I was out of doctor’s room in couple of minutes with a scribbled prescription in hand, not very sure if the physician had actually understood my problem. Clinic’s pharmacist words gave me confidence “Doctor is very experienced, he can diagnose problems within a minute. You will get better in couple of days”.
It was around 4 P.M. on a summer Sunday afternoon in 2018 when I visited this clinic in Jharkhand. I was 32nd in the queue to see the doctor. While I waited, I could see patients from all age groups and socio-economic background and various medical conditions. I was amused to see empty wrappers of the medicines in some hands to cover for lost prescriptions; the doctor kept no documentation. As I walked out of the clinic at around 6 P.M. I noticed the queue had grown longer.
On my way back home I pictured in my mind the benefits of computerizing this clinic. Then a stream of questions followed.
Would it be efficient for this doctor to use an Electronic Medical Record (EMR)?
- Can he see as many or more patients in as much time?
- Would the benefits justify the costs?
- Would the computer survive the summer heat of north India (No AC only fan)?
- What about his home visits?
Barring private hospitals and clinics in Metros and few big cities, there is acute shortage of trained doctors in remaining parts of India, according to NHP survey there is one doctor for every 28,391 person in Bihar. WHO standard is 1 doctor every 1000 population. An article published in Times of India refers to a medical journal study which shows primary physicians in India spend barely 2 minutes on average with patients.
Would they use EMR? Surveys have shown the fact that using EMR is time consuming activity for physicians worldwide. A US study showed primary care physicians spent in excess of 4 hours daily on EMR data entry. Most physicians see EMR systems as data storage systems than a powerful clinical tool, reveals a Stanford study. Given a choice, I am confident most of the physicians would not want to use current generation EMR systems even though most of them agree they should use one. Cost and effort involved outweighs apparent benefits of using an EMR. Last year new Yorker published a thought provoking article by Dr.Atul Gawande on why doctors hate their computers
On the other hand almost everyone uses WhatsApp and/or Facebook; In Indian medical community WhatsApp is liberally used as a mode for referral, 2nd opinion over specialized tools to do so. Doctors see the benefit of using mobiles and social media tools and are embracing it to make themselves more efficient. It’s easy for them to use and gets their work done and costs almost nothing.
I have met several doctors who are eager to use technology if it could enable them to do their work better with minimum disruption. They would adopt an EMR if they see it as a force multiplier for them. A tool which understands and adapts according to their needs, improves care quality, is transparent in use and cost effective. They would want a tool which would allow the doctors to do more of what they are trained to do, are best at doing & are supposed to do; that is, to take care of their patients.
What would the doctor want from EMR? Thinking of this I was reminded of a talk by Dr. Devi Prasad Shetty world renowned cardiac surgeon who is also the chairman & founder of Narayana Health, at HIMSS India conference 2018. Following picture from his talk during the conference conveys the gist.
From Dr. Devi Prasad Shetty’s slide, he listed out the following requirements:
EMR, what the doctors want?
- No instructions manual, coaching, intuitive
- No keyboard/ typing, only touch or voice
- Ubiquitous, part of patient app
- Prevent mistakes, save time, second opinion
- “Wow”, customize
- Change components on the go
- SaaS model
Indian healthcare landscape and context is diverse and unique. There are 22 Official languages in India and English is not the primary language for more than 90% of population. There are many popular streams of medicine apart from Allopathy like Ayurveda, Homeopathy, and Naturopathy etc. Though Allopathy has wider acceptability, I would not hesitate to say that during his/her life time almost every person would have tried other streams as well. Most of the healthcare happens outside hospitals, in clinics and nursing homes in small towns, suburbs and villages. These Physicians and clinics are unorganized, self-funded and run on out of pocket spends from patients. According to a research gate study computer literacy among doctors in India is about 60%, most users are basic computer users. Smartphones and mobile internet has deeper reach than computers.
Keeping the Indian healthcare context in mind. What features would an EMR designed for India have?
- Low cost of ownership Subscription based, pay as you go.
- Natively Interoperable Multi Language and Multi discipline aware.
- High tolerance to failure Network disruption, Variable bandwidth, power failure, heat etc.
- Designed for mobile (Mobile first) Physicians are not always stationary or near a workstation. They are on the move. In Clinic, hospital, patient’s home, disaster camps etc.
- Intuitive UX as iPhone or google. Not requiring special training to use.
- Non-intrusive doesn’t come between doctor and patient interaction.
- Natively patient centric Designed keeping in mind patient as owners of data, on demand patient access.
- Intelligent assistant to Physicians prevents mistakes, saves time, enables collaboration and provides real time 2nd opinion feedback.
- Open platform allows for personalization.
Universal EMR adoption in India will solely depend on its perceived value by the users and adopters. Regulations can enforce but only to a limited extent. Regulations instead should be enablers. EHR standards for India published in 2016 is a step in this direction, NRCES is doing a good job in helping implementers of these standards. However the standards proposed need to be revised as they are based on what is currently available and do not provide solutions to challenges plaguing EMR world in general and specific Indian context. I would expect more emphasis on these three areas:
- Usability & user experience,
- Enabling open platform,
- Interoperability & AI
Industry bodies like IAMI, HL7 India, and HIMSS India should work more closely with medical fraternity to understand its requirements & challenges and propose solutions. Setting up IHE India to study & profile Indian workflows can also be considered.
The diversity and uniqueness of Indian context and given that India doesn’t have a legacy either presents us with a great opportunity to design Health IT for our needs grounds up, build the EMR of the future which physicians all over the world have been waiting for. “A tool which enables doctors to do more of what they are trained to do, are best at doing & are supposed to do; that is, to take care of their patients”.
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