Electronic medical records

Canadian EMR saves lives in Belize

By Rosie Lombardi

An  open-source EMR that was implemented in Belize by a Canadian team more than three years ago is showing results. “We put it in for a buck a citizen for the whole nation, and it runs all the clinics, hospitals, pharmacies and labs,” says Dr. Michael Graven (pictured), co-developer of the system and a neonatologist with the IWK Health Centre in Halifax.

Dr. Graven has been involved in healthcare IT for almost 30 years, and has also worked overseas in developing countries for decades. “When you hold a dying baby in your arms, what are you going to do about it? It turns out you can do a lot with IT to structurally alter healthcare.”

The code for the open-source EMR system, called ACSiS, was written by Accesstec Inc, a software company based in Fredericton, although Dr. Graven and others collaborated. “I did it as an unpaid volunteer and don’t own shares in the company. But I’m considered one of the chief architects for the system in Belize, as I helped design it and set up the data structures. This is where we have the most clinical experience in judging the return on investment.”

Dr. Graven says the system was customized for Belize, and is called the BHIS. “It has a fully integrated, nation-wide enterprise architecture, and everything that can be covered in healthcare, it does for the whole nation.”

He says there’s hard evidence from the Belize experience about the enormous benefits of a unified approach and a single, open-source platform for healthcare.

“In the history of humankind, only three things have had a dramatic impact on mortality: safe water, vaccines, and antibiotics. Technology is the fourth: in Belize, the impact of the system has exceeded antibiotics.”

Compliance with regimens for chronic conditions such as hypertension and diabetes increased dramatically once the integrated system was implemented, he says. “In just a few months, compliance went from 30 percent to 90 percent.”

This was achieved with simple follow-up measures – made simple because every citizen and healthcare entity is set up on the system. Letters are automatically generated to remind patients about appointments and prescription refills. There’s one protocol for all doctors and pharmacies – who all have access to centralized medical records – specifying which medications to use, how often patients should get checked, what blood pressure readings should be, and so on.

“For people over 65, the hospitalization rate went down 79 percent over two years. Strokes due to hypertension went down from the third highest cause of death to 12th place. Controlling chronic conditions are a large piece in recouping investments in the system.”

In addition, the vertical transmission of HIV from mother to baby went down from 40 percent to 3.8 percent. “This is actually better than Canada,” says Graven.

Controlling for this is highly data dependent. “If a woman gets prenatal care here then delivers there, do they know the HIV status? Anti-retrovirals have to be given before and after the baby is delivered. If you don’t get data from A to B, you won’t be able to sort it out.”

Pharmacies can also react immediately if pharmaceuticals are tainted with melamine or other agents. “If you need to pull a drug, every single prescription and every stock is logged in the system. You can locate everyone who’s had meds from lots in a few minutes, and stop any further dispensing. There have been no repeat cases of adverse reactions to meds because everyone in the chain knows about any problems.”

The BHIS is a flexible modular system built on a Linux platform, but it doesn’t have any unique features compared with most other EMR systems – except one. “It was designed with the notion that in most cases, the amount of time a doctor has to spend entering data should never be more than 10 percent of the patient encounter. That means ensuring you don’t ever have to enter anything multiple times – but since everyone in Belize is registered in the system, no additional registration is ever needed beyond checking it’s the same address.”

Canada could achieve similar benefits if one EMR system from any vendor offering a solid product were implemented. “I would applaud the model – let’s get one that can be used countrywide for everybody. The problem isn’t technical, it’s political.”

Dr. Graven says the ACSiS EMR system, which has all the linkages with external entities needed to perform as a broader EHR system, isn’t being used in Canada nor has it been certified by any provinces. “EMR is only a part of what this system does. It not only does patient encounters, but provides the backbone over the top.”

He has provided briefings to Canada Health Infoway about the tangible benefits he saw with BHIS, but hasn’t received much interest.

“Infoway owns the EHR space, but it doesn’t go down to the patient encounter level – it relies on a pile of other EMR systems to do that. The total expense per Canadian citizen, once all the standardization, data feeds and so on are built into the EHR, will be about $250. Once it’s all done, it still hasn’t been proven that the system will accrue any of the savings Belize saw – the payback period for the BHIS system was six months.”

Similar ACSiS-based national systems are being deployed in St. Vincent, and St. Lucia, and Syria is developing its own based on the ACSiS model. “No Western country has standardized on one EMR/EHR system yet, although some are close. Belize is the first to achieve this.”

To people who are skeptical about the medical and cost benefits of building a universal EHR system from the ground up from EMRs, Graven invites them to take a look at the evidence with their own eyes. “Go to Belize and see – what I say is irrelevant.”

For more information, visit http://www.accesstec.ca

Posted September 30, 2010