Electronic Health Record (EHR) for use and

Electronic Health Record (EHR) for use and development in developing countries Professor KANO Sadahiko Waseda University Graduate School of Asia Pacific Studies Workshop on Global Medicine and Local Culture: The Role of Medical Anthropology Waseda University, 5 November 2010 Summary Developing countries are facing more health care threats, but their expenses in health are still low in comparison to developing countries. By the other side, medical expenditure is abruptly growing in developed countries. Investments in health care facilities for elderly care are the most promising investments for the future. Also health care facilities generate in proportion the largest number of jobs. 700.0 600.0 500.0 World Health Situation People in developing countries face more health threats. 400.0 300.0 200.0 100.0 0.0 Maternal mortality ratio (per 100,000 live births) 2005 Prevalence of tuberculosis l (per 100 000 population) 2007 Cambodia Laos India Indonesia Philippines Peru Thailand China Korea Japan UK USA France Germany Sweden Source: World Health Organization, World Health Statistics 2009 2

World Health Spending Developed countries are spending more on healthcare as % of GDP. Developing countries are spending similarly on military as % GDP 18 16 14 12 10 8 6 4 2 0 Health Expenditure (%GDP ) 2006 Military Expenditure (%GDP) 2008 Source: Health Expenditure as % GDP: WHO World Health Statistics 2009 Military Expenditure as % GDP: Stockholm International Peace Research Institute, Military Expenditure Database 2010 3 Medical Expenditure in developed countries are exploding Medical Expenditure in Japan from 1965-2007 Medical Expenditure (trillion yen) Medical Expenditure Ratio against GDP Ratio against GDP(%) 1955 1965 1975 1985 1995 2007 SOURCE: Ministry of Health, Labour and Welfare of Japan http://www.mhlw.go.jp/toukei/saikin/hw/k-iryohi/07/kekka1.html 4

Multiplier Effect of Initial Investment of 1 trillion yen in Japan (based on Japan s 2005 Industry Input-Output Table) Billion yen 3000 2701 2685 2564 2432 (100) (96) (95) (90) 2500 2000 1500 1000 Secondary Effect Primary Effect 500 0 Initial Investment Physical Infrastructure Medical/Health Social Welfare Elderly Care Source: MASUDA Takanobu, Master Thesis, Waseda Univ., GITS, 2009 7 Number of Jobs Created by Investment of 1 Trillion Yen (based on Japan s 2005 Industry Input-Output Table) (X1000) 500 450 400 350 300 250 200 150 100 50 0 226 (100) Physical Infrastructure 245 (108) 408 (180) 472 (208) Medical/Health Social Welfare Elderly Care Source: MASUDA Takanobu, Master Thesis, Waseda Univ., GITS, 2009 8 Electronic Health Record (EHR Offer the challenge to change from paper medical/health record to Computerized/Electronic Record. In this way it is easy to share patient health records among relevant physicians/organizations. Moreover using the Internet allows the implementation of the Evidence Based Medicine (EBM). Precautions: Privacy protection and security

The Vision 電 子 カルテおよび 地 域 健 康 情 報 ネットワーク Regional Health Information Network (RHIN) and Electronic Health Record (EHR) 患 者 市 民 Patients, People 患 者 自 宅 Patient s Home 薬 局 Pharmacist 在 宅 患 者 クリニック Clinic for Patients at Home 電 子 カルテ 地 域 健 康 情 報 NW EHR & RHIN かかりつけ 医 ( 家 庭 医 総 合 医 ) GP (General Practitioner), Primary Care Physician 救 急 車 Ambulance 地 域 中 核 病 院 Core Hospital リハビリテーション 病 院 Rehabilitation Hospital 13 This system opens the vision a health information network. The system is widely used in Nordics countries and in to certain extends in medium to big hospitals en U.S. and Japan. In Cambodia, the Health Information System Strategic Plan (2008-2015), of the Department of Planning and Health information (DPHI), Ministry of Health, is considereing the application of this system to the availability of relevant, timely and high quality health and health-related information for evidence-based policy formulation, decision making, program implementation, and monitoring and evaluation so as to contribute toward the improved health status of the Cambodian people.

Developing EHR Systems for use and development In Developing Countries At Waseda University, Graduate School of Global Information and Telecommunications Studies (GITS), three students developed EHR systems for use in developing countries, based on the openehr standards: Yunan Satria (Indonesia): EHR for emergency medical service in Jakarta. Saran Kong (Cambodia): EHR for tuberculosis data collection in Cambodia Hok Kakada (Cambodia): EHR for maternal and child care in Cambodia Choice of the openehr as a basis because: It provides semantic interoperability based on the use of archetype. It provides clear responsibility separation between clinicians and IT experts. It is standardized at ISO as ISO 13606 Standard. It facilitates generic EHR processing platform to be built. It is open-source, which is suitable for developing countries.. 15 Why open source software is suitable for developing countries and developed countries as well? Open source software modules are free and can be downloaded from websites on the internet: Example websites: openehr Java Reference Implementation Open source http://www.openehr.org/svn/ref_impl _java/ Archetype Editor Free Ocean Informatics http://www.oceaninformatics.com/ Template Designer License Wrapper technique Open source http://www.openehr.org/projects/oper effa.html Software program modules produced on the basis of open source software would usually be expected to become open source software as well Example: Programs written by the three students are available free at: http://kenai.com/projects/openehr-app/sources/subversion/show 16

Countries Using openehr Country Australia Brazil Canada Chile Denmark India Netherlands Singapore Slovakia Slovenia Sweden UK USA Organization PatientOS.com Ministry of Health PatientOS.com Ministry of Health Ministry of Health Ministry of Health National Health Service PatientOS.com Source: openehr, Governments and openehr, 2010 17 Trial EHR system for emergency service in Jakarta Waseda Univ. in Japan Internet 2G Mobile Network in Jakarta ipod Touch Blackberry EHR on PC EHR on a mobile hand set Source: Yunan Satria, Master Thesis, GITS, Waseda University, July 2009 18

EHR system for tuberculosis data collection in Cambodia Input Screen Image on PC Source: Saran Kong, Master Thesis, GITS, Waseda University, July 2010 19 EHR system for maternal and child care in Cambodia Screen Image of EHR for Uterus Examination Source: Hok Kakada, Master Thesis, Waseda University, GITS, July 2010 20

Evaluation of the EHR Trial Systems All three students produced EHR systems in a year and had been put for trial: - EHR system for emergency medical service in Jakarta for 2 months (Yunan Satria) - EHR system for tuberculosis data collection at the Ministry of Health in Phnom Penh for demonstration (Saran Kong) - EHR for maternal and child care at Maternal and Child Care Center Hospital in Phnom Penh for demonstration (Hok Kakada) Experts who used the EHR systems were all satisfied with them. The production cost was free, thanks to the use of open source software. What was needed were: PC for each, Internet Access (high speed) Produced software modules were all made available on the internet free. http://kenai.com/projects/openehr-app/sources/subversion/show 21 How would open source software people make money? Would EHR software bring revenue to developing countries? The anticipated business model 病 院 1 Hospital 1 相 互 通 信 が 可 能 Interoperable 病 院 2 Hospital 2 病 院 診 療 所 毎 の 電 子 カルテシステム EHR system for specific hospitals/clinics システム インテグレーター System Integrator 各 種 機 能 モジュールを 統 合 して 病 院 診 療 所 毎 の 電 子 カルテシステムを 作 成 維 持 する Integrates appropriate functional modules to build and maintain a specific EHR system Security Scheduling Reporting Registration Order Medication Billing... Med Staff Portal Admin Portal Patient Portal DB Access Data Base 各 種 機 能 モジュール (オープン ソースand/or 有 料 ) Various Functional Modules (Open Source and/or Priced) フロント エンド(Front-end) openehr アーキタイプ 1 Archetype 1 アーキタイプ2 Archetype 2 意 味 的 相 互 運 用 性 確 保 のための プラットフォーム(Back-end) Platform (or Back-end) for Semantic Inter-operability 22

One existing EHR business model based on open source software - PatientOS example - System Integrators Global Med Solutions (US North East) Alto Fiera (US South) Technotic (US Mid West) Clear Medica (Canada) PatientOS Inc. (patientos.com) New Creation Information Tech (India) PatientOS.org (Front-end): (Open Source Software Modules) Security- Role base Scheduling Reporting Registration Order Medication Billing Clinical form Back-end: openehr Archetypes (Free) Source: KANO Sadahiko based on documents on http://www.patientos.org/com. 23 Conclusion EHR systems are needed for evidence based policy making, as well as assisting clinicians and staff to run efficiently medical care institutions, and reducing medical expenditure, both for developing and developed countries. Current EHR systems are so expensive that even in developed countries, their use is limited to some 10-20 % in most countries, except in Nordic countries. A new trend is emerging to make EHR systems based on open source software. The openehr approach is gaining world-wide acceptance because of its beautiful architecture and its adoption as international standard as ISO 13606. This will enable both developing and developed countries to use EHR systems on a wider scale. For developing countries to bring revenues by producing EHR systems for specific hospitals, clinics and other healthcare institutions, they have to nurture people who have skills to become system integrators. 24