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Essence of eHealth

eHealth offers hope for specialist medical services to be shared among all countries

Every day the lives of a vast number of people depend on well-functioning health systems. From safe delivery of a newborn baby to the care of the elderly, health systems have a vital and continuing role to play throughout people's lives.

Information and Communications Technologies (ICT) have the potential to improve global healthcare. eHealth, a combination of electronic communication and information technology for clinical, educational and administrative purposes, both at the local level and remotely, is recognised as a key enabler in supporting health systems to deliver on their healthcare promises.

WHO's eHealth policy
ICT has already been deployed successfully in public health interventions. The control of Onchocerciasis (river blindness) in West Africa, and the control of the SARS (severe acute respiratory syndrome) epidemic are two of the best-known examples of this.

It now constitutes the third industrial pillar of the health sector. The first, in the 19th century, was chemistry, which led to the pharmaceutical industry. The second was physics, in the 20th century, which gave the world imaging systems.

ICT is the foundation of the knowledge-based health system. In recognition of this, Target 18 of the UN Millennium Development Goals, urges: `In cooperation with the private sector, make the benefits of technology, especially information and communications, available to society.'


More recently, the World Health Assembly, the highest organ of the World Health Organisation (WHO) at which all Member States are present, passed a resolution at its 58th session in May 2005, calling on all countries to develop eHealth strategies and policies, and deploy eHealth services to improve health worldwide.

Despite this call, and despite the great potential of eHealth, many countries, especially in the developing world, are unable to enjoy the benefits of eHealth because they lack the capacity to: systematically evaluate developments in ICT and make informed decisions about potential applications; adapt them to country-specific needs; and prepare for their adoption. Countries look to the WHO to provide guidance on such issues.

eHealth is at the intersection of medical informatics, public health and business, and, in a broader sense, it characterises `a commitment for networked, global thinking, to improve healthcare locally, regionally and worldwide by using information and communication technology'.

The WHO will work collaboratively with identified institutions and individuals throughout the world, leveraging existing knowledge and activities, and creating synergies with other players in the field of health delivery.

Laying foundations
The European Commission (EC) has been following the eHealth story (previously known as telemedicine/telehealth) for the past 10 years.

Indeed, a considerable investment was made by the EC in its 5th and 6th Framework programmes in order to lay the foundation for eHealth to be an effective agent in transforming healthcare systems across the European Union (EU).

The EC funded a non-governmental organisation (NGO), called the European Health Telematics Association (EHTEL) - see - in order to lead the thinking for companies within the EU to establish a strategy for eHealth.

Under Vivienne Reading, the present Commissioner for the Information Society and Media, eHealth has been placed at the top of the agenda for the five-year development plan, encapsulated in the document entitled eEurope 2005.

As a result of this investment, eHealth projects, large and small, have been implemented in European countries. Europe has thus become a field laboratory for eHealth programmes, having major implications for the global community which has been looking very closely at exemplar eHealth programmes with a view to selecting the elements of existing eHealth applications and services that might be suitable for their own healthcare systems.


Responsibility shift
There is a universal realisation that the current healthcare delivery models are financially unsustainable. This was well illustrated in the Wanless Report on the NHS in England and more recently in the Kerr Report for Scotland. Healthcare systems have evolved into models which are infrastructure-focused (hospitals and clinics) and require the patient to seek and find an appropriate level of healthcare service to meet their needs.

eHealth, however, offers the opportunity for healthcare services to move into the community setting and for patients to have their healthcare programmes tailored to their individual needs. Thus, the responsibility for linking patient needs with service provision shifts to the service provider.

We are truly at the dawn of the citizen-centric healthcare delivery model. The pharmaceutical industry would do well to pay close attention to this transformation, as it opens up major opportunities.

The pharmaceutical industry is looking at personalised medicine. Bioengineered medicines in the future will be tailor-made to individual needs, rather than to disease conditions. This approach mirrors what is happening in healthcare systems around the world.

Most European countries have either developed an eHealth strategy already or are developing one, and large-scale examples of eHealth implementation programmes are now visible; notably, NHS Connecting for Health in England, which is arguably the biggest global civilian IT programme, and the more modest but equally interesting application, the Baltic eHealth Exchange.

The challenges of eHealth are no longer technological, as most of the technology applications have been tried and tested in other environments, such as finance or the manufacturing sectors. The challenge now is to persuade the clinical community, and indeed the patients themselves, to adopt the new model of healthcare access and delivery.

Patients, armed with a formidable array of knowledge accessed via the internet, are already presenting at the doctor's surgery these days with strong opinions as to which treatments they are prepared to consider and which they will reject.

Joining forces
eHealth has shown considerable promise since the story began in the 1990s, with a variety of pilot projects mostly involving small numbers of patients. Ultimately, this has evolved into significant national eHealth applications, such as England's NHS Connecting for Health.

It is interesting to note that groups of countries are now looking seriously at utilising eHealth to share resources, so avoiding unnecessary duplication of specialist services within each country.

The Baltic eHealth Exchange is a good example of how specialist medical services from one country are delivered via eHealth and made available to patients living in rural communities in other countries.

The ASEM community, which comprises EU countries plus a number of significant countries in Asia, including China, Japan, Korea and all the ASEAN Countries (with India, Mongolia and Pakistan having just recently joined), started taking an interest in eHealth three years ago and more recently sanctioned the formation of an ASEM eHealth Working Group.

The ASEM eHealth Working Group was charged with developing an agreed methodology and processes whereby healthcare services and medical knowledge and skills could be shared across 39 countries of the ASEM Community.

This first task was to agree a common approach to standards and interoperability in respect of the technology and a significant report was put together under leading author Professor Richard Kitney of Imperial College, London.

The ASEM eHealth Working Group has also produced a report, authored by Paul Lawton of HealthSystems Group. It is a `scoping' exercise using data from the WHO's Global Observatory for eHealth designed to identify best practice projects being implemented within countries that belong to the ASEM Community.

This is an evolving story, and a large-scale eHealth project from Europe is being reviewed for translocation into a number of countries in Asia.

Other examples of regional groupings include the Commonwealth Community, which comprises 53 countries. The Commonwealth Business Council is in the process of establishing a Commonwealth eHealth Secretariat with the same objectives in mind as the ASEM eHealth Working Group.

eHealth thus not only acts as an agent for reforming healthcare systems from infrastructure-focused services into more dispersed healthcare models, but it also enables countries with similar heritage and interests to share resources across international borders, thereby providing quality without the expense of needless duplication.


WHO as a catalyst
To overcome challenges that impede the rapid and large-scale adoption and adaptation of eHealth solutions to healthcare, the WHO has identified a number of priority areas. They include the action areas endorsed by the WHO Executive Board in January 2006:

  • economic viability, organisational barriers and support, technical know-ledge and behaviour modification

  • norms and standards, and functional and semantic interoperability of systems so that solutions can be shared across technology platforms

  • legal and ethical challenges dealing with security, confidentiality and privacy issues, as well as accountability, liability and jurisdiction

  • generate evidence that ICT contributes to performance improvement in health systems, helps build human capital for health, improves access to knowledge, supports decision making, and helps lead to better outcomes for patients

  • ICT for human resources for health - using eLearning and other ICT-mediated techniques for pre- and in-service education and training, and for improving the productivity of the health workforce

  • ICT for health promotion - informing and educating the public so they can prevent disease and thereby reduce their need for care

  • Use of ICT for the delivery of health services - in-patient care, ambulatory care and public health services.

Three of the key initiatives in these priority areas are outlined below.

Global Observatory for eHealth
The WHO's Global Observatory for eHealth is conceived as a network of institutions in countries that will collect and analyse data and information on ICT in the health sector of each country.

The Observatory will, therefore, aim to develop national observatory groups in all 193 WHO Member States, and develop a permanent online survey of eHealth activities in several countries.

The Africa Health Infoway
The Africa Health Infoway (AHI) is a system to support the collection of regional health data and statistics for analysis, dissemination and use in health decision making, and for strengthening the capacity of all 53 African countries to use information in decision making.

Existing health information systems use different technology platforms within countries, making electronic sharing of information difficult or even impossible.

The AHI will develop technology standards for tools and platforms to facilitate data collection - for example, using handheld devices such as personal digital assistants (PDAs) - as well as permitting the sharing of information and knowledge across jurisdictional boundaries.

Its three main strategic thrusts are: infrastructure and connectivity; district health information systems; knowledge translation into policy and action.

ICT R&D for health
Although the healthcare sector has benefited hugely from developments in ICT, health is not simply an area of application of ICT. There should be a symbiotic relationship between the two. Health sector needs (health promotion, disease prevention, diagnosis, treatment, protection against health threats) should also drive the ICT R&D agenda.


Practical solution
Health systems are designed to ensure effective access to, and utilisation by, the whole population, especially poor and vulnerable groups.

They are designed to provide an organised, integrated and seamless service that links promotion, prevention, plus acute and chronic care across the entire continuum of care. They are based on the Alma-Ata principles of equity, intersectoral approaches and community participation.

The WHO will focus on the interactions between ICT and health systems - the development, deployment and use of the technology to support the above functions.

It will thus be concerned with solutions from the policy and practice environment within which ICT is operated, in order to support capacity building and to provide services that improve health outcomes - an environment defined by financial, socio-economic and institutional policy; human and material resources; and organisational and managerial models. The work will cover:

  • Capacity building - through access to affordable sources of reliable and current information, and educational opportunities and training materials - that develops individual competence, institutional capacity, and supports an informed and empowered public

  • Support to health service delivery and system performance, addressing: improved coverage through better access to, and availability of, interventions; increased technical quality of services; and, effective and efficient management of human, financial and physical resources

  • Monitoring, evaluation and assessment of impact in the above areas.

Cheaper healthcare
It is hoped that these developments will not only herald an era of personalised healthcare delivery, with improved outcomes, but together they will do something to reduce the cost burden of the delivery of quality healthcare, which is becoming financially unsustainable.

Perhaps most importantly, given the change in life-expectancy, which is unmasking huge numbers of patients with chronic disease around the world, we are establishing the building blocks of a citizen-centric healthcare system of the future. This new healthcare model will be of immeasurable value to our children and grandchildren.

The author
Professor S Yunkap Kwankam is a coordinator of eHealth for the WHO, Geneva, and Professor Ricky Richardson FRCP FRCPCH is a visiting professor in eHealth, Imperial College, Group Clinical Director, HealthSystems Group, and Consultant Paediatrician

2nd September 2008


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