This study is the first known assessment that compared hospital EMRs in China to the current US EHR standard, Meaningful Use objectives. This study sheds light on important US hospital EHR functionality that physicians in China actually use. To describe hospital EMRs in China, we used MU objectives because they were a de-facto national standard for necessary functionality for EHRs that listed discrete, specific US EHR functionalities. The health system in China differs from that of the US health system, and hospitals in China operate differently from US hospitals. Therefore, we expected the EMRs implemented in hospitals in China to differ from US EHR MU functionality.
The study findings indicated that the two EMRs studied met about half of the MU objectives. We found differences in EHR/EMR functionality that reflected cultural differences as well as operational differences. Cultural differences included that the EMRs in China have no need to capture preferred language or race due to the perceived homogeneity of these characteristics. Also, the US process for advanced directives is not present in the clinical care process in China. Instead, advanced directives are inferred from consent forms; patients in the study hospitals must specifically consent to each procedure before it is begun. Each consent form must be signed by hand. There is no checkbox to note the presence of an advanced directive.
Comparing MU Objectives and EMR functionality of the study hospitals in China, we identified operational differences at a number of levels. At the physician level, physicians were required to maintain a diagnoses list rather than a problem list which included abnormal signs and symptoms. Abnormal signs and symptoms are listed only when their origins are unknown since Chinese physicians emphasize causes of diseases.
Also, we did not observe medication reconciliation as an EMR function because infrequent care transitions greatly reduced the need for this functionality. The physician referred to the patient’s ambulatory record which they themselves, or a physician in their department, wrote. Medication continuity is relatively easily maintained by the same/similar physicians in the same hospital. Also, unlike physicians in US hospitals, Chinese physicians documented most of the care themselves and did not dictate any content.
In addition, at the implementation level, we noted that in both hospitals drug-allergy interaction functionality was not implemented. Usually in China, the HIS vendor implements the CPOE system where physicians input medication orders. Physicians document allergies as free text in the EMR provided by EMR vendors. The CPOE and HIS systems do not share medication allergy data in part due to the absence of standards, or due to the fact that Chinese physicians do not think this is a significant issue.
Regarding discharge, in the observed hospitals, the discharge summary included the content contained in the US summary care record. Also, physicians provided patient-specific education resources orally, unlike US hospitals where nurses tend to educate the patient and provide printed patient educational material. Finally, at the organizational level above the hospital, EMRs do not have the capability to support data exchange, external reporting, or syndromic surveillance.
Of the MU objectives that were not met, four may be easily implemented by vendors in China if they are required by the hospitals. For example, neither hospital provided patients with an electronic version of health information or education materials. Also, smoking status is implemented as free text rather than structured data. Plus vital signs are recorded but not charted.
The study hospitals in China had two notable EMR functionalities. First, similar to hospitals in other countries and unlike most US hospitals, diagnoses were coded using ICD-10 codes. Either the physician or medical record department staff documented ICD-10 codes when records were archived. Second, physicians recorded the patient’s occupation. While some states in the US collect occupation information using standardized occupation codes, recent national efforts have been focused on documenting occupation in the health record using standardized codes[20].
We also found similarities between the US hospitals and the study hospitals in China. In both countries, MU Objectives not met included that hospitals were unable to exchange patient clinical information electronically with other sites that provided care. Instead, the study hospitals gave patients paper copies of their clinical information. In addition, in PUFH it was not unexpected that one CDSS rule had not been implemented. CPOE was newly implemented and, as in US hospitals, CDSS tended to be implemented after CPOE implementation. Of particular interest was BCH’s not implementing CDSS based on physicians’ objections.
It was also very interesting that there was a lack of uniformity of the EMR functionality in these two hospitals. For example, related to the MU Core objectives, there was similarity in recording demographics and diagnoses, but not vital signs or smoking status. This lack of uniformity between the EMRs in two of the leading hospitals in China suggests the need for a national EMR standard similar to Meaningful Use.
Finally, in this study, the hospitals in China chosen to be assessed were not representative of all hospitals in China, as they were two top-tier tertiary hospitals in Beijing that were early adopters of EMRs. It is possible that the EMRs studied may not be representative of all EMRs implemented in China. While the study hospitals had recently implemented their EMRs, it is possible that other hospitals may have EMR systems with more functionality that matched MU objectives.
Due to China’s 2009 health reform initiative’s strong policy support, there has been rapid HIT adoption, including EMR adoption, by hospitals. In contrast, the US financial incentives for hospitals to implement EHRs that meet MU objectives may be less effective in encouraging EHR adoption as compared to policy support in China. While China is not viewing U.S. MU objectives as a gold standard for comparison, the MU approach and objectives can provide China a model for standardizing and evaluating EMR adoption. China has issued more than 100 HIT standards during 2010–2011 but lack standards like U.S. MU that are able to test and assess the level of EMR adoption. In the near future, China should implement not only an EMR certification program, which guarantees the required functionalities of EMR standards, but also a U.S. MU-like standards and certification program to ensure the quality of EMR adoption rather than just raise the rate of EMR adoption.