Recordkeeping Metadata Standardization for Electronic Health Records System Integration: a Preliminary Study
Keywords:Electronic Health Records, integration, interoperability, recordkeeping metadata
Electronic Health Records (EHRs) are beneficial in improving patient care, promoting safe practice, as well as enhancing patients and multiple providersâ€™ communication and risk error reduction. However, it seems that the adoption of EHR system is happening very slowly to become fully integrated in both primary care and within hospital settings. In Malaysia, the implemented system still has limited integration and interoperability for supporting clinical operations among other Ministry of Health Malaysia (MOHM) hospitals, health centres, and clinics. Therefore, the objective of this paper is to discuss about this scenario and strain the need for solution through the consideration towards metadata standard establishment in health records system integration. Method used in this study is literature review analysis and face-to-face interview. The paper begins with discussions from various literatures highlighting the need of metadata standard for recordkeeping system integration. Subsequently, the face-to-face interview is done to explore the real situation in Malaysia to encounter the scenario discuss in the literatures. The finding of this study reveals that there is significant need for further research on record keeping metadata standard development for realization of electronic health records system integration. This study is significant for records managers, information technology managers, system developers and record keeping audit.
 Palabindala, V., Pamarthy, A., & Jonnalagadda, N. R. (2016). Adoption of electronic health records and barriers. Journal of Community Hospital Internal Medicine Perspectives, 6(5), 32643.
 Mohd Salleh, M. I., & Abdullah, R. (2016). The influence of system quality characteristics on health care providersâ€™ performance: Empirical evidence from Malaysia. Journal of Infection and Public Health, 9(6), 698â€“707. https://doi.org/10.1016/j.jiph.2016.09.002
 Ekblaw, A., Azaria, A., Halamka, J. D., Lippman, A., Original, I., & Vieira, T. (2016). A Case Study for Blockchain in Healthcare: â€œ MedRec â€ prototype for electronic health records and medical research data MedRec: Using Blockchain for Medical Data Access and Permission Management.
 Rolan, G. (2017). Towards Archive 2 . 0 : issues in archival systems interoperability. Archives and Manuscripts, 43(1), 42â€“60. https://doi.org/10.1080/01576895.2014.959535
 Lee, J.-Y., Kim, Y., & Kim, G. (2013). A Study on the Analysis and Improvement of Medical Record Management in Large University Hospitals. Korean Journal of Records Management, 13(1), 107â€“134.
 AbuKhousa, E., Mohamed, N., & Al-Jaroodi, J. (2012). e-Health Cloud: Opportunities and Challenges. Future Internet, 4(4), 621â€“645. https://doi.org/10.3390/fi4030621
 Bahga, A., & Madisetti, V. K. (2013). A cloud-based approach for interoperable electronic health records (EHRs). IEEE Journal of Biomedical and Health Informatics, 17(5), 894â€“906. https://doi.org/10.1109/JBHI.2013.2257818
 Abd Ghani, M. K., Bali, R. K., Naguib, R. N. G., & Marshall, I. M. (2008). Electronic health records approaches and challenges: a comparison between Malaysia and four East Asian countries. International Journal of Electronic Healthcare, 4(1), 78â€“104. https://doi.org/10.1504/IJEH.2008.018922
 Paper, C., Khanapi, M., Ghani, A., Teknikal, U., Naguib, R., & Internat, C. (2008). Issues and Challenges in the Development of Electronic Health Records in Malaysia and VN-HISMANAG â€™ 08 - Conference on Applications of Medical Informatics in Hospital Management Issues and Challenges in the Development of Electronic Health Records in Mala.
 International Records Management Trust. (2016). Managing Metadata to Protect the Integrity of Records, (May).
 Department of Education LINC Tasmania. State Records Guideline No 5 Recordkeeping Metadata (2015).
 Aliza Ismail. (2010). Assessing the practice of trusted electronic records management in Malaysia government â€“ controlled companies. Univerisiti Teknologi MARA, Malaysia.
 Hammami, R., Bellaaj, H., & Kacem, A. H. (2014). Interoperability of healthcare information systems. The 2014 International Symposium on Networks, Computers and Communications, 1â€“5. https://doi.org/10.1109/SNCC.2014.6866536
 Kovac, M. (2014). E-health demystified: An E-government showcase. Computer, 47(10), 34â€“42. https://doi.org/10.1109/MC.2014.282
 Joanne Evans, Sue McKemmish and Barbara Reed, â€˜Making Metadata Matter: Outcomes from the Clever Recordkeeping Metadata Projectâ€™, Archives & Manuscripts, vol. 37, no. 1, 2009, pp. 28â€“56.
 Bunn, J. (2017). The Journal of the Archives and Records Association Developing descriptive standards : a renewed call to action. Archives & Records. Taylor & Francis. https://doi.org/10.1080/23257962.2013.830066
 Health Informatics Centre. (2013). HIMS Blueprint (Vol. 13). Retrieved from http://www.moh.gov.my/images/gallery/publications/hi/HIMS Blueprint.pdfWorld Health Organization. (2012). Management of patient information. Global Observatory for eHelath series â€“ Volume 6