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eHealth and health informatics @WHO/HQ by Najeeb Al-Shorbaji, Director of the Department of Knowledge Management and Sharing, World Health Organization (WHO)

 Najeeb Al-Shorbaji

Introduction

eHealth is the use of information and communication technology in health. A number of definitions have emerged depending on the scope of study or the type of project being implemented. As a result the terminology related to eHealth has also mushroomed.  Typical terms used are telemedicine (and all medical subspecialties), tele-health, mHealth, eHealth is taken to be used as an umbrella term that covers all other concepts. eHealth has been instituted in WHO for many years through the systematic use of electronic data processing in managing health data, information and knowledge. The early application of computers to manage health statistics since 1966 is a good example of that. In more recent years WHO as taken steps to make eHealth as part of its health systems strengthening efforts.

The eHealth resolution

The Fifty-eighth World Health Assembly took a historical step towards supporting eHealth when it a adopted a resolution establishing for a global movement that recognizes the role of information and communication technology in health systems strengthening and services. The resolution urges Member States:

1.  to consider drawing up a long-term strategic plan for developing and implementing eHealth services that includes an appropriate legal framework and infrastructure and encourages public and private partnerships;
2.  to develop the infrastructure for information and communication technologies for health as deemed appropriate to promote equitable, affordable, and universal access to their benefits, and to continue to work with information telecommunication agencies and other partners to strive to reduce costs to make eHealth successful;
3.  to build on closer collaboration with the private and non-profit sectors in information and communication technologies, to further public services for health;
4.  to endeavor to reach communities, including vulnerable groups, with eHealth services appropriate to their needs;
5.  to mobilize multisectoral collaboration for determining evidence-based eHealth standards and norms, to evaluate eHealth activities, and to share the knowledge of cost-effective models, thus ensuring quality, safety and ethical standards;
6.  to establish national centres and networks of excellence for eHealth best practice, policy coordination, and technical support for health-care delivery, service improvement, information to citizens, capacity building, and surveillance;
7.  to consider establishing and implementing national public-health information systems and to improve, by means of information, the capacity for the surveillance of, and rapid response to, disease and public health emergencies;

The resolution also requests the Director-General:

1.  to promote international, multisectoral collaboration with a view to improving compatibility of administrative and technical solutions in the area of eHealth;
2.  to document and analyze developments and trends, inform policy and practice in countries, and report regularly on use of eHealth worldwide;
3.  to provide technical support to Member States in relation to eHealth products and services by disseminating widely experiences and best practices, in particular on telemedicine technology; devising assessment methodologies; promoting research and development; and furthering standards through diffusion of guidelines;
4.  to facilitate the integration of eHealth in health systems and services, including in the training of health-care professionals and in capacity building, in order to improve access to, and quality and safety of, care;
5.  to continue the expansion to Member States of mechanisms such as the Health Academy which promote health awareness and healthy lifestyles through eLearning;
6.  to provide support to Member States to promote the development, application and management of national standards of health information; and to collect and collate available information on standards with a view to establishing national standardized health information systems in order to facilitate easy and effective exchange of information among Member States;
7.  to support regional and interregional initiatives in the area of eHealth among groups of countries that speak a common language.

Grand challenges to eHealth

eHealth development faces multiple challenges some of which are local others are national or even international. Here are some of the more acute challenges that requires concerted effort at all levels of planning and implementation in countries:

Development of national eHealth strategies

eHealth projects and applications require the coordinated involvement of at least two sectors: the health and the information and communication technology (ICT). Each of the two sectors has its own national strategy and plans. In some cases these are part of a national development plan, but in most cases they are not aligned. This leaves room for duplication of effort, lack of integrated solutions, and mismatching of needs of people with responses by the two sectors. The National e-Health Strategy is the only platform that will ensure bringing the different stakeholders together in a coordinated manner. Development of the strategy requires inputs from all partners and stakeholders. More important the strategy entails commitments on the part of these. Those involved in the development and implementation of the strategy are expected to take up a common position on all issues of strategic importance of the role of ICT in improving and possibly changing the healthcare system and to recognize the need to develop joint approaches for resolving issues related to use of  ICT in health at the national level. A national eHealth strategy includes the common threads that bind national health strategies with national ICT strategies. A national eHealth strategy will require compliance and alignment of sub-national and local plans. This is seen as the only guarantee that national needs are met through a synergized action, that management of scarce resources is done on a most rational manner and that eHealth solutions are interoperable and integrated (if needed).

Interoperability

Interoperability means the ability to communicate and exchange data accurately, effectively, securely, and consistently with different information technology systems, software applications, and networks in various settings, and exchange data so the clinical or operational purpose and meaning of the data are preserved and unaltered.

Interoperability standards are necessary for health information systems to share their data. They can be divided into two broad categories, syntactic standards that indicate what a piece of information is, and semantic standards that indicate what a piece of information means.  Interoperability standards must also consider a multitude of critical factors beyond the specifics of the information that they must encode, including for example security and confidentiality, bandwidth utilization and performance, cost of access, and so on. Of concern to developing countries and resource constrained implementers developers is free or low-cost access to existing standards.

The role of semantic interoperability standards is to preserve the meaning of the data communicated and exchanged between different systems. A lack of system  interoperability hampers efforts to collect information for patient care and for program monitoring and evaluation. Additionally, it increases the costs of system development and data use. While the need for standard semantic content in clinical systems is clear, the complexity of the clinical environment and multitude of systems continues to remain a challenge.

Information and communication technology infrastructure

eHealth by definition depends on ICT infrastructure and services. Absence or weakness of these limits the capacity and potential of eHealth applications. In many countries the Internet penetration rate is still very low. Which in other countries there is huge disparity between rural and urban areas. Mobile phone penetration rate has become phenomenal as over 4 billion subscribers are currently benefiting from these services. The challenge is the lack of matching of other data communication services to make the mobile phone a real tool for health services, beyond pilots and small scale demonstration projects. Mobile phones for health requires ICT infrastructure to store data, transfer data securely and at a cost-effective rate and full compatibility, interoperability and possibly integration with other services. Poor quality of information and communication technology infrastructure including healthcare institutions are not on the priority list for computerization; national Information infrastructure is very week; ICT services are very expensive; ICT services are under monopoly by the government; private sector is still weak, which makes competition very little.

Human resources for eHealth

Lack of technically competent staff at all levels including healthcare professionals do not receive ICT training as part of their undergraduate programmes; ICT professionals are mainly hardware and software engineers with little orientation on medical applications; in-service training and continuous education are missing in the area of health informatics; very few specialized health informatics programmes; and team formation (health and IT specialists) is weak;

Legislative and regulatory frameworks

Legal and regulatory issues range from ambiguous legal frameworks to poor data management including access to personal data and lack of data security rules. At the international level there is lack of trans-border data flow regulations which has resulted in creating an open space of information exchange and dissemination leading to misinformation, unethical use, concealed bias, covert self-dealing, fraudulent practices and evasion of legitimate regulation;

Evidence on value and impact of eHealth

Many eHealth projects have been deployed in almost all countries of the world. There is very little accumulated evidence to demonstrate the value of eHealth, its economic and social impact. Policy makers and financers ask legitimate questions on return of investment, the savings, the cost-effectiveness of eHealth projects. This has resulted in lack of financial support and sustainability including funding e-health as research projects. This lead to a situation to funding e-health as pilot projects; increased funding of e-health projects from donor agencies on a disproportionate rate. This funding is provided for a specific component of e-health application in isolation of other elements leading to duplication and fragmentation of applications.

Major activities and projects in WHO Headquarters

The revitalized Knowledge Management strategy has four strategic of objectives, one of which is to "Promote the use of  information and communication technologies to improve health services and systems".

The rationale for this strategic objective is that information and communication technologies can potentially improve health, as they underpin the application of knowledge in all sectors. In many countries the health sector uses such technology to improve disease surveillance and registry, better deliver health care, manage health services and educate the public and the health workforce using a variety of applications that range from personal medical records to population-based health information systems.

Ensuring that all countries benefit from these technologies requires investment in technical infrastructure, applications, content and training, as well as partnerships with United Nations agencies, governments, the private sector and civil society.
The approach to be followed included monitoring eHealth trends, identifying good practices, facilitating networks of expertise, promoting norms and standards and the integration of these technologies into health workforce training and practice.

Actively working with public and private-sector stakeholders to advocate for ethical and evidence-based policies in eHealth, highlight effective practices, monitoring trends and promoting research on – and development of – eHealth solutions to health problems.

We promote the integration of cost-effective ICTs in education and training, including the use of e-learning in professional development, health education for the public and for groups with special needs.

The eHealth and informatics unit leads the work of the Organization in this area. The team* manages the activities and projects in collaboration with technical units and regional and country offices and in full partnership with other UN agencies, donors and non-government organizations.

1. Global Observatory for eHealth

The WHO Global Observatory for eHealth was established in 2005 in response to the World Health Assembly eHealth resolution WHA58.28.  The Observatory monitors, analyses and reports the uptake of eHealth and associated policy development worldwide with the view to providing Member States with strategic information for planning and implementation of eHealth programs.  Two global surveys have been conducted - the first in 2005 and the second in 2009.  The most recent survey will produce an eHealth series of eight volumes on key eHealth themes to be published during 2010 - 2011. http://www.who.int/goe

2. The ePORTUGUÊSe

The ePORTUGUÊSe network is a WHO platform created in 2005 to support the development of human resources for health in Portuguese-speaking Member States facilitating collaboration among institutions, delivering health information, and promoting capacity building. It has contributed to the development of a Virtual Health Library (VHL) in each of the Portuguese-speaking countries as well as delivered 92 Blue Trunk Libraries (BTL) in Portuguese to Portuguese-speaking countries in Africa (PALOP). It also implements technical cooperation through a discussion group entirely in Portuguese with more than 700 members.
http://www.who.int/eportuguese/en/

3. Health Academy

The Health Academy is a World Health Organization initiative launched in December 2003 to bring health information, education and technology together in the form of eLearning adapted to local settings.  Today, there are a total of fifteen different Health Academy programs available all in English and some in other languages.  Presently we are working on developing an eLearning program on "dengue", and through our collaboration with Dasman Institute we are in the process of developing two new Health Academy programs on managing diabetes (type 1 and 2).
With its primary focus on school-age children, the project has been implemented through pilot projects in 6 countries: Egypt, Jordan, Lebanon, Ghana, the Gambia, and the Philippines. Several countries, such as Jordan, and Lebanon have expanded their initiatives beyond the pilot stage as resources have become available. We have been able to secure resources for Albania and Solomon Islands to  start their pilot implementation in the near future.

4. Health Information Systems

Integrating fragmented and vertical Health Information Systems (HIS) remains a challenge to developing national and international monitoring systems. The disease outbreaks and a need for performance-based Monitoring and Evaluation highlight the inadequacy of current systems.

Objectives:

1)Provide a source for information, ISO standards, and other guidance related to Health System Strengthening and eHealth Architecture.
2)Providing a means to make systems interoperable with respect to content and data exchange format to facilitate development of monitoring systems to support national and international reporting and decision-making.

Important deliverable and URL:

WHO Indicator and Measurement Registry (IMR) for harmonizing indicators - http://apps.who.int/gho/indicatorregistry
Statistical Data and Metadata Exchange standard for the Health Domain (SDMX-HD) for an ISO-standard exchange format - www.sdmx-hd.org
Standards Knowledge Management Toolkit (SKMT, in collaboration with ISO and WCC University of Sherbrooke) for technical assistance - www.skmtglossary.org

5. eHealth Governance

The WHO Resolution on e-Health and the World Summit on the Information Society in 2005 were milestones in recognizing the value that ICT brings to health and the shared global challenges of the Internet. eHealth governance is concerned with the rights, rules, responsibilities and risks in the networked world. The focus is on global and national frameworks, policies and tools to advance ICT for health.

Selected deliverables: 1) resources for countries developing national strategies for e-Health implementation, 2)) strategic review and guidance regarding emerging issues on the global health Internet: legal and ethical issues, information quality, consumer safety, online medical services and pharmaceutical sales, Internet top level domain for health and the use of electronic health information for public health services.

WSIS report and country profiles: http://www.who.int/kms/resources/wsis_report/en/

6. Global Health Observatory (GHO)

A project to make the Organization's data sets available to the public.  It works with the technical units of WHO to take a view of their indicator data and harmonize it as much as possible across a number of common dimensions and link it to metadata in the Indicator Metadata Registry.  The data is then made available through the web and as downloadable datasets.  The overall deliverables of this project are an operationally supported process/service for technical units to load data, standards for representing data, and online accessibility of data sets.
    http://www.who.int/ghodata
    http://www.who-mahler.net/projects/show/who-hci-gho
        (project management site, log in with guest/guest)

7. Global Health Observatory Version 2 (GHOv2)

This project stems from the GHO work.  It aims to define a clear set of business, functional, and technical requirements for the next version of GHO, to incorporate standards like SDMX/SDMX-HD for the dissemination of data and provide a good set of back-end tools and processes for technical units to now be able to fully load and maintain their data themselves in the GHO.  The overall goal is to implement a better version of the system that we currently have so that it will be easier and cheaper to maintain and use as well as to be able to replace the related legacy information systems that we must currently maintain.
    http://www.who-mahler.net/wiki/who-hci-gho
        (project management site, log in with guest/guest, see section "GHO Next Generation")

8. Code List Inventory

The Code List Inventory began as an attempt to make the GHO database metadata transparent in order that technical units can format their data.  The project has now turned into a process of harmonizing and simplifying metadata in the Organization into a consistent, and if possible, industry-recognized representation of data elements and codes.  The objective is to improve the usability and exchange of data within the organization and through the internet.  An important deliverable in the next six months is to launch a database/website that contains the metadata of the GHO and many major WHO databases.

9. Repository of Country Health Reports (RoCHR)

"The Repository of Country Health Reports is a digital library of health information documents. It aims to provide easy access to country reports related to health data collection, analysis and synthesis. It includes reports of surveys, health statistical abstracts, facility assessments, health sector reviews and more."  Two of the major deliverables within the year are (1) to collect at least 3000 country reports from country MoHs, statistics offices and institutions that conduct country-specific surveys and studies on health and (2) to migrate the application into the WHO servers.
    http://rochr.qrc.com/

10. OpenMRS Express

This work originates from earlier work done to create standardized messaging specifications for exchanging patient level HIV patient care data in resource constrained clinical settings (primarily in Africa).  OpenMRS Express is a content package and a few simple software components added to the OpenMRS Medical Record System framework to implement WHO's stock HIV care and monitoring guidelines for anti-retroviral therapy.  A set of instances of the system is currently being adapted and tested for use in Ugandan clinics through the Uganda Ministry of Health and the WHO Uganda Country Office.
    http://www.who.int/kms/initiatives/openmrs_express/en/
    http://www.who.int/hiv/pub/ptmonguidelines.pdf
    http://www.who-mahler.net/projects/show/hci-openmrs-uganda
        (project management site, log in with guest/guest)
    http://www.who-mahler.net/projects/show/who-hci-openmrsex
        (project management site, log in with guest/guest)

11. Open Concept Collaborative (OCC)

The OCC evolved from a common need shared by a number of group working with electronic medical record systems for resource constrained environments to be able to share concept definitions (usually clinical but often other types as well) across their different systems.  Note that this is different than using a common terminology or classification such as Snomed or ICD 10.  These concepts can be arbitrarily defined, are context specific, and can be created by anyone with various levels of quality or specificity.   The OCC is a repository that receives concepts from electronic medical record (EMR) instances in the field and makes them browsable and usable by other systems.  Current deliverables for the project include a broader set of WHO clinical guideline concepts (the current WHO instance holds IMAI (HIV Care concepts), OpenEHR support (a growing ISO standard for representing clinical concepts) and potentially linking it to the Indicator Metadata Registry to describe the atomic concepts against which indicators may be defined.
    
    http://openmrs.org/wiki/OCC
    http://www.who-mahler.net/projects/show/who-hci-occ
        (project management site stub, log in with guest/guest)

12. Legacy Information System support

The eHealth and Informatics unit has inherited a number of older WHO information systems including WHOSIS, Global Atlas, and the OpenHealth application stack.  Most of these applications store and disseminate data sets of various kinds and components of these systems are accessible over the public website.  We are currently engaged in basic operational maintenance and occasionally updates to these systems.  Long term deliverable is eventually for most of these systems to be functionally replaced by GHO version 2
    http://apps.who.int/whosis/data/Search.jsp
    http://apps.who.int/globalatlas/
    OpenHealth Examples:
        https://extranet.who.int/fluid/
        Water and Sanitation system
        IHR Points of Entry
        IHR Monitoring

13. Electronic Implementation specifications for WHO Clinical care guidelines

This is an offshoot of our work on messaging standards, electronic medical records, and OpenMRS Express.  This project works on creating engineering specifications for electronic medical record systems to more easily, consistently, and correctly implement WHO clinical care guidelines.  The current deliverable is to produce a specification for the new HIV system linking HIC care, TB, and maternal/neonatal care (see link)
        (original HL7 ART messaging specification, that mostly was used as first pass electronic system implementation spec for HIV care)
    http://www.hivimplementers.com/pdfs/Session%2020/20__Gove.pdf
        (presentation on 3ILPMS (The guideline documents are being finalized)

14. Learning in eHealth Informatics via Knowledge Management and Sharing

With respect to learning, embedding learning approaches into meetings, events and products is the objective. Drawing on latest theory and practice e.g.: in complexity, social media, brain / mind and learning, the unit has developed a networked, collaborative learning approach that has been implemented over the last five years. This development has entailed a shift from providing expert-driven high level advice, to peer-to-peer collaboration at all levels of the health system. Important deliverables have been regional meetings primarily in sub-Saharan Africa that have catalyzed the OpenMRS electronic medical records system development, eHealth policy, health informatics standards, and health humanitarian response information and knowledge management strategies.

15. The eHealth Intelligence Report

Since 2005, the eHealth Intelligence Report covers global developments in ehealth offering readers a broad range of information on publications, reviews, standards, conferences, and trainings as well as the latest news from countries. The eHIR does not only provide an online digest of major global events, but it also brings together eHealth stakeholders of all types - authors, implementers, governmental officials, policy makers, industry - to contribute and share their latest news. It is an produced bi-weekly.  Website: http://www.who.int/goe/ehir/en/

* the eHealth and Informatics team: Chris Bailey, Alim Khan, Diana Zandi, Fatima Sanz de Leo, Getachew Sahlu, Joan Dzenowagis , John Patrick Whitaker, John Rawlinson, Jonathan James Santos, Knut Staring, Misha Kay,  Philippe Boucher, Regina Ungerer, Steve Moore, Zoe Brillantes.   

Contact

eHealth Program
Department of Knowledge Management, Bioethics and Research
Pan American Health Organization
525 23rd ST NW, 20037, Washington DC, US
Email: ehealth@paho.org

Regional Office for the Americas of the World Health Organization
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