Recordkeeping metadata for the integration of electronic health records system in Malaysian teaching hospitals

Numerous health information systems have been established due to the development of ICT. The Twelfth Malaysia Plan 2021-2025 continued to define strategies to enhance the delivery of health system services. The pandemic of COVID-19 has tested the resilience and responsiveness of healthcare delivery systems across the globe. To ensure that the community has equal access to healthcare services and is prepared for future health crises, it is essential to revitalise the healthcare system. However, the implemented system has integration and interoperability limitations for facilitating hospital-based clinical operations. Ministry of Health (MOH) and Non-MOH hospitals are the two categories of government hospitals. As the MOH hospital's strategic plan focuses on MOH, Non-MOH is deemed essential to investigate. Integration is only effective if a portion of the health organization's structure is appropriately issued. This is where the difficulties arose, and system integration remains the primary focus of the eHealth Strategy in Malaysia to this day. After extensive research, several key issues were identified that prompted the undertaking of this study. One of the challenges is that having different records systems creates difficulties when integrating and sharing data. 2) An established standard or framework for managing operations must be established. 3) Restricted integration and interoperability. 4) Inadequate administration of the electronic health records system 5) The issue of evidence arising from the presence of many copies in various storage locations, and 6) Distinct data definition. Recordkeeping metadata is the optimal solution for the incorporation of Electronic Health Records (EHR), where metadata are elements that incorporate the relationship between records to make them comprehensible and usable. In addition to facilitating data sharing, data integration, and linking, recordkeeping metadata also facilitates data exchange. Therefore, this study proposes to generate recordkeeping metadata requirements for the integration of the EHR system in Malaysian Teaching Hospitals. A multiple case study was identified as the optimal method. Beginning with a comprehensive analysis of local and international best practises, recordkeeping metadata for integration are formulated. Six (6) standards have been evaluated and contrasted. The analysis has identified fifty (50) elements of the records metadata category as the focus of the study. The analysis has also led to the discovery of a new category which is then named as “research value” metadata. A semi-structured interview and content analysis have been conducted to collect data. Existing metadata elements utilised by teaching hospitals have been the subject of an in-depth investigation. In addition, the interview discloses forthcoming additions to the hospital's metadata. To finalise the proposition for recordkeeping metadata for the integration, the study has analysed and compared the result of RO2 to determine the obligation status. The findings identify eighteen (18) Mandatory, sixty (60) Conditional, and sixty-one (61) Optional obligation statuses. The proposal of recordkeeping metadata for the integration of Malaysian teaching hospitals has been completed based on the findings of this study. The outcome of the study will serve as standard guidance for the integration of metadata elements into the EHR system in teaching hospitals. Experts in records will identify the point of uniformity that permits system integration through verification and feedback. The documented requirements for recordkeeping metadata could motivate all Malaysian hospitals to implement an integrated EHR system. It could increase the sharing of data with institutions other than the government.