PERSPECTIVES IN E-HEALTH

1. 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

2. DEVELOPMENT ISSUES IN E-HEALTH • DEFINITION, DRIVING FORCES, AND BARRIERS • HEALTH SECTOR ASPECTS • INFRASTRUCTURE AND MARKET • IMPLEMENTATION • LATIN AMERICA & CARIBBEAN METRICS

3. DEVELOPMENT ISSUES IN E-HEALTH • DEFINITION, DRIVING FORCES, AND BARRIERS • HEALTH SECTOR ASPECTS • INFRASTRUCTURE AND MARKET • IMPLEMENTATION • LATIN AMERICA & CARIBBEAN METRICS

4. 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)

5. EVOLUTIONARY TECHNOLOGIES • POINT OF CARE TECHNOLOGIES • PROCESS AUTOMATION • ELECTRONIC MEDICAL RECORD (CPMR) • DATA WAREHOUSING • DATA ACCESS AND SECURITY TECHNOLOGIES • APPLICATION INTEGRATION • DECISION-SUPPORT TECHNOLOGIES

6. 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)

7. 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

8. 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)

9. 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)

10. 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

11. 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 VARIETYOF 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

12. 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

13. 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)

14. 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

15. DEVELOPMENT ISSUES IN E-HEALTH • DEFINITION, DRIVING FORCES, AND BARRIERS • HEALTH SECTOR ASPECTS • INFRASTRUCTURE AND MARKET • IMPLEMENTATION • LATIN AMERICA & CARIBBEAN METRICS

16. HEALTH INFORMATION DOMAINS HEALTH STATUS EPIDEMIOLOGY HEALTH PROMOTION POPULATION INDIVIDUALS EXAMINED PREVENTIVE CARE INDIVIDUALS WITH HEALTH PROBLEM MONITOR CONTROL INDIVIDUALS RECEIVING CARE CONTINUOUS RECORDING OF CARE

17. MONTHLY PREVALENCE OF ILLNESS (ADULTS 16 YEARS AND OVER) ADULT POPULATION AT RISK 1,000 ADULTS REPORTING ILLNESSES OR INJURIES PER MONTH 750 ADULTS CONSULTING PHYSICIAN PER MONTH ADULTS ADMITTED TO HOSPITAL PER MONTH 250 ADULTS REFERRED TO ANOTHER PHYSICIAN PER MONTH 9 5 ADULTS REFERRED TO SPECIALIZED MEDICAL CENTER PER MONTH 1 WHITE KL, WILLIAMS TF, GREENBERG BG. NEJM 265:885-892, 1961

18. PERSPECTIVES OF PATIENT-BASED INFORMATION POPULATION - REFERENCE - HEALTH STATUS - SERVICE UTILIZATION AND PRODUCTION - RESEARCH

19. 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

20. 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 INDIVIDUAL - SEQUENCIAL - CHRONOLOGICAL - PROBLEM-ORIENTED - PERMANENCY - HISTORICAL RECOVERY - COMMUNICATION - RECENT EVENT RECOVERY DETAIL DIFFERENT “VISIONS” OF DATA DIFFERENT OUTPUTS INTENSIVE DATA MANIPULATION POPULATION - REFERENCE - HEALTH STATUS - SERVICE UTILIZATION AND PRODUCTION - RESEARCH

21. INFORMATION IN THE HEALTHCARE OF INDIVIDUALS PROG CLINICAL PRACTICE COLLECTIVE HEALTH DIAG THERAPY PREVEN BIOMEDICAL KNOWLEDGE

22. INFORMATION IN THE HEALTHCARE OF INDIVIDUALS PROG CLINICAL PRACTICE COLLECTIVE HEALTH DIAG THERAPY PREVEN BIOMEDICAL KNOWLEDGE

23. TYPOLOGY OF REQUIRED INFORMATION AND ORGANIZATIONAL LEVEL

24. DEVELOPMENT ISSUES IN E-HEALTH • DEFINITION, DRIVING FORCES, AND BARRIERS • HEALTH SECTOR ASPECTS • INFRASTRUCTURE AND MARKET • IMPLEMENTATION • LATIN AMERICA & CARIBBEAN METRICS

25. DISTRIBUTION OF GROSS DOMESTIC PRODUCT BY SECTOR, 1995 Percentage of GDP Sector Source: World Bank, World Development Report 1997

26. HEALTH CONTRIBUTION TO THE SERVICES SECTOR HEALTH SERVICES AS PERCENTAGE OF THE SERVICE SECTOR % Source: World Bank, World Development Report 1997

27. WORLD MARKET FOR INFORMATION AND COMMUNICATIONS TECHNOLOGIES (1998) JAPAN (11%) OTHER (23%) USA (36%) EUROPE (30%) Value: 1,363 billion US dollars

28. Projection of Revenue Growth (US$ bn) 1000 Actual Projected 900 ) 800 Other: Data, Internet, bn Leased lines, telex, etc 700 600 Mobile 500 Int'l Int'l Service revenue (US$ 400 300 Domestic Telephone / Fax 200 100 0 90 91 92 93 94 95 96 97 98 99 00 01 02 Source: ITU “World Telecommunication Development Report 1999: Mobile cellular”

29. 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

30. Global Distribution of IP Hosts Developed:94 % of hosts16 % population Developing:6 % of hosts84 % population Australia, Japan & New Zealand 6.4% 3.7 % Canada & Developing US Other Asia-Pacific 65.3% 5.9% LAC Europe 1.9% Africa 22.4% 0.3 % Source: ITU 1999 “Challenges to the Network: Internet for Development”

31. 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

32. TRADITIONAL MODEL Producers - Government - Health Professionals - Healthcare-providing Organizations Intermediaries - Distributors - Marketing Channels - Value-Added Resellers Suppliers - Insurance (Pub/Priv) - Medical Supply Indust - Pharmaceutical Indust - Knowledge Distribution CLIENT

33. FIRST ORDER NETWORKING Producers - Government - Health Professionals - Healthcare-providing Organizations Customer Networks - Manufacturers - Distributors - Marketing Channels - Value-Added Resellers Supplier Networks - Managed Care Orgs - Insurance (Pub/Priv) - Medical Supply Indust - Pharmaceutical Indust - Knowledge Distribution CLIENT

34. SECOND ORDER NETWORKING Producer Networks - Government - Health Professionals - Healthcare-providing Organizations Customer Networks - Manufacturers - Distributors - Marketing Channels - Value-Added Resellers Supplier Networks -Managed Care Orgs - Insurance (Pub/Priv) - Medical Supply Indust - Pharmaceutical Indust - Knowledge Distribution CLIENT

35. THIRD ORDER NETWORKING Technology Cooperation Networks - Sharing Expertise - Knowledge Dissemination Standards Coalition Networks - Technical Standards Develop / Promotion Producer Networks - Government - Health Professionals - Healthcare-providing Organizations Customer Networks - Manufacturers - Distributors - Marketing Channels - Value-Added Resellers Supplier Networks -Managed Care Orgs - Insurance (Pub/Priv) - Medical Supply Indust - Pharmaceutical Indust - Knowledge Distribution CLIENT

36. FOURTH ORDER NETWORKING Technology Cooperation Networks - Sharing Expertise - Knowledge Dissemination Standards Coalition Networks - Technical Standards Develop / Promotion Producer Networks - Government - Health Professionals - Healthcare-providing Organizations Customer Networks - Manufacturers - Distributors - Marketing Channels - Value-Added Resellers Supplier Networks - Insurance (Pub/Priv) - Managed Care Orgs - Medical Supply Indust - Pharmaceutical Indust - Knowledge Distribution CLIENT Customer Networks - Self-help Groups - Special Interest

37. ENTERPRISE APPLICATION INTEGRATION 1a. Internal Data Sources Creating an integrated apps environment involves collecting and normalizing data from multiple sources and database structures 2. EAI Technologies Numerous technologies smooth technical differences among applications and allow connection of existing systems to the integrated framework 4. “Business” Rules More effective when applied to a comprehensive set of information • Databases • Legacy Systems / Data • EIS, ERP, CRM • Messaging MW • CORBA • COM • JAVA • XML 5. Integrated Apps Handle organizational processes more efficiently and with better control 1b. External Data Sources By using Web channels, information from outside the organization can merge with internal data • Partners • Suppliers • Customers 6. Decisions Application integration helps to achieve better informed decisions 3. Consolidated Data More realistic perspective of organizational activities EIS - Enterprise Information System ERP - Executive Reporting Program CRM - Customer Relationship Management EAI - Enterprise Application Integration COM - Component Object Model

38. 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

39. DATA WAREHOUSING

40. 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

41. FULL SERVICES DIRECT CONSUMER BYPASS STOCK TRADING HEALTH SELF-CARE E-COMMERCE FUND TRANSFER PHYSICIAN ADVERTISING PHARMACEUTICALS / DEVICES E-AUCTION PERSONALIZATION CONSUMER CAPABILITY / VALUE CUSTOMIZED NEWS HEALTH RISK APPRAISAL HMO PERSONALIZED REPORTS COMMUNITY INFO ACCESS CHAT GROUPS ONLINE INVESTMENT CLUBS HEALTH SPECIAL INTEREST GROUPS HEALTH PROMOTION NEWS KNOWLEDGE REPOSITORIES INTERACTIVITY

42. DEVELOPMENT ISSUES IN E-HEALTH • DEFINITION, DRIVING FORCES, AND BARRIERS • HEALTH SECTOR ASPECTS • INFRASTRUCTURE AND MARKET • IMPLEMENTATION • LATIN AMERICA & CARIBBEAN METRICS

43. 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

44. INFLUENCE ON HEALTH-RELATED LIFESTYLE CHOICES SOURCES USED BY THE PUBLIC FOR PERSONAL HEALTH DECISIONS % U.S. Survey by Gómez Advisors, Inc. , 2000

45. SOURCES OF INFORMATION ABOUT NEW HEALTH WEB SITES HOW THE PUBLIC LEARNS ABOUT HEALTH INFORMATION IN THE WEB % U.S. Survey by Gómez Advisors, Inc. , 2000

46. U.S. PHYSICIANS USE OF COMPUTERS PERCENT Source: Pricewaterhouse Coopers Modern Physicician 2000

47. 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)

48. 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

49. 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)

50. 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