Time and tide waits for no man.
When one is in a deteriorative state, help needs to be sought out immediately. Archiving most of our medical records in the backrooms of a hospital or warehouse doesn't alleviate the problem. Living in a technologically progressive society, we naturally think this problem can be eliminated easily.
According to the current status of EMR (Electronic Medical Record) at MOH Health Facilities, 14.7% (22 out of 150) of hospitals like Hospital Serdang, Hospital Sungai Buloh, Hospital Shah Alam, Hospital Sultanah Bahiyah, Hospital Bera and Hospital Sultan Ismail, use EMR; the rest don't as a part of their MPS (Medical Patient Summary) system.
0.1% of clinics (204 out of 3209) use EMR to store data, which includes 17.8% (200 out of 1118) health clinics & 0.2% (4 out of 1691) rural clinics; the other 99.9% of clinics still use manual medical records to keep track of patients' health. Figure 1.0 is a list that displays the clinics that utilise EMR to keep track of individuals' health.
Figure 1.0
11.4% (78 out of 682) of dental clinics use EMR, while the other 88.6% don’t. Figure 1.1 illustrates a more comprehensive outlook on the regressive state that our health facilities are in.
Figure 1.1
It’s appalling to know that the algorithm on our social media or our profile on Bumble knows more about our personal information than our healthcare system. Though changes are slowly emerging, it shows the vitality of using EMR as a centralised system to store data and how it differs from a manual medical record.
Why is EMR important?
EMR enhances the workflow's efficiency and reduces hospitals' administrative burden. It not only saves cost but also aids hospitals to redirect their energy and funds to other necessary areas while empowering the healthcare workforce to change their management for the better. Patients can have better data access to their medical records and reports, where there's reduced error of misspelling or misfiling, which is an overall improvement for patient care. Most importantly, EMR allows for smooth interoperability and data sharing between different providers and hospital institutions.
A handful of countries and organisations have tried to establish standards and guidelines for EMR systems. Estonia and the UAE have executed this system flawlessly by keying in every individual's/patient's laboratory results, like blood test, imaging results, medical history diagnosis; treatments, physician notes, pharmacy dispensation records (e-prescription data) and discharge summaries. Other features also include patient portal data where both doctors and patients have real-time access to critical patient information like vital signs and clinical observations.
IPS (International Patient Summary) Composition
The standardisations of information used in IPS are vital tools to ensure that patients get the immediate care they need or even a possible clinical diagnosis based on the few essential health information. The series of data is usually split into three categories: required, recommended, and optional. Figure 1.2 shows the general overview of an IPS composition.
Figure 1.2
Collective discussions were unwavering when the topic of recategorising these chains of critical information based on a patient's perspective came up. Based on observation, a majority find that allergies and intolerances should be under the required category while the categories of other health information vary.
The subject of genetic testing, like Genemetrics, was also implied to be implemented in one of these critical pieces of information. Such an approach combines the genetic data with bloodwork to analyse and provide a more comprehensive view of a patient's health, and it aids healthcare providers in identifying potential health risks and developing a personalised strategy with their lifestyle for prevention.
MOH has decided to put all these standardisations of health information under the optional field. Over time, data will be collected and analysed to see which information individuals are more willing to give out, which will then be slowly recategorised into either required or recommended.
There are also discussions concerning the patient's ownership and access to medical records. Unfolding cases where public hospitals deny their patients' requests for copies of their medical records, as well as the withholding of information about the patients’ care, diagnosis, treatment, and advice, is blatantly unethical.
Yet ironically, hospitals expect and demand patients' personal information (eg, pregnancy status, social history, past history of illness), but strip away the patients' rights to access their own medical records.
While Malaysia has made small strides toward digitalising its healthcare system, the data shows that the majority of our facilities still rely heavily on outdated manual records. EMR is no longer a futuristic concept, it is a necessary foundation for modern, patient-centred healthcare. EMR offers more than just convenience: it provides better patient outcomes, greater efficiency, and trust in the healthcare system.
The road to a fully digital healthcare system is not without challenges, but the benefits far outweigh the costs. Investing in EMR means investing in the dignity, safety, and empowerment of patients. It means recognising that health information belongs, first and foremost, to the individual it concerns. As Malaysia moves forward, we must make a clear, collective decision: to leave outdated practices behind and fully embrace the tools that will build a healthier future for all. The time for halfway measures has passed, the time for full EMR adoption is now.
