We talked to Anglo American Medical Consultant, Dr Brian Brink (BB), and Regional Manager of Health Services at Anglo American Coal SA, Dr Jan Pienaar (JP), about their EHR solution, theHealthSource (tHS), and their vision to harness eHealth to make a lasting contribution to South African healthcare.
Can you give us some background into the drivers for Anglo American’s involvement in healthcare and the development of tHS?
BB: Anglo American has a long history of providing healthcare to its employees in South Africa primarily due to the fact that the majority of the workforce is based at operations in remote locations that don’t have adequate health services. What initially began as occupational health services developed into integrated primary healthcare right through to hospitals. We wanted to help get those health services running more efficiently, and because we understand that information is key to monitoring, evaluating and improving health services, we developed our own Health Information System (HIS).
JP: tHS was developed entirely in-house by the development team at Anglo American Coal SA and I. I was tasked with developing the tHS solution when I joined Anglo American because of my background working in the public sector in rural South Africa where I developed an eHealth system for public use. That experience proved extremely valuable in developing a system based on the district health model.
In October 2014 we reported on your partnership with the city of Johannesburg to pilot tHS at Slovoville Clinic. How did you make the transition from being an organisational software programme serving the coal mining workforce to the public health system?
JP: We built tHS on the premise of ‘one person one record’ because we understood early on that patients, much like Anglo American’s contracted employees, migrate between different healthcare facilities. It is therefore essential to share patient records across multiple healthcare providers not only to ensure continuity of care but to prevent duplication and improve decision making.
In both the public and private sector there is a lot of duplication which amounts to waste, and the absence of continuity of care is detrimental to the patient. We understood some of the problems facing healthcare delivery in this country and began making the transition to public health services by first making tHS available to some of the NGOs that we work with. It made sense because we realised that there was already significant overlapping of patients between our NGO providers and our own health service providers.
BB: What sets tHS apart from other EHRs is that it is written around the healthcare process for the patient. Other systems are typically designed primarily around the need to bill or report but we’ve kept the patients journey central to the design.
tHS captures all the different transactions as they are happening to create a continuous record. Because the record is stored in the cloud, it’s accessible from anywhere which reduces the problem of people moving around from one provider to another, or even between provinces or countries, in which the continuity of care is often lost. Our development team went beyond worrying about who the provider is, whether they are public, private, or even an NGO provider; it really doesn’t matter. What matters is the healthcare transaction that is being carried out for the individual and maintaining a continuity of care record for the lifetime of the patient.
How did you choose Slovoville as a pilot site? Please talk us through the implementation process.
JP: The pilot originated though discussions with the executive mayor of Johannesburg about partnership opportunities in healthcare. The city had just built a new clinic to service the Slovoville municipality, which the mayor wanted to establish as a model of excellence with a world class HIS in line with the city’s vision of ‘One City One Health System.’ He asked us to run a tHS pilot at Slovoville clinic in a very short timeframe. Even though a project like this would normally take months and even years to get off the ground, he simply said “let’s remove all the barriers and just make it happen.” It was refreshing to experience the kind of leadership that wanted to get the job done.
BB: The implementation process was very fast given the deadline. Anglo American donated the hardware, network and internet connectivity. Because it was a new clinic the City Of Johannesburg actually had a wired local area network but they had no access to wireless networks so we provided them with a 3G failover satellite network that’s accessible from every work station.
JP: Deployment was done within a day and there was no time for formal classroom training so all the training was provided on the fly in an active clinic. We found the clerical staff took to tHS very easily, while some of the nursing staff took a little more time to feel comfortable using the system because they are very busy. From this pilot we believe we’ve proven that it is possible to easily and rapidly roll out such an eHealth system.
What impact has the system had on patient waiting times and staff workflow?
JP: tHS has been running in Slovoville since mid-September 2014, so it’s too early to say definitively what the impact has been. It is also a new clinic with no benchmarks to measure against however, I can say with certainty that the City of Johannesburg’s DoH is very happy with the functionality of the system and currently they receive daily reports on waiting times per patient and total transaction times. The staff at the clinic are also very happy with the transition from a paper-based system to an electronic one.
Based on your experience with tHS in the coal mining sector, what benefits are you expecting to realise in the public sector?
JP: A very important function of tHS is that we can prevent duplication of scripts and laboratory test requests, etc. which leads to significant improvements in efficiency and reduces waste. The ability to request tests and results electronically means that we are able to demonstrate that it’s possible to improve the health status of, for example, patients on ART, and you can actually then view the average CD4 count of the population on a daily basis. So, on the one hand you’ve got the ability to show that the health status of your population is improving, hopefully, and on the other hand you can make sure that resources are being utilised efficiently.
BB: Another significant benefit of tHS is that the system enables standardised care. It is crucial to point out that in standardising care everything is diagnosis driven. A diagnosis has to be made, and once it is there then it opens up other opportunities. The system can be programmed with tiered treatment protocols for specific diagnoses that make prescribing easy and accurate. But, if a drug is prescribed that doesn’t relate to the diagnosis, the system would flag it as a problem or disallow the prescription. This not only saves on waste and money, but also improves the quality of healthcare. We’ve found that tHS offers nurses in primary care in particular a sense of security because they are now provided with the right diagnosis and can ensure what is being prescribed is the correct treatment for the patient’s condition. So essentially, the system shifts a lot of the emphasis to making the right diagnosis which is fundamental to the healthcare process. If you get that right then everything else follows.
Tell us a bit about your futuristic view on HIS in SA, especially in light of NHI.
JP: I think that view culminates with the Minister of Health because he has visibility of activities in all provinces, but I wrote an article recently for the Occupational Medicine Journal that gives an overview of my futuristic view and what is possible.
BB: If you think about the future of healthcare in this country, we have to reach a much better alignment between public and private healthcare. We need to break down the barriers that prevent us from creating a unified healthcare system. As I said previously, it shouldn’t really matter whether it’s a public or private provider, what matters is that we use our resources in the best possible way to realise continuity of care that improves efficiency and gets rid of wastage.
I think a HIS like tHS can be the glue that holds it all together, and could create a much better health system for everybody. In my mind it’s what NHI is all about: trying to find that solution which will bring us together and create something better for everybody.
So is HIS the missing component to the overall solution even though the drivers for public and private healthcare are different?
BB: I think the drivers in both systems should be quality. I don’t think it should be about profit but rather the quality of care and its cost; we need to keep the cost down and get the quality up, which is done by eliminating waste, duplications and incorrect procedures. I think HIS can be a powerful driving force to achieving that.
What are your thoughts on imported systems vs locally produced software?
BB: I don’t think there’s a right or wrong answer to that question. Locally developed solutions have the opportunity to respond to the needs of the local setting at a more affordable cost. Having said that, I’ve seen excellent systems from overseas, but my experience is that they are expensive. Often you get a lot of bells and whistles which are nice, but you’ve got to get the basics right first.
Jan has worked in the public health service; he knows how the health system works and understands the needs of underprivileged populations, which amounts to the majority of South Africans. He’s also worked within the private sector and is experienced in making frontend applications work together with big backend databases which is essential to an effective solution. All totalled, he’s tried to develop a home-grown solution that meets the needs of this country. So the options and opportunities for eHealth systems are endless, we can perhaps learn from some imported systems which is why I like to keep an open mind but I think fundamentally there are a lot of advantages to locally developed systems.