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Creating the Hong Kong-wide Electronic Health Record Print E-mail
The Quarterly 2011

 

In 2009 the Hong Kong Legislative Council approved the capital commitment of HK$702M for the first stage of the "territory-wide patient-oriented electronic health record (eHR) sharing system". This article describes the background, strategies and approach taken to the development of this ambitious project.

In 2009 the Hong Kong Legislative Council approved the capital commitment of HK$702M for the first stage of the "territory-wide patient-oriented electronic health record (eHR) sharing system". This project is very much in line with global trends, as in recent years many nations and territories have also launched large-scale projects to electronically share the health records of their citizenry. In some cases these have been truly massive endeavours - the English National Program for IT was described as the largest civil IT project in the world - reflecting the widely held belief that shareable electronic health records will be vital to the future sustainability of the health care system. Unfortunately, success has proven more elusive than funding for many of these projects and few can claim to have truly met their often ambitious goals. Can the Hong Kong eHR project overcome the difficulties and hurdles? I believe so, and this article will attempt to highlight the features that give me this confidence.

A long history of sharing

Hong Kong has one particular advantage in developing her eHR - namely a long history and experience of sharing comprehensive electronic medical records (EMR) in the Hospital Authority (HA). The HA began development of such a system, the HA Clinical Management System (HA CMS), in 1994 with the explicit goal of having a single standardized longitudinal medical record shareable amongst all the hospitals and clinics of the HA. Since the HA manages all the public hospitals and most of the public clinics in Hong Kong, and is the primary training ground for all doctors in Hong Kong, both patients and providers now have well over a decadeís experience in electronic records and the sharing thereof. This experience is crucial as many stakeholders in the healthcare system have now seen first-hand not only the benefits but also the potential problems for electronic medical records, which means that support for the eHR project is very much grounded in reality. Of equal importance is the expertise accrued by the developers and health informaticians of the Hospital Authority in the development and deployment of such systems on a massive scale.

Although EMRs in the private sector are not as well developed, momentum has been building. The professional associations have developed and promulgated low cost or open source EMR systems for their members, and several of the private hospitals have developed or acquired their own EMR systems.

The importance of this experience and expertise in Hong Kong cannot be overstated. In 2006 HA was able (at very low cost) to develop a pilot program allowing patients to share their HA CMS records with private practitioners (the HA PPI-ePR project), with a very positive response and good uptake. The experience of pilots such as this provided confidence to push ahead with the eHR.

First and foremost, a healthcare project

Of equal importance to the eHR is a proper and consistent strategic positioning. The Hong Kong eHR was first proposed in 2005 in the discussion paper "Building a Healthy Tomorrow", issued by the Health and Development Advisory Committee and then further expounded in the Healthcare Reform Consultation Document "Your Health, Your Life" published in March 2008. These papers positioned eHR as an essential healthcare infrastructure enabling the key healthcare goals of:

  1. Patient centred care ñ enhancing continuity of care through the timely sharing of patients' health records; integrating healthcare services provided across the different sectors of the healthcare system
  2. Enhanced primary care ñ provision of a lifelong longitudinal health record will help promote the family doctor concept and giving patient control of their own record will in turn give greater control of their own health
  3. Strengthening hospital-primary care interface and public-private interface ñ eHR connects the various sectors of the Hong Kong healthcare system, allowing better collaboration between sectors and enables patient movement between sectors without worrying about the transfer of their medical records.

By consistently framing eHR as an enabler of specific key strategic healthcare objectives; priority and scope are more readily set and many major issues are more readily resolved. In addition, for such a large-scale project with so many diverse stakeholders, a set of guiding principles is essential. These principles are discussed below.

Government led

The Hong Kong Government has undertaken to lead, fund and develop the eHR. Not only will the sharing infrastructure be created, but hospital and clinic based EMR systems based on the HA CMS will be developed and licensed at little or no cost to the user. These latter systems are known as the CMS Adaptation Modules and CMS On-ramp respectively. To take the project forward the Government established a dedicated eHR Office to oversee the entire project, and the HA was engaged as the "technical agency" to develop and implement the system.

Compelling, but not compulsory

Participation in the eHR will be voluntary, for both patients and healthcare providers. Although the system will not be compulsory, it is hoped that it can be made sufficiently compelling.

Although participation is voluntary, the importance of privacy and security are not diminished. Access to one's own record will be controlled by the individual, and only registered healthcare professionals will be given access. Participating healthcare providers will need to engage the services of a Certified Service Provider to enable the interfaces from their local EMR to the eHR; this will include installation of electronic certificates and other security measures.

Open standards

Information standards are required to allow meaningful sharing and display of records, as well as clinical decision support or secondary use of data. A set of terminology, messaging and exchange standards will be developed and published to allow different EMRs to integrate with the eHR. These standards will be built upon international standards such as Health Level 7 International (HL7), The Systematized Nomenclature of Medicine (SNOMED) and Logical Observation Identifiers Names and Codes (LOINC), but will be customized for the Hong Kong environment.

A phased approach to standardization is being taken, with the required degree of compliance rising over time. This will allow less sophisticated EMR systems to participate initially, but eventually all systems will be expected to comply with the highest levels.

Leverage experience and expertise of the HA

As noted earlier, HA has many years experience in developing and deploying a large scale, standardized EMR. To leverage this experience, the Government has asked the HA to be the "technical agency" for the development of the eHR. HA has established an eHR Project Management Office which oversees the development of the core sharing infrastructure as well as EMR systems and modules for use by private hospitals and practitioners. A Health Informatics team has been created to lead the clinical design, training and implementation efforts.

HA is also leading the eHR Information Standards Office (eHRISO) to develop the open standards underpinning records sharing. The eHRISO has created a series of Domain Groups to develop the standards and workflows, and there is broad participation from stakeholder groups in these groups.

Governance, engagement and change management

Although the eHR is certainly a technical challenge, the user engagement and scope and change management issues are more likely to derail the project. A transparent and participatory decision making process is vital, coupled with a sustained program of engagement, and good project monitoring and control.

The Steering Committee on eHR Sharing was established by the Secretary for Food and Health, with four working groups on: Institutional Arrangements, Legal Privacy and Security, eHR and Information Standards and eHR Partnership. As mentioned above, the Government also established a dedicated eHR Office to oversee and monitor the entire project.

A multiphase and ongoing eHR Engagement Initiative (EEI) has been launched to allow healthcare providers, professional organizations and the IT industry a formal mechanism to participate in the development of the eHR and to seek support for their own initiatives in support of the eHR. To date several dozens of proposals have been received.

PPI-ePR pilot

A series of pilot projects will be instituted to take forward the eHR. The most important and largest of these is the Public Private Interface - Electronic Patient Record (PPI-ePR) project. The PPI-ePR was launched in 2006, and allowed HA patients to share their HA records with private practitioners and hospitals.

This project tested a series of concepts related to the eHR, such as the scope of data sharing, security measures, and most importantly the willingness of patients and practitioners to participate in records sharing.

The PPI-ePR has been an unqualified success, and as of mid 2011 some 140,000 patients and over 1500 private practitioners had joined the scheme. Surveys of patients and practitioners have been very positive, and patients are especially appreciative of the SMS message which is sent to them when their record has been accessed by a practitioner.

Progress and way forward

The major principles and components of the Hong Kong eHR project have been described above. The technical tasks of design and development are all in good progress. The key issues of stakeholder engagement and project control have been thoroughly addressed but of course these will be areas of continued focus throughout the project.

The full eHR infrastructure will go live in 2013/14, but in the meantime the CMS On-ramp for clinics and CMS Adaptation Modules for hospitals will be released. The initial set of eHR standards has already been released, and further standards will be released over time.

We have not yet reached the halfway point, but I believe the leadership, strategies, structure, process, expertise and enthusiasm already displayed and deployed, have put us well on the road to successfully creating a territory wide electronic health record sharing system in Hong Kong.

Dr Ngai-Tseung Cheung
Chief Medical Informatics Officer, Hospital Authority, Hong Kong;
Consultant (eHealth), Food & Health Bureau, The Government of the Hong Kong SAR


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