Nigerian Postgraduate Medical Journal

REVIEW ARTICLE
Year
: 2020  |  Volume : 27  |  Issue : 1  |  Page : 1--7

Electronic medical record systems: A pathway to sustainable public health insurance schemes in sub-Saharan Africa


Victor Alangibi Kiri1, Aaron C Ojule2,  
1 Department of Mathematics, Physics and Electrical Engineering, Faculty of Engineering and Environment, Northumbria University, Newcastle Upon Tyne, United Kingdom; Department of Pharmacy, Faculty of Pharmaceutical Sciences; Department of Chemical Pathology, College of Health Sciences, University of Port Harcourt, Choba, Rivers State, Nigeria
2 Department of Chemical Pathology, College of Health Sciences, University of Port Harcourt, Choba, Rivers State, Nigeria

Correspondence Address:
Prof. Victor Alangibi Kiri
39 Juniper Close, Guildford, Surrey GU1 1NX

Abstract

Pubic health insurance schemes are usually set up by governments to provide cover for their insured populations against healthcare costs. These schemes are usually administered by a government agency and vary both in how they are funded and provide their services. A number of developing countries have introduced such schemes to minimise the impact of financial barriers to healthcare access by their populations. These schemes are expected to bridge the inequality in healthcare. A National Health Insurance Scheme has been in operation in Nigeria since 2005 to provide health cover for government employees and those in private institutions with no less than ten workers. There are similar schemes in a number of countries in sub-Saharan Africa. We conducted a literature review of publications on public health insurance schemes in sub-Saharan Africa to identify the challenges they encounter. We found 76 relevant publications. Although much have been published on these schemes, few have addressed the critical obstacles to effective implementation, management and sustenance in the unique environments we find in sub-Saharan Africa – where poor technological infrastructures, acts of forgery, counterfeiting and other forms of fraud are common. We highlight these challenges, using the scheme in Nigeria for reference. We discuss the potential role of robust electronic medical record (EMR) systems for sustainable schemes in such environments and describe some of the ways robust EMR systems could be used to mitigate the challenges posed by most of the peculiar problems associated with poor infrastructures.



How to cite this article:
Kiri VA, Ojule AC. Electronic medical record systems: A pathway to sustainable public health insurance schemes in sub-Saharan Africa.Niger Postgrad Med J 2020;27:1-7


How to cite this URL:
Kiri VA, Ojule AC. Electronic medical record systems: A pathway to sustainable public health insurance schemes in sub-Saharan Africa. Niger Postgrad Med J [serial online] 2020 [cited 2020 Feb 21 ];27:1-7
Available from: http://www.npmj.org/text.asp?2020/27/1/1/275807


Full Text



 Background



Public health insurance is an agreement that covers the whole or part of the medical expenses incurred by the insured on the basis of the collective sharing of the healthcare risks of a large number of persons and the government.[1] In the main, it covers the costs of healthcare, starting from diagnosis to treatment, based on periodic subscription payments called premiums. Most schemes exclude certain pre-existing medical conditions in their contracts.[2] The contract, known as the plan, is usually between an individual or a sponsor (e.g., an employer or organisation) and the government-controlled agency. Each scheme usually involves the payment of premiums upfront to the provider by those who enrol in the scheme. These schemes usually offer a range of benefits, including preventive services through a network of healthcare providers (HCPs) who have agreed to supply these services to the insured.[3] The contract which typically is renewable annually, also contains the list of qualified HCPs such as physicians, health centres for primary care and hospitals for secondary care as well as laboratories and pharmacies, among others.[4] In most settings, the list only contains the network of service providers who have signed contractual agreements with the insurer, to supply services to the insured persons at costs favourable to both parties. Indeed, in most plans, the insured who uses service outside of the network may either have to pay for the full cost of the care received or be required to pay a much higher share of the cost.

The schemes which operate in sub-Saharan Africa face numerous challenges that negatively impact on their effectiveness and threaten their sustainability.[5],[6],[7] Although the literature contains descriptions of some of the schemes in the region, and a few have also highlighted some of the problems, there remains a huge gap in our knowledge of these challenges and fewer still have attempted to proffer pragmatic solutions.[5],[6],[7],[8],[9],[10] We conducted a literature review on these schemes, including information sourced directly from the national scheme in Nigeria, to identify some of these challenges. We then proposed adoption of electronic medical record (EMR) systems as essential for addressing most of the operational challenges.

 Methods



We searched the PubMed and Embase databases, as well as the Google Scholar. We restricted our search to publications in English but not on coverage period, using the terms health insurance, health coverage, universal coverage, health information, information technology, electronic communication, electronic patient records, electronic medical records and EMR as search strings in a two-stage screening process. Data extraction was conducted using an interpretive approach by the two authors as independent reviewers based on an identical data extraction form to synthesise the different studies, and we used all the 76 publications that were extracted.

We reviewed the resulting material to identify the major challenges faced by public insurance schemes in sub-Saharan Africa, using the fledgling scheme in Nigeria for reference. The Nigerian scheme was a suitable choice mainly because of its large scope and coverage that made it suitable for a comprehensive identification of the main challenges in the subregion.[5],[6]

We then described the important roles EMR systems play in such schemes in the developed countries and made the case for their involvement in sub-Saharan Africa, with its poor technological infrastructures and peculiar environment where acts of forgery, counterfeiting and other forms of fraud are common. In highlighting some of the unique challenges to effective implementation and maintenance of these schemes in such environments, we also focused on how suitably robust EMR systems could be used to realistically mitigate some of the challenges.

 Results



The Nigerian National Health Insurance Scheme

The National Health Insurance Scheme (NHIS) in Nigeria was started in September 2005 as a vehicle for the ultimate achievement of universal health coverage.[11] It is being operated under two broad categories of schemes with different operational guidelines namely, the formal and informal sector social health insurance schemes.

The formal sector scheme operates as a social health security plan, in which the costs of healthcare for employees in the formal sector are paid for from funds created by pooling the contributions of employees and their employers. This scheme includes the public and organised private sectors as well as the armed forces, police and the other uniformed services. The contributions are earnings related and are payable by either the employers and employees, or the employers alone. It also includes schemes for students in tertiary institutions. The informal sector scheme is barely functional.

Operational structure and processes

The NHIS is overseen by a government agency known by the same name, and virtually all its customers are in the formal sector. The NHIS is supposed to be completely information technology (IT) driven under the management of health maintenance organisations (HMOs) which are limited liability companies that are regulated by the agency. The agency is responsible for the guidelines, registration of the HMOs and HCPs as well as determining the level of capitation and other payments for the services rendered by the HCPs. The enrolment process requires registration with a preferred HMO and a primary HCP that serves as the enrollee's first point of contact (gatekeeper) for any access. The process is supposed to be conducted online, thus making it available for 24 h daily.[11]

The HCPs are classified as primary, secondary or tertiary, according to the types of services they have been registered to provide.[11],[12],[13] The scheme usually pays capitation for primary care as well as fee-for-service payment upon referral by the gatekeeper. Contributions to the scheme are earnings related whereby the employer pays 10%, whereas the employees pay 5% from the basic salaries. Referral by the gatekeeper is required which involves the issuance of a pre-authorisation code by the HMO.[11]

Payment for primary care service is covered by the routine capitation paid monthly to the primary HCP. The amount payable depends only on the number of enrollees registered with the HCP, whereas payments to the others are on the basis of fee for service and involve standard billing protocols approved by the NHIS. The HCPs are expected to submit their bills to their respective HMOs on a monthly basis for processing and payment through e-banking.

The main challenges

Over the 14 years of operation, the NHIS has faced several challenges, the most notable of which are (1) a weak national health system, (2) low level of awareness and enrolment, (3) insufficient political will, (4) poor management and (5) poor compliance with its procedures.[14],[15],[16],[17],[18],[19]

Weak national health system

We could find no evidence of a formal legal framework on the type of healthcare the different tiers of government should provide their populations. The local governments are currently not involved and the state governments oversee both primary and secondary healthcare with grossly inadequate management and resources.[14],[15],[16],[17]

Low level of awareness and enrolment

Literature suggests that majority of Nigerians are not aware of the services provided by the NHIS, primarily because of poor promotion, underresourcing of the scheme and its deplorable performance record, compounded by the general poor perception of public health insurance schemes.[20],[21],[22],[23],[24],[25],[26],[27],[28] At present, most enrolees of the NHIS are employees of the federal government and its various establishments, of which only about 3% have enrolled. The low enrolment may also be related to the inadequate legal framework of the scheme that makes it optional even for the state governments.[5],[6]

Insufficient political will

In common with many governments in sub-Saharan Africa, there is insufficient political will for the scheme in Nigeria. The Act which established the scheme contains the necessary policy framework for a genuine national health service system, but many of its terms are yet to be implemented.[5],[6],[12]

Poor management

The HMOs are the operational fulcrum of the NHIS, but their performance record is very poor. Their failings include poor coordination, management, incomplete remittance of capitations and delayed settlement of invoices. As a result, there is widespread dissatisfaction among many of the HCPs which, in turn, is leading to poor quality of service and rejection of enrolees.[16],[18]

Poor compliance and fraudulent practices

Several forms of fraudulent practices have been reported, including collusion with HCPs and illegal usage by non-enrolled patients.[16],[19] These occur primarily because the scheme is not supported by an effective IT system for detecting, monitoring or mitigating violations. The scheme is based on a paper recording and trailing system; patient identification and approval processes are done manually, which invite a number of abuses.

In the rest of this article, we described how the use of suitably designed robust EMRs systems can help significantly minimise most of the handicaps and challenges we have highlighted.

Electronic medical record systems

EMR systems automate the clinical operations of HCPs.[29],[30],[31] They enable digital storage of patient records including charts, with facilities for tracking patient demographics, medical histories, medications, test results and other types of patient-specific clinical information, as well as the costs associated with the services provided. It can accurately capture the state of the patient at different stages and facilitate access to the entire patient history at an instant. The system usually involves a single modifiable file that is constantly updated as activities are entered into it and, hence, reduces the chance of data replication. It facilitates efficient extraction of medical information for examination and clinical review and eliminates the logistical issues associated with paper copies of medical records. EMR systems have become a routine feature of the health sector in developed countries, and their uptake in many developing countries is on the increase because they help improve the quality of healthcare. They also provide a platform for a variety of software applications that offer benefits to patients and HCPs. A comprehensive EMR platform may include clinical and pharmaceutical administrative facilities with decision support for physicians and management. EMRs also facilitate increased efficiency, improvements in the accuracy of medical records, pharmacy inventory management and accounting.[32],[33],[34],[35],[36],[37]

Virtually, all public health insurance schemes in the developed countries involve EMR systems for their day-to-day management, including registration of customers, interactions between stakeholders and service delivery, to name but a few.[37],[38],[39],[40] However, this is not the situation in many of the poor regions of the world, especially in sub-Saharan Africa where almost every aspect of the management of such schemes is paper based.[5],[6],[7] Unfortunately, many HCPs in the region lack the basic infrastructures needed for the effective implementation of EMR systems. Indeed, only a few currently have adequate facilities for information and communication technology – considered as an essential life-saving resource by every HCP in the developed world.[41],[42] Paper-based medical records require a significant amount of physical storage capacity and other resources as well as the problems associated with collation of such information for clinical practice and decision-making at different locations. This is current situation in most countries in sub-Saharan Africa, including Nigeria.

The potential value of electronic medical record systems

An effective EMR system would be sufficiently adaptable for accommodating appropriate software applications which can assist the organisation in its operations and enable it to be able to address many of the operational challenges even in sub-Saharan Africa.

An EMR system can accommodate relevant financial accounting software packages, including those with features for monitoring financial activities in the system. These include specifically developed applications for monitoring transactions and mitigating against the risk of resource misappropriation. These could include provisions for audit trailing to track activities in the organisation and minimise the risks of forgery and false claims.

Improvement of quality of care

It is a standard requirement of EMR systems to facilitate access to patient medical records by physicians and other approved healthcare staff.[41],[42],[43],[44],[45] Such systems can also facilitate information sharing between the various authorised users, which can be extended to multiple care settings, including all approved internal and external stakeholders.[40]

Appropriate computerised decision support systems with features for improving clinical decision-making can be incorporated. These include granting timely access to patient's current treatments during prescribing to prevent drug–drug interactions and to improve compliance with best practice. The system can also accommodate appropriate disease management tools, including facilities for public health promotion.

Operational management

The EMR system can be as useful as it is designed to serve, within the limits of current electronic technology. For example, it can accommodate a suitable project portfolio management tool which can facilitate centralised management of the processes involved.[46],[47] The tool can be used to track resource levels, monitor utilisation of services and manage staff-related demands such as workload, stock levels, forecast required staff levels and absenteeism.[48] There are commercial software packages with suitable interfaces for incorporation, and access to such data can be restricted to duly designated staff by the adoption of a secured (password based) facility.[49]

An EMR system with an inventory monitoring provision can enable both the HMOs and HCPs to operate within mutually agreed terms, on the minimum standard of delivery required of the services by the way of performance targets, which each party can monitor independently. The HCPs can also use the system to prepare standard operating procedures and train their staff on such procedures for effective practice and. perhaps, also include provisions for rewarding improvement and mitigating non-compliance. Facilities for prompt identification and resolution of issues can also be incorporated to ensure smooth operation and maintenance of the EMR system itself. Such a monitoring system can also facilitate evaluation of service delivery levels by both the HCPs and HMOs, identify the problem areas and initiate appropriate processes for improvement.

Fraudulent claims and service utility

A robust EMR system can be designed to incorporate fingerprint identification mechanism, similar to the current practice on smartphones. Such a provision can facilitate confirmation of enrollees at the points of service and also serve as an additional means for the required authorisation process. Indeed, a facility for electronic photograph identification can also be incorporated.

Billing

It is imperative that service providers are paid on a timely basis, to enable them manage their cash flows effectively and be able to continue to provide their services uninterruptedly. Schemes which operate on paper-based records and paper-based billing systems are associated with costs associated with several forms of expenses, most of which are avoidable with electronic billing.[50],[51] Electronic billing also offers benefits such as faster processing and reimbursements. For example, the average turnaround time for claims ranges from several weeks to months in the NHIS paper-based billing system, which can be substantially reduced under an effective electronic billing system.[51]

We know from experience and the literature that the benefits from EMR systems significantly outweigh the costs associated with their adoption.[52],[53],[54],[55] The electronic billing system can facilitate an efficient transmission of claims to the designated clearing house for processing by the touch of a button – ensuring that the claims are delivered accurately on a timely basis, immediate confirmations are received and real-time status checks can be conducted with timely information on the stage of each claim being processed.

 Discussion



Financial constraints constitute the most critical barrier to healthcare access in most sub-Saharan African countries as most governments in the region rank healthcare low on their priorities.[56],[57],[58] Public health insurance schemes have been identified as a viable means for addressing this problem.[5],[59],[60],[61],[62],[63],[64],[65],[66],[67],[68],[69],[70],[71],[72] However, there are several stumbling blocks to the achievement of universal health coverage through effective and sustainable public health insurance schemes in the subregion.[19],[29],[30],[31],[32],[33],[34],[35],[36],[37],[38],[73],[74] These schemes operate within an environment of poor resourcing, poor management, high levels of fraudulent practices and poor physical access to healthcare facilities, with much of the cost burdens borne by the insured.[5],[75],[76] We choose the scheme in Nigeria to highlight these challenges because most of the problems also apply to the other national schemes in the subregion.[66],[67],[71]

The adoption of a mandatory public insurance scheme that is backed by more rigorous regulations has been suggested as a viable solution.[13] The involvement of alternative sources of funding (e.g., public–private partnership) has also been identified as another option for improving the scheme towards the goal of a universal health coverage.[21],[22] However, these suggestions may not be enough to compensate for the impact of the major operational challenges we have highlighted.

Evidence suggests that the current schemes in the subregion are unsustainable and face extremely high risks of failure because of the difficulty in preventing the problems of fraud and other deliberate acts of abuse under their current paper-based operations.[63],[67],[71],[74] We have made the case for the involvement of suitably robust, EMR systems for schemes in the subregion, citing evidence from other regions of the world.[77],[78],[79],[80],[81],[82],[83],[84],[85],[86] Few have identified the potential benefits which large-scale adoption of fully integrated EMR systems could facilitate in this subregion.[87],[88] For example, an EMR system can be designed to meet the objectives of the different stakeholders of the scheme. EMRs with integrated relevant software packages may enable the NHIS, HMOs and HCPs in Nigeria to carry out many of their activities more efficiently, as well as to mitigate against misappropriation of funds, improve quality of care, track staff absenteeism, check compliance with procedures and practices and monitor service delivery, among others.

Indeed, the EMR system has become a tool of necessity for healthcare delivery in the developed countries – facilitating access to standard operating procedures; treatment guidelines and the provision of comprehensive, updated information on prescription drugs, for the minimisation of contraindications, drug–drug interactions and monitoring the health status of patients.[89],[90]

 Conclusion



This review highlights the gap in literature on the peculiar challenges associated with public health insurance schemes in sub-Saharan Africa and extends our knowledge by describing some of the fundamental problems – issues which are largely ignored, despite proliferation of these schemes in recent years. It describes how some of those associated with the environment of poor infrastructures, inadequate management and high fraudulent activities can be addressed with suitably designed EMR systems, suggesting that such resolutions may enhance the sustainability of these schemes, which are vital to the goal of universal health coverage.

Acknowledgement

The authors are grateful to the reviewers for their useful suggestions.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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