge summaries, etc.). 2 HKSAR Legislative Council Legislative Council Panel on Health Services, Development of a Territory-Wide Electronic Health Record Sharing System, LC Paper No. CB(2)1006/08-09(03) (Mar 9). 3 HKSAR Hospital Authority HIMSS Electronic Health Record Global Perspective Hospital Authority: Health Informatics. 9

11 What is electronic health record sharing system? Electronic health record sharing system is a unified information model which provides standardised repository for the clinical data, assist to clinical decision support, research, report and audit purpose 4. As stated by the Food and Health Bureau (FHB) An ehr sharing system provides an information infrastructure for healthcare providers in both the public and private healthcare sectors, with informed consent from the patient and proper authorization for access to the system, to share the ehr they kept about the patient with other healthcare providers and to retrieve the ehr of the patient shared by other health care providers. 5 To develop an electronic health record sharing system, it is not only an IT project. More importantly, it has to deal with the legal, privacy and security issues, which includes ownership, access and copyrights of patients records and the safeguarding of data privacy and security. On the other hand, it also needs to handle the institutional issues, which includes governance of the ehr infrastructure holding and transferring a huge amount of health records of the majority of the patients. To ensure the ehr development support from the public, Hong Kong Government have done a public engagement from different stakeholders including the healthcare 4 Ibid. 5 HKSAR Legislative Council Legislative Council Panel on Health Services, Development of a Territory-Wide Electronic Health Record Sharing System, LC Paper No. CB(2)1006/08-09(03) (Mar 9). 10

12 providers from public and private sectors, patients representatives, IT sectors during the development process of the ehr. Why do we need ehr? In Hong Kong, most of the medical data is currently kept separately in different health providers, and they do not have linkage in between. These medical records stored in different forms (paper based records or electronic records) or data format. There is no well-defined infrastructure for sharing such medical records between different healthcare providers. Healthcare workers could not have a full picture of patients medical history for diagnosis and the treatment had been delivered. Patients may have to do duplicate medical inspections and resulted in delay of treatment. Government is not able to build a faultless database to perform disease surveillance effectively. To increase the quality of primary service, it is very important if the medical records could follow mobility patients (it should subject to the consent of patients when sharing). To transit from the traditional paper based health records to electronic health records, and to systematize and centralize the electronic health records would be the trend of future health records development. Overview of the situation in Hong Kong 11

13 In Hong Kong, there is a population of over 7 million people with 25 million visitors per year. 44 public hospitals and 14 private hospitals are serving the people in there. It spends five and a half percent of its GDP on healthcare, which are 57 percent in the public sector and 43 percent in the private sector 6. The public hospitals and clinics are governed by the Food and Health Bureau (FHB), which is one of the eleven government bureaus responsible for public policies. Under FHB, the Department of Health (DH) is the Government s health adviser and agency to execute healthcare policies and statutory functions 7. The Hospital Authority (HA) is a statutory body providing public hospitals and related services to the citizens of Hong Kong. The HA was formed in 1990 under the Hospital Authority Ordinance. At present, it has around 59,000 employees. It is responsible to manage all public healthcare services including 43 public hospitals, 47 specialty outpatient clinics and 74 general outpatient clinics. It provides 27,742 hospitals beds, there are 29,000 clinical staff to deliver services for one million inpatient visits, two million emergency visits and 13 million outpatient visits per year. HA provide 100 percent of long-term care, 93 percent and inpatient and tertiary care and 24 percent of primary care, to balance the service provided by the private sector 8. 6 CHEUNG NT, FUNG V, WONG WN, TONG A, SEK A, GREYLING A, TSE N, FUNG H Principles-Based Medical Informatics for Success How Hong Kong Built One of the World s Largest Integrated Longitudinal Electronic Patient Records. Medinfo. 2007;12 (Pt 1): HKSAR Government Overview of the Health Care System in Hong Kong. (April 24, 2012). 8 HKSAR Hospital Authority HIMSS Electronic Health Record Global Perspective

14 The Hong Kong Government has targeted to the development of ehr. Chief Executive Mr Donald Tsang stated in his Policy Address that to develop a territory-wide, patient-oriented electronic health record under health care reform is a new direction for Hong Kong 9. In the Policy Address Policy Agenda stated that set up a dedicated office under the Food and Health Bureau to co-ordinate the development of a territory-wide patient-oriented electronic health record system, for sharing the medical records between different healthcare providers will be subjected to the patients consent, nevertheless, it provided a pivotal infrastructure for implementing healthcare reform 10. In the Policy Address, it stated that the Government has formulated a series of recommendations to enhance primary care so as to provide comprehensive care support for chronic patients. We will also develop a territory-wide electronic health record sharing system, which can save medical costs, minimise errors and safeguard patients' health. This electronic system will underpin the reform of our primary healthcare services. 11 It shows that HKSAR government has paid much attention in the development of ehr. Hospital Authority: Health Informatics. 9 HKSAR Government The Policy Address. (April 24, 2012). 10 HKSAR Government The Policy Address Policy Agenda. (April 24, 2012). 11 HKSAR Government The Policy Address. (April 24, 2012). 13

15 In the "Your Health, Your Life" consultation paper, it also suggested that Develop electronic health record sharing to allow individuals health records to follow them wherever they go for healthcare to improve the quality of health care for the public and provide the necessary infrastructure to support the healthcare reform 12 The Problem In Hong Kong, up till now, the health records and clinical data are created and stored by different healthcare providers in clinics or hospitals separately, including those keeping with the patients. The health records are stored in different locations without standard formats. Apart from the Hospital Authority, the private healthcare providers are still keeping their health records and clinical data in paper based form. Although some of the healthcare providers have developed patient/medical record systems for storing or retrieving such data, these records are not able to be shared among different healthcare providers, wholly because there are different IT infrastructure platforms and different data formats being adopted. So, developing an ehr sharing system on a territory-wide and population-wide basis is essential HKSAR Government Food and Health Bureau Your Health, Your Life Healthcare Reform Consultation Document. (April 24, 2012). 13 HKSAR Legislative Council Legislative Council Panel on Health Services, Development of a Territory-Wide Electronic Health Record Sharing System, LC Paper No. CB(2)1006/08-09(03) (Mar 9). 14

16 However, it still has hurdles which hindered the implementation of ehr. It is quite sure that it will instigate a financial burden for the healthcare providers to maintain the system. In addition, it takes efforts for the healthcare workers in adopting the new clinical practice in ehr. Furthermore, patient representatives concern about data disclosure level, they are arguing whether all of the healthcare providers need to know the sensitive data such as sexual disease history, mental health history, etc; During clinical data exchange between different systems, the data formatting may not be stored in same standard. It will face the transition problems involving transiting huge amount of existing health records, especially more than half private clinic are still using paper based health records. High mobility of both the patient and data increased the risk of data leakage of health records, health care workers could copy the health records easily in electronic format, there are many incidents about patient records leakage in these years, most of them were in electronic formats, for instance, losing of USB thumb drives with patient records. Patient privacy, security, confidentiality crisis among personal information and legal protection applies in the health records will be the major concerns. Although, Personal Data (Privacy) Ordinance (PDPO) has been laid out the rules in protecting the personal data privacy, there is no legislation specific for ehr currently. 15

17 Following the rapid development of Chinese Medicine, Chinese Medicine will become one of the core healthcare service areas in future. The need for the integration between Chinese Medicine and Western Medicine becomes imminent. However, it has not been considered strategically on the implementation of a territory-wide ehr sharing system in the Chinese Medicine health records. The Chapters Chapter ONE introduces the background and basic concepts of electronic health record. Also, it will present the definitions of electronic health record and electronic health record sharing system and brief the current situation and the problems in Hong Kong. Chapter TWO addresses the development of electronic health record initiatives in Hong Kong. It covers provisional infrastructure, government policies and fiscal support as well. Since the last two decades, the HKSAR and Hospital Authority has put in a great effort in promoting electronic health record initiatives and their effort is duly recognized by other countries in the world. The participation of electronic health record includes public and private sectors. It has already been promoted in different programmes among public and private sectors including CMS, PPI-ePR, 16

18 ehr. Also, a successful case is addressed, the esars was an exemplary achievement during SARS outbreak. Also, Chinese medicine is playing an important part in the medical system in Hong Kong, the development of ehr in Chinese medicine is covered in this chapter. Chapter THREE examines the implementation of ehr in Hong Kong with Cost and Benefit Analysis (CBA). It discusses the benefits generated from electronic health record and hurdles that may hinder the transition and the expansion from traditional paper record to electronic way in several aspects including data policy, technology adoption, financial and governance. Chapter FOUR will concludes the findings from CBA and the way forward on ehr development, also, further enhancement of the implementation of electronic health record will be explored. 17

19 CHAPTER 2 DEVELOPMENT OF ELECTRONIC HEALTH RECORDS IN HONG KONG One of the major challenges of Hong Kong healthcare system facing is to integrate public and private sectors. Both public and private healthcare providers are aware that the ehr is the trend of healthcare development specially in enhancing the healthcare quality in Hong Kong. In the past two decades, Hospital Authority, Department of Health and other healthcare related providers had contributed a great effort in the development of ehr in Hong Kong. From the very beginning, it was only served for the in-house patient data storage within individual hospitals. As time goes by, it became a cross-departmental disease monitoring and surveillance tool. After that, it developed from one-way sharing to two-ways sharing of the patient health records across different healthcare providers, both public and private sectors. In this chapter, it is going to overview the development of ehr in Hong Kong, by discussing the development of ehr in different agents and the government policy support in privacy and financial aspects. Also, it will talk about the governance and provisional infrastructure of the ehr in Hong Kong. Hospital Authority 1. Clinical Management System (CMS) 18

20 Since 1995, Hospital Authority started to develop its own Clinical Management System (CMS) progressively; it was used for in-house storing and retrieving patients medical records. From 1995 to 2009, Hospital Authority had invested $1,420 million for the development of CMS Phases I and II in these years. In Hong Kong, the CMS is the largest system in clinical management, which integrated electronic medical/patient record (emr/epr) system. It is an advanced and successful system in hospital usage coverage, functionality and complexity. CMS has already stored over 8 million patients records for the community, with over 800 million laboratory results, 340 million prescription and 34 million radiological images. It covers all varieties of all HA clinical services both hospitals and clinics. CMS provides a platform for the authorized persons to access patients data within a well-developed IT architecture across the HA s IT network, it becomes an essential tool for HA to deliver healthcare services 24 hours a day - 7 days a week. For each day, medical practitioners and other health care professionals conduct over 3 million transactions in CMS. However, CMS at the present stage is for HA network only, it has limitation to share the patient records for other healthcare providers, furthermore, and there are limitations on the system design and capacity as well. Hence, CMS III is being 19

21 developed to remove the limitations. The new CMS III will extend to the private sectors, sharing patients records among different healthcare providers including private sectors in future. In the future development of ehr sharing in Hong Kong, CMS would become the foundation of the ehr sharing development infrastructure. The CMS development team would become the experts, who have the knowledge of development ehr sharing system in Hong Kong. They are the crucial assets, who could leverage the extension of the sharing of patient records among public and public and private sectors. In the future development of ehr, it could bear the benefits from the experiences of HA s CMS, including medical practitioners access to the latest patient information in associate with clinical decision making. Also, to implement better and more reliable clinical care service by computerising all of the clinical process from patient registration, appointment booking, clinical documentation, ordering to discharge and follow up. It could enhance the clinical operation support with standardised and comprehensive patient health record Electronic Severe Acute Respiratory Distress Syndrome System (esars) 14 HKSAR Legislative Council Legislative Council Panel on Health Services, Development of a Territory-Wide Electronic Health Record Sharing System, LC Paper No. CB(2)1006/08-09(03) (Mar 9). 20

22 In 2003, there was a SARS outbreak in Hong Kong. In the SARS episode 1 outbreak, from early March to 23 June 2003 (about 110 days), there were 1,755 reported SARS patients and 299 death cases 15. With the foundation of CMS s architecture, HA developed esars(electronic Severe Acute Respiratory Distress Syndrome System) in 3 days. esars data had to transmit to different departments: I. The Department of Health for disease monitoring, surveillance, outbreak management and further public health measures. II. The Police Department for contact tracing and tracking for suspected and possible suspected cases. III. Universities for clinical research and study. This is an exemplary approach of using electronic way in disease management and control, which is the first example of using HA data with the public health 16. A joint proposal has been approved by Hong Kong Jockey Club and the Government of HKSAR, to setup a Communicable Disease Information System(CDIS) which is a 15 CHEUNG Anthony, CHEUNG NT, GREYLINE Andre, FUNG Michael, KONG James esars (Electronic Severe Acute Respiratory Distress Syndrome System) Development and Technical Perspective. HKSAR Hospital Authority. 16 KONG James An Opportunity For Private-Public Interface Development, 27th Hong Kong Private Hospitals Association Meeting. Health Informatics Exchange (July 29). 21

23 tool for the Center for Health Protection (CHP) after SARS outbreak. CDIS facilitate in the capture of the communicate diseases data from the comprehensive community wide records. It takes a role in the prevention of future outbreaks and reduces the consequences. The architecture of CDIS would be integrated with CMS in future development Electronic Patient Record Image Distribution (epr-id) Filmless Hospital Since 2005, HA established centralized epr Image Distribution (epr-id) for reference images, it supported Computed Tomography (CT) and Magnetic Resonance (MR) images. epr-id is an image accessing platform to facilitate seamless, timeliness, accessible images of the patients though all HA hospitals in Hong Kong. As at February 2008, it had archived all available radiological images from 12 acute hospitals to epr-id, there were 43 million images archived with 2 million images growing per month. Through this system, the doctors are able to access the images which were captured anywhere from HA hospitals and clinics by accessing CMS/ePR. The system can retrieve the local lossless images or central reference images depend on the centralized index. epr-id improved the timeliness and availability of patient radiological image data 17 HKSAR Hospital Authority Information Technology Policy Group Clinical Information Systems Strategy ( ). 22

24 for the front line healthcare workers in wards and clinics. It enhanced the clinical decision making by increased the availability of cross-hospitals historical image data. More importantly, it minimised the unnecessary duplication of examination because of inaccessible or losing of image data or hard copy reports, as the image data could be shared among hospitals and clinics. It reduced the needs of transferring films among departments and hospitals. It enhanced the completeness of the patient-centre life-long longitudinal records with images data, and more, it increased the productivity and strengthened the support of patient care. By using the filmless approach of using epr-id, a great reduction on the film and chemical cost as well as the cost of dry laser film printing. If all of the HA hospitals implemented filmless operation mode, it is expected that there will be a save of at least HK$20 million per year. Also, the images waiting time will be reduce to less than 5 minutes 18. Department of Health The Department of Health provides and manages public health services in Hong Kong. It owns a huge amount of health records of the community, most of them are in paper forms, such as the vaccination records of the people. In recent years, DH 18 HKSAR Hospital Authority EPR Image Distribution supporting Filmless Hospital 08/09. Hospital Authority: Health Informatics. 23

25 has started to develop a centralized electronic information system to store these records. Also, the system equipped with the ehr sharing capabilities, which allows sharing such information with HA and private healthcare providers with a common electronic platform. The centralized electronic information system integrated several existing systems, such as the Maternal and Child Health Centre (MCHC) information system with immunization records, the Social Hygiene Service Information System, Clinical Genetics Service Information System with Family Clinics. In addition, DH is holding a complete drug compendium for the latest drug information in Hong Kong. In line with the ehr development, DH is exploring to implement a standardised electronic drug database, the database will contain all registered drugs information in Hong Kong. After SARS outbreak, SARS Expert Committee suggested that an enhanced information management system should be established across the sectors for effective communicable disease control on a permanent basis 19. For the purposes of enhancing the capability of the surveillance and control of communicable disease of Hong Kong, Communicable Disease Information System (CDIS) is developed. For 19 HKSAR Government SARS Expert Committee SARS in Hong Kong: from Experience to Action. (May 15, 2012). 24

26 the convenient of data sharing among ehr system in Hong Kong, it also aligns with the data standard of the ehr development. Private Healthcare Sector Private medical practitioners and clinics provide more than 70% of the out-patient consultations for Hong Kong population. However, most of them are working individually with no connection to other healthcare providers. Very sure that they are still using paper based patient records, storing in metal file cabinets. For those who are using pilot PPI-ePR or emr developed by HA and DH, those data are still not compatible for two-way sharing. Some of the private laboratories and radiological service centers in private healthcare sector, they have setup the IT system, however, these standalone systems are setup for in-house operation purposes only, with the tailor-made software for the IT system, the private healthcare IT system cannot communicate with the PPI-ePR or emr developed by HA and DH 20. The participating in using of electronic health records in private health sector is not high. A survey had been conducted by The Hong Kong Medical Association proved the interest and trend of using computers in private health sectors is increasing. 20 HKSAR Legislative Council Legislative Council Panel on Health Services, Development of a Territory-Wide Electronic Health Record Sharing System, LC Paper No. CB(2)1006/08-09(03) (Mar 9). 25

27 There are over 85% of them using computers at work. However, they are mainly using the computers for writing letters, internet access and patient demographic data indexing. There are only 49% of them who prepare the drug labels by using computer and only 43% of them store the patient clinical data in computer. 21 The current 14 private hospitals are mainly using computers for appointment, drug dispensing, billing, accounting and inventory recording purposes rather than medical records and ward functionalities. Their clinical data is still keeping in hardcopies format. Although some of them are keeping these clinical records electronically, they are using their own format which is not compatible for sharing among different healthcare providers neither private nor public institutions 22. ehr Sharing 1. One Way Sharing - Public-Private-Interface Electronic Patient Record Sharing (PPI-ePR) In 2006, a pilot project Public-Private-Interface Electronic Patient Record Sharing (PPI-ePR) had been launched through HA, its main purpose was to test the acceptability and feasibility of ehr sharing among different institutions and the 21 Hong Kong Medical Association Report of HKMA IT Survey HKSAR Legislative Council Legislative Council Panel on Health Services, Development of a Territory-Wide Electronic Health Record Sharing System, LC Paper No. CB(2)1006/08-09(03) (Mar 9). 26

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