Electronic Medical Record – Bangladesh (EMR-BD)
(A Virtual and Versatile patient management system, where resource is not a barrier)
Sudipta Kumer Mukherjee
National Institute of Neurosciences and Hospital, Agargaon, Dhaka, Bangladesh (co-authors listed following the report)
Clinicians, medical assistants, and auxiliary staff face many challenges both clinically and organizationally when managing hundreds of individuals’ clinical care. Many institutions based in high-income countries (HICs) have utilized electronic medical records (EMRs) to maximize organizational efficiency.1,2 Alternatively, most hospitals based in low- and middle-income countries (LMICs) rely on paper-based documentation, thus providing fertile grounds for EMR adoption.3,4
This study describes the design, implementation, and adoption of a novel EMR and its use for documentation in the pediatric neurosurgery department at a national referral hospital in Dhaka, Bangladesh. The EMR-BD software (http://emrbd.com/; Dhaka, Bangladesh) was first implemented in November 2017. The author (SKM) was inspired to implement an EMR system from personal experience working with various neurosurgical departments in other
countries. Key initial steps toward software development and implementation included identifying key stakeholders, facilitating utilization among attending neurosurgeons, and creating responsive feedback mechanisms among users.
EMR-BD’s design was achieved in a cost-conscious manner. As of June 2022, the EMR system’s yearly maintenance fee is approximately 8000 Taka (approximately US$90). Important features of the software include generating patient reports, conducting medication reconciliation, and viewing hospital bed availability on the online home screen dashboard. Other components include online support for telemedicine patients, technical support for users via search-engine functionality, and a patient-provider messaging system. In addition, EMR-BD’s onsite computer programmer provides technological maintenance and direct troubleshooting support.
Initial difficulties with the software development and implementation included accessing the EMR-BD within areas with low-internet connectivity, facilitating uptake among colleagues at National Institute of Neurosciences & Hospital (NINS&H), and technology upkeep. Key stakeholders included various local software engineers, programmers, and attending pediatric neurosurgeons at NINS&H. To date, EMR-BD is consistently utilized by seven attending neurosurgeons at NINS&H. Two other neurosurgical units use it partially, one neurosurgery division in a nearby teaching hospital, and a local non-governmental organization (NGO) for teleconferencing with patients . Other LMIC neurosurgeons can use this resource without any development fee. They only need computer facilities and local internet connection.
EMR implementation has enhanced data collection, identified areas for improvement within our pediatric neurosurgery department, and exposed challenges related to post-operative care and long-term follow-up, teleconferencing, outpatient follow-up appointments, and research activities. More broadly, EMR implementation in LMIC neurosurgical departments can improve departmental efficiency, reduce financial costs, and decrease the administrative burden among medical and non-medical professionals.4,5,6 At the local level, EMR implementation promotes a more accurate estimation of long-term neurosurgical outcomes of various operations performed and diseases treated.7 Organizational benefits of EMR adoption include streamlined patient tracking, reduced paperwork for neurosurgical department house-staff, and pre-populated paperwork to facilitate hospital discharge and outpatient follow-up. Enhanced EMR documentation can provide institutions with the infrastructure necessary to contribute to important population-based cancer registries. Such efforts can improve measurements of incidence, prevalence, and treatment patterns of pediatric CNS tumors at treatment centers and at the national level. This data can provide stakeholders with a comprehensive analysis of a particular geographic area’s healthcare resource distribution. In a nutshell, EMRs can aid overall national health care delivery, establishing registries for diseases and facilitate stakeholder collaboration.1,7,8,9 For example, EMR implementation in Dhaka demonstrates NINS&H’s impressive reach to remote patients who travel an average of 125 km, or 77 miles, to seek neurosurgical care through teleconferencing. Even though this EMR model is not currently a formal part of the institution, it has demonstrated feasibility and other clinical departments or specialties could easily adopt the model. NINS&H can help circumvent traditional administrative barriers and contribute to efforts to implement the EMR-BD system in other departments. This is an area of great interest for the author.
Barriers to EMR acceptance and utilization in LMIC neurosurgical and other medical and surgical departments are contextual, professional, and technical.10 These barriers – including initial start-up costs, concerns about maintenance, and individual stakeholder acceptance – are well-described in the HIC-based literature.9,11 At NINS&H, professional challenges toward EMR utilization include competing demands on neurosurgeon’s time, and technical challenges such as corrupted or locked records and missing data. A proposed solution is to delegate EMR entry tasks to specific medical auxiliary staff to facilitate utilization.4,7 Additional platform-specific improvements include “flagging” records, creating additional “radio buttons” or “tic boxes” to facilitate comprehensive tumor description (i.e., documentation of multifocal lesions). Reducing free-text Fields expedites user interaction, and also enhances the analytic and research capability of the EMR on the backend. Potential ways to offset the cost of initial EMR purchase and system maintenance include utilizing open-source EMR systems and government-driven national EMR programs to facilitate adoption.12,13 Another proposed solution is to utilize global neurosurgical collaboration to finance, implement, and help manage EMR implementation in low-resource settings.14,15 This includes “twinning” neurosurgery departments with developed countries to help facilitate exchange of information, resources, and research.14,16,17
EMR-BD represents an innovative LMIC-driven model which overcame barriers to software design and cost through private financing from departmental pediatric neurosurgeons. Benefits derived from EMR implementation at NINS&H include the facilitation of an increase in virtual telemedicine follow-up appointments among neurosurgical patients. Patients can utilize the patient portal to confirm or re-schedule any upcoming follow-up appointments. Previously, NINS&H’s large geographical catchment area, the existing transportation infrastructure, and limited telecommunications availability posed a challenge to follow-up care. This innovation can also help elucidate the mechanisms underlying global pediatric neurosurgical disparities and inform solutions to eliminate the existing disparities.
There is a need to improve EMR system-integration and utilization among provider networks in LMICs through health institutions allocating funds for EMR implementation, adopting national open-source EMR platforms, and training personnel in information technology to assist with the use and maintenance of the software.3,12 Systemic EMR integration among healthcare providers can centralize care, improve data collection and coordination, and help shift the financial burden of EMR maintenance from neurosurgical departments to hospital networks.4 Preliminary subjective feedback from attending neurosurgeons at NINS&H based on our EMR adoption study is very positive and optimistic for future growth and applicability to other low- resource settings. Future qualitative studies are however needed to identify and understand barriers to EMR design and uptake among medical professionals in LMICs and address them to increase uptake in these settings.
Analyzing EMR implementation in low-resource settings on a more systemic level remains an area of great interest for the author. We present a feasible model for LMIC EMR design, implementation, and adoption through private financing and LMIC-based software development. This model provides neurosurgeons with a medium for data collection, follow-up care coordination, and research promotion. This EMR implementation helped identify various areas for improvement in global partnerships and long-term data collection in our institution and led to the establishment of a separate outpatient pediatric neurosurgery clinic to improve follow-up care. We hope to encourage peer institutions in low-resource settings to document shortcomings of the EMR model and identified gaps in data collection which will serve as measurable evaluation indicators of this EMR model. This will help address the disparities in global neurosurgical care and challenges in long-term follow-up care. We hope the analysis presented herein can serve as a template for EMR design and implementation in other LMIC neurosurgical departments.
Acknowelgement: Mr. Monish Chakrabortty software engineer for his unconditional support.
References:
Sudipta Kumer Mukherjee1, Michael C. Dewan2, D. M. Arman3, Joseline Haizel Cobbina4, Md Ziaul Hoq5, Md Nafaur Rahman6, Abdullah Al Mahbub7, Md Ziauddin8, Md. Joynul Islam9, Md. Zahed Hossain10 , Sheikh Muhammad Ekramullah11.
Address for Correspondence (Principal and corresponding author): Dr. Sudipta Kumer Mukherjee, Associate Professor, Department of Pediatric Neurosurgery, National Institute of Neurosciences and Hospital (NINS). Mobile: +8801711-709096, E-mail - sudipta70@hotmail.com
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