Like many of its neighbours, Malaysia has been experiencing changing disease patterns. The era of acute infectious diseases and malnutrition has been succeeded by one of chronic diseases and lifestyle related illnesses. So the country’s healthcare strategy has had to shift from making traditional health and hygiene improvements to promoting healthier lifestyles and managing chronic diseases.
“This calls for change in the role of healthcare professionals and the delivery interface between the consumer and health system,” says Dato’ Dr Jai Mohan, Professor of Health Informatics at Kuala Lumpur-based International Medical University and the Vice President of the Malaysia Health Informatics Association.
“The episodic relationship between the health consumer and healthcare professionals is no longer sufficient to address new health issues,” he says, adding that ICT can build a health infrastructure that enable a continuous health-promoting relationship between individuals and health professionals.
Malaysia’s healthcare sector is not uniform. In addition to the Ministry of Health (MOH), Ministry of Education, Ministry of Defence and smaller agencies such as the Department of Aboriginal Affairs all operate public healthcare facilities. And there are more than 200 private hospitals and around 5000 general practitioners, not counting those run by NGOs. Unsurprisingly, Malaysians’ personal health data often resides in silos.
“A patient might go from one hospital to another, but the data might not follow,” says Dato’ Dr Mohan. “This is not an ideal in the long run.”
Planning
The government has a solid history of structured master planning in the area of healthcare, says Dr Rohaizat bin Yong, Deputy Director of Planning and Development Division at MOH. Currently the ninth five-year plan is being implemented, which aims „Towards achieving better health through the consolidation of services“.
Under the new Prime Minister, Najib Tun Razak, the ‘1Malaysia’ initiative was launched in September to build a “people first” government. Dr Rohaizat explains that in health this translates to ‘patient first’, and requires the provision of clear KPIs to measure performance.
In 1998, two sets of projects were launched under the name Total Hospital Information Systems, which aims to equip new and existing public hospitals with information systems, and integrated TeleHealth, which forms part of the government’s Multimedia Super Corridor (MSC) initiative.
HIS
Early IT implementations started between 1991 and 1995, and where designed to handle administrative tasks, drug inventory management, finance and health management information reporting. In 1998, the first paperless and filmless hospital in Malaysia – the 900-bed Selayang Hospital – opened its doors.
“Selayang was the best example of effective implementation of a hospital information system,” comments Dato’ Prof Mohan. Even ambulance drivers are involved. Once a driver has sent a patient to the hospital, he has to log into the system to record the route and traffic information. “In that way we know where delays can happen and improve the despatch routes,” comments Prof Mohan.
Rather than develop an in-house system, the Ministry chose vendor solutions. “While many had already reached a certain level of achievement, we were starting from scratch,” says Prof Mohan. “We needed to catch up quickly.”
The Ministry also figured out that it didn’t have the economies of scale or people to continuously maintain the systems in the long run.
The hospital uses best of breed solutions: Spacelabs for critical care, Siemens for radiology and Oracle for financials. Prof Mohan, points out that the biggest problem was integration. “Every time a vendor updates their applications, we had to rethink integration. And at Hospital Selayang we managed 20 applications from 20 different vendors.”
And often when there have been a problem with integration, finding the vendor responsible has proven tricky. Learning from the experience at Selayang, the country’s second paperless and filmless hospital, 300-bed Putra Jaya Hospital, adopted no more than two vendor providers. Overall, the two hospitals have been successful and the government decided to make IT part of the planning for all future hospitals.
The government also decided not to assign a particular hospital’s system to different vendors. A single vendor was selected to implement the HIS for the next 14 hospitals. The systems deployed at these hospitals were divided into three tiers in terms of the level of sophistication.
A Basic Health Information System (BHIS) includes a Patient Management System, simple Clinical Information System and financials; an Intermediate Health Information System (IHIS) integrates what a BHIS would encompass with laboratory and pharmacy information systems. And a more costly Total Health Information System (THIS) also includes more advanced modules such as RIS/PACS and Case Mix.
After the BHIS was implemented at Hospital Kepala Batas hospital, the MOH realised that BHIS had many limitations and decisions were made for existing BHIS to be upgraded to IHIS and THIS was to be implemented in new hospitals. Contracts have been awarded to a number of vendors, including Microsoft, Eclipsys, Cerner and IBA Health. Each get one or several public hospitals to implement, to avoid monopolies and boost competition.
“After these 14 hospitals, the MOH already has an array of data standards, code sets and workflows in place,” says Prof Mohan. “Now we have the confidence to give contracts to different vendors, because they all have to follow standards that MOH has imposed to ensure that data can exchange or migrate easily.”
Dato’ Prof Mohan also emphasises that health systems should be open. “If other people also use the system you are using and ask ‘how come it can’t do this’, innovation will come in leaps and bounds.” “Total Hospital Information System has been far more successful than TeleHealth,” he adds.
TeleHealth
Managed by the TeleHealth Division at the Ministry, the TeleHealth initiative aims to develop a multimedia network linking all healthcare product and service providers to transform healthcare service access and delivery. It contains four flagship applications: Teleconsultation (TC), Mass Customised / Personalised Health Information and Education (MCPHIE), Lifetime Health Plan (LHP), and Continuing Medical Education (CME).
Under MCPHIE, a consumer health portal (www.myhealth.gov.my) has been built where an individual citizen can make appointment, conduct health self-assessment and access health education materials.
CME is realised through the MOH’s MYCPD (Continuing Professional Development) portal, which keeps records of professional educational activities that healthcare professionals are engaged in. The portal also helps planners evaluate their staff to work out their training needs. The portal is supported by a digital library.
Teleconsultation
The core of Teleconsultation is the TelePrimary Care initiative (tpc.moh.gov.my). It provides real-time consultation on patient management between peripheral clinics and hospital specialists. Currently deployed across 55 sites across three states, TelePrimary Care also incorporates patient medical records and uses a satellite link.
Prof Mohan notes that the equipment was expensive and became very quickly outdated. RM 21 million (US$ 6.2million) was spent on equipping the first 42 sites.
And because of the high costs of teleconsultation equipment, further roll out has been slow. However, Prof Mohan remains optimistic. “The price of equipment, as well as network bandwidth, is falling dramatically, which is enabling us to deliver the same service more cost-effectively.”
In the state of Sarawak, a low-end version of tele-consultation has proved very successful since 1998. Scanners and digital cameras are issued to participants, who scan X-ray images and take pictures to send to specialists.
“This low cost solution has achieved far more consultation sessions than more expensive systems,” Prof Mohan says, adding that it is probably the flexibility that it gives users that contributes most to its success. “For the fully-fledged tele-consultation system, you need to go to a specific location within the facility and this is very troublesome for a busy clinician.”
Training nurses will be a priority. “Although most Malaysians live close to district health centres, these facilities are underused,” explains Prof Mohan. “Nurses supported with a good IT system will do many things much better than a busy doctor. Now we need to train them to manage such systems.”
MyKad
Another important part of the MSC initiative is MyKad, a smart identification card for which 2.6 kilobytes of storage is reserved for health information, including blood group, chronic diseases, allergies, current medication, health insurance records and information on whether the person is an organ donor.
“It was used to back up our lifetime health records,” says Dr Amiruddin. “Although the space was quite limited, it was actually quite sufficient for an individual.”
The TeleHealth division developed the API for any vendor CIS or HIS system to be able to read or write the health data on MyKad in a standardised way.
Provisioning card readers has proven much easier than writers - currently only two facilities are capable of writing information on the card. “As it is not mandatory requirement, vendors are reluctant to implement this unless they get paid,” says Dr Amiruddin. “Our final solution will be using MyKad to authenticate oneself to the system, as the card itself is mandatory.”
My Health Plan
The objective of Lifetime Health Plan (LHP) was for every Malaysian citizen to have his or her own health plan, based on an all-encompassing health records of that individual. Using knowledge management tools, the application would evaluate the personal’s health information periodically and generate advisories to support long term care. It was intended to provide a personalised, proactive and prospective health plan tailored to the specific needs of the individual.
LHP was also expected to generate meaningful reports using data mining tools, therefore influencing public health policies. Despite numerous intended benefits, LHP became the biggest failure for the Ministry. The application was rolled out through a public-private-partnership model where the government would only pay for what it used. As the link between health data custodians and the LHP was missing, the business model turned out to be unsustainable and the company managing the application went into receivership.
“We did a lot of work, and although the project failed, we learned a lot,” comments Dato’ Prof Mohan. A new initiative, called Malaysia Information Exchange (myHIX), was launched to replace LHP. It aims to allow care providers to share discharge or clinical summaries electronically to ensure continuity of care.
“We wanted a single lifetime record for each individual and any care provider managing that patient needed to be able to contribute to a single health plan,” says Dr Amiruddin. “For that we need to have an integration framework to make sure that all the different health systems are interoperable.” The summary will be received in the central repository and made available across the country.
“Because of the nature of telehealth projects, we are also heavily involved in ensuring the integration framework across the whole healthcare sector is put in place,” says Dr Amiruddin. “Our standards and code sets are mandatory for public hospitals; private care providers also have to comply with our reporting and exchange standards.” Ultimately the Ministry is the policy maker, he adds.
The Integrated Health Enterprise (IHE) framework for Malaysia was introduced by the Ministry in 2007 and since then, an annual event called “Connectathon” is held for vendors to test their products’ interoperability against the MOH’s specific profiles.
“We hope by next year we should have a service whereby six hospitals and clinics will be able to share their discharge summary wherever the patient goes,” says Dr Amiruddin.
“Overall we have been pretty successful in our planning and projects,” concludes Dr Rohaizat. “This can be demonstrated by comparing health facts over the past 10 years. Odd numbers don’t mean anything, but comparisons don’t lie.”
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Autor(en)/Author(s): Jianggan Li
Quelle/Source: FutureGov Magazine, 07.01.2010
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