Middle East & North Africa Healthcare IT: 2012

Adopting National Electronic Health Records for the UAE,
Benefits, Challenges & Solutions

Tawab Hamidi
IBM Middle East Software Group Healthcare Leader

Playing Russian Roulette With Your Life:Imagine a resident/citizen of the UAE getting into an accident and is in critical condition. The individual is rushed to the hospital, and they immediately determine that the patient needs to be prepared for an emergency operation. The healthcare providers face a daunting challenge, as they don’t have any patient medical history, nor are they able to access any family member to get pertinent medical information. The providers can’t determine whether the operation will have an adverse effect on other pre-existing medical conditions (eg. heart condition) or if the patient is allergic to certain anesthetics and antibiotics. Given the criticality of time, the providers are forced to make a decision, which amounts to nothing more than playing Russian roulette with someone’s life.
In the United States alone, it is estimated that medical errors are responsible for the death of 44,000 to 98,000 people per year, which is deemed a conservative estimate. The UAE is not immune to these errors either, and while it is acknowledged that medical errors exist within the UAE, statistics are not available.
Achieving high quality of care and preventing medical errors entail various measures, but one essential requirement is equipping healthcare practitioners with patient related information, in other words, full patient healthcare records. This is achieved by having a “Centralized” National Electronic Healthcare Record System, more commonly known as Health Information Exchange (HIE).

rImagine going to a new clinic or hospital for the first time, whereby the hospital automatically has access to your medical history, allergy list, bio, etc. No need to file any more paperwork or conduct medical tests that you have just recently done with another provider. You meet a physician that already knows your medical history, has access to your past and present lab results, images (CTScan, EKG, MRI, etc), can read notes from previous doctors, your medication list, operations you have had in the past and more. This is the potential of a national HIE system that has been implemented in certain nations around the world.
The HIE system ensures that all patient medical records are “centrally stored”, which consumers, Health Authorities, and healthcare providers (hospital, clinics, physicians, etc) can access at any point (upon the patients consent of course) and subsequently update appropriately. Below is a logical depiction.

The concept is not new, and many nations are pursing it with various degrees of adoption. Some nations that have reached advance stages are Canada (Canadian Infoway), Singapore, and Australia. Smaller nations have an advantage when it comes to adopting, as the numbers of integration points are far fewer.

Why The UAE Should Prioritize Adoption of HIEThis leads to my next point, as to why UAE should pursue the adoption of a National HIE model with high priority. As The UAE has prioritized on building a state of the art infrastructure, and currently at an advance level of EMR adoption, it can be contended that having an HIE system is essential to its infrastructure. Furthermore, this would position the UAE amongst the top nations/cities in the world in the healthcare space. Among the numerous benefits of an HIE system in UAE, the following are a few key ones.
• Adoption of such a system would extensively boost the quality of care provided in the Emirates.
• It will boost UAE’s healthcare reputation and attract knowledge/skilled workers to reside in.
• It will further attract businesses and investor to the UAE from the healthcare sector.
• “Secondary Use of Data” – Attract top notch physicians/practitioners providing them avenues of research by easily using/extending data collected through the HIE system. It has to be noted that patient privacy is heavily guarded with HIE systems, complex algorithms exist to de-identify patient information and ensure privacy.
• “Secondary Use of Data” – Provide local universities ability to conduct research (ex. usage of a specific diabetes drug and its effects).
• With the continuous migration of expats into and out of the UAE, their medical records can be provided to them or their home country, as a fee based service.
• Patients can have access to their medical records and further be empowered (etc, update there bio, allergy list, etc).
The solution can be a cloud based model, which all hospital/clinics can easily connect to, and obtain/update patient medical records, upon patient consent (with an audit trail running). What is unique about adopting such an infrastructure, or a healthcare information superhighway, is its extensibility to build additional value added services on top of it (e.g. research), thereby providing a state of the art quality of care. It has to be taken into consideration that a small number of Hospital may not be entirely equipped and automated for HIE adoption, thus some effort and time is required for such Tier 3 hospitals to come up to speed.
The system can easily be extended to provide physicians a mechanism of knowledge sharing and collaboration on remedies and treatment for challenging illnesses. For example, a patient with a specific illness (Irritable Bowl Syndrome-IBS) can be matched using numerous criteria against another patient providing patient similarities and predictive modeling, whereby physicians can be made aware of certain treatments that have resulted into a positive outcome for other patients.

ApproachTo begin with, each of the seven Emirates within UAE, needs to initiate their own HIE adoption plan and develop a roadmap specific to them. This may not necessarily have to be divided amongst the seven emirates rather it can based on regions given there geographic proximity, population size, providers, etc. This will allow certain regions to achieve quicker adoption rate based on there level of readiness (EMR, Automation, standardization, etc).

Challenges:
Of course, as with any good solution, it comes with certain challenges, and in our case the following three key challenges need to be remediated: Regulatory, Financials, , and ease of integration and adoption.
Financial Cost Model: Implementing a solution of this magnitude can take years and incur a hefty cost, as it needs to be integrated with every hospital/clinic in the country and fully adopted. While the MoH can play a critical role as a regulatory body, shouldering the cost of such an effort can be prohibitive for any health authority, thus it is necessary to have appropriate cost recovery models.
A viable financial model that might prove to be feasible can be a “Pay-Per-Use” Model. This model, in which the HIE solution can be located centrally in a cloud and providers (hospitals/clinics, etc), can access Health Record on a “Pay-Per-Use” Model upon every patient interaction with the provider. The charge can be as nominal as 1% of the hospital visit cost, which can be ultimately charged to the patient/insurance. The time efficiency for both the patient and providers alone would be worth far more than the nominal 1% fee. While this will requires an initial investment, the cost recovery can be reaped in a short time. Furthermore, there are numerous private market entities that are willing to invest, mitigating any cost shouldered by the government.   This brings us to our next challenge, which is ensuring adoption of the system by each and every provider.

If we are to take a very rudimentary stab it at, we are looking at generating $45 million dollars per year with the “Pay-Per-Use” Model. This is based on the fact that UAE healthcare market for 2010 was estimated to be $4.5 billion dollars (which is expected to grow to $8 billion by 2015). This amount would be more than sufficient to pay for itself, while at the same time generating business and improving the quality of care.
It is important to note that the “Pay-Per-Use” model rate of 1% is just a random number at the moment, and proper calculations have to be made to provide a more accurate understanding. Also, after reaping the initial investment cost for the HIE, Health Authorities can either lower the “Pay-Per-Use” rate or use the money to invest in value added services to further benefit patients (e.g. research).
Regulatory: The patient medical records residing “centrally” in a cloud are only valuable if providers continually update them as they see patients in a standardized and auditable manner. Of course here in lies the greatest challenge of ensuring that after each hospital/clinic visit, patient records are updated and uploaded in the cloud accordingly by the caregivers.   The role of regulatory bodies (Health Authorities) to adopt stringent regulations and measures are absolutely critical for this to work. Regulatory bodies needs to tackle the issue at three levels:
1. Stringent privacy rules and regulations for all users of HIE are needed, providing authentication, authorization (granular) and audit.
2. Provide explicit and detailed information on usage of the HIE cloud system (updating all patient information, lab results, images, records, etc., along with time span allocated for each update)
3. Stringent and incremental fines for delay of patient updates to the system, while at the same providing monetary rewards for providers that adhere to regulations. The monetary reward can be a lesser charge for usage of the “Pay-Per-Use” model (eg. 8 aed per patient, whereby the provider can keep the additional 2 aed).
4. Health Authorities need to pave the way and provide easy means of adoption and integration for providers. The next section will explain how this can be achieved.

Adoption & IntegrationAdopting and integrating clinics and hospitals to the central cloud will entail extensive time and effort, and it would be a daunting effort for any health authority to own, implement and roll out across the nation. Thus an innovative approach needs to be taken to expedite the integration and adoption of HIE.
Health authorities should focus on doing what they do best, which is creating regulations and specifications for enforcing standards, adoption & integration of the HIE, and leveraging the free market enterprise for the actual implementation. Multiple specialized IT vendors or IT service integrators can work simultaneously to integrate all providers and play an integral role in expediting this process. More importantly the IT vendors and service integrators need not be paid by the Health authority, rather they can get a share of the “Pay-Per-Use” cost that hospitals get from each patient.   Hospital can also be given the option of implementing themselves or pay an approved/certified IT vendors the cost of integration and keep the full “pay-per-use” charge for themselves.

ConclusionThere is unanimous agreement amongst healthcare experts and analyst on the value and need of adopting a national HIE model. The solution has been proven and already implemented in some nations across the world. The key challenges for HIE adoption resides in how it can be regulated, monetized, localized, integrated and adopted with speed, all while taking into consideration the population size, type of government, and patient privacy laws. As in the case of the UAE, this article has aimed to address the challenges of HIE adoption and how it can be adopted in the UAE market.
By pursuing and achieving a national HIE model, the UAE will be considered amongst the top quality of care providers in the world. It would provide the UAE a stellar reputation in healthcare, attracting investors, high end skilled workers, and top notch practitioners (physicians/nurses). Given the monetizing model, the cost would be nominal to the health authorities (might even be a source of revenue) and would propel economic growth and development of the nation.

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