The Role of Electronic Medical Records in Improving Management of Type 2 Diabetes Mellitus at Primary Healthcare Level in Malaysia

Abstract

Malaysia has undergone an epidemiologic transition in the prevalence and distribution of disease, shifting towards chronic diseases. Diabetes Mellitus is one of the most common chronic disease conditions which is also associated with significant morbidity and mortality. The National Health and Morbidity Surveys in Malaysia have reported an increase in prevalence of Diabetes Mellitus from 6.3% in 1986, 8.2% in 1996, and 14.9% in 2006. The monitoring of HbA1C control at the primary healthcare clinics over the years 2009 – 2011, by the Ministry of Health, revealed that less than 20% of patients achieved HbA1C of 6.5% nationally. It is well recognized that information technology through the use of an electronic medical records (EMR) system is an enabler to deliver good quality and safe health care.

Effective electronic chronic disease management programmes can manage information better so as to support appropriate interventions and thereby minimize or even prevent the impact of chronic disease conditions on the patient and the health system. The potential benefits of use of Health Information Technology include improvements in health care quality, prevention of medical errors and reduction in health care costs, increased administrative efficiency and “decreased paperwork” as well as greater or expanded access to healthcare through telemedicine. In the Year 2000, an Electronic Medical Records system (EMR system) was implemented at the Putrajaya Health Clinic in Precinct 9, Putrajaya. This was the first primary healthcare clinic in the Ministry of Health, Malaysia to have an Electronic Medical Records system. Recognising the importance of good clinical management of Diabetes Mellitus and the benefits of using Health Information Technology, this study is undertaken to ascertain whether the implementation of an EMR system at the Putrajaya Health Clinic resulted in improved care of Type 2 Diabetes Mellitus patients in comparison with the traditional manual paper based system used at the Tanglin Health Clinic (which has been functioning as a primary care health clinic since 1960). Both the clinics are urban primary health care clinics and have patients with similar socioeconomic background. The variables examined were outcomes of weight and body mass index(BMI), systolic and diastolic blood pressure, HbA1C, serum creatinine and serum low density lipoprotein cholesterol (LDL-C), and, the processes of care involving regularity of dietary counselling, and annual assessments of weight/ BMI, fundus and foot examinations, HbA1C, serum creatinine and serum LDL-C, and urine micro-albuminuria. Patient satisfaction with diabetes treatment and the waiting time at the pharmacy to receive medication were also investigated. In addition, this study will also determine whether the implementation of the EMR system has achieved the benefits of using Health Information Technology as realised in other primary care centres in the long term management of patients with Type 2 diabetes mellitus. METHODOLOGY This study has both qualitative and quantitative components. The qualitative component involves direct non-participant observation by the researcher and documentation of the work process and activities and or tasks carried out at the various stations in the processes of care at both centres. It will also involve a comparative analysis of these activities and tasks with EMR implementation in other primary care centres. The quantitative component of the study incorporates a retrospective review and chart abstraction of the selected patient records with Type 2 diabetes mellitus, seen at the two urban primary care clinics. The data collected from chart abstraction was analysed. A repeated measures analysis of variance (ANOVA) was used to test for significant differences between means within the groups as well as between the groups. The prospective part of the study also involved a quantitative component for a survey of patient satisfaction with diabetes treatment at the two clinics. The standardised licensed Diabetes Treatment Satisfaction Questionnaire (DTSQ) was used in the survey of patient satisfaction with diabetes treatment. The waiting time at the pharmacy to collect medication was also investigated at both clinics. RESULTS The clinic with the EMR system had better compliance to the regularity of monitoring tests for HbA1C, Serum Creatinine, Serum LDL-C, and urine micro-albuminuria. The clinic without the EMR system performed better with regularity of weight measurements and foot examinations. Efficiency and patient satisfaction were similar in both clinics. The on-site observation also revealed rapid retrieval of medical records of patients, thus leading to savings in waiting time for registration at the EMR clinic.

Some international studies have demonstrated that the EMR system has the potential to achieve benefits of improving monitoring, and or clinical outcomes, and or quality of care, and or efficiency and effectiveness. CONCLUSION This study found that in the clinic with the EMR system, some benefits with respect to regularity of monitoring and efficiency in the dispensing of prescriptions were achieved. However, the expected benefits of improved quality of care, and achievement of treatment targets in clinical outcomes were not achieved. There was lack of intensive dietary interactions and interventions in the care of the patients at both clinics, contrary to that advocated by clinical practice guidelines. The patient satisfaction scores were almost similar in both clinics. The review of EMR implementations in primary care centres, and in comparing the mechanisms through which the benefits of implementation of an EMR system in the long term management of Type 2 Diabetes Mellitus were achieved, it was found that the EMR system at the Putrajaya Clinic has not incorporated features of Clinical Decision Support Systems, alerts and registry functionalities, as well as use of structured templates. Therefore, appropriate improvements to the work process and data capture templates, automated interventions (appropriate reminders and alerts for action) to facilitate improved health outcomes for Type 2 Diabetes Mellitus at primary care level, are necessary for the EMR system to achieve its full potential to improve quality of care, whilst increasing efficiency and effectiveness of care in the management of Type 2 Diabetes Mellitus.