Critical analysis of the usage of patient demographic and clinical records during doctor-patient consultations: a Malaysian perspective.
Int. J. Healthcare Technology and Management, Vol. 11, Nos. 1/2, 2010
113
Critical analysis of the usage of patient demographic
and clinical records during doctor-patient
consultations: a Malaysian perspective
Mohd Khanapi Abd Ghani
Faculty of Information and Communication Technology,
Universiti Teknikal Malaysia Melaka,
Hang Tuah Jaya, 76100,
Durian Tunggal, Melaka, Malaysia
E-mail: khanapi@utem.edu.my
Rajeev K. Bali, Raouf N.G. Naguib
and Ian M. Marshall
Faculty of Computing and Engineering,
Biomedical Computing and Engineering Technologies
Applied Research Group (BIOCORE),
Coventry University Coventry, CV1 5FB, UK
E-mail: r.bali@coventry.ac.uk
E-mail: r.naguib@coventry.ac.uk
E-mail: i.marshall@coventry.ac.uk
Nilmini S. Wickramasinghe*
School of Business IT and Logistics,
RMIT University,
GPO Box 2476, Melbourne, VIC 3001, Australia
Fax: +61 3 9925 5850
E-mail: nilmini.wickramasinghe@rmit.edu.au
*Corresponding author
Abstract: The Lifetime Health Record (LHR) is the central key delivery
component of Malaysia’s integrated telehealth application. The LHR consists
of the summarised health records of every individual compiled from their
Electronic Medical Record (EMR). The most important consideration however
is that the patient health record should not only be available and accessible
seamlessly, but also has the ability to be continuously captured by healthcare
professionals. This research aims to analyse and identify the most crucial
patient demographic and clinical records that are referred to and recorded by
the doctors during the consultation encounter.
Keywords: clinical record; patient demographic; knowledge management;
telehealth; Malaysia.
Copyright © 2010 Inderscience Enterprises Ltd.
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Reference to this paper should be made as follows: Abd Ghani, M.K.,
Bali, R.K., Naguib, R.N.G., Marshall, I.M. and Wickramasinghe, N.S. (2010)
‘Critical analysis of the usage of patient demographic and clinical
records during doctor-patient consultations: a Malaysian perspective’, Int. J.
Healthcare Technology and Management, Vol. 11, Nos. 1/2, pp.113–130.
Biographical notes: M.K. Abd Ghani is a Senior Lecturer at Universiti
Teknikal Malaysia Melaka (UTeM). He has 16 years experiences in
Implementing and Managing Commercial and National ICT projects before
changed his career path from industry to academia in 2003. He earned his MSc
in Real-time Software Engineering from Malaysia Technology of University.
His research areas of interest include electronic healthcare systems,
telemedicine, ICTs and system architecture and design. He currently undertakes
his PhD at Coventry University on formulating an Integrative Telemedicine
Framework for Malaysia.
Rajeev K. Bali is a Reader in Healthcare Knowledge Management at Coventry
University (UK). His main research interests lie in clinical and healthcare
knowledge management (from both technical and organisational perspectives).
He founded and leads the Knowledge Management for Healthcare (KARMAH)
research subgroup (working under BIOCORE). He is well published
in peer-reviewed journals and conferences and has been invited to deliver
presentations and speeches in the USA, Canada, Singapore and Finland
among other countries. He serves on various editorial boards and conference
committees and is a regular international invited speaker.
Raouf N.G. Naguib is Professor of Biomedical Computing and Head of
BIOCORE. Prior to this appointment, he was a Lecturer at Newcastle
University, UK. He has published over 290 journals and conference papers and
reports in many aspects of biomedical and digital signal processing, image
processing, AI and evolutionary computation in cancer research. He was
awarded the Fulbright Cancer Fellowship in 1995–1996 when he carried out
research at the University of Hawaii in Mãnoa, on the applications of artificial
neural networks in breast cancer diagnosis and prognosis. He is a member
of several national and international research committees and boards.
Ian M. Marshall is Pro-Vice Chancellor for Research at Coventry University.
His applied research interests are focused around the use of games in education
and training and in development effort estimation for multimedia and other
interactive courseware. He has worked extensively as a Computer and
Information Systems Consultant, Flexible Learning Material Developer and
Trainer. In addition, he has extensive experience of working with small to
medium-sized enterprises as well as city councils and Regional Development
Agencies.
Nilmini S. Wickramasinghe researches and Teaches in several areas within
Information Systems, including IT for competitive advantage, knowledge
management, e-commerce and m-commerce and organisational impacts of
technology. In addition, she specialises in the impacts of technologies on the
healthcare industry and various aspects of medical informatics. She is well
published in all these areas, having written books, numerous refereed scholarly
papers and encyclopedia entries. She regularly presents her work throughout
North America as well as in Europe and Australiasia. Currently, she is the
Professor of Information Management and Library Science at RMIT
University’s School of Business IT and Logistics.
Critical analysis of the usage of patient
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Introduction
In its attempt to propel Malaysia into a ‘developed nation’ status, the Malaysian
Government has formulated vision and mission statements, such as the Malaysian Vision
2020 and the Malaysian Healthcare Vision (Mohamad, 1996; Government of Malaysia,
2007). In trying to realise both these visions, the Government and the Ministry of Health
of Malaysia (MOHM) have established the Integrated Telehealth initiative where the
Lifetime Health Record (LHR) is used as the basis for continuous care.
The LHR is the summarised health record of every individual compiled from
their Electronic Medical Record (EMR) (EMRWorld, 2006). EMR refers to the patient’s
EMR that is cumulatively derived from the clinical support system and which
can be collected from the various spectra of healthcare information systems (Mohd Yusof
et al., 2007).
An integrated LHR is crucial for continuing care and is currently operating in many
countries such as Canada, the UK and in mainland Europe. The Canadian Government
has committed to the development of an interoperable enterprise Electronic Health
Record (EHR) solution by integrating approximately 40,000 existing health information
systems in use across the country (Canada Health Infoway, 2006). Similar efforts are
also being undertaken in the UK National Health Service (NHS) through its extensive
health ICT project, connecting for Health, CfH (National Health Services, 2006).
The NHS has identified EHR services as the most integral component among the
applications and a crucial backbone of the NHS health infrastructure (National Health
Services, 2007).
Both Canada and the UK have acknowledged that disparate health information
systems and isolated EHRs will not be sustained in the long term. The healthcare services
will not be improved if the services are still episodic and access to health records is
always restricted within a healthcare facility and application system (Williams and
Moore, 1995). Good care is dependent on access to the previous medical records, which
should be a feature of healthcare systems in the future.
Malaysia, like many other countries, is still trying to find the best solution to link all
EHRs (termed as LHR) into single an integrated system. The LHR is the central key
delivery component of the Malaysian integrated telehealth application. The most
important consideration however is that the patient health record should not only be
available and accessible seamlessly, but also possesses the ability to be continuously
captured by the doctors.
In order to achieve this, the minimal health records that need to be captured by
doctors have to be identified, prioritised and simplified. Minimal health records and quick
data entry will assist and encourage doctors to use the system to create the many EMRs
require to generate the integrated LHR repository for future references.
This paper analyses and identifies the most crucial patient demographic and clinical
records that are referred to and recorded by doctors during consultation encounters.
The results will be used to identify the minimal patient health records for developing and
proposing standard data sets for the LHR that would be used to support the
implementation of Malaysia’s integrated telehealth system.
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M.K. Abd Ghani et al.
Background to the Malaysian healthcare system
2.1 The current healthcare delivery system and physical set-up
The public healthcare system in Malaysia has a hierarchical pyramid-based structure.
At the base of the pyramid is a broad array of primary healthcare services (such as health
centres, polyclinics, mobile clinics and maternal and child clinics) spread throughout the
country. The next level is that of the district hospitals in every one of 120 districts,
feeding into state general hospitals in each state capital (Nguyen et al., 2008). At the top
of the pyramid lies the Hospital Kuala Lumpur which is the national tertiary reference
centre which provides specialist and super specialist services for the nation (Abu Bakar,
2007; Ariff et al., 2002).
In terms of physical healthcare facility setup, the healthcare premises are normally
developed in the most populated areas. Since 1998, 95% of the population are living
within a 5-km radius of the nearest healthcare facility (Suleiman, 2001). This set-up
enables patients from anywhere in the country to be referred to the appropriate hospital
and to access and visit several healthcare facilities through a nationwide network of
clinics, hospitals and other health programmes in a convenient manner.
2.2 Background to the outpatient clinics
The outpatient clinics department administratively reports to the Family Health Division
of the Public Health Services of MOHM. Healthcare services are provided through
various health centres and community polyclinics strategically located in the most
populated areas in the district. The health centres and community polyclinics comprise
the first level of service made available to the community.
The services provided are comprehensive at this level, essentially comprising
maternal health, child health, acute care of diseases, chronic care of diseases, mental
health, geriatric care, community-based rehabilitation, well person services and health
promotion. These services are provided on an outpatient basis.
In order to support such services, there are laboratory services and also radiological
services. Pharmaceutical services are also provided in-house. These comprehensive
services and workflows were the main reason for the selection of the outpatient clinic
department as a case study organisation for advancing knowledge in this area. The
selected organisation will cover most of the processes of consultation and medical
diagnosis workflow in the outpatient clinic. The healthcare setting provides relevant
evidence and extensive information about patient demographics and clinical data that
would contribute in developing the LHR components and structure.
3
Methods
The chosen research design was a case-study approach conducted at the outpatient clinics
of MOHM. Two key techniques contributed to the primary data collection and the
proposition of the LHR data sets:
•
conducting of system analysis
•
conducting of an analysis of patient demographics and clinical data.
Critical analysis of the usage of patient
117
The first method – conducting a system analysis – is where the case being studied was
explored through case study analysis by way of accessing archival records, discussions
and interviews. The crucial patient demographics and health records were identified
and obtained initially through the collection of the secondary data from various sources,
such as documents and archival records (paper-based consultation templates and
administrative and clinical forms). The pilot telemedicine application was also
investigated and analysed extensively by way of open-ended interviews, discussions and
reviews of the archived records. A telemedicine contractor was also contacted for
accessing crucial information and data (such as technical reports and application
implementation experiences) that could provide invaluable input and a clear
understanding of the pilot telemedicine application blueprint.
The second method was an analysis of patient demographics and clinical data.
Outpatient clinic personnel were contacted for accessing and obtaining the primary
source of evidence (analysis of patient demographics and clinical data through structured
interviews). Based upon responses and feedback from the initial case study, detailed
questionnaires were created to collect the primary evidence and data. Through the main
personnel contact of the case study organisation, 30 respondents (Medical Officers or
GPs) from different health clinics and polyclinics were identified for interview.
According to Naiburg and Maksimchuk (2001), the best way to understand the business
process and information obtained from the many players and sources is to begin by
modelling their descriptions. In this research, this is performed through an analysis of the
outpatient clinic business model, which describes the activities, users and stakeholders
involved in the workflow.
The interviews were carried out by ten assistant researchers who were appointed to
conduct the interviews with 30 doctors in outpatient clinics. The assistant researchers
were selected among medical graduates who had extensive knowledge in the area under
study. This ensured the discussion between interviewer and respondent was conducted
smoothly.
4
Results
The results presented below fall into several categories including:
1
general knowledge of health informatics
2
opinion on the importance of patient health records
3
crucial questions asked by the doctors during doctor-patient encounter
4
patient demographics information
5
findings from the analysis of clinical data.
4.1 General knowledge of health informatics
The first part of the questionnaire focused on the general knowledge of the doctors
regarding health ICT and health informatics initiatives. Approximately 81% of the
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doctors previously knew of health ICT and health informatics. However, when doctors
were asked about telemedicine, telehealth and e-health applications, 94% said that they
were aware of these applications. This statistic gives a good indication that the majority
of doctors are aware of health informatics and its applications. This factor is important
for management implementing the health ICT initiatives in the healthcare system where
the training and awareness programmes will be identified accordingly.
On the other hand, approximately 48% of the doctors answered that they had heard
about EMR and LHR before, while 52% were unaware of them. The small percentage in
the ‘Yes’ category may be attributed to the terms used in the questionnaire being
unfamiliar to the doctors.
Figure 1 shows the percentage of doctors who were aware of health ICT project
initiatives at the MOHM. Approximately 65% answered that they were aware of the
project currently being implemented in certain healthcare facilities nationwide. However
35% of the doctors did not know of it. The doctors reported that most of them were not
equipped with the right ICT facilities (PCs and Internet) and the nature of their work
process was still ingrained with the traditional method (manual systems such as pen and
paper to record the clinical findings and medical reference books to look up any
necessary references) to provide healthcare services to patients. This finding is important
for the management to take action in providing ICT infrastructure and telemedicine
applications across healthcare centres and levels.
Figure 1
Doctor’s general knowledge of health informatics (see online version for colours)
4.2 Opinion on the importance of patient health records
The findings and evidence obtained from the primary data collection show that seamless
and continuous access to patient demographics are critical and crucial. This fact was
supported from the findings during the primary data collection and include:
approximately 52% and 35% of the doctors ‘strongly agreed’ or ‘agreed’, respectively,
that they faced difficulties if they could not access a patient’s medical history. Additional
findings were that approximately 74% of the doctors ‘strongly agreed’ that by sharing
the health records with the patient, the quality of healthcare service would be improved
(refer to Figure 2).
Critical analysis of the usage of patient
Figure 2
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Doctor’s opinion on the important of patient health record (see online version
for colours)
An effective way of handling and disseminating patient medical records is crucial for
ensuring the medical history of the patent can be accessed efficiently and promptly in the
future. Based on the answers obtained from the interview, approximately 65% of the
healthcare centres have a pre-defined way of creating, accessing and disseminating
patient medical records. This shows that outpatient clinics still require improvement by
way of enforcing all healthcare centres to use a standardised process to continuously
maintain the patient health records. The current situation might be due to the time
constraints and heavy workloads faced by doctors in the outpatient clinics. The main
responsibility and priority of the doctors in outpatient clinics is to provide the best and
highest quality of patient care.
4.3 Crucial questions asked by doctors during a doctor-patient encounter
Figure 3 reflects the crucial questions asked by doctors during consultation and medical
diagnosis. The survey found that 77% of doctors ‘strongly agree’ that the current
problems (see column B) and past medical problems (see column F) are the most
critical questions to be asked prior to further treatment being administered to a patient.
The symptoms and signs (see column C), as well as when the problems occurred
(see column E), are also critical information needed to be known by the doctors – 74%
of doctors ‘strongly agree’ that this was the case. This demonstrates that the past
health conditions of patients are very important and critical in helping the doctors give
accurate treatment and ensuring a high quality of healthcare. Correct treatment requires
accurate past medical history and this is why 65% and 52% respectively of doctors asked
about medication information (see column H) and family medical history (see column G).
Such information should be available at all times and accessible continuously and
seamlessly. The availability of an integrated LHR through a telemedicine system is vital
for achieving accurate and continuous care.
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Figure 3
A
B
C
D
E
F
G
H
The types of questions frequently asked during a doctor-patient consultation
(see online version for colours)
Hello/How are you?
What is your problem?
Can you tell me your complaints/symptoms
How severe is your problem?
How long ago did you realise you had the problem?
Can you tell me about your past medical history?
Does your family have any history of chronic diseases?
Do you previously take any medication?
4.4 Patient demographics information
Figure 4 shows the list of patient demographic information that needs to be known by the
doctors during consultation and medical diagnosis. The use of demographic information
is to get the biological (such as age and gender) and sociological (occupation, race,
ethnicity and religion) background of the patient. According to the interviews with the
doctors, they singled out five attributes (marked as A, B, C, D and H in Figure 4) that
they strongly agreed to use during consultation and medical diagnosis. The doctors
commonly ask three attributes of patient information:
1
patient’s name
2
date of birth
3
gender.
This information is to ensure the patient’s medical record security and they are treating
the right patient; date of birth and gender are the best practice guidelines to identify the
biological aspect with regard to the medical problems. They also mentioned that the
occupation information is to extend the knowledge of the patient’s work-related
conditions that might contribute to the medical problems experienced.
The majority of the doctors marked the religion (35%), ethnicity (35%) and
nationality (48%) as ‘neutral’ where they believe that this information is less important
(nice to have) and do not impact significantly on the treatment given to the patient
(see column E, F and G in Figure 4). Identity Card (IC) number (35%) and Passport
number (35%) are marked as ‘strongly disagree’ which means they are less important to
clinical aspects during consultation process (see column I and J in Figure 4).
Critical analysis of the usage of patient
Figure 4
A
B
C
D
E
F
G
H
I
J
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The analysis of patient demographic information to be viewed by doctors
during consultation (see online version for colours)
Patient’s name
Age/Date of birth
Gender
Race
Religion
Ethnicity
Nationality
Occupation
IC number
Passport number
The most important point to be noted from this finding is that not all demographic
information is required by the doctors during the consultation and medical diagnosis.
The minimum crucial information could be summarised in simple text so that it could be
stored into limited portable storage devices and transported via a limited bandwidth
network (e.g. the use of SMS via GSM digital network).
4.5 Findings from the Analysis of the Clinical Data
4.5.1 Medical history
When questioned regarding the patient’s medical history and asked to identify could be
important to be viewed during doctor-patient consultation; the doctors believe that all of
the information are crucial for helping them in diagnosing the patient’s problem and
providing the right treatment and accurate medication. Based on the findings given in
Figure 5, the doctors agreed that information about blood, immunisation, disability,
previous doctor dealing with the problem and previous healthcare facility attended
(see columns B, K, M, N and O) are important but still could not be categorised as critical
information. The doctors explained that the gathering of this information would only
provide administrative advantages compared to clinical advantages.
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Figure 5
A
B
C
D
E
F
G
H
I
M.K. Abd Ghani et al.
The list of patient medical history to be viewed by doctors during consultation
(see online version for colours)
Diagnosis/problems
Blood information
Allergies information
Lab test result
Radiology report
Medication information
Complaints information
Symptoms
Vital signs
J
K
L
M
N
O
P
Q
Family history
Immunisation
Social history
Disability information
Previous doctor attending to the problem
Previous healthcare facility
Date of the visit/episode
Onset date of diseases
The doctors answered ‘strongly agree’ to the questions related to diagnosis/problems,
allergies information, lab test results, radiology reports, medication information,
complaints information, symptoms, vital signs, family history, social history, date of
previous visits and onset date of diagnosis (see columns A, C, D, E, F, G, H, I, J, L, P and
Q). They elaborated that this information provides critical evidence and knowledge
on patient’s past health condition. Such information could give the doctors the ability
to carry out better clinical prognoses and provide more accurate treatment to the patient.
Based on the above findings, the medical history is crucial in providing high quality
healthcare services to the patient. The doctors also mentioned that the availability and
accessibility to the information would improve patient security and the efficacy of
healthcare services.
Nevertheless, the challenge to be undertaken here is how to simplify the information
and maintain the critical attributes so that it can be accessed and stored continuously and
seamlessly when needed. The information listed in Figure 5 could be simplified and
categorised into several levels based on the highest percentages of the survey result.
Finally, the doctors further pointed out that if the listed medical history information
could be provided continuously, continuum of care could be achieved and the quality
of healthcare services would be improved.
4.5.2 Radiology information
Figure 6 shows the findings of the questions related to radiological information that
would be useful in providing care during consultation processes. Most of the doctors
‘strongly agreed’ and ‘agreed’ that the date and time of studies conducted (52% and 45%,
respectively), study reports (55% and 45%, respectively) and part of the body examined
Critical analysis of the usage of patient
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(58% and 39%, respectively) were crucial in providing clues about the patient’s
condition. The doctors pointed out that the three attributes (see column A, B and C) were
commonly accessed for medical diagnosis processes. The doctors explained that the date
and time of studies undertaken provide information on the last investigation was being
performed. While the study reports attribute provide the most important finding of the
examination and part of body examined provide information regarding location of the
body part being examined.
Figure 6
A
B
C
D
E
F
The list of radiology information that would be viewed by the doctor
during consultation (see online version for colours)
Date and time of studies done
Study reports
Parts of body examined
Name of interpreter
Number of pictures taken
Place and location of studies done
The doctors agreed that another three attributes – the name of interpreter (39%), number
of images taken (52%) and place or location of studies conducted (45%) – were also
useful and contained some interesting information. The doctors pointed out, however,
that they observed that these attributes were not considered to be important information.
The doctors further commented that these attributes would be more beneficial for
administrative purposes rather than clinical functions.
4.5.3 Test information
Regarding the question about which test information is important to assist in the
consultation and medical diagnosis processes, the doctors strongly agreed that the date
and time of test (55%), test result (68%), test report (68%) and type of test (65%)
(see columns A, B, C and D in Figure 7) are vital. The doctors pointed out that this
information would provide clinical evidence with regard to the problems suffered by the
patients.
The doctors observed that the attributes concerning the number of tests taken and
place and location of the tests (see columns E and F in Figure 7) were not considered to
be important. Feedback given by doctors, indicated that approximately 26% said
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they ‘strongly agree’ and 48% said they ‘agree’ that the number of tests taken was
important. When asked about the importance of the place and location of the test
information, approximately 19% said they ‘strongly agree’ and 29% said they ‘agree’ that
these were important. The doctors further pointed out that this information was not
considered necessary for clinical purposes but may be beneficial for administrative
purposes.
Figure 7
A
B
C
D
E
F
The list of test information to be viewed by the doctors during consultation
(see online version for colours)
Date and time of test
Test result
Test report
Type of test
Number of tests taken
Place and location of test done
4.5.4 Medication information
Figure 8 shows doctors’ views on the importance of medication information in
influencing the outcome of a consultation and medical diagnosis. The doctors ‘strongly
agreed’ that the date the drug started to be taken (65%), drug name (61%), dosage (65%)
and frequency of taking the drug (64%) (see columns A, B, C and D in Figure 8) are
active considerations before prescribing the medication. The doctors pointed out that best
practice regarding medication is to continue prescribing the medication that has been
taken by the patient before.
The findings also showed that the location of the drug taken (see column E
in Figure 8) is considered less important in the consultation and medical diagnosis
processes. Approximately, only 19% ‘strongly agree’ and 35% ‘agree’ that this
information should be known by the doctors. In fact, 26% answered ‘neutral’, 13%
‘disagree’ and 6% ‘strongly disagree’ that this information is important to be known or
considered. This was attributed to the fact that each healthcare centre has an internal
pharmacy service and normally the prescription will be dispensed in the same healthcare
centre. As such, the location of the drug can be referred to the healthcare facility that is
visited by the patient.
Critical analysis of the usage of patient
Figure 8
125
The list of medication information to be viewed by the doctors during consultation
(see online version for colours)
A
B
C
D
E
Date the drug started to be taken
Name of drug
Dosage
Frequency of taking the drug
Place and location of the drug taken
5
Proposed LHR Data Sets
Based on inputs and evidence obtained from the case study, the LHR was divided into
three components (refer Figure 9).
•
Patient Master Information (PMI)
•
Health condition summary
•
Episode summary.
Figure 9
Proposed LHR components
5.1 Patient Master Information (PMI)
Patient Master Information (PMI) comprises administrative records and the information
required to identify and distinguish the patient across healthcare facilities and levels
(Health Level 7, 2008; Ministry of Health Malaysia, 2003). It is often used to locate
the patient identifier, including patient demographics and the related health
administration information. It includes: demographic record, next of kin record,
birth record, family health record, medical insurance record, employment record and
organ donor record.
It was noted from the findings of the primary data collection that the analysis of
patient demographic information is very important during the consultation and medical
diagnosis workflow. The demographic information is indicated as compulsory due to the
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fact that it is a key identifier of the patient. The administrative records (examples are next
of kin, birth, family health, medical insurance, employment and organ donor records)
could be included as optional records in the patient information.
5.2 Health condition summary
The health condition summary comprises records which summarise the illness and
wellness conditions of the patient. Each condition has a status indicator to indicate
whether the condition is active or inactive. This summary of the patient’s condition will
enhance the continuity of care by providing a method for communicating the most
relevant information about a patient and providing support for the generation of the LHR
(Medical Record Institute, 2006; Ministry of Health Malaysia, 1997b). It was noted from
the primary data collection that the first step in patient care or treatment was for the
doctor to gather information about the patient’s current health status. Here, many types
of information were collected about the patient and placed in the patient’s health record.
By giving the latest health condition summary of the patient at the beginning of a first
doctor-patient encounter, the accuracy, quality, safety and continuity of care would be
ensured.
The health condition summary component could be added and enhanced in the future,
and the set of information given below is the initial information revealed from the
primary data collection and system analysis. The health condition summary comprises
such information as chronic disease record, allergy record, immunisation/vaccination
record, social history record, surgical medical procedure record, disability record and
obstetric record.
5.3 Episode summary
The episode summary is comprised of data on a particular episode or visit. If required,
it provides the necessary data for reference to the source of the information where details
of the episodes are stored. It comprises the following information: episode record,
encounter record, symptoms record, diagnosis record, lab test record, radiology record,
medication record, vital sign record and health plan record.
The LHR components defined above provide the conceptual structure for the LHR
information and it is hoped that the many LHRs could be collected and generated
continuously from telehealth applications and various health information systems.
6
Discussion
It was noted from the findings that doctors in outpatient clinics have limited time to deal
with patient problems; the average consultation is normally 20 min. This shows that the
patient health records required by the doctors to help them diagnose the patient’s problem
should be simplified (number of attributes and size in bytes) to facilitate the consultation
process and to complete it efficiently and effectively. In fact, the simplified version
of the LHR could assist the doctor in maintaining the patient’s LHR systematically
within the limited time allocated for each patient in the consultation room. This would
enhance the prompt access to patient health records and to ensure that the LHR repository
could be generated continuously.
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127
It is not sufficient to only develop the LHR component without interoperability.
The proposed LHR component should be designed in an interoperable manner.
There is a need to provide details about the LHR component and to research its
interoperability (Health Level 7, 2007). Failure to meet system interoperability could
result in a variety of unfavourable consequences, including a reduction in participation
from other health information systems, a reduction in motivation from doctors to use the
computer system and incomplete or inaccurate information being stored in the LHR
repository. Ultimately, the result of these problems may be a failure to achieve the
expected gains in efficiency and effectiveness of healthcare services, which are expected
gains from the investment in the integrated telehealth application.
The healthcare system is complex and involves multi-level clinical disciplines and
organisational structures (Bali and Wickramasinghe, 2008). The analysis on consultation
and medical diagnosis workflow in outpatient clinics through this case study research
conducted at MOHM only focuses on one of the many disciplines in healthcare services.
Specialist care was not covered in the research, and health records requirements for
treating specialist patients were not included in the development of the LHR components
and structure. As a result, the findings may not represent the views of the specialist
domain. However, a modular and scalable design of LHR components enables the
specialist care information to be added in the future.
The proposition of LHR data sets and components would impact the knowledge
management contact and practice in the healthcare sector especially in the Malaysian
healthcare context. The possible impacts from the proposed LHR data sets for generating
the LHR repository are listed as follows.
(a) Platform for research and development
The integrated telehealth system, via its role as the premier database repository for
Malaysian patients LHR, will function as the health knowledge platform from which a
variety of research and development activities within the healthcare domain can be
launched (Harun, 2002). These research and development initiatives will spearhead the
development and establishment of initiatives which will produce innovative healthcare
products and services of national and international significance.
(b) Health group data services
The standard data sets of LHR would ensure that the LHR for every citizen could be data
mined for various applications and transcends geographical and service-level constraints.
The LHR repository would be a premier health database repository in the country and it
will be an important source for health knowledge data mining purposes (Ministry of
Health Malaysia, 1997a; Wickramasinghe et al., 2006)
(c) Health knowledge communication protocol
The benefits of standard LHR data sets are numerous. The interaction with various
applications within a healthcare facility and between healthcare facilities will be
facilitated through a standard LHR document as a means of communication. The LHR
data sets would ensure that many applications could be integrated and thus increase the
interoperability of the telehealth system for integration with other health information
systems.
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M.K. Abd Ghani et al.
(d) Personalised lifetime health plan
The LHR data sets enable the many LHRs of individuals to be data mined systematically.
The LHR repository contains the LHRs of patients in a chronological order. Through
proper knowledge management applications with standardised practices, the personalised
health plans could be created or suggested, tailored to the specific needs of the individual
and formulated based on the person’s integrated LHRs (Mohan and Raja Yaacob, 2004).
The health plans and care plans jointly created by the patients (accessible through internet
with certain health record parameters such as body temperature, blood pressure, weight,
height, etc.) and doctors would generate personalised lifetime health plan for individuals
and become vital in providing quality healthcare (Ministry of Health Malaysia, 1997;
Wickramasinghe et al., 2006).
7
Conclusions
The analysis of patient demographics and clinical data usage in public outpatient clinics
across Malaysia reinforced the evidence that the summary of the patient’s health
condition is the most invaluable information required by the doctors during a consultation
and medical diagnosis encounter. The analysis concluded that the simplified version of
patient health records should be developed for incorporation into integrated telehealth
application. This was to be achieved through developing standardised LHR component
and structure. It is hoped that the proposed LHR components (which derived from the
research findings) should be able to be captured more quickly and systematically by
doctors and focusing only on the important clinical data. Through this, the complete
patient LHR in ordered in a chronological manner would be generated and this makes the
medical decision processes faster and thus directly affects the quality of patient care
(Schabetsberger et al., 2006).
Finally, the LHR components need to be detailed out and tested for interoperability.
The next step of the research will be to finalise the LHR components and validate their
interoperability. The LHR components will be tested through a working prototype system
and piloting the system in certain healthcare centres.
Acknowledgement
This research was funded by the Universiti Teknikal Malaysia Melaka (UTeM) and
Ministry of Higher Education (MOHE), Malaysia, through a research student fund. The
authors would like to thank the MOHM staff and clinicians who contributed to this study
for their support, advice and anonymous input, which assisted in improving this paper.
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113
Critical analysis of the usage of patient demographic
and clinical records during doctor-patient
consultations: a Malaysian perspective
Mohd Khanapi Abd Ghani
Faculty of Information and Communication Technology,
Universiti Teknikal Malaysia Melaka,
Hang Tuah Jaya, 76100,
Durian Tunggal, Melaka, Malaysia
E-mail: khanapi@utem.edu.my
Rajeev K. Bali, Raouf N.G. Naguib
and Ian M. Marshall
Faculty of Computing and Engineering,
Biomedical Computing and Engineering Technologies
Applied Research Group (BIOCORE),
Coventry University Coventry, CV1 5FB, UK
E-mail: r.bali@coventry.ac.uk
E-mail: r.naguib@coventry.ac.uk
E-mail: i.marshall@coventry.ac.uk
Nilmini S. Wickramasinghe*
School of Business IT and Logistics,
RMIT University,
GPO Box 2476, Melbourne, VIC 3001, Australia
Fax: +61 3 9925 5850
E-mail: nilmini.wickramasinghe@rmit.edu.au
*Corresponding author
Abstract: The Lifetime Health Record (LHR) is the central key delivery
component of Malaysia’s integrated telehealth application. The LHR consists
of the summarised health records of every individual compiled from their
Electronic Medical Record (EMR). The most important consideration however
is that the patient health record should not only be available and accessible
seamlessly, but also has the ability to be continuously captured by healthcare
professionals. This research aims to analyse and identify the most crucial
patient demographic and clinical records that are referred to and recorded by
the doctors during the consultation encounter.
Keywords: clinical record; patient demographic; knowledge management;
telehealth; Malaysia.
Copyright © 2010 Inderscience Enterprises Ltd.
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M.K. Abd Ghani et al.
Reference to this paper should be made as follows: Abd Ghani, M.K.,
Bali, R.K., Naguib, R.N.G., Marshall, I.M. and Wickramasinghe, N.S. (2010)
‘Critical analysis of the usage of patient demographic and clinical
records during doctor-patient consultations: a Malaysian perspective’, Int. J.
Healthcare Technology and Management, Vol. 11, Nos. 1/2, pp.113–130.
Biographical notes: M.K. Abd Ghani is a Senior Lecturer at Universiti
Teknikal Malaysia Melaka (UTeM). He has 16 years experiences in
Implementing and Managing Commercial and National ICT projects before
changed his career path from industry to academia in 2003. He earned his MSc
in Real-time Software Engineering from Malaysia Technology of University.
His research areas of interest include electronic healthcare systems,
telemedicine, ICTs and system architecture and design. He currently undertakes
his PhD at Coventry University on formulating an Integrative Telemedicine
Framework for Malaysia.
Rajeev K. Bali is a Reader in Healthcare Knowledge Management at Coventry
University (UK). His main research interests lie in clinical and healthcare
knowledge management (from both technical and organisational perspectives).
He founded and leads the Knowledge Management for Healthcare (KARMAH)
research subgroup (working under BIOCORE). He is well published
in peer-reviewed journals and conferences and has been invited to deliver
presentations and speeches in the USA, Canada, Singapore and Finland
among other countries. He serves on various editorial boards and conference
committees and is a regular international invited speaker.
Raouf N.G. Naguib is Professor of Biomedical Computing and Head of
BIOCORE. Prior to this appointment, he was a Lecturer at Newcastle
University, UK. He has published over 290 journals and conference papers and
reports in many aspects of biomedical and digital signal processing, image
processing, AI and evolutionary computation in cancer research. He was
awarded the Fulbright Cancer Fellowship in 1995–1996 when he carried out
research at the University of Hawaii in Mãnoa, on the applications of artificial
neural networks in breast cancer diagnosis and prognosis. He is a member
of several national and international research committees and boards.
Ian M. Marshall is Pro-Vice Chancellor for Research at Coventry University.
His applied research interests are focused around the use of games in education
and training and in development effort estimation for multimedia and other
interactive courseware. He has worked extensively as a Computer and
Information Systems Consultant, Flexible Learning Material Developer and
Trainer. In addition, he has extensive experience of working with small to
medium-sized enterprises as well as city councils and Regional Development
Agencies.
Nilmini S. Wickramasinghe researches and Teaches in several areas within
Information Systems, including IT for competitive advantage, knowledge
management, e-commerce and m-commerce and organisational impacts of
technology. In addition, she specialises in the impacts of technologies on the
healthcare industry and various aspects of medical informatics. She is well
published in all these areas, having written books, numerous refereed scholarly
papers and encyclopedia entries. She regularly presents her work throughout
North America as well as in Europe and Australiasia. Currently, she is the
Professor of Information Management and Library Science at RMIT
University’s School of Business IT and Logistics.
Critical analysis of the usage of patient
1
115
Introduction
In its attempt to propel Malaysia into a ‘developed nation’ status, the Malaysian
Government has formulated vision and mission statements, such as the Malaysian Vision
2020 and the Malaysian Healthcare Vision (Mohamad, 1996; Government of Malaysia,
2007). In trying to realise both these visions, the Government and the Ministry of Health
of Malaysia (MOHM) have established the Integrated Telehealth initiative where the
Lifetime Health Record (LHR) is used as the basis for continuous care.
The LHR is the summarised health record of every individual compiled from
their Electronic Medical Record (EMR) (EMRWorld, 2006). EMR refers to the patient’s
EMR that is cumulatively derived from the clinical support system and which
can be collected from the various spectra of healthcare information systems (Mohd Yusof
et al., 2007).
An integrated LHR is crucial for continuing care and is currently operating in many
countries such as Canada, the UK and in mainland Europe. The Canadian Government
has committed to the development of an interoperable enterprise Electronic Health
Record (EHR) solution by integrating approximately 40,000 existing health information
systems in use across the country (Canada Health Infoway, 2006). Similar efforts are
also being undertaken in the UK National Health Service (NHS) through its extensive
health ICT project, connecting for Health, CfH (National Health Services, 2006).
The NHS has identified EHR services as the most integral component among the
applications and a crucial backbone of the NHS health infrastructure (National Health
Services, 2007).
Both Canada and the UK have acknowledged that disparate health information
systems and isolated EHRs will not be sustained in the long term. The healthcare services
will not be improved if the services are still episodic and access to health records is
always restricted within a healthcare facility and application system (Williams and
Moore, 1995). Good care is dependent on access to the previous medical records, which
should be a feature of healthcare systems in the future.
Malaysia, like many other countries, is still trying to find the best solution to link all
EHRs (termed as LHR) into single an integrated system. The LHR is the central key
delivery component of the Malaysian integrated telehealth application. The most
important consideration however is that the patient health record should not only be
available and accessible seamlessly, but also possesses the ability to be continuously
captured by the doctors.
In order to achieve this, the minimal health records that need to be captured by
doctors have to be identified, prioritised and simplified. Minimal health records and quick
data entry will assist and encourage doctors to use the system to create the many EMRs
require to generate the integrated LHR repository for future references.
This paper analyses and identifies the most crucial patient demographic and clinical
records that are referred to and recorded by doctors during consultation encounters.
The results will be used to identify the minimal patient health records for developing and
proposing standard data sets for the LHR that would be used to support the
implementation of Malaysia’s integrated telehealth system.
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2
M.K. Abd Ghani et al.
Background to the Malaysian healthcare system
2.1 The current healthcare delivery system and physical set-up
The public healthcare system in Malaysia has a hierarchical pyramid-based structure.
At the base of the pyramid is a broad array of primary healthcare services (such as health
centres, polyclinics, mobile clinics and maternal and child clinics) spread throughout the
country. The next level is that of the district hospitals in every one of 120 districts,
feeding into state general hospitals in each state capital (Nguyen et al., 2008). At the top
of the pyramid lies the Hospital Kuala Lumpur which is the national tertiary reference
centre which provides specialist and super specialist services for the nation (Abu Bakar,
2007; Ariff et al., 2002).
In terms of physical healthcare facility setup, the healthcare premises are normally
developed in the most populated areas. Since 1998, 95% of the population are living
within a 5-km radius of the nearest healthcare facility (Suleiman, 2001). This set-up
enables patients from anywhere in the country to be referred to the appropriate hospital
and to access and visit several healthcare facilities through a nationwide network of
clinics, hospitals and other health programmes in a convenient manner.
2.2 Background to the outpatient clinics
The outpatient clinics department administratively reports to the Family Health Division
of the Public Health Services of MOHM. Healthcare services are provided through
various health centres and community polyclinics strategically located in the most
populated areas in the district. The health centres and community polyclinics comprise
the first level of service made available to the community.
The services provided are comprehensive at this level, essentially comprising
maternal health, child health, acute care of diseases, chronic care of diseases, mental
health, geriatric care, community-based rehabilitation, well person services and health
promotion. These services are provided on an outpatient basis.
In order to support such services, there are laboratory services and also radiological
services. Pharmaceutical services are also provided in-house. These comprehensive
services and workflows were the main reason for the selection of the outpatient clinic
department as a case study organisation for advancing knowledge in this area. The
selected organisation will cover most of the processes of consultation and medical
diagnosis workflow in the outpatient clinic. The healthcare setting provides relevant
evidence and extensive information about patient demographics and clinical data that
would contribute in developing the LHR components and structure.
3
Methods
The chosen research design was a case-study approach conducted at the outpatient clinics
of MOHM. Two key techniques contributed to the primary data collection and the
proposition of the LHR data sets:
•
conducting of system analysis
•
conducting of an analysis of patient demographics and clinical data.
Critical analysis of the usage of patient
117
The first method – conducting a system analysis – is where the case being studied was
explored through case study analysis by way of accessing archival records, discussions
and interviews. The crucial patient demographics and health records were identified
and obtained initially through the collection of the secondary data from various sources,
such as documents and archival records (paper-based consultation templates and
administrative and clinical forms). The pilot telemedicine application was also
investigated and analysed extensively by way of open-ended interviews, discussions and
reviews of the archived records. A telemedicine contractor was also contacted for
accessing crucial information and data (such as technical reports and application
implementation experiences) that could provide invaluable input and a clear
understanding of the pilot telemedicine application blueprint.
The second method was an analysis of patient demographics and clinical data.
Outpatient clinic personnel were contacted for accessing and obtaining the primary
source of evidence (analysis of patient demographics and clinical data through structured
interviews). Based upon responses and feedback from the initial case study, detailed
questionnaires were created to collect the primary evidence and data. Through the main
personnel contact of the case study organisation, 30 respondents (Medical Officers or
GPs) from different health clinics and polyclinics were identified for interview.
According to Naiburg and Maksimchuk (2001), the best way to understand the business
process and information obtained from the many players and sources is to begin by
modelling their descriptions. In this research, this is performed through an analysis of the
outpatient clinic business model, which describes the activities, users and stakeholders
involved in the workflow.
The interviews were carried out by ten assistant researchers who were appointed to
conduct the interviews with 30 doctors in outpatient clinics. The assistant researchers
were selected among medical graduates who had extensive knowledge in the area under
study. This ensured the discussion between interviewer and respondent was conducted
smoothly.
4
Results
The results presented below fall into several categories including:
1
general knowledge of health informatics
2
opinion on the importance of patient health records
3
crucial questions asked by the doctors during doctor-patient encounter
4
patient demographics information
5
findings from the analysis of clinical data.
4.1 General knowledge of health informatics
The first part of the questionnaire focused on the general knowledge of the doctors
regarding health ICT and health informatics initiatives. Approximately 81% of the
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M.K. Abd Ghani et al.
doctors previously knew of health ICT and health informatics. However, when doctors
were asked about telemedicine, telehealth and e-health applications, 94% said that they
were aware of these applications. This statistic gives a good indication that the majority
of doctors are aware of health informatics and its applications. This factor is important
for management implementing the health ICT initiatives in the healthcare system where
the training and awareness programmes will be identified accordingly.
On the other hand, approximately 48% of the doctors answered that they had heard
about EMR and LHR before, while 52% were unaware of them. The small percentage in
the ‘Yes’ category may be attributed to the terms used in the questionnaire being
unfamiliar to the doctors.
Figure 1 shows the percentage of doctors who were aware of health ICT project
initiatives at the MOHM. Approximately 65% answered that they were aware of the
project currently being implemented in certain healthcare facilities nationwide. However
35% of the doctors did not know of it. The doctors reported that most of them were not
equipped with the right ICT facilities (PCs and Internet) and the nature of their work
process was still ingrained with the traditional method (manual systems such as pen and
paper to record the clinical findings and medical reference books to look up any
necessary references) to provide healthcare services to patients. This finding is important
for the management to take action in providing ICT infrastructure and telemedicine
applications across healthcare centres and levels.
Figure 1
Doctor’s general knowledge of health informatics (see online version for colours)
4.2 Opinion on the importance of patient health records
The findings and evidence obtained from the primary data collection show that seamless
and continuous access to patient demographics are critical and crucial. This fact was
supported from the findings during the primary data collection and include:
approximately 52% and 35% of the doctors ‘strongly agreed’ or ‘agreed’, respectively,
that they faced difficulties if they could not access a patient’s medical history. Additional
findings were that approximately 74% of the doctors ‘strongly agreed’ that by sharing
the health records with the patient, the quality of healthcare service would be improved
(refer to Figure 2).
Critical analysis of the usage of patient
Figure 2
119
Doctor’s opinion on the important of patient health record (see online version
for colours)
An effective way of handling and disseminating patient medical records is crucial for
ensuring the medical history of the patent can be accessed efficiently and promptly in the
future. Based on the answers obtained from the interview, approximately 65% of the
healthcare centres have a pre-defined way of creating, accessing and disseminating
patient medical records. This shows that outpatient clinics still require improvement by
way of enforcing all healthcare centres to use a standardised process to continuously
maintain the patient health records. The current situation might be due to the time
constraints and heavy workloads faced by doctors in the outpatient clinics. The main
responsibility and priority of the doctors in outpatient clinics is to provide the best and
highest quality of patient care.
4.3 Crucial questions asked by doctors during a doctor-patient encounter
Figure 3 reflects the crucial questions asked by doctors during consultation and medical
diagnosis. The survey found that 77% of doctors ‘strongly agree’ that the current
problems (see column B) and past medical problems (see column F) are the most
critical questions to be asked prior to further treatment being administered to a patient.
The symptoms and signs (see column C), as well as when the problems occurred
(see column E), are also critical information needed to be known by the doctors – 74%
of doctors ‘strongly agree’ that this was the case. This demonstrates that the past
health conditions of patients are very important and critical in helping the doctors give
accurate treatment and ensuring a high quality of healthcare. Correct treatment requires
accurate past medical history and this is why 65% and 52% respectively of doctors asked
about medication information (see column H) and family medical history (see column G).
Such information should be available at all times and accessible continuously and
seamlessly. The availability of an integrated LHR through a telemedicine system is vital
for achieving accurate and continuous care.
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M.K. Abd Ghani et al.
Figure 3
A
B
C
D
E
F
G
H
The types of questions frequently asked during a doctor-patient consultation
(see online version for colours)
Hello/How are you?
What is your problem?
Can you tell me your complaints/symptoms
How severe is your problem?
How long ago did you realise you had the problem?
Can you tell me about your past medical history?
Does your family have any history of chronic diseases?
Do you previously take any medication?
4.4 Patient demographics information
Figure 4 shows the list of patient demographic information that needs to be known by the
doctors during consultation and medical diagnosis. The use of demographic information
is to get the biological (such as age and gender) and sociological (occupation, race,
ethnicity and religion) background of the patient. According to the interviews with the
doctors, they singled out five attributes (marked as A, B, C, D and H in Figure 4) that
they strongly agreed to use during consultation and medical diagnosis. The doctors
commonly ask three attributes of patient information:
1
patient’s name
2
date of birth
3
gender.
This information is to ensure the patient’s medical record security and they are treating
the right patient; date of birth and gender are the best practice guidelines to identify the
biological aspect with regard to the medical problems. They also mentioned that the
occupation information is to extend the knowledge of the patient’s work-related
conditions that might contribute to the medical problems experienced.
The majority of the doctors marked the religion (35%), ethnicity (35%) and
nationality (48%) as ‘neutral’ where they believe that this information is less important
(nice to have) and do not impact significantly on the treatment given to the patient
(see column E, F and G in Figure 4). Identity Card (IC) number (35%) and Passport
number (35%) are marked as ‘strongly disagree’ which means they are less important to
clinical aspects during consultation process (see column I and J in Figure 4).
Critical analysis of the usage of patient
Figure 4
A
B
C
D
E
F
G
H
I
J
121
The analysis of patient demographic information to be viewed by doctors
during consultation (see online version for colours)
Patient’s name
Age/Date of birth
Gender
Race
Religion
Ethnicity
Nationality
Occupation
IC number
Passport number
The most important point to be noted from this finding is that not all demographic
information is required by the doctors during the consultation and medical diagnosis.
The minimum crucial information could be summarised in simple text so that it could be
stored into limited portable storage devices and transported via a limited bandwidth
network (e.g. the use of SMS via GSM digital network).
4.5 Findings from the Analysis of the Clinical Data
4.5.1 Medical history
When questioned regarding the patient’s medical history and asked to identify could be
important to be viewed during doctor-patient consultation; the doctors believe that all of
the information are crucial for helping them in diagnosing the patient’s problem and
providing the right treatment and accurate medication. Based on the findings given in
Figure 5, the doctors agreed that information about blood, immunisation, disability,
previous doctor dealing with the problem and previous healthcare facility attended
(see columns B, K, M, N and O) are important but still could not be categorised as critical
information. The doctors explained that the gathering of this information would only
provide administrative advantages compared to clinical advantages.
122
Figure 5
A
B
C
D
E
F
G
H
I
M.K. Abd Ghani et al.
The list of patient medical history to be viewed by doctors during consultation
(see online version for colours)
Diagnosis/problems
Blood information
Allergies information
Lab test result
Radiology report
Medication information
Complaints information
Symptoms
Vital signs
J
K
L
M
N
O
P
Q
Family history
Immunisation
Social history
Disability information
Previous doctor attending to the problem
Previous healthcare facility
Date of the visit/episode
Onset date of diseases
The doctors answered ‘strongly agree’ to the questions related to diagnosis/problems,
allergies information, lab test results, radiology reports, medication information,
complaints information, symptoms, vital signs, family history, social history, date of
previous visits and onset date of diagnosis (see columns A, C, D, E, F, G, H, I, J, L, P and
Q). They elaborated that this information provides critical evidence and knowledge
on patient’s past health condition. Such information could give the doctors the ability
to carry out better clinical prognoses and provide more accurate treatment to the patient.
Based on the above findings, the medical history is crucial in providing high quality
healthcare services to the patient. The doctors also mentioned that the availability and
accessibility to the information would improve patient security and the efficacy of
healthcare services.
Nevertheless, the challenge to be undertaken here is how to simplify the information
and maintain the critical attributes so that it can be accessed and stored continuously and
seamlessly when needed. The information listed in Figure 5 could be simplified and
categorised into several levels based on the highest percentages of the survey result.
Finally, the doctors further pointed out that if the listed medical history information
could be provided continuously, continuum of care could be achieved and the quality
of healthcare services would be improved.
4.5.2 Radiology information
Figure 6 shows the findings of the questions related to radiological information that
would be useful in providing care during consultation processes. Most of the doctors
‘strongly agreed’ and ‘agreed’ that the date and time of studies conducted (52% and 45%,
respectively), study reports (55% and 45%, respectively) and part of the body examined
Critical analysis of the usage of patient
123
(58% and 39%, respectively) were crucial in providing clues about the patient’s
condition. The doctors pointed out that the three attributes (see column A, B and C) were
commonly accessed for medical diagnosis processes. The doctors explained that the date
and time of studies undertaken provide information on the last investigation was being
performed. While the study reports attribute provide the most important finding of the
examination and part of body examined provide information regarding location of the
body part being examined.
Figure 6
A
B
C
D
E
F
The list of radiology information that would be viewed by the doctor
during consultation (see online version for colours)
Date and time of studies done
Study reports
Parts of body examined
Name of interpreter
Number of pictures taken
Place and location of studies done
The doctors agreed that another three attributes – the name of interpreter (39%), number
of images taken (52%) and place or location of studies conducted (45%) – were also
useful and contained some interesting information. The doctors pointed out, however,
that they observed that these attributes were not considered to be important information.
The doctors further commented that these attributes would be more beneficial for
administrative purposes rather than clinical functions.
4.5.3 Test information
Regarding the question about which test information is important to assist in the
consultation and medical diagnosis processes, the doctors strongly agreed that the date
and time of test (55%), test result (68%), test report (68%) and type of test (65%)
(see columns A, B, C and D in Figure 7) are vital. The doctors pointed out that this
information would provide clinical evidence with regard to the problems suffered by the
patients.
The doctors observed that the attributes concerning the number of tests taken and
place and location of the tests (see columns E and F in Figure 7) were not considered to
be important. Feedback given by doctors, indicated that approximately 26% said
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they ‘strongly agree’ and 48% said they ‘agree’ that the number of tests taken was
important. When asked about the importance of the place and location of the test
information, approximately 19% said they ‘strongly agree’ and 29% said they ‘agree’ that
these were important. The doctors further pointed out that this information was not
considered necessary for clinical purposes but may be beneficial for administrative
purposes.
Figure 7
A
B
C
D
E
F
The list of test information to be viewed by the doctors during consultation
(see online version for colours)
Date and time of test
Test result
Test report
Type of test
Number of tests taken
Place and location of test done
4.5.4 Medication information
Figure 8 shows doctors’ views on the importance of medication information in
influencing the outcome of a consultation and medical diagnosis. The doctors ‘strongly
agreed’ that the date the drug started to be taken (65%), drug name (61%), dosage (65%)
and frequency of taking the drug (64%) (see columns A, B, C and D in Figure 8) are
active considerations before prescribing the medication. The doctors pointed out that best
practice regarding medication is to continue prescribing the medication that has been
taken by the patient before.
The findings also showed that the location of the drug taken (see column E
in Figure 8) is considered less important in the consultation and medical diagnosis
processes. Approximately, only 19% ‘strongly agree’ and 35% ‘agree’ that this
information should be known by the doctors. In fact, 26% answered ‘neutral’, 13%
‘disagree’ and 6% ‘strongly disagree’ that this information is important to be known or
considered. This was attributed to the fact that each healthcare centre has an internal
pharmacy service and normally the prescription will be dispensed in the same healthcare
centre. As such, the location of the drug can be referred to the healthcare facility that is
visited by the patient.
Critical analysis of the usage of patient
Figure 8
125
The list of medication information to be viewed by the doctors during consultation
(see online version for colours)
A
B
C
D
E
Date the drug started to be taken
Name of drug
Dosage
Frequency of taking the drug
Place and location of the drug taken
5
Proposed LHR Data Sets
Based on inputs and evidence obtained from the case study, the LHR was divided into
three components (refer Figure 9).
•
Patient Master Information (PMI)
•
Health condition summary
•
Episode summary.
Figure 9
Proposed LHR components
5.1 Patient Master Information (PMI)
Patient Master Information (PMI) comprises administrative records and the information
required to identify and distinguish the patient across healthcare facilities and levels
(Health Level 7, 2008; Ministry of Health Malaysia, 2003). It is often used to locate
the patient identifier, including patient demographics and the related health
administration information. It includes: demographic record, next of kin record,
birth record, family health record, medical insurance record, employment record and
organ donor record.
It was noted from the findings of the primary data collection that the analysis of
patient demographic information is very important during the consultation and medical
diagnosis workflow. The demographic information is indicated as compulsory due to the
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M.K. Abd Ghani et al.
fact that it is a key identifier of the patient. The administrative records (examples are next
of kin, birth, family health, medical insurance, employment and organ donor records)
could be included as optional records in the patient information.
5.2 Health condition summary
The health condition summary comprises records which summarise the illness and
wellness conditions of the patient. Each condition has a status indicator to indicate
whether the condition is active or inactive. This summary of the patient’s condition will
enhance the continuity of care by providing a method for communicating the most
relevant information about a patient and providing support for the generation of the LHR
(Medical Record Institute, 2006; Ministry of Health Malaysia, 1997b). It was noted from
the primary data collection that the first step in patient care or treatment was for the
doctor to gather information about the patient’s current health status. Here, many types
of information were collected about the patient and placed in the patient’s health record.
By giving the latest health condition summary of the patient at the beginning of a first
doctor-patient encounter, the accuracy, quality, safety and continuity of care would be
ensured.
The health condition summary component could be added and enhanced in the future,
and the set of information given below is the initial information revealed from the
primary data collection and system analysis. The health condition summary comprises
such information as chronic disease record, allergy record, immunisation/vaccination
record, social history record, surgical medical procedure record, disability record and
obstetric record.
5.3 Episode summary
The episode summary is comprised of data on a particular episode or visit. If required,
it provides the necessary data for reference to the source of the information where details
of the episodes are stored. It comprises the following information: episode record,
encounter record, symptoms record, diagnosis record, lab test record, radiology record,
medication record, vital sign record and health plan record.
The LHR components defined above provide the conceptual structure for the LHR
information and it is hoped that the many LHRs could be collected and generated
continuously from telehealth applications and various health information systems.
6
Discussion
It was noted from the findings that doctors in outpatient clinics have limited time to deal
with patient problems; the average consultation is normally 20 min. This shows that the
patient health records required by the doctors to help them diagnose the patient’s problem
should be simplified (number of attributes and size in bytes) to facilitate the consultation
process and to complete it efficiently and effectively. In fact, the simplified version
of the LHR could assist the doctor in maintaining the patient’s LHR systematically
within the limited time allocated for each patient in the consultation room. This would
enhance the prompt access to patient health records and to ensure that the LHR repository
could be generated continuously.
Critical analysis of the usage of patient
127
It is not sufficient to only develop the LHR component without interoperability.
The proposed LHR component should be designed in an interoperable manner.
There is a need to provide details about the LHR component and to research its
interoperability (Health Level 7, 2007). Failure to meet system interoperability could
result in a variety of unfavourable consequences, including a reduction in participation
from other health information systems, a reduction in motivation from doctors to use the
computer system and incomplete or inaccurate information being stored in the LHR
repository. Ultimately, the result of these problems may be a failure to achieve the
expected gains in efficiency and effectiveness of healthcare services, which are expected
gains from the investment in the integrated telehealth application.
The healthcare system is complex and involves multi-level clinical disciplines and
organisational structures (Bali and Wickramasinghe, 2008). The analysis on consultation
and medical diagnosis workflow in outpatient clinics through this case study research
conducted at MOHM only focuses on one of the many disciplines in healthcare services.
Specialist care was not covered in the research, and health records requirements for
treating specialist patients were not included in the development of the LHR components
and structure. As a result, the findings may not represent the views of the specialist
domain. However, a modular and scalable design of LHR components enables the
specialist care information to be added in the future.
The proposition of LHR data sets and components would impact the knowledge
management contact and practice in the healthcare sector especially in the Malaysian
healthcare context. The possible impacts from the proposed LHR data sets for generating
the LHR repository are listed as follows.
(a) Platform for research and development
The integrated telehealth system, via its role as the premier database repository for
Malaysian patients LHR, will function as the health knowledge platform from which a
variety of research and development activities within the healthcare domain can be
launched (Harun, 2002). These research and development initiatives will spearhead the
development and establishment of initiatives which will produce innovative healthcare
products and services of national and international significance.
(b) Health group data services
The standard data sets of LHR would ensure that the LHR for every citizen could be data
mined for various applications and transcends geographical and service-level constraints.
The LHR repository would be a premier health database repository in the country and it
will be an important source for health knowledge data mining purposes (Ministry of
Health Malaysia, 1997a; Wickramasinghe et al., 2006)
(c) Health knowledge communication protocol
The benefits of standard LHR data sets are numerous. The interaction with various
applications within a healthcare facility and between healthcare facilities will be
facilitated through a standard LHR document as a means of communication. The LHR
data sets would ensure that many applications could be integrated and thus increase the
interoperability of the telehealth system for integration with other health information
systems.
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M.K. Abd Ghani et al.
(d) Personalised lifetime health plan
The LHR data sets enable the many LHRs of individuals to be data mined systematically.
The LHR repository contains the LHRs of patients in a chronological order. Through
proper knowledge management applications with standardised practices, the personalised
health plans could be created or suggested, tailored to the specific needs of the individual
and formulated based on the person’s integrated LHRs (Mohan and Raja Yaacob, 2004).
The health plans and care plans jointly created by the patients (accessible through internet
with certain health record parameters such as body temperature, blood pressure, weight,
height, etc.) and doctors would generate personalised lifetime health plan for individuals
and become vital in providing quality healthcare (Ministry of Health Malaysia, 1997;
Wickramasinghe et al., 2006).
7
Conclusions
The analysis of patient demographics and clinical data usage in public outpatient clinics
across Malaysia reinforced the evidence that the summary of the patient’s health
condition is the most invaluable information required by the doctors during a consultation
and medical diagnosis encounter. The analysis concluded that the simplified version of
patient health records should be developed for incorporation into integrated telehealth
application. This was to be achieved through developing standardised LHR component
and structure. It is hoped that the proposed LHR components (which derived from the
research findings) should be able to be captured more quickly and systematically by
doctors and focusing only on the important clinical data. Through this, the complete
patient LHR in ordered in a chronological manner would be generated and this makes the
medical decision processes faster and thus directly affects the quality of patient care
(Schabetsberger et al., 2006).
Finally, the LHR components need to be detailed out and tested for interoperability.
The next step of the research will be to finalise the LHR components and validate their
interoperability. The LHR components will be tested through a working prototype system
and piloting the system in certain healthcare centres.
Acknowledgement
This research was funded by the Universiti Teknikal Malaysia Melaka (UTeM) and
Ministry of Higher Education (MOHE), Malaysia, through a research student fund. The
authors would like to thank the MOHM staff and clinicians who contributed to this study
for their support, advice and anonymous input, which assisted in improving this paper.
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