Transcript No Slide Title

PERSPECTIVES IN E-HEALTH
Roberto J. Rodrigues
Regional Advisor for Health Services Information Technology
Division of Health Systems and Services Development
Pan American Health Organization / World Health Organization
Washington, D.C.
Workshop on Global Telehealth/Telemedicine and the Internet
2001 Symposium on Applications and the Internet (SAINT 2001)
San Diego, January 8-12, 2001
DEVELOPMENT ISSUES IN E-HEALTH

DEFINITION, DRIVING FORCES, AND BARRIERS

HEALTH SECTOR ASPECTS

INFRASTRUCTURE AND MARKET

IMPLEMENTATION

LATIN AMERICA & CARIBBEAN METRICS
DEVELOPMENT ISSUES IN E-HEALTH

DEFINITION, DRIVING FORCES, AND BARRIERS

HEALTH SECTOR ASPECTS

INFRASTRUCTURE AND MARKET

IMPLEMENTATION

LATIN AMERICA & CARIBBEAN METRICS
INTERACTIVE HEALTH COMMUNICATIONS
APPLICATION OF INFORMATION AND TELECOMMUNICATIONS
TECHNOLOGIES TO HEALTH AND HEALTHCARE

TELEMEDICINE
PATIENT CARE APPLICATIONS

TELEHEALTH
TELEMEDICINE, DISTANT EDUCATION AND TRAINING,
HEALTH PROMOTION, PUBLIC HEALTH, SERVICES MANAGEMENT,
TECHNICAL INFORMATION RETRIEVAL

CYBERMEDICINE
INTERSECTION OF INFORMATICS WITH BIOENGINEERING,
IMPLANTABLE DEVICES, PROCESS AUTOMATION, BIOSENSORS,
DEVELOPMENTAL ROBOTICS, NANOTECHNOLOGY

E-HEALTH
INTERNET-BASED HEALTH APPLICATIONS, INCLUDING PURELY
ADMINISTRATIVE (B2B, E-COMMERCE, ETC)
EVOLUTIONARY TECHNOLOGIES

POINT OF CARE TECHNOLOGIES

PROCESS AUTOMATION

ELECTRONIC MEDICAL RECORD (CPMR)

DATA WAREHOUSING

DATA ACCESS AND SECURITY TECHNOLOGIES

APPLICATION INTEGRATION

DECISION-SUPPORT TECHNOLOGIES
REVOLUTIONARY TECHNOLOGIES

ELECTRONIC COMMERCE
 “PUSH TECHNOLOGIES”

RESOURCE ADQUISITION TECHNOLOGIES (Auction Technologies)

ON DEMAND REMOTELY-BASED APPLICATIONS (ASP)

MOBILE AND WIRELESS TECHNOLOGIES

INTELLIGENT AGENTS

INTERACTIVE TECHNOLOGIES (Voice, Writing Recognition)

ALWAYS-ON CONNECTIVITY WITH COMMUNITIES

KNOWLEDGE MANAGEMENT (Retrospective >>> Simultaneous)
DRIVING FORCES (1)
 QUEST FOR QUALITY AND COST MANAGEMENT
 RISING DEMAND FOR ADVANCED MEDICAL TECHNOLOGY
 SHORT PRODUCT LIFE CYCLES / OBSOLESCENCE
 DISSATISFACTION WITH HEALTH SYSTEM (CHOICE, ACCESS, QUALITY)
 DISREGARD FOR “CUSTOMER SERVICE”
 CONVENIENCE MORE IMPORTANT THAN PRICE
DRIVING FORCES (2)
 CAPTURING LONG-TERM SERVICE RELANTIONSHIPS
 INEFFICIENCY OF ADMINISTRATIVE PROCESSES (ELIGIBILITY,CLAIMS,
REIMBURSEMENT, PROCUREMENT AND SUPPLY MANAGEMENT)
 INCREASED DEMAND FOR DATA AND INFORMATION (DISTRIBUTED
MULTIDISCIPLINARY PRACTICE, IMPROVED DOCUMENTATION)
 LOGISTICS OF HEALTHCARE (DYNAMIC SCHEDULING, DATA COMMUNICATION)
 ACCESS TO BIOMEDICAL KNOWLEDGE (REFERENCE, PROTOCOLS OF CARE,
REGISTRIES, KNOWLEDGE BASES, EVIDEDENCE-BASED PRACTICE,
CONSUMER PARTICIPATION)
DRIVING FORCES (3)
 26% U.S. HEALTHCARE SPENDING ARE ON ADMINISTRATIVE TASKS (HCFA)
 PHYSICIANS/PAYERS BOTTLENECK 13% COST (12.7 BILLION IN 1999)
 E-HEALTH B2B GROWTH (6 BILLION IN 1999 ….. 348 BILLION IN 2004)
 ONLINE PROCUREMENT WILL REACH 27.3 BILLION BY 2004
 CONNECTIVITY OF THE PUBLIC TO THE INTERNET
 MOBILE TECHNOLOGIES AND PORTABLE DATA MEDIA (SMART CARDS)
HEALTH SECTOR BARRIERS (1)
HEALTH SECTOR REQUIREMENTS SPECIFICATION

LOW DEFINITION LEVEL OF CONTENTS (DELIVERABLES) OF
HEALTH INTERVENTIONS

INDETERMINATION OF OBJECTIVES AND FUNCTIONALITIES

CONFLICTS IN DEFINING MINIMUM DATA SETS FOR OPERATIONAL
MANAGEMENT AND CLINICAL DECSISION-MAKING

HEALTHCARE ORGANIZATIONS AND PROVIDERS TEND TO
SEE THEIR OWN DATA AS THE ONLY GOOD AND VALID DATA

DISTRUST OF HEALTH PROFESSIONALS IN OFF-SITE DATA
STORAGE AND ACCESS CONTROL
HEALTH SECTOR BARRIERS (2)
ORGANIZATIONAL AND POLICY-RELATED

INFRASTRUCTURE, INVESTMENT SUSTAINABILITY AND
DEPLOYMENT CAPABILITY

HEALTHCARE ORGANIZATIONS FEEL PROPRIETARY ABOUT
THEIR INFORMATION -- HEALTH PLANS DO NOT LIKE TO LET
PROVIDERS INTO THEIR INFORMATION CYCLE AND VICE VERSA

COMPLEXITY AND VARIETY OF OBJECTIVES, FUNCTIONS, AND
TECHNICAL CONTENTS OF APPLICATIONS

NATIONAL POLICIES AND STRATEGIES FOR THE STANDARDIZATION
AND COST-EFFECTIVE USE OF TECHNOLOGY AND INFORMATION

CONSISTENCY AND CONTINUITY OF POLITICAL SUPPORT
TECHNOLOGY BARRIERS (1)
INFORMATION TECHNOLOGY INFRASTRUCTURE

TECHNICAL RESOURCES AND WEB DEMOGRAPHICS

DATA AND COMMUNICATION STANDARDS

INCREMENTAL DEVELOPMENT X BIG BANG

TECHNOLOGICAL INNOVATION X ACTUAL USE GAP

OPEN x PROPRIETARY ARCHITECTURE

COST-BENEFIT
TECHNOLOGY BARRIERS (2)
INFORMATION TECHNOLOGY DEPLOYMENT (1)
 SECURITY, PRIVACY AND CONFIDENTIALITY
 ALIGNMENT TO INSTITUTIONAL GOALS, IMPROVEMENT OF
HEALTH AND EXPECTATIONS OF PROVIDERS, CLIENTS,
PAYERS AND REGULATORS
 INTEGRATION IN THE WORK ENVIRONMENT

PROJECT MANAGEMENT

ACCESS TO RELIABLE APPLICATIONS PRODUCTS AND
SERVICES (INTEGRATION, CUSTOMER SUPPORT, SECURITY,
AND TRAINING)
TECHNOLOGY BARRIERS (3)
INFORMATION TECHNOLOGY DEPLOYMENT (2)

LACK OF INVOLVEMENT OF LINE MANAGERS
 DISCONTINUITY OF INSTITUTIONAL STRATEGIES / POLICIES
 LOW QUALITY OF PRIMARY DATA
 OVERRIDING OF DEPARTMENTAL BORDERS AND AUTHORITIES
 EDUCATION AND TRAINING OF HEALTH PROFESSIONALS

VENDOR DEPENDENCY
DEVELOPMENT ISSUES IN E-HEALTH

DEFINITION, DRIVING FORCES, AND BARRIERS

HEALTH SECTOR ASPECTS

INFRASTRUCTURE AND MARKET

IMPLEMENTATION

LATIN AMERICA & CARIBBEAN METRICS
HEALTH INFORMATION DOMAINS
POPULATION
HEALTH STATUS
EPIDEMIOLOGY
HEALTH PROMOTION
INDIVIDUALS
EXAMINED
PREVENTIVE
CARE
INDIVIDUALS
WITH HEALTH
PROBLEM
MONITOR
CONTROL
INDIVIDUALS
RECEIVING
CARE
CONTINUOUS
RECORDING
OF CARE
MONTHLY PREVALENCE OF ILLNESS (ADULTS 16 YEARS AND OVER)
1,000
750
ADULT POPULATION AT RISK
ADULTS REPORTING
ILLNESSES OR INJURIES
PER MONTH
ADULTS CONSULTING
PHYSICIAN PER MONTH
250
9
5
1
WHITE KL, WILLIAMS TF, GREENBERG BG. NEJM 265:885-892, 1961
ADULTS ADMITTED
TO HOSPITAL PER MONTH
ADULTS REFERRED TO
ANOTHER PHYSICIAN
PER MONTH
ADULTS REFERRED TO
SPECIALIZED MEDICAL CENTER
PER MONTH
PERSPECTIVES OF PATIENT-BASED INFORMATION
POPULATION
- REFERENCE
- HEALTH STATUS
- SERVICE UTILIZATION
AND PRODUCTION
- RESEARCH
PERSPECTIVES OF PATIENT-BASED INFORMATION
POPULATION
- REFERENCE
- HEALTH STATUS
- SERVICE UTILIZATION
AND PRODUCTION
- RESEARCH
GROUPS
- BY CLINICAL ATTRIBUTES
CLINICAL FINDINGS REFERENCE
GROUP COMPARISONS
IDENTIFY ASSOCIATED ATTRIBUTES
- BY INTERVENTION CHARACTERISTICS
MANAGEMENT AND REPORTING
PROCESS CONTROL
PERSPECTIVES OF PATIENT-BASED INFORMATION
POPULATION
- REFERENCE
- HEALTH STATUS
- SERVICE UTILIZATION
AND PRODUCTION
- RESEARCH
GROUPS
- BY CLINICAL ATTRIBUTES
CLINICAL FINDINGS REFERENCE
GROUP COMPARISONS
IDENTIFY ASSOCIATED ATTRIBUTES
- BY INTERVENTION CHARACTERISTICS
MANAGEMENT AND REPORTING
PROCESS CONTROL
INDIVIDUAL
-
SEQUENCIAL
CHRONOLOGICAL
PROBLEM-ORIENTED
PERMANENCY
HISTORICAL RECOVERY
COMMUNICATION
RECENT EVENT RECOVERY
DETAIL
DIFFERENT “VISIONS” OF DATA
DIFFERENT OUTPUTS
INTENSIVE DATA MANIPULATION
INFORMATION IN THE HEALTHCARE OF INDIVIDUALS
PROG
CLINICAL
PRACTICE
COLLECTIVE
HEALTH
DIAG
THERAPY
PREVEN
BIOMEDICAL
KNOWLEDGE
INFORMATION IN THE HEALTHCARE OF INDIVIDUALS
PROG
CLINICAL
PRACTICE
COLLECTIVE
HEALTH
DIAG
THERAPY
PREVEN
BIOMEDICAL
KNOWLEDGE
TYPOLOGY OF REQUIRED INFORMATION AND ORGANIZATIONAL LEVEL
LEV EL OF CARE
SERVI CE CHARACTERISTICS
Primary Health
Center
Community
Hospital
Reference
Hospital
+++
+++
+
+++
+
+++
++
++
++
++
+
++
++
+
++
++
++
++
+++
+
++
+++
+++
+++
INFORMATION
SOURE
Patient / Fam ily
Epidem iological
Biomedical Data
TECHNOLOGY
UTILIZATION
Simple Diagnostic Tests
Clinical Lab & Im agenology
Complex Diagnostic Equipment
ORIENTATION
Health Promotion / Prevention
Early Diagnosis and Treatment
Specialized Care / Rehabilitation
+++
+++
HEALTH
PROBLEM
Rare and complicated
Infrequent and specific
Common and non-specific
PLACE OF
SERVICE
Out-patient setting
In-patient general services
Specialized Hospital
+
+
+++
+++
RESPONSIBILITY
Continuous
Interm ittent
Episodical
+++
++
+
+++
+++
+++
+
+
+++
+++
+++
+
+
+++
+
++
+++
DEVELOPMENT ISSUES IN E-HEALTH

DEFINITION, DRIVING FORCES, AND BARRIERS

HEALTH SECTOR ASPECTS

INFRASTRUCTURE AND MARKET

IMPLEMENTATION

LATIN AMERICA & CARIBBEAN METRICS
DISTRIBUTION OF GROSS DOMESTIC PRODUCT BY SECTOR, 1995
80
70
60
50
40
30
20
10
Sector
0
ARG BRA CAN CHI COL COR DOR ECU ELS GUA JAM MEX PAN PAR PER TRT USA URU VEN
Agriculture
6
14
5
7
14
18
15
12
14
25
9
8
11
24
7
4
2
9
6
Industry Non-Manufacturing
11
13
18
17
14
5
7
15
22
19
20
7
15
6
14
33
8
8
21
Industry Manufacturing
20
24
22
21
18
19
15
21
18
19
16
24
9
18
18
17
Services
63
49
55
55
54
58
63
52
53
66
54
55
54
72
65
56
Source: World Bank, World Development Report 1997
64
56
74
HEALTH CONTRIBUTION TO THE SERVICES SECTOR
HEALTH SERVICES AS PERCENTAGE OF THE SERVICE SECTOR
%
30
URU
25
USA
20
ARG
COL
COR
15
VEN
ECU
CHI
ELS
JAM
PAN
PAR
10
BRA
CAN
DOR
TRT
MEX
5
0
Source: World Bank, World Development Report 1997
GUA
PER
WORLD MARKET FOR INFORMATION AND
COMMUNICATIONS TECHNOLOGIES (1998)
JAPAN (11%)
OTHER (23%)
USA (36%)
EUROPE (30%)
Value: 1,363 billion US dollars
Projection of Revenue Growth (US$ bn)
1000
Actual
Service revenue (US$ bn)
900
800
Projected
Other: Data, Internet,
Leased lines, telex, etc
700
600
Mobile
500
Int'l
Int'l
400
300
Domestic Telephone / Fax
200
100
0
90
91
92
93
94
95
96
97
98
Source: ITU “World Telecommunication Development Report 1999: Mobile cellular”
99
00
01
02
GLOBAL WIRELESS INTERNET ACCESS GROWTH
BY 2005 THERE WILL BE MORE THAN 1 BILLION WIRELESS PHONE SUBSCRIBERS
OF THOSE, 87 PERCENT WILL BE USING INTERNET DATA SERVICES
Global Distribution of IP Hosts
Developed:
94 % of hosts
16 % population
Developing:
6 % of hosts
84 % population
Australia,
Japan &
New Zealand
6.4%
Canada &
US
65.3%
Other
5.9%
Europe
22.4%
Source: ITU 1999 “Challenges to the Network: Internet for Development”
3.7 %
Developing
Asia-Pacific
LAC
1.9%
Africa
0.3 %
E-HEALTH BUSINESS IMPERATIVE
 GLOBAL MARKET PLACE AND INTERACTIVE COMMUNICATIONS
 LEASING, MEMBERSHIP, SERVICE AGREEMENT, STRATEGIC
ALLIANCES REPLACE OWNERSHIP OF PHYSICAL ASSETS AND
LONG-TERM ORGANIZATIONAL STRUCTURES
 NETWORKS OF PRODUCERS, SUPPLIERS, AND CUSTOMERS
 LIFE-TIME VALUE OF CUSTOMER REPLACES “ONE TIME SELL”
 ECONOMIES OF SPEED REPLACE ECONOMIES OF SCALE
 CUSTOMIZATION OF PRODUCTS AND SERVICES
 MAXIMIZE CONVENIENCE AND “JUST-IN-TIME” PROCESSES
 PRIVACY AND SECURE TRANSACTION PROCESSING
 SEAMLESS APPLICATIONS
TRADITIONAL MODEL
Producers
- Government
- Health Professionals
- Healthcare-providing
Organizations
Intermediaries
- Distributors
- Marketing Channels
- Value-Added Resellers
CLIENT
Suppliers
- Insurance (Pub/Priv)
- Medical Supply Indust
- Pharmaceutical Indust
- Knowledge Distribution
FIRST ORDER NETWORKING
Producers
Customer Networks
Supplier Networks
- Government
- Health Professionals
- Healthcare-providing
Organizations
- Manufacturers
- Distributors
- Marketing Channels
- Value-Added Resellers
- Managed Care Orgs
- Insurance (Pub/Priv)
- Medical Supply Indust
- Pharmaceutical Indust
- Knowledge Distribution
CLIENT
SECOND ORDER NETWORKING
Producer Networks
- Government
- Health Professionals
- Healthcare-providing
Organizations
Customer Networks
Supplier Networks
- Manufacturers
- Distributors
- Marketing Channels
- Value-Added Resellers
- Managed Care Orgs
- Insurance (Pub/Priv)
- Medical Supply Indust
- Pharmaceutical Indust
- Knowledge Distribution
CLIENT
THIRD ORDER NETWORKING
Standards Coalition
Networks
Technology Cooperation
Networks
- Technical Standards
Develop / Promotion
- Sharing Expertise
- Knowledge Dissemination
Producer Networks
- Government
- Health Professionals
- Healthcare-providing
Organizations
Customer Networks
Supplier Networks
- Manufacturers
- Distributors
- Marketing Channels
- Value-Added Resellers
- Managed Care Orgs
- Insurance (Pub/Priv)
- Medical Supply Indust
- Pharmaceutical Indust
- Knowledge Distribution
CLIENT
FOURTH ORDER NETWORKING
Standards Coalition
Networks
Technology Cooperation
Networks
- Technical Standards
Develop / Promotion
- Sharing Expertise
- Knowledge Dissemination
Producer Networks
- Government
- Health Professionals
- Healthcare-providing
Organizations
Customer Networks
Supplier Networks
- Manufacturers
- Distributors
- Marketing Channels
- Value-Added Resellers
- Insurance (Pub/Priv)
- Managed Care Orgs
- Medical Supply Indust
- Pharmaceutical Indust
- Knowledge Distribution
CLIENT
Customer Networks
- Self-help Groups
- Special Interest
ENTERPRISE APPLICATION INTEGRATION
1a. Internal Data Sources
Databases
Legacy Systems / Data
EIS, ERP, CRM
Creating an integrated apps
environment involves collecting
and normalizing data from multiple
sources and database structures
1b. External Data Sources
2. EAI Technologies
Messaging MW
CORBA
COM
JAVA
XML
Numerous technologies
smooth technical differences
among applications and
allow connection of
existing systems to the
integrated framework
Partners
Suppliers
Customers
By using Web channels, information
from outside the organization can
merge with internal data
EIS - Enterprise Information System
ERP - Executive Reporting Program
CRM - Customer Relationship Management
4. “Business” Rules
More effective when
applied to a comprehensive
set of information
5. Integrated Apps
Handle organizational
processes more efficiently
and with better control
6. Decisions
3. Consolidated Data
More realistic perspective
of organizational activities
EAI - Enterprise Application Integration
COM - Component Object Model
Application integration
helps to achieve better
informed decisions
ENTERPRISE APPLICATION INTEGRATION
PROS




Improve organizational efficiency
Expand “business” vision to include outside partners / suppliers
Embrace real-time or near real-time data from all operational aspects
Offers higher-level management of business rules
CONS





Clear definition of workflow and control rules
Involvement of external organizations (partners / suppliers)
Complex and expensive to implement
Difficult to find IT professionals with expertise
Rapidly evolving market
DATA WAREHOUSING
THE CONNECTED EMPOWERED CONSUMER
 WELLNESS AND MEDICAL INFORMATION

SHOPPING FOR PROVIDERS AND SERVICES
 RISK ASSESSMENT TESTING
 BUYING PRESCRIPTION AND OVER-THE-COUNTER DRUGS
 BUYING HEALTH PRODUCTS
 COMMUNICATION WITH SPECIAL INTEREST GROUPS
 E-MAIL PROVIDERS AND PAYERS
CONSUMER CAPABILITY / VALUE
FULL
SERVICES
E-COMMERCE
PERSONALIZATION
COMMUNITY
INFO
ACCESS
DIRECT CONSUMER BYPASS
STOCK TRADING
HEALTH SELF-CARE
FUND TRANSFER
PHYSICIAN ADVERTISING
PHARMACEUTICALS / DEVICES
E-AUCTION
CUSTOMIZED NEWS
HEALTH RISK APPRAISAL
HMO PERSONALIZED REPORTS
CHAT GROUPS
ONLINE INVESTMENT CLUBS
HEALTH SPECIAL INTEREST GROUPS
HEALTH PROMOTION
NEWS
KNOWLEDGE REPOSITORIES
INTERACTIVITY
DEVELOPMENT ISSUES IN E-HEALTH

DEFINITION, DRIVING FORCES, AND BARRIERS

HEALTH SECTOR ASPECTS

INFRASTRUCTURE AND MARKET

IMPLEMENTATION

LATIN AMERICA & CARIBBEAN METRICS
E-HEALTH COMPONENTS
POLICY / REGULATORY / LEGAL
SUPPLIER / PRACTITIONER / ORGANIZATIONS
PATIENT/ EMPLOYER / PAYER / RESEARCHER
ELECTRONIC CLEARINGHOUSES / BROKERS
TRANSACTION & SERVICE PROVIDERS
INTERFACE EQUIPMENT / EDI / SECURITY
TELECOMMUNICATION INFRASTRUCTURE
HEALTH INFORMATION INFRASTRUCTURE
(BUSINESS RULES, ROUTINES, STANDARDS)
NATIONAL / INTERNATIONAL MARKETS
INFLUENCE ON HEALTH-RELATED LIFESTYLE CHOICES
SOURCES USED BY THE PUBLIC FOR PERSONAL HEALTH DECISIONS
14
Other
6.5
Support Groups
Health Plan
9.2
Pharmacist
10
16.3
Online Health Sites
TV
13.3
Fitness Center
14.8
Books/Magazines
36.6
Friends/Family
53.6
Physician/Nurse
54.7
Personal Experience
57.4
0
U.S. Survey by Gómez Advisors, Inc. , 2000
20
40
60
80 %
SOURCES OF INFORMATION ABOUT NEW HEALTH WEB SITES
HOW THE PUBLIC LEARNS ABOUT HEALTH INFORMATION IN THE WEB
Health Professional
0.5
Billboards
1.2
Radio
6.3
Media Story
10.2
17.4
Newsprint
19.1
TV
26.5
Web Banners
32.9
Friends/Family
40.3
Internet Search
45.7
Web Links
61.3
E-mail
0
U.S. Survey by Gómez Advisors, Inc. , 2000
20
40
60
80 %
U.S. PHYSICIANS USE OF COMPUTERS
Billing
Scheduling
Patient Reminders
Managed Care Apps
Patient Records
Treatment Alerts
Referrals
Telemedicine
Prescriptions
0
20
40
60
PERCENT
Source: Pricewaterhouse Coopers Modern Physicician 2000
80
100
SHARED STANDARDS GOALS

Single industry-wide information model adaptable to each
implementation environment
- generic health information framework (modules, functions)
- standard terminology and classifications (data definition)
- standard health record structure (contents)
- standard management/patient-oriented transactions
- minimum data sets
- user defined tables and queries
- common data exchange protocols

Hardware/Software Platform “Independence”
- health data networks (Internet/Intranets)
HEALTH DATA STANDARDS

ACCREDITATION BY INTERNATIONAL SDOs

DESCRIPTION OF STANDARD

READINESS OF STANDARD

INDICATOR OF MARKET ACCEPTANCE

LEVEL OF SPECIFICITY

RELANTIONSHIPS WITH OTHER STANDARDS

COSTS
LEADING HEALTH DATA STANDARDS ORGANIZATIONS



















International Organization for Standardization (ISO)
Comité Europeen de Normalisation (CEN)
UN Electronic Data Interchange (EDIFACT)
Data Interchange Standards Association (DISA)
Health Level Seven (HL-7) version 3
Digital Imaging and Communication in Medicine (DICOM)
American Society for Testing and Materials (ASTM)
American National Standards Institute (ANSI)
Institute of Electrical and Electronic Engineers (IEEE)
Agency for Healthcare Policy and Research (USDHHS)
Health Care Financing Organization (USDHHS)
Computer-based Patient Record Institute (CPRI)
Joint Commission on Accreditation of Healthcare Organizations
World Health Organization
American Medical Association
College of American Pathologists
Food and Drug Administration (FDA)
National Library of Medicine (NLM / NIH)
National Council for Prescription Drug Programs (NCPDP)
HEALTH RECORD DATA STANDARDS
 IDENTIFIER (PATIENT, PROVIDER, SITE-OF-CARE, PRODUCT)
 MESSAGE FORMAT (COMMUNICATIONS)
 CONTENT AND STRUCTURE OF HEALTH RECORDS
 CLINICAL DATA REPRESENTATION (CODES)
 CONFIDENTIALITY, DATA SECURITY, AND AUTHENTICATION
 COMMON MINIMUM AND EXTENDED DATA SETS
 QUALITY
DATA INTEGRITY, SECURITY, AND PRIVACY

RELIABILITY
Data is accurate and remains accurate

SECURITY
Owner/users can control data transmission and storage
 PRIVACY
Subject of data can control its use and dissemination
DATA INTEGRITY, SECURITY, AND PRIVACY
 PHYSICAL PROTECTION
Protection against intentional of accidental damage
 INTEGRITY
Prevention of unauthorized modification of information
 ACCESS
Prevention of unauthorized entry into information resources
 CONFIDENTIALITY
Protection against unauthorized disclosure of information
DATA INTEGRITY, SECURITY, AND PRIVACY
 Reliability and privacy require security, but implementation
of data security may impair privacy
 Patients may be unable to consent
 Clinically anonymous information is useless
 Differently than in national security and defense environment
where it is better to lose information than to loose it, in the
health sector it is preferable to expose information than to
loose it
 In healthcare responsibility is distributed among different
stakeholders
 Security is a multidimensional problem that must be solved
for each specific situation, not as a generic technical add-on
SECURITY AND PRIVACY ISSUES
 Highly sensitive personal and identified data
 Interdisciplinary activities and multiprofessional access
 Remote access to medical records
 Access by clerical staff (payers, controllers, insurers)
 Unobtrusive in the healthcare environment
 Balance of need for access and integrity / privacy issues
 Individual rights versus collective needs of public health
 Great concern regarding the physical protection of records
and intrusion, unauthorized use, data corruption, intentional or
unintentional damage, theft, and fraud
IMPLEMENTING A SECURITY AND PRIVACY PROGRAM
 HIGH SECURITY RISK OF HEALTHCARE ORGANIZATIONS
 DISTRIBUTED RECORDS AND AUTHORITY
 TIMELY ACCESS IS ESSENTIAL
 DATA IN USE MUST BE DECRYPTED
 DATA IN TRANSIT MUST ME ENCRYPTED
 MOST SECURITY VIOLATIONS ARE UNINTENTIONAL
 OPERATOR’S ERROR IS FREQUENT REASON
 MOST DAMAGING VIOLATIONS ARE INTERNAL
 EXTERNAL ATTACKS ARE ON THE INCREASE
MAINTENANCE STAFF X SW PORTFOLIO SIZE
Source: META Group, 2000
28 countries / 30 sectors / 16,000 sources
SYSTEMS MAINTENANCE CONSULTING COST
Source: META Group, 2000
SYSTEMS MAINTENANCE CONSULTING COST
Source: META Group, 2000
SOFTWARE MAINTENANCE IN KLOC X PROFESSIONAL
100 KLOC
73 KLOC
Source: META Group, 2000
28 countries / 30 sectors / 16,000 sources
EXTERNAL CONSULTANTS EXPENDITURE (1999)
in US$ millions
28 countries / 30 sectors / 16,000 sources
Reengineering
I/S Strategy
Systems
Applications
Systems
Systems
Perform Impr
& Planning Integration Development Maintenance Outsourcing
Other
All
0.9
0.4
0.7
4.9
2.6
2.7
2.4
US
1.2
0.5
1.1
6.6
2.7
3.2
3.3
Non-US
6.0
3.4
3.0
35.9
25.2
20.8
14.4
Non-U.S. companies spend 6 times more on external
consultants than U.S. companies. These companies have
increased their spending 19% over that of 1998.
Source: META Group, 2000
IT “MARKET BASKET” COST (1999)
28 countries / 30 sectors / 16,000 sources
Country
Austria
India
Brazil
Italy
Switzerland
China
Netherlands
Germany
United Kingdom
Mexico
Sweden
United States
Colombia
Canada
Australia
New Zealand
France
Source: META Group, 2000
* U.S. = 1.00
Relative Cost
2.21
1.38
1.25
1.24
1.22
1.18
1.16
1.05
1.05
1.04
1.00
1.00 *
0.89
0.84
0.79
0.66
0.61
DEVELOPMENT ISSUES IN E-HEALTH

DEFINITION, DRIVING FORCES, AND BARRIERS

HEALTH SECTOR ASPECTS

INFRASTRUCTURE AND MARKET

IMPLEMENTATION

LATIN AMERICA & CARIBBEAN METRICS
IT DEVELOPMENT AND IMPLEMENTATION
INFORMATION SYSTEMS
IN HEALTH CARE
MANAGEMENT AND
ORGANIZATIONAL ISSUES
IMPLEMENTATION
ENVIRONMENT
TECHNOLOGY BASE
HEALTH SECTOR IN LATIN AMERICA & THE CARIBBEAN
 80% URBANIZATION / LARGE URBAN AREAS
 INADEQUATE INFRASTRUCTURE AND DISTRIBUTION
 WESTERN EUROPEAN BIOMEDICAL / SOCIAL SECURITY MODELS
 VARIETY OF REIMBURSEMENT MODELS
 HEALTH SECTOR REFORM
E-MARKET IN LATIN AMERICA
NEW TECHNOLOGY NETWORKS AND FOR DEVELOPING COUNTRIES
 >95 per cent of global IP capacity passes through the U.S.
 96 out of top 100 websites are in the U.S.
 Developing countries wanting to hook up to the U.S.
backbone must pay both half-circuits of the leased line
 Smaller ISPs must pay bigger ones for transit
 Accelerating returns to scale
 High volume routes have lowest unit costs
 Large hubs get larger
 Resources go to the strongest
IMPLEMENTATION IN LATIN AMERICA & CARIBBEAN

E-HEALTH DEVELOPMENT INTEGRATES TECHNOLOGY,
GEOGRAPHY, CULTURE, LANGUAGE, AND….HEALTHCARE SYSTEMS

NO SINGLE “COOKBOOK” OR “TRANSLATED”SOLUTION

MOST USERS PREFER A CAREFULLY CRAFTED PARTNERSHIP
TO A PURE VENDOR-CLIENT RELATIONSHIP

LEASING / OUTSOURCING

LEADERSHIP

GROWING MARKET WITH GREAT POTENTIAL BUT IDENTIFICATION
OF OPPORTUNITIES AND MARKET DEVELOPMENT MAY BE A
LONG AND DIFFICULT PROCESS
Pan American Health Organization
Organización Panamericana de la Salud
Organização Panamericana da Saúde
www.paho.org
http://165.158.1.110/english/hsp/hsphsi.htm
PAHO/WHO
HEALTH SERVICES IT DEVELOPMENT INDICATORS
INITIATIVE
Regional Advisor for Health Services Information Technology
Division of Health Systems and Services Development
Pan American Health Organization / World Health Organization
Washington, D.C.
INFORMATION TECHNOLOGY METRICS
 STANDARDIZED INFORMATION (CONSISTENCY, COMPARABILITY)
 SYSTEM / APPLICATION ENVIRONMENT RANKING
 MONITOR CHANGES
 FOLLOW TRENDS
 QUANTITATIVE AND QUALITATIVE INDICATORS
“NOT EVERYTHING THAT CAN BE COUNTED COUNTS, AND NOT
EVERYTHING THAT COUNTS CAN BE COUNTED”
ALBERT EINSTEIN
HEALTH INFORMATION TECHNOLOGY DEVELOPMENT INDICATORS
LIMITATIONS OF INFORMATION TECHNOLOGY METRICS
 LACK OF STANDARDIZED DEFINITIONS FOR IT COMPONENTS
 DATA ON IT RARELY COLLECTED ON A SYSTEMATIC BASIS
 ABSENCE OF COST DATA
 INFORMATRION ON HOW IT IS BEING ACTUALLY USED
 EVALUATION OF POSITIVE AND NEGATIVE IMPACTS
 RAPIDLY CHANGING TECHNOLOGY
HEALTH INFORMATION TECHNOLOGY DEVELOPMENT INDICATORS
 INFRASTRUCTURE
general population aptitudes; physical IT and telecom
infrastructure; market openness; information distribution capability
 EXTENT OF IT INSERTION IN SOCIETY
penetration computers; labor force and revenues in
the computer and telecommunications sectors
 UTILIZATION OF IT BY THE HEALTH SECTOR
penetration of information systems in the private and
public sectors; implementation of regulatory aspects
 IMPACT
state-of-the-art, appropriateness; technical effectiveness;
effect on policy, structures organization, equity and privacy
60
55
50
45
40
35
30
25
20
15
10
5
0
Source: PAHO Basic Indicators
VEN
UVI
URU
USA
TUC
TRT
SUR
SVG
SLU
SKN
PUR
PER
PAR
PAN
NIC
NAT
MON
MEX
MAR
JAM
HON
HAI
GUY
GUA
GDL
GRE
FGUY
ELS
ECU
DOR
DOM
CUB
COR
COL
CHI
CAY
CAN
BVI
BRA
BOL
BER
BEL
BAR
BAH
ARU
ARG
ANT
ANG
PERCENTAGE OF ADULT ILLITERACY (1998)
PERCENT
AVERAGE
14
13
12
11
10
9
8
7
6
5
4
3
2
1
0
Source: World Bank Health Report
VEN
UVI
URU
USA
TUC
TRT
SUR
SVG
SLU
SKN
PUR
PER
PAR
PAN
NIC
NAT
MON
MEX
MAR
JAM
HON
HAI
GUY
GUA
GDL
GRE
FGUY
ELS
ECU
DOR
DOM
CUB
COR
COL
CHI
CAY
CAN
BVI
BRA
BOL
BER
BEL
BAR
BAH
ARU
ARG
ANT
ANG
AVERAGE YEARS OF EDUCATION FOR AGE 25+ (1999)
YEARS
MAIN (FIXED) TELEPHONE LINES X 100 INHABITANTS (1999)
UVI
VEN
URU
USA
TRT
TUC
SUR
SLU
SVG
SKN
PER
PUR
PAR
NIC
PAN
NAT
MEX
Source: International Telecommunication Union and PAHO Basic Indicators
MON
MAR
HON
JAM
HAI
GUY
GUA
GRE
GDL
ELS
FGUY
ECU
DOR
CUB
DOM
COR
CHI
COL
CAY
BVI
CAN
BRA
BER
BOL
BEL
BAR
BAH
ARU
ANT
ARG
90
85
80
75
70
65
60
55
50
45
40
35
30
25
20
15
10
5
0
ANG
NUMBER
0
Source: International Telecommunication Union
VEN
UVI
URU
USA
TUC
TRT
SUR
SVG
SLU
SKN
PUR
PER
PAR
PAN
NIC
NAT
MON
MEX
MAR
JAM
HON
HAI
GUY
GUA
GDL
GRE
FGUY
ELS
ECU
DOR
DOM
CUB
COR
COL
CHI
CAY
CAN
BVI
BRA
BOL
BER
BEL
BAR
BAH
ARU
ARG
ANT
ANG
WAITING TIME FOR NEW WIRED CONNECTION IN YEARS (1998)
YEARS
11
10
9
8
7
6
5
4
3
2
1
COST OF WIRED CONNECTION
ANNUAL RESIDENTIAL SUBSCRIPTION AS
PERCENTAGE OF GNP x CAPITA (1997)
PERCENT
20
18
16
14
12
10
8
6
4
Source: International Telecommunication Union and PAHO Basic Indicators
VEN
UVI
URU
USA
TRT
TUC
SUR
SVG
SLU
SKN
PER
PUR
PAR
PAN
NIC
NAT
MON
MEX
MAR
HON
JAM
HAI
GUY
GDL
GUA
GRE
ELS
FGUY
ECU
DOR
CUB
DOM
COR
COL
CHI
CAY
CAN
BVI
BRA
BER
BOL
BEL
BAR
BAH
ARU
ANT
ARG
0
ANG
2
WIRELESS TELEPHONE SUBSCRIBERS x 100 INHABITANTS (1999)
NUMBER
35
30
25
20
15
10
Source: International Telecommunication Union and PAHO Basic Indicators
UVI
VEN
URU
USA
TUC
TRT
SUR
SLU
SVG
SKN
PER
PUR
PAR
NIC
PAN
NAT
MON
MEX
JAM
MAR
HAI
HON
GUY
GDL
GUA
GRE
FGUY
ELS
ECU
DOR
CUB
DOM
COR
COL
CHI
CAY
CAN
BVI
BRA
BOL
BER
BEL
BAR
BAH
ARU
ANT
ARG
0
ANG
5
LATIN AMERICAN AND CARIBBEAN TELECOMMUNICATIONS MARKET
Millions
Mobile Subscribers
70
Main Lines
69
60
50
54
50
40
30
25.3
20
10
12.7
7
0
1995
Source: International Telecommunication Union, Jan 2000
1997
2000
0
Source: International Telecommunication Union and PAHO Basic Indicators
VEN
UVI
URU
USA
TUC
TRT
SUR
SVG
SLU
SKN
PUR
PER
PAR
PAN
NIC
NAT
MON
MEX
MAR
JAM
HON
HAI
GUY
GUA
GDL
GRE
FGUY
ELS
ECU
DOR
DOM
CUB
COR
COL
CHI
CAY
CAN
BVI
BRA
BOL
BER
BEL
BAR
BAH
ARU
ARG
ANT
ANG
PERSONAL COMPUTERS x 100 INHABITANTS (1998)
NUMBER
50
45
40
35
30
25
20
15
10
5
PERCENTAGE OF POPULATION CONNECTED TO THE INTERNET (1999)
PERCENT (LOG)
100.00
10.00
1.00
UVI
VEN
URU
USA
TRT
TUC
SUR
SLU
SVG
SKN
PER
PUR
PAR
NIC
PAN
NAT
MEX
Source: International Telecommunication Union and PAHO Basic Indicators
MON
MAR
JAM
HAI
HON
GUY
GDL
GUA
GRE
ELS
FGUY
ECU
DOR
CUB
DOM
COR
CHI
COL
CAY
BVI
CAN
BRA
BER
BOL
BEL
BAR
BAH
ARU
ANT
ARG
0.01
ANG
0.10
INTERNET HOSTS x 1,000 INHABITANTS (JAN 2000)
NUMBER (LOG)
1000.00
100.00
10.00
1.00
0.10
0.01
UVI
VEN
URU
USA
TUC
TRT
SUR
SLU
SVG
SKN
PER
PUR
PAR
NIC
PAN
NAT
MEX
Source: International Telecommunication Union and PAHO Basic Indicators
MON
MAR
HON
JAM
HAI
GUY
GUA
GRE
GDL
ELS
FGUY
ECU
DOR
CUB
DOM
COR
CHI
COL
CAY
CAN
BVI
BRA
BOL
BER
BEL
BAR
BAH
ARU
ANT
ARG
0.00
ANG
0.00
1
Source: International Telecommunication Union
VEN
UVI
URU
USA
TUC
TRT
SUR
SVG
SLU
SKN
PUR
PER
PAR
PAN
NIC
NAT
MON
MEX
MAR
JAM
HON
HAI
GUY
GUA
GDL
GRE
FGUY
ELS
ECU
DOR
DOM
CUB
COR
COL
CHI
CAY
CAN
BVI
BRA
BOL
BER
BEL
BAR
BAH
ARU
ARG
ANT
ANG
INTERNET SERVICE PROVIDERS (JAN 2000)
NUMBER (LOG)
10,000
1,000
100
10
INFORMATION TECHNOLOGY GROWTH, 1985-1995 & 1995-2000
NA
LAC
WE
1985-1995
EE/ME/AF
1995-2000
Asia/Pac
Total
0
Source: International Data Corporation, 1996
5
10
PERCENT
15
20
INTERNET USE - PHYSICIANS IN BRAZIL
42,744 PHYSICIANS
60
50
58
User
40
Non User
%
42
30
20
10
0
Group
1999 SURVEY
INTERNET USE - PHYSICIANS IN BRAZIL
24,603 PHYSICIANS
SITE FROM WHERE INTERNET IS ACCESSED
90
80
85
70
Home
University
Office
Hospital
60
50
%
40
30
20
10
10
0
Site of Access
1999 SURVEY