Shafiq* is a middle-aged Pakistani man, working as a driver for a household in Lahore. His son has just been diagnosed with early-stage lung cancer. He finally manages to take time off to take his son to an oncologist in a government hospital. The oncologist asks for all the lab reports of the patient. Shafiq hands over a heavy file. It turns out, one of the reports has been misplaced. The doctor tells Shafiq to come back after getting his son’s lab work done again. Shafiq now has to find the money to pay for more testing and also has to plead with his boss to give him another day off. Meanwhile, his son’s condition is only getting worse.
When a healthcare system has no proper infrastructure for medical record keeping, the result is waste and medical errors. For example, the cost of repeat lab work will either be borne by Shafiq if he goes to a private lab or by the taxpayer if he opts for a government one. Repetition of tests will also use up limited laboratory resources and delay the test results of other patients. Shafiq’s story also points out another avenue of concern: medical misdiagnoses. Generally, a primary care physician, or family doctor, ensures an individual’s health through keeping family histories, doing annual health screenings and ensuring immunisations. These doctors maintain all this information is the form of electronic medical records. Shafiq’s son had no such family doctor to track his smoking habits or note the prevalence of cancer in his family history. In fact, the first doctor he saw gave him antibiotics for what he diagnosed as a bacterial infection of the lungs.
In a country with less than 125,000 government hospital beds for more than 200 million people, there is little room for such errors. According to the World Health Organisation (WHO), Pakistan has one of the lowest per capita current health expenditures among Eastern Mediterranean countries, second only to Afghanistan. Because of our chronic debt issues, our healthcare spending will likely remain dismal. In such an environment, technology is a relatively inexpensive tool that can be used to improve efficiencies and better population health.
Pakistan’s larger cities are home to a select few secondary and tertiary care hospitals, which are meant to provide inpatient care, ambulatory services and specialist care. The major swathe of the country, however, does not have access to these hospitals. In rural areas, the major public health facilities are small establishments called Basic Health Units (BHUs). In the more than 5,500 BHUs across Pakistan, outpatient facilities are provided to ordinary citizens. Contrastingly, the private sector is dominated by specialist care with doctors running their own independent clinics. Here, primary care is seen as neither lucrative nor prestigious. Patients do their own guesswork at diagnosing their problems and then decide which specialist they should see.
But be it private or public, most doctors in Pakistan are reliant on pen and paper for record keeping. Patients like Shafiq* are meant to keep these physical records safe in a folder and bring them to each appointment. According to one doctor practicing in a government-run tertiary hospital in Lahore, the only records their hospital keeps is the patient’s admission date, discharge date and what kind of operation was performed. Any blood tests, imaging or other notes go into a black hole of patient data.
This is all set to change in the province of Punjab. The government is in the process of completing its transition from physical registers to electronic medical records in BHUs across the province.
Khalid Sharif is Manager MIS in the government’s Health Information and Service Delivery Unit (HISDU). His unit aids the primary and secondary health department in developing and running health dashboards, inventory management systems and mobile applications.
“Electronic Medical Records (EMR) came about because we wanted to be able to assess our performance as a department,” he said. “Before this, we had no credible way of knowing any metrics like doctor-patient ratios or the number of daily births.”
The process began in around 2017, when they began testing out earlier versions of EMR in select BHUs. Now, they are running the multi-module application across more than 2,500 BHUs.
“We expect to be fully paperless in about one and a half month’s time,” he said.
Each employee at a BHU logs in using their computerised national identity card (CNIC) number and has access to a different module of the system. When a patient comes in, they are registered using their CNIC number. The receptionist takes the patient’s vitals and adds them to their profile. Then, when the patient goes to the doctor’s office, the doctor select a diagnosis and prescribes medicine. Finally, the medicine dispenser checks off the prescription he/she is filling, which automatically updates inventory records.
“If someone doesn’t have a CNIC we have created another option,” Sharif said. “They can use a relative’s CNIC and we can select their relationship to the CNIC holder.”
Dr. Faiza Ahmed* has been practicing as a health officer at a BHU near Faisalabad for the last couple of years. When I visited her, they were partially using the EMR system. Out of the 150 patients that had been to the BHU that day, they had electronically registered around 90 of them.
Most of her patients, especially women, don’t bring along CNICs. But she has made it a point to especially encourage expectant mothers to bring along their own or a relative’s CNIC so that she can track the health of mothers and babies. “This way, I can see a patient’s data even if she had her baby six months ago,” she said. “I can see if she was hypertensive or diabetic back then and how her child was doing back then.”
Dr. Ahmed has not received instructions to go paperless and she is skeptical of the idea.
“It’s practically impossible to register all 200 patients because of resource limitations,” she told me. “Internet speed in this area is also very slow.”
When I asked Khalid Sharif about this, he said that they had already address this issue by creating an offline version of the software which automatically uploads the data when the internet reconnects. However, Dr Ahmed said that the offline version is not functional yet.
Another reason why the system might feel tedious to Dr Ahmed is because they are currently running two parallel systems. The EMR system has been designed with the idea of print receipts. When the midwife sends the patient off to the doctor, they are supposed to bring their registration slip along. Similarly, the doctor is supposed to print out a prescription slip and hand it to the patient. However, Dr. Ahmed contended that the BHU cannot afford to thermally print slips for every patient. So currently they are both logging data online and writing all the information manually on pieces of paper to give to the patients.
“I think there’s always resistance to change — everyone gets used to a certain system and doesn’t want to get out of it,” Zara Ansari, a consultant for the government, said. “As with any new data system, it takes time, but this is definitely the future.”
Zara Ansari is a senior consultant at ACASUS, a management consultancy firm that is assisting the health department with the rollout of electronic medical records. Ansari and her team have been giving trainings to doctors to make them comfortable with the new system. They have also been analysing data for the government to monitor the level of compliance that each BHU is showing.
“We started off by assigning lax targets so people can be onboard with actually doing this and then progressively over time making it more strict,” she said. “As of recently, we will be monitoring to see which facilities are doing completely paperless entry.”
There are of course caveats to this new age technology. There is not a lot of clarity around the privacy of the date being collected and how it will be kept safe. There seem to be no conversations happening around data privacy or patient confidentiality in government halls.
Caveats and all, Punjab is making a step forward into modern healthcare. How successful they will be is something only time can tell.
(*Names have been changed to protect privacy)
