Review Paper

IMIA Yearbook of Medical Informatics 2005: Ubiquitous Systems. Haux R, Kulikowski C, editors. : Schattauer; 2004. p. 157-164. N. M. Lorenzi Review

Vanderbilt University Nashville, Tennessee E-Health Strategies Worldwide USA

Abstract: Healthcare worldwide is in a state of constant change. The multitude of changes require creative solutions that range from restructuring healthcare to provide better services to the effective use of information technology (e-health). Both are daunting tasks in any individual organization let alone on a national or international level. To completely cover the many e-health initiatives worldwide would require a more compre- hensive document than is possible within this article. Therefore, this article represents a sample of the e-health efforts that are occurring simaltenously throughout the world.

E-health Definition world with such dazzling applications puter and telecommunications tech- as surgical procedures performed by nology across all economic sectors There are a number of definitions of remote-controlled robotic devices, the was fueled by the ease of communica- e-health. The following two definitions transmission of digitized medical im- tion, transactions and information gath- reflect the most prominent definitions. ages and biological signals, and the use ering through this new medium. Con- • “The application of the Internet of real-time teleconsultation. Many sumers were intrigued by the ability to

and other related technologies in clinical and administrative information gather information from a variety of the healthcare industry to improve and communication technology appli- sources and to make purchases quickly the access, efficiency, effective- cations are available in healthcare or- using a variety of shopping tools. Entry ness, and quality of clinical and ganizations. Most organizations have into this new world to establish a web business processes utilized by the goal of a fully integrated informa- site could be achieved by acquiring a healthcare organizations, practitio- tion system for the benefit both indi- domain name and a webpage, at a ners, patients, and consumers to viduals and their organizations. nominal cost. From chat groups to improve the health status of pa- Given what is occurring, E-Health is individual web pages, the sharing of tients.” (Healthcare Information not only a realistic and viable concept health information also grew rapidly, and Management Systems Soci- it is also the underlying support struc- and often without quality controls [4]. ety (HIMSS))[1]. ture for the changes that are mandated During this same period, many health • E-health is health’s version of e- or required to support the complex care organizations increased their in- commerce: that is, conducting health care systems in the world today. vestment in the technical infrastruc- health business electronically. E- E-Health will continue to evolve driven ture for healthcare was increased to health is the combined use of elec- by technology and the need of consum- meet the new challenges of managed tronic communication and IT in the ers (patients) for health care informa- care and financial pressures. Clini- health sector, both at the local site tion and services. There will be con- cians who had used computers in their and at a distance for clinical, edu- tinuous development of new and inno- academic training demanded the same cational and administrative pur- vative techniques and the consumers’ ease of access to on-line reference poses [2]. (patients’) needs will only increase the materials. As new tools, such as radi- need to access to healthcare informa- ology Picture Archive Communica- tion and services. tions Systems (PACS), laboratory and Introduction During the last 12 plus years the electronic medical record systems were explosive growth of the worldwide introduced, physicians expected to have Over the past few years, telecom- Internet has exceeded the expecta- current information available at their munications-mediated health interven- tions and imagination of the technology fingertips wherever they were – at tions have made headlines around the industry [3]. The expansion of com- home, in the office, at the hospital.

IMIA Yearbook of Medical Informatics 2005 157 Review Paper

The competing demands for instant 3. Evidence based - e-health inter- health may deepen the gap be- access to information and transactions ventions should be evidence-based tween the “haves” and “have- as well as the increased availability of in a sense that their effectiveness nots”. People, who do not have the technical equipment supported rapid and efficiency should not be as- money, skills, and access to com- growth of the information delivered sumed but proven by rigorous sci- puters and networks, cannot use through various web services. Just entific evaluation. Much work still computers effectively. As a result, about every company connected with has to be done in this area. these patient populations (which health care saw the benefit of using 4. Empowerment of consumers and would actually benefit the most technology to fill the demand for im- patients - by making the knowl- from health information) are those mediate healthcare information. edge bases of medicine and per- who are the least likely to benefit There is an unfortunate issue in sonal electronic records accessible from advances in information tech- this new direction and that is that some to consumers over the Internet, e- nology, unless political measures companies are adding “e-” to old solu- health opens new avenues for pa- ensure equitable access for all. tions. Many new initiatives remain tient-centered medicine, and en- The digital divide currently runs unproven. It will take time to know ables evidence-based patient between rural vs. urban popula- which solutions will be successful. Stra- choice. tions, rich vs. poor, young vs. old, tegic goals and needs must be the 5. Encouragement of a new rela- male vs. female people, and be- focus of our e-health systems and not tionship between the patient and tween neglected/rare vs. common the vendors or suppliers’ business health professional, towards a true diseases. models. partnership, where decisions are made in a shared manner. 6. Education of physicians through E-Health World Review What is the “E” in E-Health? [5] online sources (continuing medical education) and consumers (health In order to better understand the e- According to Gunther Eysenbach, education, tailored preventive in- health initiatives that are taking place

the “e” in e-health does not only stand formation for consumers) worldwide, we surveyed a number of for “electronic,” but implies a number 7. Enabling information exchange International Medical Informatics As- of other “e’s,” which together perhaps and communication in a standard- sociation members. We are grateful best characterize what e-health is all ized way between health care es- for those that responded and they are about (or what it should be).. tablishments. future recognized in the Acknowl- 1. Efficiency - one of the promises 8. Extending the scope of health edgement section of this article. of e-health is to increase efficiency care beyond its conventional bound- in health care, thereby decreasing aries. This is meant in both a geo- costs. One possible way of de- graphical sense as well as in a The Asia-Pacific Area creasing costs would be by avoid- conceptual sense. E-health enables ing duplicative or unnecessary di- consumers to easily obtain health Australia agnostic or therapeutic interven- services online from global provid- The NSW Department of Health tions, through enhanced communi- ers. These services can range from will begin prototyping its new elec- cation possibilities between health simple advice to more complex tronic health records project this month care establishments, and through interventions or products such a in what is believed to be the first, wide- patient involvement. pharmaceuticals. scale online patient information data- 2. Enhancing quality of care - in- 9. Ethics - e-health involves new base of its type in Australia. Dubbed creasing efficiency involves not forms of patient-physician inter- “Healthelink”, the project has received only reducing costs, but at the same action and poses new challenges $19.4 million in funding for five years time improving quality. E-health and threats to ethical issues such and started “well before” the national may enhance the quality of health as online professional practice, in- HealthConnect project came into be- care for example by allowing com- formed consent, privacy and eq- ing, according to assistant director of parisons between different pro- uity issues. electronic records strategy for infor- viders, involving consumers as ad- 10. Equity - to make health care more mation business solutions at NSW ditional power for quality assur- equitable is one of the promises of Health Joanna Kelly. “Healthelink was ance, and directing patient streams e-health, but at the same time there born out of a review of health in NSW to the best quality providers. is a considerable threat that e- where a major recommendation was

158 IMIA Yearbook of Medical Informatics 2005 Review Paper that NSW move towards electronic for sick patients incapable of traveling Japan health records which dovetails well to the nearest medical centre or hospi- Japan has a significant number of into the national network,” Kelly told tal. When the nurse is unable to diag- initiatives to create a national electric Computerworld. “We’re literally days nose a given ailment on-site, the tech- health record. They envision involving away from developing and prototyping nician takes a digital photo, which can many physicians and others belonging the electronic health records system then be transmitted via a wireless to different hospitals to share informa- which will go live in September. The Internet connection to a doctor at a tion. One approach includes using a prototyping will be finished by the end medical institution, such as the Harvard Web-cgi-SQL database. However, of the year.” Healthelink’s first imple- for instance [8]. they are facing the problem is how to mentation will involve GPs and private complete a concise and satisfactory clinics, and then be extended to include Indonesia medical history. In order to meet these other services like pharmacies, and Hospitals in Indonesia have an elec- requirements, they propose 1) to record eventually be available to all clinicians, tronic hospital information system for the visits of the patient on an IC card, not just GPs, because present health their medical record, but they gener- 2) to establish a regional hospital visit information is “fragmented across many ally build their own system from many directory service. This system would segments” [6]. sources. To create their own system contain only the history of visits to they purchase a system from a regional hospitals, and each hospital The Distributed Systems Technol- developer(s) or imported it from would maintain its own detailed medi- ogy Centre (DSTC) has signed a $2.9m abroad. There are many developers cal information internally. We will dem- contract with the federal Department and IT consultant in Indonesia with onstrate how this system works, and of Health and Ageing to develop soft- many coming from Malaysia, will discuss problems which will arise ware for Australia’s planned system Singapore, and India. in the development of this system [9]. of shared electronic health records, Indonesia has offered a number of HealthConnect. The project, carried Hospital/Health Information System Japan e-Health Trends: Japan e- out in partnership with the General Seminars. Several include: (1) choos- Health Trends segments the Japanese

Practice Computing Group and ing the right Hospital Information Sys- e-health market into four key compo- Queensland Health, marks the second tem Software by PERMAPKIN nent areas - Pharma (pharmaceutical phase of a two-year endeavor to de- (Jakarta, April 28th2004. industry), Patient, Provider (practicing velop a national electronic health record PERMAPKIN is an Indonesian Col- clinicians) and Payer (health insur- (EHR) software solution based on an lege for Healthcare Executive, http:// ance providers), i.e. the 4Ps of e- open systems approach, with DSTC www.permapkin.or.id); (2) Health In- Health. The focus of the study, based completing the initial analysis and de- formation System and Develop Data on a combination of online survey and sign phase in March 2003. The latest Bank of Health at the City by Ministry face-to-face interviewing methodolo- HealthConnect trial, which aims to of Health Republic of Indonesia gies, has been on Pharma, Patient and provide improved support for consum- (Jakarta, August 27th 2004). Indonesia Provider areas where the change man- ers with diabetes in Brisbane’s south- MOH’s website: http:// agement issues have been most criti- ern suburbs, will test the value, techni- www.depkes.go.id; and (3) Legality cal. The report evaluates the various cal feasibility and sustainability of an of e-Document to support Hospital e-health growth and barrier segments electronic health record. The trial is Management System by Outpatient in view of current trends and healthcare jointly funded by the Department of Department Dr Soetomo Hospital professional-physician-consumer atti- Health and Ageing, General Practice Surabaya East Java, September 22nd tudes [10]. Computing Group (GPCG) and 2004, http://irj3.tripod.com/ Queensland Health, and initially aims semilokakarya. Malaysia to recruit about 1000 consumers who Indonesia established 2 health/medi- Malaysia has adopted a national visit participating clinics in the Brisbane cal websites that produce only Medi- level strategy to leapfrog the country’s South area [7]. cal/Health News to inform what is healthcare system to a new e-Health occurring throughout the country. One paradigm. This plan was conceptualized Cambodia site is hosted by a pharmaceutical com- 7 years ago. The Malaysian government In Robib, a very isolated village in pany in Indonesia, http://www. envisages a transformation of its Cambodia, a nurse and a technician kalbefarma.com and the second is healthcare system to take place that visit once per month to administer hosted by the Indonesian Hospital will lead to a nation of healthy individu- medical examinations and treatments Association, http://www.pdpersi.co.id. als, families and communities through IMIA Yearbook of Medical Informatics 2005 159 Review Paper the adoption of information technology. tries. So that a truly seamless regional Although not all health-care providers This strategic approach will be patient- healthcare that transcends the geopo- use the EDI system to make their centric and will emphasize on wellness, litical boundaries can be attained. reimbursement claims, most do. Out of seamless and continuity of care deliv- a total of 63,675 medical care facilities, ery. With that, the citizens will be em- Nepal 42,280 are connected to the network powered with knowledge to perform HealthNet (www.HealthNet.org. and HIRA receives 77 per cent of all self-care in the community setting. np) is a international NGO providing claims electronically. An additional 15 Since its inception, significant mile- health care information and communi- per cent are submitted by diskette and stones have been achieved. Two cation services in the development the remaining claims are sent in paper “paperless and filmless” pilot hospitals world. HealthNet Nepal began in 1994, format. The benefits of electronic pro- were rolled out. Thirty-four other such and has since become the premier cessing have been enormous. Errors hospitals are in the pipeline to be rolled provider of health care-related infor- have been cut back significantly, and out in 2 phases over the next couple of mation to over 500 users in 134 orga- overall wastage of time and resources years. There are 42 health centers nizations throughout the kingdom. By substantially reduced. Besides making linked up with tele-consultation tech- providing services such as e-mail, re- the processing of medical claims more nology. In addition to that, clinical in- ports, computerized medical records efficient, the system also allows pa- formation systems (CIS) have been and statistics, and a comprehensive tients to check their medical records. implemented in 37 health centers and 2 library of medical information and use- HIRA has a near-term target of hav- district hospitals. 14 intensive care units ful links, HealthNet gives users access ing over 90 per cent of medical institu- (ICU) have managed to converge their to a wealth of information on how to tions submitting electronic claims [12]. information into a central repository. protect themselves from a variety of At least 3 clinical pathways were suc- viruses and diseases. For instance, cessfully incorporated into clinical in- Nepal has a chronic problem with water Europe formation systems. This paper also contamination, and HealthNet provides examines the Malaysian e-Health strat- the tools for users to arm themselves The “European e-Health Area” has

egy as a whole from six different with information to avoid or effectively stated its goals as follow: perspectives, namely political, eco- address illnesses related to a given • National level: By 2005, Member nomic, social, technological, ethical and water problem. HealthNet is currently States are asked to develop na- legal aspects of the project. in the process of updating and expand- tional and regional e-Health strat- The critical success factors of Ma- ing its services to all of the country’s egies. A public portal will be laysian e-Health implementation are health care practitioners [11]. launched to provide “one-stop said to be “beyond technology”. Most shop” access to information on of the current challenges faced by Republic of Korea health in the entire EU. Malaysia are of non technological in One of the most computerized parts • Interoperability: By 2006, national . Among the most important of the health sector in the Republic of healthcare networks should be challenge is the shortage of domain Korea is the Health Insurance Review “well advanced” in their efforts to experts in designing, development and Agency (HIRA) (www.hira.or.kr), an better exchange information and deployment of e-Health projects. This independent agency set up in 2000 to ‘talk’ to each other. As part of this shortage is also apparently in the area review and process health claims. With effort, standards for electronic of healthcare informatics standards close to 600 million claims a year, health records are to be agreed so development, adoption and integration. HIRA has a strong incentive to pro- that patients can be identified and Future challenges anticipated by Ma- mote efficient and timely processing information made easily readable laysia are technology obstacles related through the adoption of information and exchangeable over the net- to availability, performance, user inter- technology. It has been actively en- work. Movement of patients and face, and privacy and information se- couraging medical care institutions to healthcare professional should as curity. adopt electronic data interchange (EDI) a result be made easier. The business opportunities in e- technology for submitting claims. HIRA • Networks: By 2008, health infor- Health in Malaysia are tremendous, has a backbone network connecting its mation and services are to become with a lot more room for expansion of seven regional offices through high- commonplace and accessible over the project scopes. The wealth of knowl- speed ATM links to the headquarters both fixed and wireless broadband edge gained by Malaysia from these in Seoul. Medical institutions can log networks. Expected services in- projects can be shared with other coun- into HIRA’s site to submit their claims. clude tele-consultations, prescrip-

160 IMIA Yearbook of Medical Informatics 2005 Review Paper

tions available online. So-called tem in order to make it more efficient the efficiency and automation of these “Grids” are to be set up to boost and reliable. This strategy aims to in- processes, in order to remove errors, the networks’ computing power troduce lifelong electronic patient ensure security, and prevent system and ability to interact. records and to offer seamless care failure, and so on. These represent a Meanwhile, an important step is to through the sharing of information. huge range of challenging projects to be made with the introduction of a This represents one of the most de- be tackled by tomorrow’s health European health card as of 1 June manding and complex IT projects in informaticians [15]. 2004. The card is set to replace current the UK. If this agenda is to be met, administrative procedures to cross- informaticians are faced with major border healthcare in the EU (forms challenges to integrate a vast array of South America E111, E128, E110, etc.) with a single systems and technologies across the Among the problems facing health personalized card. sector, including management and de- and healthcare in Latin America and cision support systems, operational the Caribbean, the need to provide Bulgaria systems, and medical imaging, report- expanded and equal access to quality Bulgaria faces another e-challenge ing and office systems. IT develop- healthcare services and, the need to after the government adopted an E- ments in Pathology are just one ex- reduce or at least control the rising Health Action Plan over the project for ample of how this IT integration is costs of healthcare services are very developing an electronically based occurring. The Pathology department important. The following represent health information and services sys- at Leeds General Infirmary is develop- examples of what is happening in South tem. The health institutions of Bul- ing a computerized blood testing pro- America. garia, including the health ministry, the cess to deal with the half a million national health fund, Non Governmen- samples taken and tested each year. Bolivia tal Organizations and academic asso- This process is best illustrated by fol- ciations in the field of health are work- lowing the progression of one blood The constant flow of information ing on developing an e-health strategy sample, from one individual patient, throughout the world has made it easier for physicians to diagnose a variety of with experts from the European Com- through the diagnostic process. The mission [13]. patient is first identified by scanning illnesses and identify new treatments their wrist tag with a portable comput- for a multitude of diseases. This infor- United-Kingdom ing device. The doctor uses this device mation, which is collected in massive The United-Kingdom-based Isabel to select the required tests and takes a databases, has given both physicians Medical Charity, “Isabel.org.uk”, was blood sample from the patient. The and patient’s access to more informa- designed in response to a misdiagnosis portable computer then prints a bar- tion about health improvement and risk that almost killed a three year-old named coded label for the blood sample which assessment. The Bolivian Familial Isabel. The parents of Isabel created uniquely identifies it in the hospital Cancer Database is one such interna- the site in 2000 to provide clinical information system. From here, the tional database that allows physicians decision support for pediatricians in sample is automatically transported to to compare and contrast tumor and order to avert misdiagnoses and pre- the Pathology laboratory for analysis non-tumor features of a person’s ge- ventable illnesses. At the heart of the by an air tube transport system. On netic makeup with existing database site is Autonomy Corporation’s so- arrival, the sample’s bar code label entries. This interactive database al- phisticated cataloging software, which communicates to the automatic ana- ready contains over 300 entries and is allows members of the medical com- lyzing equipment which of the 300 or updated regularly. Another similar site munity to input patient symptoms to so possible tests are required for this administered by Harvard University retrieve a range of 15 diagnoses from particular sample, and the machinery allows users to calculate their risk of a library of over 3,500 entries. The site will then perform the appropriate tests. getting cancer free of charge. Overall, also contains an annotated image li- During this process, samples can be ICTs and access to the global informa- brary that allows doctors to compare tracked at any point by their barcode tion network are allowing citizens x-rays and clinical pictures from a reference. Once complete, the test around the world better prepare for variety of medical fields [14]. results are communicated electroni- and treat cancer and other illnesses. cally back to the hospital results server, The government in the UK has an and from there to the hospital consult- Brazil ambitious ‘e-health’ agenda for fur- ant or local GP. There is enormous During the past two to three years ther computerizing the healthcare sys- scope for yet further improvements in there was a marked increase of infor-

IMIA Yearbook of Medical Informatics 2005 161 Review Paper mation systems usage in healthcare. ized support for their operation and and police health systems and other Brazil has a mixed hospital system of logistics. Some will have more com- smaller ones government controlled (70%) and pri- plete electronic records for their pa- Uruguay has created new regula- vate run (30%) hospitals. On the other tients, but most will focus on billing/ tions regarding the Electronic Health hand hospital expenses reflect a dif- receivables, supply chain, physical pa- Record in Uruguay. The new regula- ference. Generally the government tient management. Laboratories are tions foster the creation of a unique expenses are 40% and private ex- implementing new systems as part of electronic medical record, in a seg- penses are 60%. Private healthcare is their ISO 9000 goal. mented Health system, assure the le- more expensive, probably more effi- On the technological high-end the gality of electronic support, in every cient in most of the cases, but public country has interesting experiences on: aspect, preserve the confidentiality of shows similar clinical outcomes. The • New technologies for multimedia/ individual clinical information, and as- public system receives around 8.5% of Internet education of healthcare sure the interrelationship among sys- the national GP, meaning 50 billion US professionals tems, through the use of standards dollars/year, or roughly 100 dollars per • Combining non-structured data (im- The regulations are directed toward person. ages, signals) into the Patient “the creation of a unique electronic Brazil has introduced the National Record health record for each person, from Health Card. This card is probably the • Mobility technologies (the country perinatal information until death, is most substantial new technology that has poor legacy/wired infra-struc- declared of public interest” http:// was introduced in the last few years. ture investment, thus wireless op- www.presidencia.gub.uy/decretos/ The card has both a magnetic stripe tions are spreading very fast) 2003093001.htm and printed information that has the • The National health card person 15 digit unique number. More • Intelligent systems to monitor/man- than 100 million people are registered, age the SUS (National Unified The Middle East but less than 10 million cards were Healthcare System) actually issued. The card is an attempt • More emphasis on homecare ac- Syria to have a unique identification for each tions (the country already started, E-health initiatives and medical citizen and open the potential to gather few years ago its Family in Syria are at an early healthcare data for the country or for Program) stage of development in all sectors. In the patient’s record. Issuing more than the Syrian Ministry of Health, the di- 180 million cards is proving to be a Uruguay rectorate of Decision Information Sup- VERY difficult task. The main prob- Uruguay touches Brazil in the north- port was established few years ago in lem is political, not technical. east, Argentina in the south-west and the ministry building in Damascus. It On the hospital side of healthcare the Atlantic Ocean on the south. There supports all parts of the ministry with there are many initiatives. There are are 3.4 million people in the country. personal computer hardware, training about a dozen of good/very good infor- Half of the population lives in the capi- of the staff members, and networking. mation systems that are being used. tal and 91% lives in urban areas. The It also started a pilot projects in the PACS is also being implemented at a literacy rate is 97%, and the public fields of Electronic Medical Records very fast pace. Telemedicine is still in system provides compulsory educa- and a Smart Card System. It also plans its infancy, but growing, especially with tion from age four. Life expectancy is to provide Internet Service Provider. results of ECG analysis, and 75 years (71-79) and infant mortality www.moh.gov.sy teleradiology. rate is 15 deaths/1000. http:// Syria held an E-Health Seminar: Education is very important in a www.ine.gub.uy/ Mapping the Future of E-Health in large country, diverse cultures, and a 10% of the Gross Domestic Prod- Syria, that was sponsored in coopera- wide spectrum of professional forma- uct is spent in health care. The private tion with the Ministry of Health at the tion. This is probably one of the main sector is dominated by non-profit or- Syrian Telecommunication Establish- areas of investment in the near future. ganizations which provide services ment in Damascus on Tuesday 12th All government agencies are increas- through prepaid health insurance cover October 2004.The Seminar Recom- ing their budgets for continued educa- approximately 55% of the population mendations include: tion programs, distance learning, etc. and exist since the 19th century. One 1. To focus on the necessity to carry out Administrative systems are almost a third of the population is covered by a survey on the health sector in Syria. common place by now. Most hospi- the Ministry of Health Public System 2. To stress the importance of adopting tals/clinics will have some computer- and the rest is assisted by the military Medical Record of patient in Syria.

162 IMIA Yearbook of Medical Informatics 2005 Review Paper

3. To suggest a national program aimed screen reveals discrepancies better tions, nutritional and psychosocial sup- at identifying the information that needs than numbers on charts [16]. port, and prevention of maternal to to be registered in the Medical Record. child transmission of HIV using both 4. To carry out a pilot project with the Kenya HAART and Nevirapine, as well as help of NOSSTIA to automate patient Administering and monitoring diagnostic services. The AMPATH medical records, taking into account therapy is crucial to the battle against Training Institute (ATI) offers both international health standards, as WHO HIV/AIDS in sub-Saharan Africa. didactic courses and mentored appren- offered the help and support in this Electronic medical records (EMRs) ticeships in the comprehensive care of projects . can aid in documenting care, monitor- the HIV infected patient via 5. To prepare for a medical confer- ing drug adherence and response to multidisciplinary health care teams. ence specialized in E-health in coop- therapy, and providing data for quality To date, the EMR contains more eration with the Ministry of Health, improvement and research. than 30,000 visit records for more than Ministry of Higher Education, Ministry Faculty at Moi University in Kenya 4000 patients, almost half taking of Communication and international and Indiana and University in the USA antiretroviral drugs. We describe the organizations). opened adult and pediatric HIV clinics development and structure of this EMR 6. To prepare for a summer Training in a national referral hospital, a district and plans for future development that Project on E-Health to be held in hospital, and six rural health centers in include wireless connections, tablet Tartous and to identify partners, audi- western Kenya using a newly devel- computers, and migration to a Web- ences, topics, speakers, location, time oped EMR to support comprehensive based platform. and a cost estimation. outpatient HIV/AIDS care. Demo- 7. To participate in the development graphic, clinical, and HIV risk data, process of human resources in local diagnostic test results, and treatment North America hospitals information are recorded on paper encounter forms and hand-entered into a central database that prints summary Canadians value their health care

Africa flow sheets and reminders for appro- system above any other social pro- priate testing and treatment. There are gram. Ghana separate modules for monitoring the The Canadian healthcare system is Since 1989 Dr. Fred Binka and his Antenatal Clinic and Pharmacy. The undergoing widespread review, nation- staff have been conducting a project EMR was designed with input from ally, and within each province and named “Health Net Project”. It aims clinicians who understand the local territory, where the bulk of care provi- to improve the quality of life in North- community and constraints of provid- sion is financed and managed. The ern Ghana. The Guinea Savannah of ing care in resource poor settings. challenges are being addressed by Northern Ghana is possibly the most In 2001, the Departments of Medi- national, regional and provincial initia- risky place to live during infancy. For cine and Child Health and Pediatrics at tives in the public, private and not-for- every 1,000 children born, 222 die be- Moi University, Eldoret and the De- profit sectors. fore age 5. The most common causes partment of General Internal Medicine Canada created the Canada Health of death are malnutrition, measles, lung and Geriatrics at the Indiana Univer- Infoway project with mandate: to ac- infection and malaria. Dr. Binka ex- sity School of Medicine, in collabora- celerate the development and adoption plains, “We are building a large data- tion with the Moi Teaching and Refer- of electronic health information sys- base containing the names, ages, preg- ral Hospital in Eldoret, Kenya, estab- tems in Canada. Infoway was created nancies, births, illness, recoveries and lished AMPATH: the Academic Model in response to a commitment of deaths” of the populations there. To for Prevention And Treatment of HIV/ Canada’s First Ministers to “work to- educate the population and know AIDS [1, 2 ].1, 2 AMPATH has the gether to strengthen a Canada-wide where to send this information, the tripartite mission of patient care, medi- health infrastructure to improve qual- Center uses Digital Mapping. A de- cal education, and research focusing ity, access and timeliness of health vice the size of a calculator uses satel- on HIV. It was the first organization to care for Canadians.” Infoway is an lites to isolate landmarks such as fam- offer comprehensive ambulatory HIV/ independent, not-for-profit corporation, ily compounds. With a computer map AIDS care in Kenya, including highly and a genuine partnership of federal, that shows where planning is being active antiretroviral therapy (HAART). provincial, and territorial governments. practiced, the areas that require atten- Patient care also includes the manage- Its members are the deputy ministers tion become obvious. Information on ment of opportunistic and other infec- of health from across Canada.

IMIA Yearbook of Medical Informatics 2005 163 Review Paper

Infoway now has $1.1 billion in break down resistance to computeriz- report prepared in September 1999 on investment capital. The Government ing records” in the medical commu- trends and policy issues in the evolution of electronic service delivery in the health of Canada allocated an initial $500 nity, which is “moving too slowly to sector in Australia. Available from: http:/ million in 2001, and provided an addi- adopt the new technology,” the edito- /www2.dcita.gov.au/ie/ebusiness/devel- tional $600 million following the 2003 rial states. According to the editorial, oping/facilitation/e-health/rise First Ministers’ Accord on Health Care the “payoff” from a national EMR 3. Kendall JE, Kendall KE. Web Pull and Renewal. The three main goals of system “could be substantial.” EMRs Push Technologies: The Emergence and Future of Information Delivery Sys- Infoway’s telehealth program are to could improve health care quality, “bet- tems. In: Kenneth E. Kendall KE, edi- optimize the use of existing networks, ter gauge the effectiveness of health tor. Emerging Information Technolo- maximize the use of telehealth in the providers and ultimately change how gies: Improving Decisions, Cooperation clinical setting and to maximize the link they are paid to a system based on the and Infrastructure. Sage Publications, CA; 1999. p. 265-87. between telehealth and Electronic quality of their results instead of the 4. Zwass V. Structure and Macro-Level Im- Health Records to benefit patients. quantity of services,” the editorial pacts of Electronic Commerce: From Tech- states. Although some health care pro- nological Infrastructure to Electronic United States of America viders maintain that “new technology Marketplaces. In: Kenneth E. Kendall is expensive” and “proof is lacking that KE, editor. Emerging Information Tech- While skyrocketing healthcare costs nologies: Improving Decisions, Coopera- and HIPAA compliance are the main the investment would pay off finan- tion and Infrastructure. Sage Publications, drivers for the adoption of electronic cially or result in improved patient care,” CA; 1999. p. 289-315. health records, government and pay- the editorial states that the cost “isn’t 5. http://www.jmir.org/2001/2/e20/ exorbitant” and that physicians who 6. http://www.computerworld.com.au/ ers are beginning to recognize the value index.php/id;1113312711;relcomp;1 of Electronic Health Records (HER). have implemented EMRs “say they 7. http://www.computerworld.com.au/ EHR implementation is moving from make fewer mistakes and provide bet- index.php/id;1997573756;fp;2;fpid;1 larger institutions to pre-ambulatory ter service.” The editorial adds that 8. http://www.itu.int/ITU-D/ict/cs/ care, although this migration will be HHS has said the nation could save cambodia/material/KHM%20CS.pdf. $140 billion per year through a national 9. http://www.seagaia.org/sgmeeting/docu- difficult because of the complex legacy ment/GMHD_html/GMHD.html systems installed in hospitals [17]. EMR system, concluding, “That’s cer- 10. http://www.the-infoshop.com/study/ tainly worth the investment” [18] jks19385_e_health.html In April of 2005 President George 11. http://www.itu.int/ITU-D/ict/cs/nepal/ Summary material/nepal.pdf. Bush announced plans to establish a 12. www.itu.int/ITU-D/ict/cs/korea/material/ national electronic medical records The items listed are a very small CS_KOR.pdf system within in the next decade and sample. If your country does not ap- 13.http://novinite.com/ created a new national health informa- pear on this list, I apologize. view_news.php?id=42543 tion technology office within HHS. Dr. 14. http://www.isabel.org.uk. 15. http://www.informatics.leeds.ac.uk/ David Brailer was named as the na- Acknowledgements bscminf-informatics/e- tional health information technology HM Goh, Malaysia health_low_band.htm coordinator, a role designed to support Terry J. Hannan, Australia 16. http://www.itu.int/osg/spu/wsis-themes/ government and private sector efforts ict_stories/.html Alvaro Margolis, Uruguay 17. http://www.healthcareitnews.com/ to develop standards and infrastruc- Eneida A Mendonca, Brazil and USA NewsArticleView.aspx? ture for using IT to promote better care Ghassan Shahrour, Syria ContentID=776&ContentTypeID=3&IssueID=6 quality and reduce health costs. The Umberto Tachinardi, Brazil 18. http://www.ihealthbeat.org/ new HHS office will first examine William M. Tierney, USA index.cfm?action=dspItem&itemid=102721 options to create incentives in Medi- Ryan Webb, Vanderbilt University care and other HHS programs to spur Address of the author: the adoption of electronic health Nancy M. Lorenzi, PhD. References Vanderbilt University Medical Center records. President Bush is “trying to Informatics Center drag medicine into the 21st century” 1. E-Health: Navigating the Internet for Health Eskind Biomedical Library with his proposal to make electronic Information Healthcare. Advocacy White Biomedical Informatics health records available to most U.S. Paper. Healthcare Information and Man- 2209 Garland Avenue agement Systems Society, May, 2002 Nashville, TN 37232-8340, USA residents within 10 years, according to 2. From Telehealth to E-health: the Unstop- Tel: +1 615 936 1423 a editorial. The efforts could “help pable Rise of E-health. An Australian E-mail: [email protected]

164 IMIA Yearbook of Medical Informatics 2005