Improving and Expanding Electronic Health Records in a Rural Setting

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IKP Center for Technologies in Public Health instead fit into an “other” category (Arora, 2010). Furthermore, even if CDSS were able to help a non-physician correctly diagnose symptoms, the patient would still have to seek a doctor for further tests and prescriptions for medications, meaning that physicians are never completely removed from the equation (Arora, 2010). Public Health EHRs predominantly have had a clinical focus, providing patient appointment information and decision support for medical professionals. EHR can be utilized to support public health, long-term preventative measures by incorporating additional components. A widely accepted definition of public health centers around three core functions: assessment (assessing the state of public health), policy development (developing policies to promote health) and assurance (assuring that these policies are implemented) (Figure 1) (Kukafja et al., 2007). Public health works to prevent disease rather than treating them after symptoms arise. Figure 1 Public health practitioners place disease and disability in the context of societal, behavioral, and environmental factors. The public health system seeks measures that can benefit populations through social and legal policy, and behavioral and environmental interventions (Kukafja et al., 2007). Assessment Assurance In order to incorporate a public health focus to EHRs, new non-clinical information about patients would need to be gathered in order to populate societal, behavioral and environmental risk factors that would identify potential diseases patients would be at risk for. This endeavor would follow the assessment function of public health. Policy Development Once this is incorporated into an EHR this information would go alongside family history, past clinical information, lab test results, etc. and would be available at point of care. The availability of this additional public health component in EHR would provide medical practitioners the information necessary to create and promote needed preventative initiatives tailored to individual patients depending on their identified risk factors (Kukafja et al., 2007). This information could then be used to develop policies that would work to change population level environmental factors and conditions. As of yet there is little research regarding implementing a public health focus to EHR systems in rural regions. A holistic public health EHR system would need to evaluate patient behavioral, psychosocial, and environmental variables. In rural India environmental factors play a primary role in the main diseases affecting their populations. According to recent estimates, premature death and illness due to major environmental health risks accounts for nearly 20 percent of the total burden of disease in India (Environment and Social Development Unit, 2001). Water, sanitation and hygiene as well as indoor air pollution contribute greatly to this burden of disease and are the leading causes of gastrointestinal diseases (Prüss-üstün et al., 2008) and respiratory diseases (Rehfuess, 2006), respectively. While the rising incidence of diabetes and cardiovascular disease within India has shifted attention to behavioral and psychosocial risk factors of disease, this shift should not come at the expense of environmental risk factors, which can be especially hazardous for India’s rural population (Environment and Social Development Unit, 2001). These environmental risk factors are primed for interventions at the individual, household, and community level; in fact, many evidence-based interventions already exist for limiting these risk factors (Environment and Social Development Unit, 2001). For this reason, EHR systems with a public health component should place an emphasis on collecting data relevant to these factors and then use these data to develop targeted interventions. Water, Sanitation, and Hygiene The lack of adequate sanitation and safe water has significant health impacts. In 2002 the World Health Organization estimated that around 700,000 Indians die each year from diarrhea (Planning Commission Government of India, 2002). Between 69 to 74 percent of India’s rural population take their drinking water from protected sources, leaving an unserved population of 26 to 31 percent (Panning Commission Government of India, 2002). Improved water supply, namely improvements in drinkingwater quality through household water treatment such as chlorination at point of use, can reduce diarrhea morbidity by 20 www.ictph.org.in
Improving and Expanding Electronic Health Records in a Rural Setting: Clinical Decision Support System & Public Health Component between 6 to 25% (Prüss-üstün et al., 2008). The availability of potable water alone may not result in significant decline in gastrointestinal diseases, especially diarrhea, unless it is coupled with improved sanitation and hygiene (Prüss-üstün et al., 2008). Improved sanitation can reduce diarrhea morbidity by 32% (Prüss-üstün et al., 2008). Between 18 and 19 per cent of India’s rural households have a toilet, with most studies showing an increase in health benefits once access to toilets within a community reaches 50-60 percent (Environment and Social Development Unit, 2001). Indoor Air Pollution Respiratory diseases account for a greater share of mortality and morbidity in developing countries in general than diarrheal diseases. However, the causal link between respiratory diseases and air pollution is less well characterized than is the link between diarrhea and waterborne pathogens (Environment and Social Development Unit, 2001). Studies indicate that particles of small diameter emitted from solid fuels can lead directly to respiratory infections, asthma attacks, and allergies (Environment and Social Development Unit, 2001). Indoor air pollution has been linked to tuberculosis, interstitial lung disease and laryngeal cancers (Rehfuess, 2006). Inhaling indoor smoke doubles the risk of pneumonia and other acute infections of the lower respiratory tract among children younger than 5 years of age (Rehfuess, 2006). Women exposed to indoor smoke are three times more likely to suffer from COPD, such as chronic bronchitis or emphysema than women who cook with electricity, gas, or other cleaner fuels (Rehfuess, 2006). Objectives The current study aims to expand upon and improve the EHR currently in use by adding both a public health component and a CDSS. To this end, the methodology behind such an expansion is explained, including previous work conducted in these areas as well as the methodology specific to the system envisioned by ICTPH. The current EHR system in place at ICTPH’s clinic in the Alakkudi village serves as a database of patient appointment and medical information. The EHR system was introduced to the clinic in order to tackle the lack of medical documentation in rural regions and to facilitate better patient care. The motivation for expanding the EHR to include a CDSS is rooted in the lack of quality healthcare available to India’s rural population. The shortage of doctors in India is one of the most critical barriers to expansion and quality of health care (Ranjan, 2008). Of the 21,490 doctors needed in community health centers across the country, only 5,910 are available (Ranjan, 2008). Of the 66,059 nurses and midwives needed in these same centers, 41,313 are available (Ranjan, 2008). These numbers are even starker in the rural village setting, where nearly two-thirds of India’s population resides (Ranjan, 2008). The doctor to population ratio is six times lower in rural settings than urban, and villagers spend an average 1.5 times more on healthcare compared to their urban counterparts for the same illness (Jhunjhunwala, 2008). CDSS operated by non-physicians with the capacity for physician consultation via telemedicine may offer a way to alleviate this inequality in healthcare. The CDSS will expand upon the information management capacities of the current EHR by evaluating symptoms and other data to reach a diagnosis. In this way, ICTPH envisions the CDSS as a mechanism through which healthcare will be standardized and evidence-based, not only increasing access to care but also quality of care. A public health component utilizes non clinical patient information (i.e. behavioral, psychosocial, environmental factors) to foresee what conditions patients will be at-risk for. This information can be used by a health professional in order to better understand patients’ health profiles. While the CDSS addresses improving the immediate care of patients, a public health component will allow the EHR system to address preventive care. Both these expansions work together to efficiently and effectively improve the health of the rural populations served by ICTPH. Methodology CDSS ICTPH aims to remedy the disparities between the healthcare needs of the rural population and the available resources by establishing rural clinics run by nursing staff. Clinics are designed to serve a population of approximately 10,000 people each. Nurses work under the supervision of a doctor, and follow a set of protocols designed to promote evidence based care and www.ictph.org.in 21
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Improving and Expanding Electronic Health Records in a Rural Setting

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