Improving and Expanding Electronic Health Records in a Rural Setting

Improving and Expanding Electronic Health
Records in a Rural Setting: Clinical Decision
Support System & Public Health Component
Data collection/use
CDSS
Based on consultations with the clinic doctor, it was decided that the initial decision-trees for the CDSS should focus on
the cardiovascular system, respiratory system, and gastrointestinal system as most patients presented to the clinic with
diseases pertaining to one or more of these systems. Data required for the formation of decision-rules represented by
the decision-tree were collected through interviews with the clinic doctor and an ICTPH staff doctor, as well as through
review of medical textbooks. For example, when designing the decision-tree for the cardiovascular system, the physician
first provided symptoms relevant to this system (e.g., chest pain, dyspnea, syncope). From there, the physician described
the physical exams (e.g., palpation, auscultation) and laboratory tests (e.g., echocardiogram, electrocardiogram)
required to probe into the nature of these symptoms. The potential results of this objective portion of the visit were
then described (e.g., mid-systolic ejection, widely split S2) and a diagnosis for each outcome was given (e.g., pulmonic
outflow obstruction). In this way, flow-charts for various cardiovascular diseases were created based on the answers to
yes/no questions.
Incorporating a Public Health Component into the EHR
Data required to assist us in developing the public health survey, and, more specifically, the decision tree for the environmental
factors was obtained through a series of interviews and conversations with the clinic doctors, nurses and the local panchayat
office. The discussions with the clinic alerted us to what predominant health concerns should be the focus of our protocols.
We conducted literature searches regarding the linkage between various environmental factors present in rural India and the
at-risk health concerns.
Our discussion with the local panchayat office provided us the knowledge to expand on the questions for the environmental
survey, as well as what other issues/factors need to be looked at, such as trash burning practices and water quality reviews.
We conducted numerous field visits to Alakkudi to view and observe the various environmental factors in the village which
also gave us a better understanding of what additional information would need to be incorporated into the proposed surveys,
such as the local indoor cooking practices.
Conclusion
Expanding EHR to include both public health and CDSS components has the potential to improve healthcare in rural
settings. The dearth of physicians in these areas as well as inadequate medical training offered in rural settings creates
a need for an enhanced EHR system. CDSS with diagnostic capabilities can increase standardized care and assist nurses
in making evidence-based decisions. The public health addition to the EHR, coupled with environmental interventions
at the community and household levels, adds a preventive focus that could have an impact on long-term patient
outcomes.
Limitations
Implementing both a public health focus to an EHR system and a CDSS in a rural clinic is an endeavor not previously
attempted. As such, very little literature and background information is available that will lead to a definitive conclusion
regarding the effectiveness of these initiatives in rural settings. Technology is a key component to implementing these EHR
expansions, which often times is not available to the needed degree in certain rural areas. Similarly, the effectiveness of these
EHR additions hinges on the training of the nurses using the system. Nurses will need to be comfortable with computers
and will need a comprehensive understanding of the system’s use and utility. The public health component of the EHR, as of
yet, does not provide an at-risk score for households and hamlets. Its utility will only come to fruition once definitive at-risk
conclusions for all questions and response choices addressed on the surveys and decision trees have been given. These atrisk
scores will be needed in order to bridge the survey results to the EHR system. The surveys, in turn, should be piloted in
the village setting before being incorporated into the EHR system.
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