Lessons for the Global South:Malaysia’s Foray into Electronic Health Records

This article is an edited version of the research paper titled Lessons for the Global South: Malaysia's Foray into Electronic Health Records submitted by the author at the Global Governance and Public Health Vulnerabilities in the Global South Conference, jointly organised by the Rethinking Economics India Network (REIN) and the Young Scholars’ Initiative (South Asia Working Group) on October 2, 2021. The conference was a part of the REIN 2021 Annual Event.

The author, Ilyana Syafiqa Mukhriz Mudaris, is a Research Associate at Khazanah Research Institute, policy research institute that focuses on pressing issues in Malaysia. She holds a Master of Science in Translational Neuroscience from Imperial College London and a BSc in Biomedical Science from the University of Sheffield. She also has experience looking at digital health solutions through her stint as a Research Associate at Frost & Sullivan. The views expressed in this paper are those of the author and do not represent views from any other bodies.

Introduction

The global healthcare industry has been forced to rapidly embrace digitalisation to navigate the Covid-19 crisis, and countries in the Global South have also been pushed to follow suit, especially in the face of unprecedented nationwide lockdown measures. For many of these countries, which are still considered developing, the pre-existing issue of limited healthcare resources and accessibility has been exacerbated by the pandemic. To compensate for this, governments, such as China and India, have turned to digital concepts such as telehealth as these measures have been previously effective in controlling the SARS and MERS epidemics (Keshvardoost et al., 2020).

However, increased digitalisation in the healthcare space in response to Covid-19 has brought to the fore the issue of health data and its various dimensions, including personal data privacy, collection and sharing. Although digital solutions hold the potential to improve patient and healthcare provider experience, careful planning at a policy level is crucial. This paper will focus on an aspect of healthcare digitalisation that is extremely important in the long run but which may have received less attention, particularly in the midst of the pandemic: Electronic health records (EHRs).

Effective implementation of EHRs would provide many long-term advantages including ensured continuity of care, improved clinical decision-making and increased healthcare efficiency by supporting better patient outcomes. Using Malaysia as a case study on EHR implementation, this paper will dissect some of the major issues that developing countries may face in executing an EHR system and attempt to provide general recommendations based on global EHR governance for policymakers to consider.

Making the case for EHRs

An EHR is a longitudinal digital health record that follows an individual throughout their journey across the healthcare landscape through seamless sharing between providers (Garrett & Seidman, 2011). In Norway, a country considered to have one of the best healthcare systems in the world (Tandon et al., n.d.), EHR has been implemented across all its hospitals, allowing practitioners to transmit electronic prescriptions to pharmacies, provide referrals and discharge letters as well as synchronise after-hours emergency care information with primary care facilities to allow continuity of care (Tikkanen et al., 2020).

In terms of cost savings, a study conducted in the United States found that hospitals with advanced EHR systems, i.e., they had automated their ancillary services and implemented an integrated clinical decision support system, saved USD731 in treatment costs per patient admission (Kazley et al., 2014). Benefits beyond use of EHRs in hospitals can also be seen through examples such as Australia through its implementation in residential aged care facilities (RACF). EHRs in RACF increased the efficiency of administrative tasks, eased access to aged care and facilitated communication with external healthcare providers to inform caretakers about the residents’ needs (Zhang et al., 2012).

Malaysia: Examining implementation in a developing country

Malaysia is not a newcomer to the effort of healthcare digitalisation seeing how it was one of the first countries in Asia to explore the implementation of telemedicine through the conception of the Telemedicine Blueprint 1997 (MHTC, 2020). In fact, in the World Health Organisation’s (WHO) official manual for EHRs for developing countries published in 2006, Malaysia is the first cited as an example of countries with EHR practices. Unfortunately, Malaysia’s digitalisation initiatives have largely been hampered by lack of uptake and budget constraints, with a lack of follow-through over the years (Shaik Allaudin, 2014).

In the early 90s, Malaysia’s Ministry of Health (MOH) attempted to introduce hospital information systems (HIS), referring to an “integrated electronic system that collects, stores, retrieves and displays overall patients’ data and information” in government hospitals (Ismail et al., 2015). A cloud-based system that allows healthcare providers to access patient records via a centralised database was also introduced in government health clinics beginning in 2005. This system was dubbed the Teleprimary Care-Oral Health Clinical Information System (TPC-OHCIS). As of 2020, MOH reported that 25% of 146 public hospitals and 9% of 1,090 public clinics had implemented either HIS or TPC-OHCIS (Parliament of Malaysia, 2020). The MOH has attributed the slow uptake of these systems to the rapid evolution of technology and a lack of adequate funding (Parliament of Malaysia, 2020).

It should be noted that both HIS and, to an extent, TPC-OHCIS cannot be considered EHRs since they merely facilitate computerisation of patient records within a facility. HIS does not allow sharing of patient information between healthcare facilities. Thus, Malaysia has attempted to move towards EHR through the implementation of health information exchange (HIE). In 2008, the homegrown Malaysia HIE project known as MyHix was launched as a platform designed to electronically transmit patient information between government hospitals and clinics with an integrated HIS or TPC-OHCIS. MyHix’s sharing capabilities would be enabled via an online virtual private network (VPN), with plans to transition into a cloud platform in the future (Ismail & Abdullah, 2017; Salleh et al., 2021).

As in the case of systems rollout, MyHix has had a low take-up rate, with only 10 public hospitals and one public clinic successfully integrated in 2020 (Parliament of Malaysia, 2020). Yet again, a limited budget has been cited as an obstacle in implementation, with high costs needed for installation, maintainence and revamping existing infrastructure. Another major issue is that interoperability is a key prerequisite in a nationwide EHR system and the MyHix platform has been called out for its inability to effectively integrate patient information across providers (Ismail & Abdullah, 2017).

To date, MyHix has mostly been implemented in large, public hospitals with a lack of focus on primary care facilities and in different geographical regions. This means that patients may not even reap the benefits of information sharing since it would not follow a typical patient’s movement throughout the healthcare landscape, as patients typically interact not just with large hospitals but also with primary care facilities. Additionally, MyHix has not yet been trialled in any private healthcare facilities.

After facing a lull in progress for over a decade, in November 2018, the Malaysian government announced its plans to expand HIS and TPC-OHCIS in all government hospitals and clinics, predicting a cost of RM1.5 billion over the next five years for such a venture. Malaysia’s 2020 Budget also dedicated a portion of an RM31 million allocation to conduct a pilot rollout project involving nine hospitals in different districts within the country (Jaafar, 2019; Koh, 2018; Tay, 2019).

However, in July 2020, under new government rules, the MOH announced that this pilot would be replaced with a phased implementation plan. This new plan would begin with a project executed in one state, Negeri Sembilan, across seven public hospitals, 44 public clinics and 12 dental clinics, with its success dictating the rollout of a nationwide system. The HIS and TPC-OHCIS systems of each of these facilities would be integrated through the MyHix platform to create a Master Patient Index and Lifetime Health Records (Parliament of Malaysia, 2020). This recent change in strategy appears to be in line with WHO recommendations, to establish a PMI and with phased implementation considered the most appropriate for developing countries with limited resources (WHO, 2006). As of September 2021, there have been no further updates on the project, and little is known as to whether the problems related to the initial rollout are being addressed.

Considerations for EHR implementation in the Global South

Considering the high costs involved with developing, designing, and implementing EHRs, coupled with the limited capital available to many developing countries in the Global South, it is important to ensure that policymakers consider the key issues and risks prior to rollout. In fact, it was an EHR project that became one of the biggest healthcare IT failures in the world, when the United Kingdom’s deployment of a nationwide EHR resulted in a loss of GBP12.1 billion (Syal, 2013; Wilson & Khansa, 2018). The dismantling of this project was a result of the government neglecting to address key issues, such as end user needs, complexity of data integration as well as patient confidentiality (Centre for Public Impact, 2017). These issues will be explored further within the Malaysian context as well as how Malaysian policies align with global health governance recommendations in the following part of this piece.

Thinking of end user demographics

One of the most frequently reported barriers to EHR implementation is resistance to uptake by end users, i.e., healthcare practitioners (HCPs) (Kruse et al., 2016). A study commissioned by Philips, a leading health technology company, in 16 countries worldwide found that a majority of doctors believed that EHRs negatively impacted their professional satisfaction and was a major contributor to physician burnout (Philips, 2018). These findings implicate a lack of a “for clinicians by clinicians” approach whereby the architecture of the system does not consider HCP workflows, thus impeding healthcare delivery instead of enhancing it.

From a Malaysian perspective, a study on three government hospitals implementing HIS found that local doctors also had a negative perception of the system due to its propensity towards errors. These errors would arise due to a lack of knowledge about the system, problems with usability and reliability of the system as well as limited organisational resources causing HCPs to resort to manual data entry (Salahuddin et al., 2019). The usability and reliability issues are particularly worrying since it could potentially lead to patient harm (Howe et al., 2018) and highlights the need for user-friendly and HCP-centric systems architecture for EHR systems. WHO has also recommended the involvement of HCPs as part of a steering committee providing inputs from the early stages of EHR development (WHO, 2006).

Particularly pertinent for developing countries is the need to consider who might be left behind in the attempt to move towards fully digitalised patient records. One of the aspects that must be considered is that the facilities in the more rural areas of the country may lack the infrastructure and connectivity needed to facilitate the implementation of EHR. Thus, it is important to take into account these geographical considerations and allocate resources towards improving infrastructure in less developed areas.

Besides the infrastructural considerations, it is important to assess the information and communications technology (ICT) capabilities of the healthcare workforce as it is a major contributor towards adoption resistance. Perhaps the adoption of EHRs in Malaysia may face less resistance considering the vast majority of primary care doctors working in the public sector, as reported in 2014, were within a younger age group (25–34 years old) (Sivasampu et al., 2016), but it is important for policymakers to consider technical support for those who face issues using the EHR system.

Ensuring nationwide interoperability and standard adherence

The uncoordinated purchasing of digital health systems seen in Malaysia’s public healthcare infrastructure and independent implementation by private providers is expected to serve as a challenge for Malaysia’s MyHix platform. Singapore’s NEHR also faced a similar struggle in integrating various data sources during its initial launch due to variations in data codification and standards, including having to match different terminologies used in different facilities (HHMGlobal, n.d.).

Also in 2019, the Malaysian Director General of Health remarked that Malaysia was “continuously developing and managing standards with international benchmarking” in order to pursue a standardised digital health agenda (SNOMED International, 2019). According to a publication by the MOH, the health informatic standards implemented for semantic interoperability includes International Classification of Disease (ICD), Malaysia Health Reference Data Model (MyHRDM), Malaysian Health Data Dictionary (MyHDD), Logical Observation Identifiers Names and Codes (LOINC) and SNOMED CT (Ministry of Health, 2016).

Although there exists a policy for ICD implementation and training programmes for medical officers on proper ICD use (Ministry of Health, 2016), less is known about the implementation of other standards. The specific focus on ICD could be in line with WHO recommendations of having ICD embedded into the EHR (WHO, 2006). More information is needed to address whether these standards are also mandated in private hospitals and how adherence to these standards is monitored by Pusat Informatik Kesihatan (PIK).

Fortunately, since Malaysia, and perhaps its other counterparts in the Global South, are still in the early stages of planning, with only a quarter of public hospitals and even a smaller proportion of primary health facilities implementing EHR, there remains a window of opportunity for regulators to provide clearly defined policies for the harmonisation of standards and systems. A consensus across both private and public stakeholders, including vendor companies, should be reached on the data formats and protocols to ensure efficient interoperability between providers. These standards should be enforced through regular audits of collected data, as recommended by WHO, to ensure providers meet the required standards (WHO, 2006).

Considering data security and ownership

In implementing seamless data sharing between healthcare providers, it is important to give thought towards how this data is protected and utilised. When the issue of health data protection was raised in March 2019 in response to the plans for EHR rollout, the Malaysian government’s stance was that they would prioritise the completion of the system rollout and then consider the issue of cybersecurity (CodeBlue, 2019). Whether this remains the stance of the current government is unknown, but it is worrying since privacy considerations must be factored into the actual design of the system, not merely as an afterthought.

It is assumed that the EHR implementation would be compliant to the national Cybersecurity Act and the Personal Data Protection Act (PDPA) 2010, but in the face of the ever-evolving digital technology landscape, these frameworks are potentially outdated and inadequate. In fact, these frameworks have been highlighted in the Malaysia Digital Economy Blueprint as due for review (Economic Planning Unit, 2021). There is a need for more comprehensive governance regarding health data use especially in terms of who will be able to access this data, who owns the data once it is uploaded into the system and what should be done in the event of a cyberattack.

The official WHO manual recommends monitoring of access and changes to patient data through audits, incident reporting mechanisms and a designated information security officer who will carry out clearance checks on members who have regular access to the system. A combination of policies, procedures and training are also required to ensure patient data is used and only disclosed in permitted conditions (WHO, 2006). Malaysia’s MyHix policy requires facilities to undergo preliminary compliance audits to assess compliance to user access policy and to monitor unethical access via an audit trail. However, the monitoring of data quality and the incident response mechanism is up to the discretion of each facility (Ministry of Health, 2017).

When looking at data ownership, policies need to be geared towards empowering the patient, those who should benefit the most from EHR creation in the first place. An example of such policy is found in Australia, which passed a My Health Records Amendment (Strengthening Privacy) Bill in 2018. With this amendment, Australians can choose to permanently delete their health record at any time and are protected from disclosure of health information for employment, government, or insurance purposes. Australia also ensures that everyone can set access controls, receive notifications of access to records and request for certain information to not be uploaded (Australian Digital Health Agency, 2021).

This enabling of citizens to access as well as control access to their health record is also echoed by the European Union, through recommendations on EHRs to its member states. The principles laid out for EHRs include ensuring citizens can access and securely share their health data across borders in addition to being able to choose what will be shared and with whom (European Commission, 2019). In contrast, according to the User Access Control Policy that MyHix is subject to, patients are not included as authorised users of the EHR data, limiting it to only healthcare providers (MOH, 2011).

Additionally, under the MyHix policy, implied consent is applicable for every patient that registers within a facility that implements the system. It is unclear whether this implied consent translates into informed consent, as there have been no measures of compliance to MyHix standard operating procedures (SOP) which require HCPs to explain to patients their right to Opt Out of MyHix (Ministry of Health, 2017). Patients are also unable to delete their health record and cannot reverse their decision for an earlier admission.

In terms of cybersecurity, Malaysia needs to acknowledge that traditional security tools that rely on retrospective analysis of cyberattacks may not be sufficient. With countries such as Singapore and Australia still subject to technical glitches that compromise patient data, there is a need to consider more forward-thinking concepts. For example, allowing ethical hackers or industry experts to test the security of the database before official implementation (Khazanah Research Institute, 2021) or integrating AI technology that learns on-the-go (Ng, 2018).

Considerations of cybersecurity for health data are particularly important due to its sensitive nature. Unlike financial data, which eventually becomes unusable as people can change details such as credit card numbers in response to a breach in security, medical data is not perishable, making it potentially more valuable. According to IBM, healthcare data breaches have incurred the highest average total cost for 11 consecutive years. In 2021, the average total cost of a data breach in the healthcare industry was USD9.23 million compared to USD5.72 million in the financial industry (IBM, 2021).

Concluding remarks

Overall, this paper has assessed the current situation of medical record digitalisation in Malaysia as well as the efforts and investments made in achieving an EHR system. Despite the initiatives launched by the government to move Malaysia’s healthcare towards digital adoption, there are still many gaps that need to be considered and addressed to ensure these efforts ultimately come to fruition. The lessons learned from Malaysia as a developing country can be implemented in the Global South as more countries move towards EHR implementation.

This paper has outlined three key areas that need to be revisited by policymakers in terms of EHR implementation. The first of these is the need to consider end users in the design and rollout of the EHR, making sure that the system can cater to all demographics of healthcare practitioners. Secondly, emphasis must be placed on harmonisation of standards and systems across the healthcare landscape, coupled with appropriate enforcement to ensure compliance of providers. Lastly, questions surrounding health data security and ownership need to be explored in more detail. Importantly, the current frameworks on cybersecurity need to be further examined and contextualised alongside existing medical laws to provide comprehensive policy recommendations.

The implementation of EHR can be perceived as a double-edged sword, requiring the fine balancing of achieving efficiency and continuity of care with the risks it poses to privacy and security. However, one of the key lessons of the Covid-19 pandemic is that digitalisation is the inevitable future, and we must be ever ready to meet its demands. Currently, Covid-19 has brought a halt to the plans of EHR expansion in Malaysia and only a minority of the country’s public healthcare facilities are implementing the system. Thus, this is an opportune time to re-evaluate the mechanism of EHR introduction, addressing the flaws in its architecture and execution, before an imperfect, and costly, system is put into place.

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