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PERSPECTIVES IN E-HEALTHPERSPECTIVES IN E-HEALTH
Roberto J. Rodrigues
Regional Advisor for Health Services Information TechnologyDivision of Health Systems and Services Development
Pan American Health Organization / World Health OrganizationWashington, D.C.
Workshop on Global Telehealth/Telemedicine and the Internet2001 Symposium on Applications and the Internet (SAINT 2001)
San Diego, January 8-12, 2001
DEVELOPMENT ISSUES IN E-HEALTH
INFRASTRUCTURE AND MARKET
HEALTH SECTOR ASPECTS
LATIN AMERICA & CARIBBEAN METRICS
IMPLEMENTATION
DEFINITION, DRIVING FORCES, AND BARRIERS
DEVELOPMENT ISSUES IN E-HEALTH
INFRASTRUCTURE AND MARKET
HEALTH SECTOR ASPECTS
LATIN AMERICA & CARIBBEAN METRICS
IMPLEMENTATION
DEFINITION, DRIVING FORCES, AND BARRIERS
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)
INTERACTIVE HEALTH COMMUNICATIONS
POINT OF CARE TECHNOLOGIES
PROCESS AUTOMATION
ELECTRONIC MEDICAL RECORD (CPMR)
DATA WAREHOUSING
DATA ACCESS AND SECURITY TECHNOLOGIES
APPLICATION INTEGRATION
DECISION-SUPPORT TECHNOLOGIES
EVOLUTIONARY 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 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 (1)
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
HEALTH SECTOR BARRIERS (2)
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 (1)
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 (2)
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
TECHNOLOGY BARRIERS (3)
DEVELOPMENT ISSUES IN E-HEALTH
INFRASTRUCTURE AND MARKET
HEALTH SECTOR ASPECTS
LATIN AMERICA & CARIBBEAN METRICS
IMPLEMENTATION
DEFINITION, DRIVING FORCES, AND BARRIERS
INDIVIDUALSRECEIVING
CARE
INDIVIDUALSWITH HEALTH
PROBLEM
INDIVIDUALSEXAMINED
POPULATION
CONTINUOUSRECORDING
OF CARE
MONITORCONTROL
PREVENTIVECARE
HEALTH STATUSEPIDEMIOLOGY
HEALTH PROMOTION
HEALTH INFORMATION DOMAINS
MONTHLY PREVALENCE OF ILLNESS (ADULTS 16 YEARS AND OVER)
1,000
750
250
9
5
1
ADULT POPULATION AT RISK
ADULTS REPORTINGILLNESSES OR INJURIES
PER MONTH
ADULTS CONSULTINGPHYSICIAN PER MONTH
ADULTS ADMITTEDTO HOSPITAL PER MONTH
ADULTS REFERRED TOSPECIALIZED MEDICAL CENTER
PER MONTH
ADULTS REFERRED TOANOTHER PHYSICIAN
PER MONTH
WHITE KL, WILLIAMS TF, GREENBERG BG. NEJM 265:885-892, 1961
PERSPECTIVES OF PATIENT-BASED INFORMATION
POPULATION
- REFERENCE- HEALTH STATUS- SERVICE UTILIZATION AND PRODUCTION- RESEARCH
PERSPECTIVES OF PATIENT-BASED INFORMATION
GROUPS
- BY CLINICAL ATTRIBUTES CLINICAL FINDINGS REFERENCE GROUP COMPARISONS IDENTIFY ASSOCIATED ATTRIBUTES
- BY INTERVENTION CHARACTERISTICS MANAGEMENT AND REPORTING PROCESS CONTROL
POPULATION
- REFERENCE- HEALTH STATUS- SERVICE UTILIZATION AND PRODUCTION- RESEARCH
PERSPECTIVES OF PATIENT-BASED INFORMATION
INDIVIDUAL
- SEQUENCIAL- CHRONOLOGICAL- PROBLEM-ORIENTED- PERMANENCY- HISTORICAL RECOVERY- COMMUNICATION- RECENT EVENT RECOVERY DETAIL DIFFERENT “VISIONS” OF DATA DIFFERENT OUTPUTS INTENSIVE DATA MANIPULATION
GROUPS
- BY CLINICAL ATTRIBUTES CLINICAL FINDINGS REFERENCE GROUP COMPARISONS IDENTIFY ASSOCIATED ATTRIBUTES
- BY INTERVENTION CHARACTERISTICS MANAGEMENT AND REPORTING PROCESS CONTROL
POPULATION
- REFERENCE- HEALTH STATUS- SERVICE UTILIZATION AND PRODUCTION- RESEARCH
CLINICALPRACTICE
COLLECTIVEHEALTH
BIOMEDICALKNOWLEDGE
THERAPY
DIAG
PROG
PREVEN
INFORMATION IN THE HEALTHCARE OF INDIVIDUALS
CLINICALPRACTICE
COLLECTIVEHEALTH
BIOMEDICALKNOWLEDGE
PROG
DIAG
PREVENTHERAPY
INFORMATION IN THE HEALTHCARE OF INDIVIDUALS
LEVEL OF CARESERVICE CHARACTERISTICS
Primary HealthCenter
CommunityHospital
ReferenceHospital
Patient / Family +++ +++ +++Epidemiological +++ ++INFORMATION
SOUREBiomedical Data + ++ +++Simple Diagnostic Tests +++ ++Clinical Lab & Imagenology + ++ +++TECHNOLOGY
UTILIZATIONComplex Diagnostic Equipment + +++Health Promotion / Prevention +++ ++ +Early Diagnosis and Treatment +++ ++ +ORIENTATION
Specialized Care / Rehabilitation + +++Rare and complicated + ++ +++Infrequent and specific + ++ +++HEALTH
PROBLEMCommon and non-specific +++ ++Out-patient setting +++ ++ +In-patient general services +++ +PLACE OF
SERVICESpecialized Hospital + +++Continuous +++ ++ +Intermittent ++ +++ ++RESPONSIBILITY
Episodical + +++ +++
TYPOLOGY OF REQUIRED INFORMATION AND ORGANIZATIONAL LEVEL
DEVELOPMENT ISSUES IN E-HEALTH
INFRASTRUCTURE AND MARKET
HEALTH SECTOR ASPECTS
LATIN AMERICA & CARIBBEAN METRICS
IMPLEMENTATION
DEFINITION, DRIVING FORCES, AND BARRIERS
DISTRIBUTION OF GROSS DOMESTIC PRODUCT BY SECTOR, 1995
Source: World Bank, World Development Report 1997
0
10
20
30
40
50
60
70
80
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 64 56 53 66 74 54 55 54 72 65 56
ARG BRA CAN CHI COL COR DOR ECU ELS GUA JAM MEX PAN PAR PER TRT USA URU VEN
Per
cen
tag
e o
f G
DP
Sector
HEALTH CONTRIBUTION TO THE SERVICES SECTOR
Source: World Bank, World Development Report 1997
ARG
CHI
COR
TRT
VEN
URU
USA
PER
PARPAN
MEX
JAMELS
CAN
GUA
ECU
DOR
COL
BRA
0
5
10
15
20
25
30%
HEALTH SERVICES AS PERCENTAGE OF THE SERVICE SECTOR
JAPAN (11%)
USA (36%)
EUROPE (30%)
OTHER (23%)
Value: 1,363 billion US dollars
WORLD MARKET FOR INFORMATION AND WORLD MARKET FOR INFORMATION AND COMMUNICATIONS TECHNOLOGIES (1998)COMMUNICATIONS TECHNOLOGIES (1998)WORLD MARKET FOR INFORMATION AND WORLD MARKET FOR INFORMATION AND COMMUNICATIONS TECHNOLOGIES (1998)COMMUNICATIONS TECHNOLOGIES (1998)
0
100
200
300
400
500
600
700
800
900
1000
90 91 92 93 94 95 96 97 98 99 00 01 02
Ser
vice
rev
enu
e (U
S$
bn
)
Actual Projected
Domestic Telephone / FaxDomestic Telephone / Fax
Int'lInt'l
Mobile
Other: Data, Internet, Leased lines, telex, etc
Source: ITU “World Telecommunication Development Report 1999: Mobile cellular”
Projection of Revenue Growth (US$ bn)
BY 2005 THERE WILL BE MORE THAN 1 BILLION WIRELESS PHONE SUBSCRIBERSOF THOSE, 87 PERCENT WILL BE USING INTERNET DATA SERVICES
GLOBAL WIRELESS INTERNET ACCESS GROWTH
Developing:Developing:6 % of hosts6 % of hosts
84 % population84 % population
Developing:Developing:6 % of hosts6 % of hosts
84 % population84 % population
Developed:Developed:94 % of hosts94 % of hosts
16 % population 16 % population
Developed:Developed:94 % of hosts94 % of hosts
16 % population 16 % population
Source: ITU 1999 “Challenges to the Network: Internet for Development”
Other5.9%
Canada & US
65.3%Europe22.4%
LAC1.9%
Australia, Japan &
New Zealand6.4% 3.7 %
DevelopingAsia-Pacific
Africa 0.3 %
Global Distribution of IP Hosts
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
CLIENTCLIENT
Intermediaries
- Distributors- Marketing Channels- Value-Added Resellers
Suppliers
- Insurance (Pub/Priv)- Medical Supply Indust- Pharmaceutical Indust- Knowledge Distribution
Producers
- Government- Health Professionals- Healthcare-providing Organizations
TRADITIONAL MODEL
CLIENTCLIENT
Producers
- Government- Health Professionals- Healthcare-providing Organizations
FIRST ORDER NETWORKING
Customer Networks
- Manufacturers- Distributors- Marketing Channels- Value-Added Resellers
Supplier Networks
- Managed Care Orgs- Insurance (Pub/Priv)- Medical Supply Indust- Pharmaceutical Indust- Knowledge Distribution
CLIENTCLIENT
Customer Networks
- Manufacturers- Distributors- Marketing Channels- Value-Added Resellers
Producer Networks
- Government- Health Professionals- Healthcare-providing Organizations
SECOND ORDER NETWORKING
Supplier Networks
- Managed Care Orgs- Insurance (Pub/Priv)- Medical Supply Indust- Pharmaceutical Indust- Knowledge Distribution
CLIENTCLIENT
Customer Networks
- Manufacturers- Distributors- Marketing Channels- Value-Added Resellers
Producer Networks
- Government- Health Professionals- Healthcare-providing Organizations
Standards Coalition Networks
- Technical Standards Develop / Promotion
Technology Cooperation Networks
- Sharing Expertise- Knowledge Dissemination
Supplier Networks
- Managed Care Orgs- Insurance (Pub/Priv)- Medical Supply Indust- Pharmaceutical Indust- Knowledge Distribution
THIRD ORDER NETWORKING
FOURTH ORDER NETWORKING
CLIENTCLIENT
Customer Networks
- Self-help Groups- Special Interest
Customer Networks
- Manufacturers- Distributors- Marketing Channels- Value-Added Resellers
Supplier Networks
- Insurance (Pub/Priv)- Managed Care Orgs- Medical Supply Indust- Pharmaceutical Indust- Knowledge Distribution
Producer Networks
- Government- Health Professionals- Healthcare-providing Organizations
Standards Coalition Networks
- Technical Standards Develop / Promotion
Technology Cooperation Networks
- Sharing Expertise- Knowledge Dissemination
1a. Internal Data Sources
Creating an integrated appsenvironment involves collectingand normalizing data from multiplesources and database structures
1a. Internal Data Sources
Creating an integrated appsenvironment involves collectingand normalizing data from multiplesources and database structures
1b. External Data Sources
By using Web channels, informationfrom outside the organization canmerge with internal data
1b. External Data Sources
By using Web channels, informationfrom outside the organization canmerge with internal data
2. EAI Technologies
Numerous technologiessmooth technical differencesamong applications andallow connection ofexisting systems to theintegrated framework
2. EAI Technologies
Numerous technologiessmooth technical differencesamong applications andallow connection ofexisting systems to theintegrated framework
3. Consolidated Data
More realistic perspectiveof organizational activities
3. Consolidated Data
More realistic perspectiveof organizational activities
4. “Business” Rules
More effective whenapplied to a comprehensiveset of information
4. “Business” Rules
More effective whenapplied to a comprehensiveset of information
5. Integrated Apps
Handle organizationalprocesses more efficientlyand with better control
5. Integrated Apps
Handle organizationalprocesses more efficientlyand with better control
6. Decisions
Application integrationhelps to achieve betterinformed decisions
6. Decisions
Application integrationhelps to achieve betterinformed decisions
DatabasesLegacy Systems / DataEIS, ERP, CRM
PartnersSuppliersCustomers
Messaging MWCORBACOMJAVAXML
EIS - Enterprise Information SystemERP - Executive Reporting ProgramCRM - Customer Relationship Management
EAI - Enterprise Application Integration COM - Component Object Model
ENTERPRISE APPLICATION INTEGRATION
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
INFOACCESS
COMMUNITY
PERSONALIZATION
E-COMMERCE
FULLSERVICES
DIRECT CONSUMER BYPASSSTOCK TRADINGHEALTH SELF-CARE
FUND TRANSFERPHYSICIAN ADVERTISINGPHARMACEUTICALS / DEVICESE-AUCTION
CUSTOMIZED NEWSHEALTH RISK APPRAISALHMO PERSONALIZED REPORTS
CHAT GROUPSONLINE INVESTMENT CLUBSHEALTH SPECIAL INTEREST GROUPSHEALTH PROMOTION
NEWSKNOWLEDGE REPOSITORIES
INTERACTIVITY
CO
NS
UM
ER
CA
PA
BIL
ITY
/ V
AL
UE
DEVELOPMENT ISSUES IN E-HEALTH
INFRASTRUCTURE AND MARKET
HEALTH SECTOR ASPECTS
LATIN AMERICA & CARIBBEAN METRICS
IMPLEMENTATION
DEFINITION, DRIVING FORCES, AND BARRIERS
HEALTH INFORMATION INFRASTRUCTURE(BUSINESS RULES, ROUTINES, STANDARDS)
INTERFACE EQUIPMENT / EDI / SECURITYTELECOMMUNICATION INFRASTRUCTURE
SUPPLIER / PRACTITIONER / ORGANIZATIONS PATIENT/ EMPLOYER / PAYER / RESEARCHER
ELECTRONIC CLEARINGHOUSES / BROKERS TRANSACTION & SERVICE PROVIDERS
POLICY / REGULATORY / LEGAL
NATIONAL / INTERNATIONAL MARKETS
E-HEALTH COMPONENTS
INFLUENCE ON HEALTH-RELATED LIFESTYLE CHOICES
57.4
54.7
53.6
36.6
14.8
13.3
16.3
10
9.2
6.5
14
0 20 40 60 80
Other
Support Groups
Health Plan
Pharmacist
Online Health Sites
TV
Fitness Center
Books/Magazines
Friends/Family
Physician/Nurse
Personal Experience
U.S. Survey by Gómez Advisors, Inc. , 2000
%
SOURCES USED BY THE PUBLIC FOR PERSONAL HEALTH DECISIONS
SOURCES OF INFORMATION ABOUT NEW HEALTH WEB SITES
61.3
45.7
40.3
32.9
26.5
19.1
17.4
10.2
6.3
1.2
0.5
0 20 40 60 80
Health Professional
Billboards
Radio
Media Story
Newsprint
TV
Web Banners
Friends/Family
Internet Search
Web Links
U.S. Survey by Gómez Advisors, Inc. , 2000
HOW THE PUBLIC LEARNS ABOUT HEALTH INFORMATION IN THE WEB
%
U.S. PHYSICIANS USE OF COMPUTERS
0 20 40 60 80 100
Prescriptions
Telemedicine
Referrals
Treatment Alerts
Patient Records
Managed Care Apps
Patient Reminders
Scheduling
Billing
PERCENTSource: Pricewaterhouse Coopers Modern Physicician 2000
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
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)
LEADING HEALTH DATA STANDARDS ORGANIZATIONS
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
HEALTH RECORD DATA STANDARDS
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
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
DATA INTEGRITY, SECURITY, AND PRIVACY
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
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
IMPLEMENTING A SECURITY AND PRIVACY PROGRAM
Source: META Group, 2000
MAINTENANCE STAFF X SW PORTFOLIO SIZE
28 countries / 30 sectors / 16,000 sources
Source: META Group, 2000
SYSTEMS MAINTENANCE CONSULTING COST
SYSTEMS MAINTENANCE CONSULTING COST
Source: META Group, 2000
Source: META Group, 2000
SOFTWARE MAINTENANCE IN KLOC X PROFESSIONAL
73 KLOC
100 KLOC
28 countries / 30 sectors / 16,000 sources
Source: META Group, 2000
Reengineering
Perform Impr
I/S Strategy
& Planning
Systems
Integration
Applications
Development
Systems
Maintenance
Systems
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 externalconsultants than U.S. companies. These companies have
increased their spending 19% over that of 1998.
EXTERNAL CONSULTANTS EXPENDITURE (1999)
in US$ millions28 countries / 30 sectors / 16,000 sources
Source: META Group, 2000
IT “MARKET BASKET” COST (1999)
* U.S. = 1.00
Country Relative CostAustria 2.21India 1.38Brazil 1.25Italy 1.24Switzerland 1.22China 1.18Netherlands 1.16Germany 1.05United Kingdom 1.05Mexico 1.04Sweden 1.00United States 1.00 *Colombia 0.89Canada 0.84Australia 0.79New Zealand 0.66France 0.61
28 countries / 30 sectors / 16,000 sources
DEVELOPMENT ISSUES IN E-HEALTH
INFRASTRUCTURE AND MARKET
HEALTH SECTOR ASPECTS
LATIN AMERICA & CARIBBEAN METRICS
IMPLEMENTATION
DEFINITION, DRIVING FORCES, AND BARRIERS
IT DEVELOPMENT AND IMPLEMENTATION
INFORMATION SYSTEMS IN HEALTH CARE
MANAGEMENT ANDORGANIZATIONAL ISSUES
TECHNOLOGY BASE
IMPLEMENTATION ENVIRONMENT
80% URBANIZATION / LARGE URBAN AREAS
INADEQUATE INFRASTRUCTURE AND DISTRIBUTION
WESTERN EUROPEAN BIOMEDICAL / SOCIAL SECURITY MODELS
VARIETY OF REIMBURSEMENT MODELS
HEALTH SECTOR REFORM
HEALTH SECTOR IN LATIN AMERICA & THE CARIBBEAN
E-MARKET IN LATIN AMERICA
>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
NEW TECHNOLOGY NETWORKS AND FOR DEVELOPING COUNTRIES
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
www.paho.orgwww.paho.orgwww.paho.orgwww.paho.org
Pan American Health OrganizationPan American Health OrganizationOrganización Panamericana de la SaludOrganización Panamericana de la Salud
Organização Panamericana da SaúdeOrganização Panamericana da Saúde
Pan American Health OrganizationPan American Health OrganizationOrganización Panamericana de la SaludOrganización Panamericana de la Salud
Organização Panamericana da SaúdeOrganização Panamericana da Saúde
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PAHO/WHOPAHO/WHOHEALTH SERVICES IT DEVELOPMENT INDICATORS HEALTH SERVICES IT DEVELOPMENT INDICATORS
INITIATIVEINITIATIVE
Regional Advisor for Health Services Information TechnologyDivision of Health Systems and Services Development
Pan American Health Organization / World Health OrganizationWashington, 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
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
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
PERCENTAGE OF ADULT ILLITERACY (1998)
Source: PAHO Basic Indicators
0
5
10
15
20
25
30
35
40
45
50
55
60
0
5
10
15
20
25
30
35
40
45
50
55
60PERCENT
AVERAGE
AVERAGE YEARS OF EDUCATION FOR AGE 25+ (1999)
Source: World Bank Health Report
0
12
3
4
56
7
89
10
11
1213
14
ANG
ANT
ARG
ARU
BAH
BAR
BEL
BER
BOL
BRA
BVI
CAN
CAY CH
I
COL
COR
CUB
DOM
DOR
ECU
ELS
FGUY GRE
GDL
GUA GUY HA
I
HON
JAM
MAR MEX
MO
N
NAT
NIC
PAN
PAR
PER
PUR
SKN
SLU
SVG
SUR
TRT
TUC
USA
URU
UVI
VEN
0
12
3
4
56
7
89
10
11
1213
14
ANG
ANT
ARG
ARU
BAH
BAR
BEL
BER
BOL
BRA
BVI
CAN
CAY CH
I
COL
COR
CUB
DOM
DOR
ECU
ELS
FGUY GRE
GDL
GUA GUY HA
I
HON
JAM
MAR MEX
MO
N
NAT
NIC
PAN
PAR
PER
PUR
SKN
SLU
SVG
SUR
TRT
TUC
USA
URU
UVI
VEN
YEARS
MAIN (FIXED) TELEPHONE LINES X 100 INHABITANTS (1999)
Source: International Telecommunication Union and PAHO Basic Indicators
05
1015202530354045505560657075808590
AN
G
AN
T
AR
G
AR
U
BA
H
BA
R
BE
L
BE
R
BO
L
BR
A
BV
I
CA
N
CAY CH
I
CO
L
CO
R
CU
B
DO
M
DO
R
EC
U
ELS
FGU
Y
GR
E
GD
L
GU
A
GU
Y
HA
I
HO
N
JAM
MA
R
ME
X
MO
N
NAT NIC
PAN
PAR
PE
R
PU
R
SK
N
SLU
SV
G
SU
R
TRT
TUC
US
A
UR
U
UV
I
VE
N
05
1015202530354045505560657075808590
AN
G
AN
T
AR
G
AR
U
BA
H
BA
R
BE
L
BE
R
BO
L
BR
A
BV
I
CA
N
CAY CH
I
CO
L
CO
R
CU
B
DO
M
DO
R
EC
U
ELS
FGU
Y
GR
E
GD
L
GU
A
GU
Y
HA
I
HO
N
JAM
MA
R
ME
X
MO
N
NAT NIC
PAN
PAR
PE
R
PU
R
SK
N
SLU
SV
G
SU
R
TRT
TUC
US
A
UR
U
UV
I
VE
N
NUMBER
WAITING TIME FOR NEW WIRED CONNECTION IN YEARS (1998)
Source: International Telecommunication Union
0
1
2
3
4
5
6
7
8
9
10
11
AN
G
AN
T
AR
G
AR
U
BA
H
BA
R
BE
L
BE
R
BO
L
BR
A
BV
I
CA
N
CA
Y
CH
I
CO
L
CO
R
CU
B
DO
M
DO
R
EC
U
EL
S
FG
UY
GR
E
GD
L
GU
A
GU
Y
HA
I
HO
N
JAM
MA
R
ME
X
MO
N
NA
T
NIC
PA
N
PA
R
PE
R
PU
R
SK
N
SL
U
SV
G
SU
R
TR
T
TU
C
US
A
UR
U
UV
I
VE
N
0
1
2
3
4
5
6
7
8
9
10
11
AN
G
AN
T
AR
G
AR
U
BA
H
BA
R
BE
L
BE
R
BO
L
BR
A
BV
I
CA
N
CA
Y
CH
I
CO
L
CO
R
CU
B
DO
M
DO
R
EC
U
EL
S
FG
UY
GR
E
GD
L
GU
A
GU
Y
HA
I
HO
N
JAM
MA
R
ME
X
MO
N
NA
T
NIC
PA
N
PA
R
PE
R
PU
R
SK
N
SL
U
SV
G
SU
R
TR
T
TU
C
US
A
UR
U
UV
I
VE
N
YEARS
ANNUAL RESIDENTIAL SUBSCRIPTION AS PERCENTAGE OF GNP x CAPITA (1997)
Source: International Telecommunication Union and PAHO Basic Indicators
0
2
4
6
8
10
12
14
16
18
20
AN
G
AN
T
AR
G
AR
U
BA
H
BA
R
BEL
BER
BO
L
BR
A
BVI
CA
N
CAY C
HI
CO
L
CO
R
CU
B
DO
M
DO
R
ECU
ELS
FGU
Y
GR
E
GD
L
GU
A
GU
Y
HA
I
HO
N
JAM
MA
R
MEX
MO
N
NAT NIC
PAN
PAR
PER
PUR
SKN
SLU
SVG
SUR
TRT
TUC
USA UR
U
UVI
VEN
0
2
4
6
8
10
12
14
16
18
20
AN
G
AN
T
AR
G
AR
U
BA
H
BA
R
BEL
BER
BO
L
BR
A
BVI
CA
N
CAY C
HI
CO
L
CO
R
CU
B
DO
M
DO
R
ECU
ELS
FGU
Y
GR
E
GD
L
GU
A
GU
Y
HA
I
HO
N
JAM
MA
R
MEX
MO
N
NAT NIC
PAN
PAR
PER
PUR
SKN
SLU
SVG
SUR
TRT
TUC
USA UR
U
UVI
VEN
PERCENT
COST OF WIRED CONNECTION
WIRELESS TELEPHONE SUBSCRIBERS x 100 INHABITANTS (1999)
Source: International Telecommunication Union and PAHO Basic Indicators
0
5
10
15
20
25
30
35
ANG
ANT
ARG
ARU
BAH
BAR
BEL
BER
BOL
BRA
BVI
CAN
CAY
CHI
COL
COR
CUB
DOM
DOR
ECU
ELS
FGUY GRE
GDL
GUA GUY HA
I
HON
JAM
MAR MEX
MO
N
NAT
NIC
PAN
PAR
PER
PUR
SKN
SLU
SVG
SUR
TRT
TUC
USA
URU
UVI
VEN
0
5
10
15
20
25
30
35
ANG
ANT
ARG
ARU
BAH
BAR
BEL
BER
BOL
BRA
BVI
CAN
CAY
CHI
COL
COR
CUB
DOM
DOR
ECU
ELS
FGUY GRE
GDL
GUA GUY HA
I
HON
JAM
MAR MEX
MO
N
NAT
NIC
PAN
PAR
PER
PUR
SKN
SLU
SVG
SUR
TRT
TUC
USA
URU
UVI
VEN
NUMBER
0
10
20
30
40
50
60
70
1995 1997 2000
Mobile Subscribers
Main Lines
Millions
LATIN AMERICAN AND CARIBBEAN TELECOMMUNICATIONS MARKET
77
5050
12.712.7
5454
6969
25.325.3
Source: International Telecommunication Union, Jan 2000
PERSONAL COMPUTERS x 100 INHABITANTS (1998)
0
5
10
15
20
25
30
35
40
45
50
AN
G
AN
T
AR
G
AR
U
BA
H
BA
R
BE
L
BE
R
BO
L
BR
A
BV
I
CA
N
CAY CH
I
CO
L
CO
R
CU
B
DO
M
DO
R
EC
U
ELS
FGU
Y
GR
E
GD
L
GU
A
GU
Y
HA
I
HO
N
JAM
MA
R
ME
X
MO
N
NAT NIC
PAN
PAR
PE
R
PU
R
SK
N
SLU
SV
G
SU
R
TRT
TUC
US
A
UR
U
UV
I
VE
N
0
5
10
15
20
25
30
35
40
45
50
AN
G
AN
T
AR
G
AR
U
BA
H
BA
R
BE
L
BE
R
BO
L
BR
A
BV
I
CA
N
CAY CH
I
CO
L
CO
R
CU
B
DO
M
DO
R
EC
U
ELS
FGU
Y
GR
E
GD
L
GU
A
GU
Y
HA
I
HO
N
JAM
MA
R
ME
X
MO
N
NAT NIC
PAN
PAR
PE
R
PU
R
SK
N
SLU
SV
G
SU
R
TRT
TUC
US
A
UR
U
UV
I
VE
N
NUMBER
Source: International Telecommunication Union and PAHO Basic Indicators
0.01
0.10
1.00
10.00
100.00
ANG
ANT
ARG
ARU
BAH
BAR
BEL
BER
BOL
BRA
BVI
CAN
CAY CH
I
COL
COR
CUB
DOM
DOR
ECU
ELS
FGUY GRE
GDL
GUA GUY HA
I
HON
JAM
MAR MEX
MO
N
NAT
NIC
PAN
PAR
PER
PUR
SKN
SLU
SVG
SUR
TRT
TUC
USA
URU
UVI
VEN
0.01
0.10
1.00
10.00
100.00
ANG
ANT
ARG
ARU
BAH
BAR
BEL
BER
BOL
BRA
BVI
CAN
CAY CH
I
COL
COR
CUB
DOM
DOR
ECU
ELS
FGUY GRE
GDL
GUA GUY HA
I
HON
JAM
MAR MEX
MO
N
NAT
NIC
PAN
PAR
PER
PUR
SKN
SLU
SVG
SUR
TRT
TUC
USA
URU
UVI
VEN
PERCENTAGE OF POPULATION CONNECTED TO THE INTERNET (1999)
PERCENT (LOG)
Source: International Telecommunication Union and PAHO Basic Indicators
INTERNET HOSTS x 1,000 INHABITANTS (JAN 2000)
0.00
0.00
0.01
0.10
1.00
10.00
100.00
1000.00
ANG
ANT
ARG
ARU
BAH
BAR
BEL
BER
BOL
BRA
BVI
CAN
CAY CH
I
COL
COR
CUB
DOM
DOR
ECU
ELS
FGUY GRE
GDL
GUA GUY HA
I
HON
JAM
MAR MEX
MO
N
NAT
NIC
PAN
PAR
PER
PUR
SKN
SLU
SVG
SUR
TRT
TUC
USA
URU
UVI
VEN
0.00
0.00
0.01
0.10
1.00
10.00
100.00
1000.00
ANG
ANT
ARG
ARU
BAH
BAR
BEL
BER
BOL
BRA
BVI
CAN
CAY CH
I
COL
COR
CUB
DOM
DOR
ECU
ELS
FGUY GRE
GDL
GUA GUY HA
I
HON
JAM
MAR MEX
MO
N
NAT
NIC
PAN
PAR
PER
PUR
SKN
SLU
SVG
SUR
TRT
TUC
USA
URU
UVI
VEN
NUMBER (LOG)
Source: International Telecommunication Union and PAHO Basic Indicators
INTERNET SERVICE PROVIDERS (JAN 2000)
Source: International Telecommunication Union
1
10
100
1,000
10,000
ANG
ANT
ARG
ARU
BAH
BAR
BEL
BER
BOL
BRA
BVI
CAN
CAY
CHI
COL
COR
CUB
DOM
DOR
ECU
ELS
FGUY GRE
GDL
GUA GUY HA
I
HON
JAM
MAR MEX
MO
N
NAT
NIC
PAN
PAR
PER
PUR
SKN
SLU
SVG
SUR
TRT
TUC
USA
URU
UVI
VEN
1
10
100
1,000
10,000
ANG
ANT
ARG
ARU
BAH
BAR
BEL
BER
BOL
BRA
BVI
CAN
CAY
CHI
COL
COR
CUB
DOM
DOR
ECU
ELS
FGUY GRE
GDL
GUA GUY HA
I
HON
JAM
MAR MEX
MO
N
NAT
NIC
PAN
PAR
PER
PUR
SKN
SLU
SVG
SUR
TRT
TUC
USA
URU
UVI
VEN
NUMBER (LOG)
INFORMATION TECHNOLOGY GROWTH, 1985-1995 & 1995-2000
Source: International Data Corporation, 1996
0 5 10 15 20
Total
Asia/Pac
EE/ME/AF
WE
LAC
NA
1985-1995
1995-2000
PERCENT
INTERNET USE - PHYSICIANS IN BRAZIL
0
10
20
30
40
50
60
Group
User
Non User
42,744 PHYSICIANS
1999 SURVEY
58585858
42424242%
INTERNET USE - PHYSICIANS IN BRAZIL
24,603 PHYSICIANSSITE FROM WHERE INTERNET IS ACCESSED
1999 SURVEY
Site of Access0
10
20
30
40
50
60
70
80
90
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