PERSPECTIVES IN E-HEALTH Roberto J. Rodrigues Regional Advisor for Health Services Information Technology Division of Health Systems and Services Development

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





IMPLEMENTATION


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)


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






IMPLEMENTATION


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


GROUPS

- BY CLINICAL ATTRIBUTES CLINICAL FINDINGS REFERENCE GROUP COMPARISONS IDENTIFY ASSOCIATED ATTRIBUTES

- BY INTERVENTION CHARACTERISTICS MANAGEMENT AND REPORTING PROCESS CONTROL

POPULATION



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


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





IMPLEMENTATION


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


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


Producer Networks


SECOND ORDER NETWORKING

Supplier Networks


CLIENTCLIENT

Customer Networks


Producer Networks


Standards Coalition Networks

- Technical Standards Develop / Promotion

Technology Cooperation Networks

- Sharing Expertise- Knowledge Dissemination

Supplier Networks


THIRD ORDER NETWORKING

FOURTH ORDER NETWORKING

CLIENTCLIENT

Customer Networks

- Self-help Groups- Special Interest

Customer Networks


Supplier Networks

- Insurance (Pub/Priv)- Managed Care Orgs- Medical Supply Indust- Pharmaceutical Indust- Knowledge Distribution

Producer Networks


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





IMPLEMENTATION


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

E-mail

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


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

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


SYSTEMS MAINTENANCE CONSULTING COST

SYSTEMS MAINTENANCE CONSULTING COST



SOFTWARE MAINTENANCE IN KLOC X PROFESSIONAL

73 KLOC

100 KLOC



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


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






IMPLEMENTATION


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

http://165.158.1.110/english/hsp/hsphsi.htmhttp://165.158.1.110/english/hsp/hsphsi.htm

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)


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)


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


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)


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)


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

Home

University

Office

Hospital%

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PERSPECTIVES IN E-HEALTH Roberto J. Rodrigues Regional Advisor for Health Services Information Technology Division of Health Systems and Services Development