KUALA LUMPUR, Feb 13 – In 1999, Selayang Hospital became the first tertiary hospital in Malaysia – and even, the world – to go fully electronic and paperless with a comprehensive total hospital information system (THIS).
Consultant nephrologist Dr Ghazali Ahmad, who served as one of the Ministry of Health (MOH) team members for Selayang Hospital in Selangor from 1997 to 2000, wrote for CodeBlue in 2021 that THIS, with electronic health records, was implemented in the public hospital for all processes: from admission and registration to clerking and prescription writing, ordering medications, laboratory tests, imaging, scheduling, nursing entries, reports, discharges, and transfers.
“Being an electronic hospital that has taken the initiative to implement THIS, Selayang Hospital has become a showcase to the rest of the world,” states Selayang Hospital’s official website.
But now, about two decades later, Selayang Hospital’s once historic electronic medical record (EMR) system has declined into an “embarrassing” and “demeaning” mess, staff say, that creates unnecessary and stressful burdens for doctors, significantly delays operations, and leads to sub-standard care.
According to four medical doctors at Selayang Hospital – who wrote separately to CodeBlue earlier this month, speaking on condition of anonymity – the MOH did not upgrade Selayang Hospital’s EMR system, Cerner, after glitches started appearing in 2018, leading to a total crash in January 2021.
Cerner Corporation, a US-based provider of digital information systems used within hospitals and health systems, had been among the IT consultants who worked with MOH to digitise all manual work processes in Selayang Hospital back in the late 90s. Cerner was acquired by American software giant Oracle Corporation in 2022. Selayang Hospital doctors described Cerner as an “excellent” EMR system.
“All departments in the hospital used it for daily documentations of anything with regards to patient care. It was used by doctors, nurses, pharmacists, physiotherapists, and dieticians,” Dr Cinta (pseudonym) told CodeBlue, referring to Cerner.
“We used it for patient notes, lab investigations, radiology reports, referral letters, previous medical records, prescribing medications, vital signs recording – just about everything done in the hospital. Nurses used to also give patients appointments in this system and registration was also done via this system. We could create our own list of patients for studies/ research or to look into records or investigation results later.”
In-House BHIS System: Like ‘Notepad on Windows’
Selayang Hospital was then forced to resort to an in-house IT system called the Backup Health Information System (BHIS) that was developed by a radiologist, who has since resigned from Selayang Hospital. MOH discontinued maintenance and renewal of Cerner in 2022.
However, BHIS was inferior to Cerner, as doctors pointed out that the in-house system could not upload large data, such as CT films, X-rays, or laboratory investigations, that would cause the system to crash.
Dr Cinta said BHIS, initially meant as a temporary backup system, was only able to record patient notes, “just like Notepad on Windows”.
Worse, patient information was allegedly unsafe on BHIS due to the lack of an effective audit mechanism.
“Patient information vulnerable to deletion as an operator can log on to BHIS and delete the patient notes for the day. Unsure how effective audit trail is as a person who deletes using their own account, even if traced, can state deletion is by mistake. If a user forgets to log off, anyone in contact with that pc (personal computer) can go in and delete the notes as there is no auto log mechanism for ward pc,” Dr Lili (pseudonym) told CodeBlue.
“This system is unlike the THIS system in other IT hospitals, for example Ampang Hospital, where the mechanism for amendments is well established and the audit trail easily seen.
“If notes are deleted and the patient has multidisciplinary team involvement, then outstanding plans are not able to be carried out for the patient, which will lead to delay in management. There have been episodes when this has occurred.”
Dr Lili stressed that “real harm” has not occurred “per se”, as clinicians troubleshoot to the best of their ability to prevent such harm: “You must understand these patients are provided reasonable care despite these major shortcomings.”
Another medical practitioner at Selayang Hospital, Dr Dahlia (pseudonym), said Selayang Hospital’s laboratory has gone manual since BHIS was unable to host lab reports.
“This has added burden to our workforce as everything had to be done manually. The radiological reports initially were able to go online, but since the end of December 2022, even the reports could not be uploaded due to the lack of storage space in the IT system. Since then, even the radiology reports needed to go manual,” Dr Dahlia told CodeBlue.
“Since the breakdown of Cerner, we have been suffering from tracing results, especially those urgent investigations. It is compromising patients’ care, especially those who are ill and need close monitoring on the blood parameters. We have delayed blood results and have to rely fully on clinical judgement to treat those conditions, which is totally unacceptable.
“With the lack of an online system for the laboratory and radiology reports, we are prone to making unavoidable mistakes. This delays patient management.”
Current CPRC System Causes Over Five Hours’ Delay in Clinic Operations
BHIS officially became non-functional last month when its memory hit maximum capacity after just 18 months of use, forcing Selayang Hospital staff to turn to a hospital system by MOH’s Crisis Preparedness and Response Centre (CPRC) that was initially designed for Covid-19 quarantine centres during the pandemic.
“This system is very user-unfriendly and is not suitable to be used in a tertiary hospital like Hospital Selayang that offers a wide range of sub-specialised inpatient and outpatient services for complex cases,” Dr Melly (pseudonym) wrote to CodeBlue.
“The daily clinic operation is slowed down significantly due to the incompatible system design and the slow internet speed in the hospital. The morning clinics that are supposed to finish by 1pm end up being dragged until past 6pm.
“Doctors can only attend to the ward patients after finishing the clinics, resulting in delayed care and compromised patients’ well-being, on top of prolonged waiting time at the emergency department due to delayed ward discharges and admissions.”
Dr Melly said that the stranding of patients in Selayang Hospital’s emergency room for between 24 and 72 hours is mainly due to the lack of beds and ward staff, made worse by the delay of morning clinics that subsequently delays clinical care and discharges.
However, she stressed that the long waits for ward admission and clinic consultations are also directly caused by the lack of a proper EMR system, resulting in “inefficient ward patient management with delayed clinical decision-making, delayed clinical recovery, prolonged hospitalisation with associated complications etc.”
Dr Dahlia similarly complained that the CPRC system currently being used is not linked to laboratory or radiology reports that are very important in their daily work.
“We need to trace those reports manually and type it into the charting system. As the workload increases, we are bound to make mistakes as we have no results/ reports to refer back if there are any doubts. And I’m sure human errors like wrong labelling, similar names, and wrong entry can happen,” she told CodeBlue.
Dr Cinta said blood results, radiology reports, medication prescriptions, as well as referral letters, vital signs, registrations, and appointments now all have to be done manually at Selayang Hospital.
“Blood results – this has become a mess since it has gone manual, with frequent missing results, [posing an] extra work burden on the nurses and junior doctors whereby it has to be traced manually,” she said, adding that the manual tracing of radiology reports causes a delay in implementing patient management plans.
Dr Melly said that while medico-legal issues may not arise directly from the CPRC system that staff just began using in January 2023, she warned of such problems potentially arising from difficulties in extracting medical records for regular patients at Selayang Hospital and the unavailability of an online real-time laboratory results platform.
“One needs to look at three different interfaces – Speedminer: to extract some crude medical record from the demised Cerner system; BHIS: the temporary system used while waiting for a new HIS from MOH; and now CPRC, which we are struggling to use because of the faulty, over-simplistic design,” she told CodeBlue.
“As for the laboratory results which have been offline since the demise of Cerner in January 2021, many important results were either delayed, missed, or not traceable at all. Additional manpower was never given when we were told to offline (i.e. manual) with the shutdown of Cerner since January 2021.
“Quality of care and patient safety is definitely compromised because medical judgement will be impaired when quick access to the patients’ medical records and laboratory results is denied.”
IT Department Disbanded, Many Computers Broken (Keyboard, Hard Drive, Mouse)
Dr Lili complained that numerous personal computers in Selayang Hospital are not functioning, such as with the keyboard, hard drive, and mouse.
“Yet, we claim to be an IT hospital,” she said. “It saddens me that KKM (Kementerian Kesihatan Malaysia) is fully aware of this but yet, categorically does nothing concrete to assist Hospital Selayang.”
Dr Melly pointed out that Selayang Hospital’s information technology department was even disbanded recently due to the termination of the facility’s IT vendor service without a replacement.
“The hospital administration and Ministry of Health is fully aware of the hardship that the hospital staff is facing for more than two years now, but yet there is no permanent solution offered. We are expected to cope with some half-baked stop-gap measures, resulting in all working in a very inefficient mode with low morale due to the lack of support,” she said.
“It is hoped that the Ministry of Health will finally pay attention to Hospital Selayang now – the flagship hospital with an electronic medical record (EMR) system back in 1999 that is now operating in a highly inefficient, embarrassing manner with little regards in providing a conducive working environment for staff and compromised patients’ quality of care.”
Dr Cinta urged MOH to provide Selayang Hospital with the latest Cerner system with newer technologies “that will definitely bring health care to new levels while ensuring patient confidentiality and safety”.
“Being a pioneer hospital for IT, it saddens me to see the decay and decline of patient information storage to this demeaning standard,” Dr Lili said.
Dr Dahlia said staff were told that the CPRC system is meant to be interim until a “definite” system is ready, but no timelines were provided, as she lamented: “Our plight has gone to deaf ears when higher management was approached.”
CodeBlue has contacted Selayang Hospital director Dr Afidah Ali and Health Minister Dr Zaliha Mustafa’s office for comment.
Editor’s note on Feb 14: The radiologist who designed the in-house BHIS and has since left Selayang Hospital has written a response to this article.
