Opinion, South Africa

Dilip Naran: On SA’s Readiness for EHRs

General Manager of Product & Development at Med-e-Mass, Dilip Naran, talks about the uptake of EHRs and why now is the time for doctors to embrace them.

Dilip Naran - EHN

General Manager of Product & Development at Med-e-Mass, Dilip Naran, talks about the uptake of electronic health records (EHRs) and why now is the perfect time for doctors to embrace them.

You have spent a number of years working with clinical systems. What initially attracted you to the digital health space?

After studying a medical science degree at university I went straight into the commercial world, and in 1999 I joined a Cape Town-based medical device start-up that exposed me to the digital health space. The company developed an integrated PC-based Blood Pressure, Spirometer, Body Composition and ECG solution. It was my interaction with users that drew me into the industry and gave me insights into the technical processes associated with capturing biomedical signals from the human body and converting these into digital signals, which could be meaningfully displayed and interpreted. The experience gave me an appreciation of how technology can improve healthcare.

South Africa is still largely reliant on paper-based medical records and the adoption of eHealth systems is still very slow. Give us your take on why that is.

It’s true that EHR adoption is still very low in SA and this is largely due to the fact the there are no incentives for using an EHR. Initially it made sense for specialists to use an EHR system for efficiency in being able to get a report back to the referring doctor. And while a lot of other doctors did see value in EHRs, there really wasn’t anything in it for them to make the investment. However, this has changed over the last two years because there’s now a greater interest from funders, medical schemes and administrators to use eHealth to improve patient care and save costs.

To answer your question, I think doctors will start using EHRs when it becomes a requirement by funders or HMO-type organisations like the Centre for Diabetes and Endocrinology (CDE). In my opinion, doctors will also be more motivated to use an EHR if it’s prepopulated with patient and funder-specific information. More importantly, doctors need to be fairly reimbursed to use content in an EHR that requires data collection for managing outcomes. Med-e-Mass is currently working closely with funders so that healthcare providers can start using EHRs at reduced cost in addition to other benefits.

Tell us a bit about HEALTHone Connect (H1C), Med-e-Mass’ online EHR. How has it been received in the local market?  

H1C is our flagship product. It’s a funder agnostic, cloud-based platform that can support both primary healthcare as well as specialist care. We have two iterations of the product; one to support corporate applications (Occupational Health & Wellness) and the other for private practitioners (PHC and Specialists). The main advantage of the product is that all a user requires is an internet connection and a browser.

Over the past two years we’ve partnered with Medscheme on their chronic disease management project using H1C. In essence we built a secure connection between Medscheme and ourselves to deliver a care plan for particular patients directly to the doctor’s desktop that was pre-populated with pertinent information from the funder to help them manage the patient from that point onwards. That pilot was successful because the technology was easy to use and there was an alternative reimbursement mechanism that the GP could leverage.

We’ve since integrated our platform with a number of other funders, such as Discovery Health’s HEALTH ID and Medscheme administered schemes (Fedhealth,  Bonitas and Sasolmed). And we’ve now got close to 350 practitioners signed up and another 300+ practices using the system via the CDE. We are also rolling out to Medicross as well and that will result in another 600 doctors using EHRs. So finally after 15 years we’re starting to see the uptake of an EHR in the South African space gain some momentum because we have gotten the value vs incentive balance more or less right.

What will the next iteration of HC1 mean for patients?

We are currently taking our platform a step further by adding patient insights obtained from the Internet of Things (IoT) into the EHR. So we are able to communicate in real-time directly with wearable devices, be it an activity tracker or blood pressure monitor or glucometer, to collect information from the patient and present it as meaningful data to the practitioner. To make the data more manageable we’ve built in very clever filters so that if the patient’s healthcare reading is out of range it alerts either the patient or the doctor. We believe this is the next step in closing the loop between the three stakeholders: the funder, the provider and the patient.

Let’s talk about your involvement in the public healthcare space.

We were fortunate to have won the City of Johannesburg’s EHR tender last year. They have 81 clinics across the metro that service a population of close to four million people. Med-e-Mass had limited exposure to the public health sector previously, so we had to go through a very steep learning curve to understand the workflow and specific issues that the public health service face. For example, we were surprised by the necessity to reduce identity fraud. This was often the case with foreigners who perhaps didn’t have the necessary legal papers and were scared to seek treatment under their own names and IDs. We solved the problem by introducing biometric identification and verification. Now every patient on the City of Joburg system has an associated digital vault that includes a photograph, a copy of their ID and a set of fingerprints. When the patient moves through the clinic, they are verified at every encounter to ensure they are the same person who was registered at reception.

We’re dealing with other challenges in the public service, including the roll out of internet infrastructure to the remaining 30+ clinics out of 81. But on the other hand, we’re still making progress. We’ve started integrating with the National Health Laboratory Service (NHLS) to pull lab results directly into the EHR, which is a big step forward. We’ve also made progress in reporting on outcomes, which up until now had to be done by manual data capture into the District Health Information System (DHIS). We have now automated that process because outcomes are captured digitally into the EHR and can be pushed into the DHIS automatically. This will officially go live in a couple of weeks.

Lastly, EHRs are making an impact on improving clinic management because managers are able to track exactly how long each process is taking and where the bottlenecks are, allowing them to allocate more resources if possible or make the necessary changes to address the situation. It proves the tangible value of doing things electronically because it gives you real-time information that managers can act on.

You’ve talked about the benefit of EHRs to clinicians but how is it impacting patients?  

In the public service, EHRs reduce waiting times significantly and improves communication with the patient. We’ve rolled out digital appointment bookings and SMS reminders for returning patients which makes a big difference to the patient experience when visiting the facility.

We’ve added an online appointment booking tool in the private space that gives patients the flexibility to book an appointment whenever is convenient for them. In the two months since we’ve launched this service at Medicross, we’ve seen 40,000 online bookings and again, it makes a big difference to how the patient is able to interact with the practice and manage their health needs together with practitioners. In the case of Medicross, the online appointment tool is integrated with the billing system which then synchronises with the EHR so we’re making progress towards more complete, updated patient records.

In the context of the move to value-based care which is emerging in South Africa, there are some advocating that reimbursement to doctors should be outcomes based. What are your thoughts on that?  

My opinion is that it’s only going to be possible if funders have access to the outcome data and are using some sort of electronic mechanism to gather that information or enable it. I’m privy to some of the funder’s strategy in terms of what the next steps are, and that’s definitely in the pipeline. Up until now doctors and specialists have collected data exceptionally well, but we haven’t been able to exploit the data in a meaningful way. But the tools that are available today will enable proper exploitation of that information, and having a view on how well a patient is managed will certainly go a long way in terms of reimbursing healthcare providers fairly.

So if you have a cohort of patients that are better treated than another group of patients from another region, then I believe the first group of healthcare providers should be better reimbursed. Some will look at that as being unfair, but at the end of the day if you look at the patient’s best interests and start applying rules you are going to get better outcomes. And if you are going to get better outcomes then you need to be reimbursed accordingly.

What’s the vetting criterion that a doctor should use when choosing an EHR system for their practice?

Some of the important things that a doctor should be asking is if the application is standards-based, and while we don’t have many standards governing us in South Africa right now, it’s important to know if the application complies with recognised European or US standards. In the South African context the National Health Normative Standards Framework (HNSF) is a good place to start to see if the system is interoperable with other systems – the billing system, online appointment system, laboratory system, and a host of other third party applications such as radiology, etc. Integration is very important because you can’t use an EHR as a standalone system; it has to support the workflow of the practice.

The other very important aspect to consider is desktop vs cloud, especially with internet speeds increasing and the need to comply with privacy and security measures, such as POPI. But if you are going to choose a desktop application over a cloud based application, you need to make sure that the database that you’re being sold is not one of those ‘free databases’ that requires you to spend lots of money to upgrade to the full version.

The downside to the cloud is that if the internet is down you can’t access it, but with a desktop version you need local infrastructure and a local server, as well as someone to look after those things which usually add up to a higher cost. So those are some of the factors to consider when purchasing an EHR.

Any closing thoughts? 

I think we’re at a turning point in the use of EHRs in this country because many more people are acknowledging that at the end of the day it’s cheaper to implement an EHR system than it is to expand a storage room where paper-based medical records are kept. And while a lot of the older systems weren’t that easy to use we’ve made great progress over the last 10 years in making them more user-friendly and easier to capture information.

We also know enough to dispel the myth that a computer is an intrusion in the doctor-patient interaction. Patients want to be able to communicate with their health service providers; they want access to their information and to be reassured that doctors are using enabling technology to make their patient journey easier and more convenient. And on the other hand, doctors see the wider value of EHRs in conjunction with the advantages to them by working with digital systems and funders. We can’t stop the move to a digital health system and the time is right for doctors who aren’t yet on board to make the switch.

Find out more about managing chronic diseases in the latest whitepaper by Med-e-Mass. Click here to download.

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