The document discusses electronic health records (EHR) and shared care in India. It defines EHR and outlines benefits like reducing paperwork, allowing rapid information sharing, and making data accessible to researchers. Challenges of EHR include logistical issues in sharing unsolicited healthcare information, physical storage of data, privacy concerns, and ensuring systems are accessible to patients and clinicians. The document also discusses guidelines for using hardware, networking, connectivity, and mobile health records to properly manage EHRs while respecting data ownership, disclosure, patient privilege, and privacy.

1. Shared Care & Electronic
Health Records
Babitha K Devu, RN, RM, M.Sc (N), MBA
Assistant Professor, SMVD College of Nursing, J & K
Research Scholar, Ph.D (N), Amity University, Gurugram

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INTRODUCTION
• Changing technology and legislation have ushered in a shift in
healthcare.
• The Affordable Care Act (Indian Health Service) improves patients’
access to their health information.
• Additionally, it urges different healthcare organizations to share vital
information.
• All these data must make their way into electronic health records
(EHR), and those who deal with this must understand the nuances of
health records management.
• The challenges of storing health information records are varied but
ubiquitous (common).

3. Definition – Electronic Health Records (EHR)
 Electronic health records (EHR) are any
information on an individual’s physical and
mental health or disorders that is captured,
stored, sent, accessed, associated, and
processed using digital technology.
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Benefits
The replacement of traditional paper records with an EHR system and the
ability to access it anytime and anywhere has the following benefits:
– it reduces/prevents the continuous growth of paperwork, which creates
serious problems with physical storage;
– it allows the rapid transfer of patient health information to distant locations,
unifying medical records above the limits of institutional care;
– it reduces includes the possible risk of loss and deterioration of conventional
medical records;
– makes this information available to researchers and health planners in an
easily accessible and treatable way.

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CHALLENGES
Logistical Problems
• One area of potential logistical challenge is “unsolicited healthcare information,”
which is “data received by a healthcare provider who has taken no active steps
to ask for or collect that information” (American Health Information Management
Association).
• Traditionally, this type of data would come piecemeal to different providers, so it
would disappear in the bureaucratic paperwork shuffle.
• For example, say a patient has a primary care physician but was recently
admitted to the hospital.
• Any information the hospital staff take down becomes the responsibility of health
records management professionals.
• Ensuring the information makes it to the right record is highly important — it
could even mean the difference between life and death.
• Afterward, health records managers must store this information indefinitely and
provide it to the patient’s primary care physician.

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CHALLENGES
Physical Problems
• Most consumers think of electronic health records as ethereal: they are
electronic, so they weigh nothing, which means their storage takes no physical
space.
• However, the truth is that electronic records must exist somewhere, and that
somewhere must be accessible and secure.
Ethical Problems
• Conversely, many health records management professionals are turning to cloud
computing to resolve the issue of server space.
• Cloud data storage is capable of handling massive amounts of sensitive data.
However, adoption of this technology is slow.
• “Reliability, integration, and data portability are some of the significant
challenges and barriers to implementation that are responsible for its slow
adoption.”
• Lack of technical knowledge or detailed familiarity of the underlying
communications processes and data sharing among applications may put the
health care provider in direct violation of ethics.

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CHALLENGES
Accessibility
• Perhaps one of the most important concerns when dealing with this data is
creating a system that works for patients and clinicians alike.
• Interface issues are the greatest system risk because these failures can be
invisible initially.
• When clinicians do not know how to handle EHR properly, problems can go
overlooked, and that can cost lives.
• Thus, it is imperative that healthcare institutions employ health records
management professionals to ensure doctors and patients understand these
new technologies and how to use them.
• While electronic health records simplify many aspects of the healthcare industry,
they are not without their challenges.
• Collecting, storing and protecting data is the responsibility of a relatively new
group of professionals.
• Health records management is an integral part of the healthcare industry, and it
is leading the way in innovative healthcare.

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CHALLENGES
• Privacy concerns: Patient do not feel confident in sharing their information
using digital platform.
• Requirement of Specialized people: Recruiting people with technical
expertise.
• Digital user experience: Improper handling of an electronic equipment by nurse
on patient will be dis-comfortable and misleading for both. The prior knowledge
and digital experience of the nurse and patient is significant.
• Data Processing: Collected data is not processed properly
• Time Consuming: Time of entering the data .
• Lack of Standardized Procedures: Lack of using standardized nomenclature.
Non usage of NANDA nursing diagnosis.
• Burnouts: Overburden and lack of skilled staff.
• Level of Satisfaction: due to lack of human interaction
• Improper Big Data Analytics: Data utilization is not optimum. Once the
patient is discharged the data is dead left.

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CHALLENGES
• Dependability: Over dependency on computer system.
• Nurse-Patient Relationship: Lack of human interaction.
• Technical Issues: Power cut, unfriendly interface, complex software

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Latest Global Developments in EHR
• Digitization of health records in public health facility and its instant availability in
the form of electronic records anywhere any time health service is yet to be
implemented in developing nations like India and other countries.
• In India, patient care is mainly delivered through 3 levels namely
Primary/Community Healthcare Centre (PHC/CHC), Secondary healthcare
centre (District Hospital), and Tertiary Healthcare Centre (National level).
• The healthcare facilities face many challenges in collecting, processing, and
storing these data and managing it without compromising security and privacy.
• Presently, some of the secondary and tertiary care facilities have started
implementing healthcare IT application in terms of Hospital Information System,
Hospital Management Information System, Electronic Medical Records (EMR)
etc. to manage the patient data in electronic format.
• However, these systems are developed by different vendors by using different
programming languages and databases.

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Latest Global Developments in EHR
• This approach makes the system unique, but the patient details remains in the
same hospital and cannot be shared with other hospitals when patient moves
from one hospital to other for advanced or specialized treatment.
• This is because the data is not interoperable and semantic. In the proposed
work, a standard secure Electronic Health Record(EHR) framework is developed
using standard medical terminology and coding standards.
• Implementation of EHR framework for Indian health system will improve the
work-flow of health services to the population. EHR at all levels of healthcare
system enable efficient and continuous care to the patient.

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Need for electronic health records in Indian hospitals
• With the Government of India ‘Digital Health Mission’, there has been a lot of
advancements in the conglomerations (group of things brought together) of
Healthcare and IT industry (Srivastava 2016;Sarbadhikari 2019).
• The Electronic Health Record (EHR) is one such solution to support the
healthcare facility, irrespective of levels and sizes to improve patient care by
enabling functions that other types of records cannot deliver.
• The major requirements in healthcare facility is to use interoperability and
standardization technique to enable easy sharing and exchange of healthcare
data between the various levels.
• The main foundation for the interoperability is the standard terminology, which
improves the effective communication between the two healthcare users
(Warren et al. 2015).
• Government of India has taken the initiative and formulated and published an
HER standard in September 2013 and consequently revised and published the
next version on 31 December 2016 (2016).

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Need for electronic health records in Indian hospitals
• For EHR standards, Ministry of Health and Family Welfare (MoHFW) suggest
the healthcare facility to use the following standards namely Systematized
Nomenclature of Medicine – Clinical Terms (SNOMED CT) (2016), International
Classification of Diseases (ICD 11) (2016), Logical Observation Identifiers
Names and Codes (LOINC) (2016), and National Drug Code(NDC) (2016).
• The adoption of terminologies and standard coding system in Health Information
System (Sarbadhikari 2019) ensures that data in the system is unambiguous.
Content Exchange Standards(CES) are helpful to share clinical information
including clinical summaries, prescriptions etc.
• The Digital Imaging and Communications in Medicine (DICOM) (2016) and
Health Level-7(HL-7) (2016) are the CES used for sharing health information
with other healthcare levels when patient moves from one healthcare facility to
other.

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Need for electronic health records in Indian hospitals
• To boost the implementation of digital health in a countrywide manner, the standard
committee Ministry of Electronics and Information Technology(Meity)has prepared the draft
of National Digital Health Blueprint (NDHB) (2016). The draft was submitted to Ministry of
Health and Family Welfare, Government of India on 24th April 2019.
• Accordingly, NDHB draft was placed for the public domain for comments. The model of the
HER proposed is complying with guidelines outlined in the NDHM document as per EHR
minimum dataset requirement (Ganiga et al. 2017, 2020).
• This EHR will allow the healthcare facility from primary up to tertiary level to capture and
share patient data without any restriction and in a secure manner.
• Indian Healthcare System has also evidenced the development of ICT application but
mainly limited to only few private hospitals such as Max Health (Soi 2019), Apollo (J. C.
International 2019), Sankara Nethralaya (M. R. Foundation 2019), Fortis, Narayana Health
etc.
• All India Institute of Medical Sciences (AIIMS) and the Postgraduate Institute of Medical
Education and Research (PGIMER) are major public hospitals which have Electronic
Medical Record (EMR) in place to share the patient data with other departments of the
same group of hospitals (Sharma 2018).

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Need for electronic health records: International Scenario
• In 2001, Canada initiated to modernize its Information and Communication
Technology (I&CT) infrastructure in healthcare sector by setting up objectives of
standardized procurement practices, sustainable investment, and accelerate
innovation adoption scale across the Canadian digital health marketplace (Banff
2015; Rozenblum et al. 2011).
• England initiated to modernize its healthcare system by launching the national
initiative called National Plan for IT (Basu 2017; P. O. of Science and Technology
(2016) to provide connectivity between different levels of health records across
primary, secondary, and social care by 2020. With this initiative, summary of
health records were created for 54 million persons, i.e. 96 %of the England
population. Using this system, healthcare professionals can monitor the
summary view of the patient during episode of care.

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Need for electronic health records: International Scenario
• About 90% of the private practice physicians in Germany are using EHR system
(Lehr 2016). With the modernization of the healthcare system, the patient data
safety has been considered as the first priority by the healthcare provider during
the point of care.
• To modernize the healthcare system in Korea, nationwide (Lee et al. 2015)
Health Information Exchange (HIE) platform is being built. With this initiation,
most of the tertiary hospitals have started using EHRs to exchange among the
healthcare facilities.

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Development of standardized electronic health record (EHR)
• In a country like India, with its large population spread across a large
geographical landscape, to make the patient data accessible by all levels of
healthcare providers is difficult as the data is not interoperable and semantic.
• To meet consistent representation of the interoperability requirements,
standardizing vocabularies, or mapping between different vocabularies are
necessary.
• Cloud computing (Guo et al. 2012) has emerged as a main role in providing
healthcare IT solution.
• Therefore, healthcare organizations can largely benefit from cloud infrastructure
which could be an excellent solution for the country’s needs to have improved
healthcare in all levels of healthcare system.
• With the EHR, it is possible to capture and store distinct patient health data and
be made accessible at point of care including PHC, SHC and THC. EHR
contains health information about patient history, laboratory test reports, and
diagnosis images stored in a digital format which is available to healthcare
providers through computer network (Ministry of health and family welfare 2013).

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Guidelines Regarding the use of hardware,
networking and connectivity and mobile health
records
• These guidelines were recommended to ensure proper use of HER even
in future.
• Data ownership: The physical or electronic records are to be owned by
the health care provider, but it must be held in trust on behalf of the
patient. Sensitive personal data ownership was given to the patient
whereas additional privilege was given to health care provider to
modify/change/append any record related to the patient care as per the
necessity of making a complete document.
• Disclosure of information: It was advised to take a general consent
from the patient before disclosing the patient’s information for his
treatment, payments or other hospital related functions. But this is
exempted in case of the situations related to national priorities.

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Guidelines Regarding the use of hardware,
networking and connectivity and mobile health
records
• Patient Privilege: This allows the patient to ask for a copy of their
health records from the hospital.
• Conservation of the electronic health: This makes the health
organization liable to keep the electronic patient’s records for the lifetime
of the person ever.
• Data privacy and security: The data should be duly protected from the
cyber criminals and the principle of confidentiality must be maintained.

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