It’s no longer a question of whether you need to have an electronic health record (EHR) system in place; but rather a question of whether you should build your own EHR system in-house or buy an existing solution.

The global push towards the development and implementation of eHealth systems, whether it be organisational, regional or national, is based on the necessity of having good quality data to improve healthcare practices and patient outcomes. Good quality data gives valuable insights into patient health and behaviour, which in turn can be used for disease surveillance, clinical decision support, population health management and improved service delivery, to name but a few.

While there are countless benefits associated with EHR systems and the data that they generate, it’s not an easy task to decide whether to build or buy. Governments and healthcare organisations, both big and small, often grapple with the right path to follow because a lot of different factors need to be considered, such as what financial resources and IT manpower they have at their disposal and the red tape that they have to cut through.

Buying instead of trying

The decision to buy an off-the-shelf EHR system is often the more direct option to implementation and has numerous benefits. For one, the solution provider is responsible for updating and maintaining the system, reducing the investment of your internal resources, both financial and human (in the form of developers and EHR system experts) who’ll not only have to build and maintain the system, but also fix it when it goes down or is affected by a security breach.

Cost is also a primary consideration, and carefully weighing up short and long term spend is necessary to understand the benefit of buying off-the-shelf. Often the ongoing operational costs associated with maintaining the system, server and/or cloud infrastructure, are underestimated and can be prohibitive when opting to build a solution in-house. Whereas buying an already built system means that you have an upfront understanding of spend and can expedite the implementation process and realise benefits faster than building a system from the ground up.

If going the buy route, it’s important to determine whether the EHR provider has an established international, and local, footprint to demonstrate that the product’s interoperability with other eHealth systems and can be customised based on local needs, such as managing HIV patients who are on antiretroviral therapy (ART) treatment, for example, but most importantly the systems have a proven ability to scale.

Epic and InterSystems are the leading international EHR system providers because, for the most part, they meet all the necessary criteria. The Global EMR Market Share 2017 KLAS report found that both Epic and InterSystems won more new hospital contracts in 2016 than any of their competitors due to the affordability and functionality of their solutions. As such, these two vendors are also leading the way in empowering their customers to derive business intelligence (BI) and value from their healthcare data in the form of cost savings and improved patient outcomes.

In the South African context, InterSystems has actively demonstrated their ability to digitise healthcare services on a big scale. The National Health Laboratory Service (NHLS), the largest diagnostic pathology laboratory service in South Africa, chose InterSystems’ TrakCare Laboratory Information System (LIS) to manage patient results in all of its 349 laboratories nation-wide. By implementing InterSystems’ TrakCare patient demographics, order entry and results can now be exchanged between the TrakCare Lab and 17 other eHealth systems. These include hospital information systems in the Western Cape, Kwazulu-Natal and the Free State, Netcare, Right to Care and Contract Laboratory Service (CLS). Implementing the system is also allowing the NHLS to significantly improve their processes and efficiencies in that lab results are now available faster and online.

Going back to the benefit of having the vendor investing their own resources in improving their system, earlier this year Epic unveiled a series of new and upgraded functionalities intended to improve interoperability, streamline workflows and facilitate access to important data to improve patient care. The update also granted patients improved access to all of their health data irrespective of where it was stored, just as long as their different healthcare providers were using Epic systems.

There are also a number of local EHR vendors that are offering complete solutions. Med-e-Mass is one such provider offering clinical and financial management solutions to medical professionals, clinics and small-to-medium sized hospitals. In mid-2016 the City of Johannesburg partnered with Med-e-Mass to rollout their EHR system to 81 clinics across the city with the aim of improving health delivery, reducing clinic waiting times and improving patient record-keeping. In an interview with Med-e-Mass’ General Manager of Product & Development, Dilip Naran, he acknowledged the challenges  associated with working in the public health system, such as inadequate internet infrastructure and prevalent identify fraud. He also noted a number of positive milestones to come out of the EHR rollout. For example, integrating with the NHLS to pull lab results directly into the EHR; helping improve the reporting of patient outcomes because  it no longer has to be done manually; and giving  clinic managers relevant and up-to-date data to track exactly how long each process within the clinic or practice takes, identify the bottlenecks and initiate data-proven  improvement initiatives.

Build it to own it

While there are many reasons for choosing to buy a ready built EHR system, there are almost just as many valid arguments for wanting to build your own. The two main drivers for building are a) because you can’t find a system that caters for your specific needs, and b) because you’ve established that it’s more cost-effective to build the system in-house.

For some private and public health services, having complete control over their EHR system is non-negotiable. If there are capable health IT software developers on hand it would make sense to develop in-house instead of forking out a once-off or even on-going, monthly fees for a system that doesn’t live up to your expectations. Developing an EHR system could result in quicker customisation and improvements in functionality because it avoids having to deal with the middleman to turn your ideas into a reality.

Organisations and governments in developing countries are largely resistant to implementing systems from big international providers. Again this is due to the customisable factor and the systems being developed with (largely) functioning health systems in mind like those in the US, UK and Australia. The high costs involved, as well as being caught up in long contracts, are other major factors in choosing to build in-house.

The decision to implement open source systems has almost become the go-to, if not default solution for organisations and government catering to low-resource settings. As the Founder and CEO of non-profit Jembi Health SystemsDr Chris Seebregts – who develops open source interoperability software solutions – explained in an interview, free and open license software lowers the barrier to entry in terms of costs and procuring such systems, compared with commercial alternatives where the license costs and procurement processes can present a significant barrier. Open source solutions have also reached a level of maturity where, for the most part, their functionality is comparable to commercial solutions and also promotes interoperability between different systems.

However, the perception that open source equates to free isn’t necessarily true; open source means that only the licence cost is free. While this may be appealing, organisations and governments that choose open source still have to invest time and human resources (developers) to customise and maintain the systems. Another downside to open source is that there’s often no support available and no updates released to improve the system. Therefore before choosing the open source route it’s important to determine what’s more cost effective and a better investment for you – an off-the-shelf solution or in developers to build and maintain the system. It’s important to weigh up the startup costs and long terms benefits of each option so that you can choose the solution that’s right for you.

The South African way

Historically, the South African EHR system experience has been a siloed one where provincial health departments have been building and using their own disparate, bespoke systems. Fast forward to the present day, this has resulted in large disparities between the quality and functionality of the systems. While the Western Cape has been successful in the development of their IT strategy through their Healthcare 2030 Strategy, and is the only province in the country with a single Health Information System (HIS) across all hospitals, other provinces have failed miserably when attempting to follow suit because of corruption and the inefficient management of funds.

Now as the implementation of National Health Insurance (NHI) draws ever closer, the National Department of Health (NDoH) needs to decide on and implement a national EHR system to ensure patients receive continuity of care irrespective of which healthcare facility they visit across the country. During an interview with Competency Area Manager: Integrative systems, platforms and technologies at the CSIR Meraka Institute, Matthew Chetty, he explained that over the last few years the CSIR has been working with the NDoH to facilitate interoperability between different existing eHealth systems across the country, as well as developing and implementing a national patient registration system. Although not much information has been released to date, it will be interesting to see the success of the system’s ability to scale nationally to cover our near to 56 million population.

It appears that our government does generally prefer to build systems internally. The reason is because they can then remain in complete control of the system and can alter and adjust it as they see fit. However while the Western Cape may be the exception to the rule, it’s often challenging for government departments to develop systems in-house due to insufficient resources. This is where open source software is a viable solution because  instead of trying to develop and/or recruit and retain engineers in-house, they can look to open source communities to provide the basic engineering skills they require.

But what does this all mean for local eHealth providers? It’s inevitable that the final national EHR system, and other NHI eHealth systems, will be built on solutions with a proven ability to scale. This might seem like bad news for smaller eHealth solution providers, but it also presents an opportunity to develop specialist data capturing and management solutions that above all else are interoperable.

The release of the National Health Normative Standards Framework for Interoperability in eHealth (HNSF) in 2014 was the first move by the government in setting out a set of rules or guidelines for eHealth developers to follow in ensuring healthcare data can be exchanged between disparate systems to reduce duplication of effort and redundancies. While over four years have passed since its release, it’s the eHealth vendors’ responsibility to keep up to date on government policy and what NHI will mean for them. In the current period of uncertainty before NHI, smaller eHealth vendors can focus on differentiating themselves to ensure they’ll remain afloat in the local eHealth market; for example they can create a bespoke plugin to collect specialised information.

On a smaller scale, the eHealth vendors should remain in-tune with the business models of healthcare organisations to ensure they are aligned with their strategic goals, network requirements and anticipated growth projections; as well as have a continual focus on improving data governance and protection.

Whether you as a healthcare organisation choose to build or buy, at the end of the day the main focus should be on generating quality patient data because it will become the most important commodity going forward in ensuring healthcare is of better quality, more affordable and accessible to more people.

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