null

From Silos to Systems: An Overview of eHealth’s Transformative Power

Rockefeller Foundation Report

Making the eHealth Connection:

Global Partnerships, Local Solutions

Bellagio Center Conference Series

The Rockefeller Foundation shapes and supports innovative solutions to some of the world’s mostcritical challenges. Few of these solutions are more encouraging than those emerging in the fieldof eHealth. As wireless connectivity rapidly increases globally, information and communicationstechnology unleashes the potential not only to improve the quality and efficiency of health care,

but also to bridge divides between services and the people who most need them.

During the summer of 2008, the Rockefeller Foundation hosted Making the eHealth Connection:Global Partnerships, Local Solutions, a month-long conference series at our Bellagio Center. Whilegathered there, more than 200 experts, working across disciplines and sectors, set and championed a new agenda to expand use of technology in health systems—one crucial component of the globalhealth community’s strategy to make modern care more accessible and affordable for all.

This report, “From Silos to Systems,” arises from that seminal convening. It advocates for strongereHealth capacity, coordinated funding and policy, collaborative networks, public-private partnerships,and greater attention to interoperability. It informs our ongoing investment in projects includingRwanda’s endeavor to develop a comprehensive, nation-wide eHealth plan and the Kigali Institute of Science and Technology’s work to establish an eHealth center of excellence, which will serve as a national and regional anchor of research, teaching, and learning.

The Rockefeller Foundation’s support for eHealth is part of our five-year, $100 million TransformingHealth Systems initiative, which helps low-income countries—beginning with Ghana, Rwanda, andVietnam and Bangladesh—steer their fast-evolving health systems toward better performance and universal coverage. Our initiative also fosters professional stewardship of national health systems and engages the private sector in providing and financing health services for low-income families.

Almost a century ago, John D. Rockefeller, Sr., committed his foundation to addressing the diseasesthat he called “the supreme ill of human life.” During subsequent decades, our predecessors led cam-paigns against scourges of the poor, including malaria and hookworm, and helped establish the field of public health in the process. They earned a Nobel Prize for their discovery of a yellow fever vaccine.They mobilized a worldwide effort to align public-private partnerships that accelerate the search forvaccines and medications to end HIV/AIDS, tuberculosis, and other illnesses.

Today, we forge boldly into the 21st century’s second decade with our eyes fixed on a new generation of health challenges and opportunities. As the Foundation has since its inception, we nurture innovationsthat can help more people lead healthier, more resilient, and more productive lives. Because of dramaticadvances in technology and communications, tools like eHealth can connect people and communitieswith better care at lower cost. We welcome and value your partnership in spreading their promise.

Judith RodinJanuary 2010

President’s Letter

© 2010 The Rockefeller Foundation, New York

Cover photo: Joel Selanikio/DataDyne.org

Inside photos: © Steve McCurry/Rockefeller Foundation (page 4), © Antony Njuguna/Rockefeller

Foundation (page 5), © Jonas Bendiksen/Rockefeller Foundation (page 6), © Patrick de Noirmont/

Asiaworks/Rockefeller Foundation (page 8), © Jonas Bendiksen/Rockefeller Foundation (page 10),

© Peter Essick/Aurora Photos/Corbis (page 11), © Antony Njuguna/Rockefeller Foundation (pages

12, 14, 15), © Patrick de Noirmont/Asiaworks/Rockefeller Foundation (page 16), © Jonas Bendiksen/

Rockefeller Foundation (page 17), © Paula Bronstein/Getty Images (page 18), © Antony Njuguna/

Rockefeller Foundation (pages 20, 21, 24),© Patrick Zachmann/Magnum Photos (page 25), Antony

Njuguna/Rockefeller Foundation (page 30), © Paul Morris/Time Life Pictures/Getty Images (page 31),

© Chaiwat Subprasom/Reuters/Corbis (page 32), © Susan Meiselas/Magnum Photos (page 34),

© Antony Njuguna/Rockefeller Foundation (pages 36, 37), © Patrick de Noirmont/Asiaworks/

Rockefeller Foundation (pages 38, 39), © Antony Njuguna/Rockefeller Foundation (page 40), UN

Photo/Joao Araujo Pinto (page 42), © Tim McCaig/istockphoto.com (page 46), © Bruno Barbey/

Magnum Photos (page 47), © Antony Njuguna/Rockefeller Foundation (page 49), © Gary McNutt/

Community to Community Productions (page 50).

Design: Amy Janello Sturge

4 Introduction

10 The Path to Interoperability

14 Public Health Informatics

20 eHealth Capacity Building

24 Access to Information and Health: ICT’s Transformative Impact

30 mHealth and the Future of Medicine

36 The Promise of Electronic Medical Records

42 “Glocal” eHealth Policy

46 Catalyzing Markets for Global eHealth

51 The Road Ahead

52 Making the eHealth Connection

Overview

Partners

Participants

60 Contributors

Table of Contents

eHealth: An Introduction

Despite good intentions, health systems across the globe are unable to deliverhigh-quality, affordable services to all. Thirty thousand children die each dayneedlessly of preventable disease. Quality of care is substandard. Sick patients—if they can get to a clinic and afford treatment—face long waits. Critical healthinformation is buried in thick medical files, and facilities are plagued with severeshortages of those who can heal. Inequities in the provision of health care areone of the greatest challenges we currently face as global citizens—and thesedemands are only amplified in the developing world.

Ill health handicaps not only people but economies and development. The World Health Orga-nization (WHO) recently noted that countries, particularly those in Africa, will not develop eco-nomically and socially without substantial improvements in the health of their people. Theeconomic shifts of the past few years have further contracted economic growth worldwide and affected developing countries unduly. The World Bank predicts a $700 billion shortfall inemerging markets, for example. If anything positive can be said about the global recession, it isthat it more deeply binds the fate of nations together and provides momentum for new andsystemic approaches to persistent cross-border challenges.

Experts agree that it will take an unprecedented transformation to reverse the tide of failinghealth systems, particularly in light of shrinking resources that must now be used more effi-ciently. Fortunately, support is increasingly available through a set of breakthrough tools knownas eHealth, commonly understood to be the innovative application of emerging informationand communications technology in health systems.

eHealth includes a broad range of implements, such as electronic health records, information-gathering software, mobile devices, e-learning tools and horizon technologies that defy humanimagination. Combined, these tools can narrow health disparities, equip health care providersand enable immense leaps in quality of care. For example, a nurse in a remote village—throughher laptop and mobile phone—can now access information on the world’s best treatments, pre-viously only available to the rich and privileged, and can track and treat her patients using longi-tudinal electronic health records.

eHealth: An Introduction

From Silos to Systems

Introduction

Growing numbers of experts believe thateHealth will fuel the next breakthroughs inhealth systems improvement, from Johannes-burg to Jakarta. Recognizing both the prom-ise and the challenges of these emergingtechnologies, the Rockefeller Foundation haslaunched an effort to identify new solutionsto eHealth and health system improvementwith a spotlight on low-resource settings.

eHealth Around the Globe

eHealth deployment is moving forward onevery continent and often in low-resourceareas where it might be least expected. Tech-nological breakthroughs are happening pre-cisely because the trials and health needs inthese places are so pressing and solutions areso few. Some examples include telemedicinenetworks in Bangladesh; e-pharmacy projectsin Malaysia; low-cost, sustainable electronichealth records for HIV/AIDS patients inKenya; and web-based communication tools

5


to decrease maternal and child deaths inPeru. In the industrialized world, meanwhile,multiple national initiatives are underway,such as the creation of an electronic healthrecords system in Australia, the linking ofinteroperable health information technologyin the United States, and the development ofa single electronic health record for everyindividual in the United Kingdom.

Discussions about creating new eHealth sys-tems are now truly transnational, transcend-ing the boundaries of geography as well asthe boundaries of organizations. Mountingevidence suggests that countries—regardlessof their political leadership, gross domesticproducts (GDPs) or health-insurance sys-tems—share common eHealth challenges.Among them are the need for clear businessand funding cases, strong stakeholderengagement, documented best practices,cooperation between business and govern-ment, integration of local perspectives, affordable open-source options, and work-able approaches to interoperability, privacyand security.

International agencies are beginning to rampup eHealth activities as a way to improveglobal health, overhaul health systems andsupport the United Nations Millennium

Development Goals. The World Health Organi-zation has adopted Resolution WHA58.28,which urges member states to develop long-term strategic plans for eHealth services. The53-nation Commonwealth Secretariat andthe Commission for Africa have establishedeHealth programs. The European Union hasan eHealth action blueprint in place to achieveborderless trans-European health informationsystems by 2010. And the Group of Eightlargest industrialized countries, plus Russia,have launched a Providing for Health Initia-tive, or P4H, as an international platform fordialogue and collaboration on health-systemsissues, including eHealth.

Despite the wonders and continued progressof eHealth, an international public-private sec-tor framework for understanding and movingforward on these issues is not yet in place.Consensus on how health technology canproliferate in the absence of traditional busi-ness models and methods for it to communi-cate across institutions or continents—knownas interoperability—is not a reality in mostplaces. Although incredible amounts of infor-mation about health can be electronically col-lected and analyzed, it is often not integratedfor a complete picture of health. And policyoptions and funding to support eHealth proj-ects are often inadequate and unaligned.

6

Making the eHealth Connection

Making the eHealth Connection: Global Partnerships, Local Solutions

A key milestone in the Rockefeller Founda-tion’s endeavor to improve health systemswas the month-long Making the eHealth Con-

nection: Global Partnerships, Local Solutions

conference series held during July andAugust 2008 at the Foundation’s BellagioCenter in Italy. For 50 years, the Bellagio Cen-ter has been a place for developing bold ideasand initiatives to “promote the well-being” of humanity, as John D. Rockefeller, Sr.,intended when he established the Foundationitself in 1913. In keeping with this tradition,the eHealth conference series convenedsome of the world’s best minds to collaborateon devising innovative methods of using thenewest digital technologies to improve healthcare in developing countries—an area fre-quently referred to as the Global South.

In a pivotal 2007 meeting in Pocantico, NewYork, worldwide health leaders made recom-mendations for addressing the challenges ofglobal health systems. And at the Making the

eHealth Connection conference, attendeestook action on these recommendations. Theevent fell squarely within the RockefellerFoundation’s broader commitment to engagepartners with diverse perspectives in mean-ingful alliances, while encouraging new prod-ucts, processes and practices that empowerbeneficiaries to cultivate and spread progressin their communities and countries.

The Making the eHealth Connection conferenceoccurred at a very important point in time, withwireless and mobile technology at a tippingpoint. Key countries in South America, Sub-Saharan Africa and Southeast Asia are commit-ted to major eHealth endeavors. With countriesincluding Brazil, Thailand, and Rwanda onboard, other developing nations are poised tofollow suit. Experts say that now is the optimalmoment for eHealth to have the greatestimpact, and they stress that agreed-upon direc-tion at an international level is sorely needed.

Designed to be a consensus launching padand a networking hub, the Making the eHealth

Connection conference series provided a neutral, information-rich locale where pas-sionate people and organizations could worktogether to begin to achieve real technologyand health breakthroughs. Attendeesexplored pathways for new investment andnew policies, coming away with a new deter-mination to revitalize health systems in devel-oping countries.

Ensuring that every voice would be heard, con-ference dialogue was shaped around the artic-ulated needs of those who are active on theground as health technology implementers,policymakers and funders in developing coun-tries. Two hundred experts participated in theMaking the eHealth Connection conferenceseries, including representatives from 34developing nations, 32 donors and 10 promi-nent print and online media representatives.Conference attendees were asked to offer theirbest ideas on eHealth knowledge develop-ment, capacity building, possible country-leveltechnology investments, and the mobilizationof key partners to build global momentum forstronger health systems through eHealth.

To organize the Making the eHealth Connec-

tion conference series, the Rockefeller Foundation joined forces with leading institu-tions in health, international development,and information and communications tech-nology (ICT), including the American MedicalInformatics Association (AMIA), International Medical Informatics Association (IMIA),Health Level Seven (HL7), Health Metrics Network (HMN), the Latin American andCaribbean Center on Health Sciences Infor-mation (BIREME), Partners in Health (PIH), the Regenstrief Institute, the TelemedicineSociety of India, the United Nations Founda-tion (UNF), Vodafone Group Foundation Technology Partnership, the University ofWashington’s Center for Public Health Informatics (CPHI) and the World HealthOrganization (WHO).

“eHealth is truly a

disruptive technology...

rendering former

geographic and economic

barriers meaningless.”

The Most ReverendDesmond Tutu, Archbishop Emeritus of Cape Town, South Africa

The action-oriented Making the eHealth Con-

nection conference agenda included discus-sion in eight key areas, all designed toprovide seasoned eHealth advice and roadmaps for delivery of health services and infor-mation in a fundamentally different waythroughout the developing world:

} Public health informatics and national health-information systems

} Interoperability

} Access to health information and knowledge sharing

} Health informatics and eHealth capacity building

} Electronic health records

} Mobile health and telemedicine

} eHealth markets

} National eHealth policies

Each week, Making the eHealth Connection

participants attended one of two parallel con-ferences with joint plenary and keynotespeaker sessions. Subject tracks convened25 to 30 world experts from important stake-holder groups—industry, donors, govern-ments, researchers and civil society—to focuson a specific area of eHealth. Participantsexamined eHealth obstacles, potential solu-tions and successful sustainability models.

Outcomes from the conference wereexpected to inform both national and interna-tional eHealth agendas and result in ideasand products to drive a marked increase ineHealth dialogue and action.

From Talk to Action: A New eHealth Paradigm

Along with providing eHealth education andinforming future eHealth dialogue, this book-let is intended to promote the findings of theMaking the eHealth Connection conferencewithin the broader health, development andtechnology communities. The booklet, organ-ized by conference session, features agreed-upon recommendations for necessary actionsand policy priorities that can guide the devel-opment and implementation of global,national, regional and local eHealth andhealth systems. These testimonials representstakeholders’ substantial commitment toimprove health and decrease disparities bypromoting innovative eHealth solutions.

Overall—through the signing of an official Bel-lagio eHealth Call to Action that is beingtaken to global institutions, individuals andgovernments with the power to changeeHealth policy and practice—Making the

eHealth Connection conference participants

8


GLOBAL eHEALTH CONVENTION_Engage in aglobal eHealth convention process aimed atproviding an overarching legal and regulatoryframework for eHealth, beginning with inter-operability issues

CULTIVATE INTEROPERABILITY CULTURE_Promote government adoption of an interop-erability and standards culture in relation to eHealth

OPEN STANDARDS/OPEN SOURCE_Make openstandards and open-source software freelyavailable

UNIVERSITY-BASED INFORMATICS NETWORKS_Create a network of regional health informat-ics centers, in resource-constrained countries,with mechanisms for collaboration betweenuniversities in the developing and the devel-oped world

SHARED OPEN-ACCESS INFORMATION SPACE_Create a shared space using social-networkand open-access approaches to enable infor-mation producers, intermediaries and usersto develop and share content, methods andtechnologies

mHEALTH ALLIANCE_Seed a mobile-healthalliance to track, leverage and shape the rapidgrowth in the mHealth sector

EMR TOOLKITS AND TRAINING_Create an EMRtoolkit and foster support for local EMR train-ing and capacity building

NATIONAL eHEALTH COUNCILS_SupportNational eHealth Councils and eHealthambassadors/advocates, particularly fromthe developing world

GLOBAL eHEALTH ENTREPRENEUR COMMONS_Design a global eHealth commons and aneHealth promotion network to support financ-ing and matchmaking among eHealth entre-preneurs and donors

committed themselves to promoting and sup-porting the following:

} Timely, consensus-based global agenda setting

} A rational policy process for eHealth

} Adequate and coordinated funding

} Collaborative networks and action platforms

} Knowledge sharing and capacity building

} Interoperable eHealth demonstration projects

To date, more than 240 individuals havesigned the Bellagio eHealth Call to Action,which was launched by Cape Town Arch-bishop Emeritus Desmond Tutu, who callseHealth “a ray of light on the horizon for thehealth and equity challenges that plaguehumanity.”

Making the eHealth Connection recommenda-tions about what must be done across coun-tries and by those involved in eHealth include:

} Keeping in mind that the ultimate goal ofeHealth should be to strengthen health sys-tems and improve people’s health

} Documenting the impact of eHealth on access,affordability and quality of health services

} Supporting collaboration and innovationacross resource-constrained countries andsupporting learning between developingcountries, with the understanding that theequator is not the dividing line for innovation

} Reducing donor fragmentation and harmoniz-ing donor requirements and reporting

} Developing the ICT “business case” toincrease donor and stakeholder involvement

} Strengthening stakeholder collaboration

} Providing funding for demonstration projects,reference implementations and adequateevaluation

Other recommended strategies to addresscommon eHealth policy and organizational,technical, legal, financing and sustainabilitychallenges conceived at the Making the

eHealth Connection conference series are alsohighlighted in this booklet. These include:

WE-CAN_Form a World eHealth CollaborativeNetwork (WE-CAN) to enable eHealth ideasand priorities to flow from the bottom up andfrom the top down

“There has been a ten-

dency in the past to con-

sider ICT solutions as

elitist, stand-alone proj-

ects that are implemented

to the expense of more

developmental pursuits.

Rwanda’s eHealth

experience illustrates the

reverse; namely that

ICT is a powerful tool

and agent for drastically

improving health care

delivery to ordinary folks

and even in the remotest

parts of our country.”

His Excellency Paul Kagame,President, Republic ofRwanda

Interoperability is broadly defined as the ability of two or more systems toexchange and use information. For health care, interoperability enables dataand technology systems to work together across organizational boundaries forbetter individual and community health. Attaining true interoperability requiressignificant coordination and cooperation among stakeholders. While expertstoday concur that consensus-based health care interoperability rules and stan-dards are needed, many questions remain about how to achieve this in bothdeveloped and developing nations.

The World Health Organization (WHO) and Health Level Seven (HL7) jointly convened Path to

Interoperability, part of the Rockefeller Foundation’s Making the eHealth Connection: Global Part-

nerships, Local Solutions Bellagio Center conference series. Participants discussed essentialsteps along the interoperability path and examined what is needed to promote interoperability inthe developing world—to get the machines talking and to put patients at the center of their care.

eHealth Interoperability: Key Issues

Electronic health information exchange across institutions and borders is increasingly impor-tant, in light of the growing global disease burden and a mobile populace. Critical challenges inthe process of meaningful data exchange are the lack of interoperable health systems and thelack of consensus on data standards. Several key issues are involved in moving toward morewidespread health care interoperability. These include:

} Understanding interoperability needs in an organizational, geographic and health system context

} Finding consensus among key interoperability stakeholders, such as patients, providers, health carefacilities, ministries of health, districts, technology vendors, donors and development agencies

} Providing avenues for developing nations (which are largely absent in current standards-development and interoperability discussions) to become more engaged

} Clearly articulating what technologies, policies, skills and leadership by government and industryare necessary to achieve interoperability

} Properly leveraging open, standards-based platforms and open-source collaborative models when needed

The Path to Interoperability


Chapter 1

Interoperability Defined

Interoperability is a complex concept with asimple end goal: creating better health forindividuals, communities, nations and theworld. Interoperability involves the successfuloperation of many interlocking pieces atincreasing levels of sophistication. True inter-operability is a particularly difficult task ifundertaken all at once. Participants at thePath to Interoperability conference recom-mended that interoperability in a health carecontext be tackled in distinct steps, startingfrom the most straightforward and movingtoward the most intricate and multifaceted.

Interoperability Model

LEVEL 1 Non-electronic data (e.g., paper, mailand phone calls)

LEVEL 2 Machine-transportable data (e.g., fax,email and unindexed documents)

LEVEL 3 Machine-organizable data (structuredmessages and unstructured content;e.g., indexed or labeled documents,images and objects)

LEVEL 4 Machine-interpretable data (structuredmessages and standardized content;e.g., the automated transfer from anexternal lab of coded results into aprovider’s electronic , allowing data tobe transmitted, or accessed withouttransmission, by health informationtechnology (HIT) systems without theneed for further semantic interpreta-tion or translation)

Interoperability and Standards: Progressing on the Path

Path to Interoperability conference partici-pants emphasized that interoperability shouldbe treated as a direction rather than as theend point. Examples are already emerging ofcountries that have implemented informationtechnology systems and worked toward inte-gration, but been unable to progress fully oraggregate the data needed to contribute tothe nation’s health due to a lack of interoper-ability. What can be done to support a morerobust vision of interoperability—one that iscapable of being implemented across nationsregardless of governance, health systemstructure, financing and disease burden? Andhow can these solutions address the largeand complicated standards and interoperabil-ity issues in the developing world?

As a starting point, Path to Interoperability

conference participants categorized interop-erability imperatives and recommendationsinto seven distinct priority areas, based on thereal-world experience of systems developers,implementers, ministries of health anddonors in geographies such as Sub-SaharanAfrica, Southeast Asia and Eastern Europe.

1. STANDARDS_Despite the funding andenergy put into standards making, inter-operability remains a largely unsolved prob-lem. eHealth-specific standards require

11


“There is an opportu-

nity with the excitement

that this [eHealth]

series has generated

for the world to come

together to create a

common architecture,

a common approach.

Once we have a frame-

work in place and can

share and compare

information, there will

be a huge new ability to

innovate on the edges

instead of having to

reinvent wheels.”

Sally Stansfield, MD,Executive Secretary,Health Metrics Network,Switzerland

consideration of business, clinical and techni-cal issues. These factors make it difficult toobtain consensus on standards and datarequirements in a timely fashion. Informationand communications technology (ICT) and itsvalue are established, yet without patient dataand standards to enable data exchange ordelivery at the point of care, these technolo-gies remain largely moot in practice settings.

Some standards today are currently availablefree of charge, but others have associatedfees. Required standards should be freelyavailable to all through the development of aconsortium for eHealth standards distributionin which standards bodies provide materialsand resources at no or very low cost to quali-fying developing countries and projects.

Developing nations should increasingly par-ticipate in standards-development organiza-tions to form partnerships with developedcountry representatives and to have theirvoices heard in deliberations about the inter-operability standards needed to exchangehealth data at the national, regional, districtand clinic levels.

2. IDENTIFIERS AND REGISTRIES_Identifiersare considered a building block of eHealth.The successful exchange of information andthe use of eHealth will require unique identi-fiers for patients, providers, facilities and per-haps other parties that have yet to bedetermined. Most countries do not havepatient identifiers in place, but Path to Interop-

erability conference participants recom-mended that identifiers be generated andused for the following categories:

} Patients

} Health care workers, specific to their roles

} Sites of health service delivery

Registries are considered a desirable and per-haps necessary component of eHealth. Reg-istries support several needs, providing lists ofpersons with demographic characteristics, dis-ease-to-family linkages and a variety of otherfunctions. Registries also support patient track-ing, which is often critical, as patients rarely

see the same provider consistently. Subse-quently, registries and patient identifiers enablegreater continuity of care, linking patient visitsto multiple sites and multiple providers.

3. ENVIRONMENT_The recognition of localculture, languages and indigenous medicineis critical for successful eHealth implemen-tation and interoperability practices. These factors must be considered and woven intoeHealth solutions.

4. GOVERNMENT_There is no clear precedentfor a government’s role in eHealth and thevarying government structures among differ-ent nations do not lend themselves to a one-size-fits-all solution. Governments shouldconsider creating a national body to overseeand house standards and interoperabilitywork. Internationally, a model global interoper-ability resolution should be developed thatencourages each nation to adopt a core set ofstandards for global eHealth interoperability.This would make it possible to share datausing freely available standards and to sup-port national data collection to improvehealth. To the greatest extent possible, nationsshould ensure that local eHealth standards arenot contrary to established global standards.

“There are a handful of

breakthroughs in interop-

erability. The most

successful ones are when

we meet the needs of

stakeholders in developing

and developed countries.

Vendors and end-users

of technology have come

to realize that this is a

boundary that must be

crossed before real infor-

mation-sharing is possible

and, even more impor-

tant, for data re-use.”

Charles Jaffe, MD, CEO,Health Level Seven,United States

5. RESOURCE DEVELOPMENT_Many develop-ing countries lack access to capital andhuman resources. Some nations have limitedaccess to hardware, supplies, computers andprinters. Salaries in the informatics field aregenerally low and training opportunities arelimited, making it difficult to attract or sustaina sufficient workforce. At a higher level, gov-ernment and health care industry leaders donot have the capacity or staff to participate innational or international standards activitiesand may have limited knowledge of stan-dards. These challenges must be addressed.

6. TECHNOLOGY_ICT purchasers should beeducated and informed about the technicaland business requirements that an eHealthsystem must satisfy. Governments, sponsor-ing agencies, or organizations may considercertifying vendors or ICTs that meet eHealthand interoperability requirements and pub-lishing a list of such certified parties for poten-tial purchasers.

Several current information technology (IT) ini-tiatives involve developing countries. Whilemany of these systems are effective, they fallfar short in making a significant impact on thehealth of these countries. Planning effectiveeHealth systems and understanding therequirements for interoperability here will be areal challenge. The concept of appropriatetechnology should be a major focus. What-ever is done must have immediate value andinclude scalable, sustainable eHealth systemswith simple user interfaces and, potentially,open architecture. An overarching frameworkfor dealing with vendor issues, technology,system design and decision making is needed.

7. EDUCATION_Educational tools should becreated and presented to decision makers,especially in developing countries. Opportuni-ties for informatics training, university part-nerships and introductory virtual courses ontopics such as standards, application develop-ment and eHealth are essential.

Conclusion

Most of the standards necessary to make val-ued progress toward systemic interoperabil-ity currently exist. Part of the problem is thatthere are duplicating and overlapping stan-dards—and the need to identify a consensusset. Another concern is that not every nationhas an equal seat at the standards-develop-ment table. Progress is being made in theseefforts. Standards-development organizationsare forming international collaborations.Experts are coming together to work on inte-grated eHealth systems in African countries.Donors are beginning to put a higher priorityon understanding interoperability and how itcan best be supported by their investments.

In addition, individuals—such as EddieMukooyo, MD, in Uganda’s Ministry ofHealth—are also stepping forward to exertvisionary leadership. Dr. Mukooyo, who over-sees his country’s efforts to deploy technol-ogy to connect medical personnel, is nowactively engaging in conversations with thestandards community. He shares Uganda’seHealth story while gathering vital detailsabout the most current standards and inter-operability developments worldwide. Dr.Mukooyo observes that, “this knowledgetransfer is absolutely critical in building a successful, interoperable health ICT systemthat works effectively both inside and outsideUganda’s borders. It offers the valuableopportunity to be vocal participants at thestandards development table.” Uganda may very well be the harbinger of the futureof interoperability.

A January 2006 Davos World Economic Forum report cites the woeful state ofthe world’s public health infrastructure as the greatest obstacle to progress onglobal health goals. Health information systems remain inadequate, making itimpossible to monitor and improve the delivery of interventions in a timely andeffective way. Fortunately, eHealth tools offer novel ways to improve publichealth by gathering data from disparate sources and rapidly transporting thatdata to health workers on the ground.

Public health includes responding to the health needs of individuals as well as populations. Prevention is a primary focus. The Internet, computer resources and mobile devices such ascell phones and personal digital assistants (PDAs) are increasingly available in the developingworld. Public health professionals are adapting these technologies to the health care setting.The avenues of technology and public health meet at the intersection of public health informat-ics (PHI). PHI is the systematic application of information and computer science and technol-ogy to public health practice, research and learning. PHI strategies are increasingly used toobtain a complete picture of a population’s health and risk status and to support effective pub-lic health data flow and decision making in both urban and remote locales.

To address these issues, the University of Washington’s Center for Public Health Informatics(CPHI) and the World Health Organization's Health Metrics Network convened Public HealthInformatics, part of the Rockefeller Foundation’s Making the eHealth Connection: Global Part-nerships, Local Solutions Bellagio Center conference series. Participants focused on methodsof accelerating progress in the public health informatics field and widening the discipline's rele-vance in low-resource and developing-world settings.

Public Health Informatics: Key Issues

Internet cafes, computer centers, and mobile devices from cell phones to handheld PDAs aretools in regular use among many health workers and policymakers. The challenge for publichealth informaticians is how to enhance the delivery of high-quality, contextually relevant con-tent, focused on a broad range of data (such as disease incidence, immunization rates, morbid-ity, mortality statistics, practice guidelines, research findings, protocols, maps and images) sothis content can be used on the ground at the local, district and national levels.

Public Health Informatics


Chapter 2

There is great potential for public health informatics innovations to improve health,particularly in these areas:

} Communication among geographically dispersed health workers and consumers

} Delivery of public-health services by strength-ening and streamlining data collection

} Support of primary and secondary preventionvia electronic health records and improvedlaboratory systems

} Data collection for research studies, such asdrug and vaccine trials

} Environmental health interventions, such asbiosurveillance, road safety and geographicmapping systems applications

However, public health informatics impedi-ments remain, including the following:

} A lack of integrated, interoperable healthinformation systems to support decision mak-ing at all levels

} System fragmentation at the donor, NGO,ministries of health, clinics and hospital levels

} Capacity shortfalls in technical support andtechnology availability for day-to-day healthinformation systems tasks

} Data stewardship challenges, including theneed to provide incentives for people to col-laborate on collecting and sharing accurateand useful data

} The one-way flow of information that is sentupward, but not back to health workers onthe ground

} Too many vertical disease silos across health sectors

} Short donor-funding horizons and invest-ments that are not long-term, coherent orconsistent

} Inconsistencies between “industrial” IT solu-tions and on-the-ground realities

} A need for national ownership

Public Health and Developing Nations: The Potential of eHealth

The rapid expansion of eHealth interventionsin developing countries offers the public-health sector many improvements and effi-ciencies. eHealth projects, focusing both onmedical and public health practice, haveintroduced new methods of expanding con-nectivity; brought breakthrough technologytools and devices; facilitated provider educa-tion and consultation; and built applicationsdesigned to meet the needs of specific dis-ease or practice data collection and analysis.Two examples of public health informaticsbreakthroughs are in the areas of lab andpharmaceutical data.

15


Laboratory Information ManagementSystems (LIMS)

A well-designed health management informa-tion system, constituting reliable, accurate andtimely availability of data, is widely recognizedas a cornerstone of a good public health sys-tem. A laboratory information managementsystem, developed as part of a national healthmanagement information system (HMIS) in apublic health setting, can support a variety ofprograms and functions, including epidemiol-ogy surveillance and monitoring; outcomesassessment; administrative activities (e.g.,billing and utilization); program planning andevaluation; quality assurance; policy analysis;research; and information dissemination.1

Increasingly, many nations are adopting inte-grated disease surveillance and reportingprocesses to improve public health out-comes. Through computerized data entry andthe access and retrieval of reliable laboratorydata, LIMS addresses important issues inher-ent in the laboratory, including sample track-ing; quality-assurance activities; automatedinterfaces for laboratory equipment; theacquisition of specimens; the creation ofwork lists and test scheduling; the generationof aggregate reports; and the automateddelivery of patient reports.

The implementation of laboratory-informationsystems in developed countries first occurredin the clinical-laboratory environment. Publichealth laboratories either developed theirown non-standard systems using in-house ITstaff, or purchased proprietary products thatwere oriented toward the clinical laboratoryand then customized for public health needs.Both approaches had advantages and disad-vantages, but increasingly, the need for infor-mation systems in public health laboratorieshas resulted in the availability of more propri-etary products. Currently, the situation forinternational laboratories in resource-limitedsettings is similar. Laboratories are faced withdeveloping their own systems using toolssuch as Microsoft Access databases or Epi-Info—but often without attention to standardsfor vocabulary and messaging.

Some laboratories are working with vendorswhose primary product is focused on the clin-ical laboratory and modified to address publichealth laboratory needs. An open-sourceproduct used by six Association of PublicHealth Laboratories (APHL) member statelabs is also under consideration in Vietnamand Kenya and may provide alternatives to in-house development or vendor-supportedsoftware using open-source approaches.Developing a reliable LIMS is certainly a com-plex undertaking. When implemented utiliz-ing best informatics practices, however, thesystem can yield valuable and timely resultsfor public health action.

The Health Metrics Network (HMN)2 has beenestablished to help countries develop thecapacity and expertise for collection andanalysis of health information. HMN, alongwith its partners, has developed objectivesthat will have an impact on the implementa-tion of LIMS in resource-limited countries.Those objectives include the following:

} Creating a harmonized framework for country HIS development (the HMN Framework) that describes standards forhealth information systems

} Strengthening country HIS by providing tech-nical and catalytic financial support to applythe HMN framework

16


Catherine Omaswa, Chairperson, NationaleHealth Committee, Uganda

} Ensuring access to and the use of informationby local, regional and global constituencies

The work of HMN and its partners will bringuniformity and a common framework thatsets standards for health information systemsand laboratory information systems and willbe an important component of a country’scollective data systems.

Pharmaceutical Systems and Informatics

Without efforts to ensure that public healthdecision makers have accurate and timelypharmaceutical management information,there is a risk that significant resources couldbe wasted, poor-quality products could cause harm, and suboptimal use of medicinescould adversely affect patient outcomes.Pharmaceutical systems informatics or efforts to understand and promote the effec-tive organization, analysis, management anduse of information in the pharmaceutical sector is providing important new avenues of innovation to address these challenges.Pharmaceutical systems informatics sits atthe intersection of data, science, and technol-ogy and includes the basic functions of thepharmaceutical management framework,such as selection, procurement, distributionand use.

Medicines are an essential component ofhealth care systems in developing countries,accounting for one-third or more of a govern-ment’s health services budget. It is commonfor 20 to 50 percent of the recurrent govern-ment health budget in developing countriesto be used to procure drugs.3 The potentialfor medicines, including both drugs and vac-cines, to improve the health of those in devel-oping countries is widely acknowledged. Forexample, medicines are among the mostimportant health interventions, their promi-nence illustrated by their rating by the Dis-ease Control Priorities Project—an ongoingeffort to produce evidence-based analysisand resource materials to inform health poli-cymaking in developing countries—as someof the “best buys” in health. Medicines areused to vaccinate children; to prevent andtreat childhood pneumonia, diarrhea andmalaria; to attack the spread of HIV; and totreat tuberculosis patients.4

With the proclamation of the United NationsMillennium Development goals and theimplementation of multinational programssuch as the Global Fund to Fight AIDS, Tuberculosis and Malaria, both public and pri-vate donors to developing countries are mak-ing a new, concerted effort to improve access to medicines.

“ICT is important for

disease surveillance.

We [in Uganda] are one

of those who had ebola.

It was good that mobile

phones had already spread

throughout the country

...within a short amount

of time, it was possible

to reach the Minister

of Health, get a team

together and get action.”

Like other parts of the world, developing countries need essential, quality-assured med-ications to be available continuously and dis-tributed in a timely manner to those whorequire them. Stakeholders at every level needinformation to make decisions that affect theoverall functioning of medication systems. For example, a good pharmaceutical manage-ment information system should alert staff toproblems and trigger critical actions on multi-ple levels—whether the problem is related tothe supply chain or to patients’ use of prescrip-tion drugs. Medication systems informaticscould greatly benefit the following areas:

} Prescribing. Clinical decision support to facilitate evidence-based, rational and cost-effective prescribing

} Dispensing. Interpretation, translation andverification of medication orders, includinginformatics and technology in dispensing

} Pharmaceutical care. Chronic disease monitoring, assuring that patients adhere to their medications and that medication ispersistent5

} Administration. Information flow and deci-sion support with electronic medicationadministration and documentation

} Patient monitoring. Pharmacoepidemiology,pharmacovigilance and pharmacoeconomicsto enhance patient outcomes performed on acomplete medication continuum

} Education. Promoting professional andpatient education suited to cultural norms

} Supply-chain management. Beginning withprocurement and proceeding to inventorycontrol, order management and point-of-service delivery

} Monitoring and evaluation. Careful trackingof program performance

Overall, medication systems informaticsenables more routine, systematic data collec-tion and analysis, increased prevention ofadverse reactions to medicines and support forscaling up treatment programs, which is partic-ularly critical in resource-challenged regionswith high disease burdens and co-morbidity.

Revolutionizing Public Health Informatics: Ingredients for Success

Public health informatics (PHI) is a rapidlyemerging field with many successes, butadditional initiative is required to expand thePHI community and its initiatives, particularlyin the developing world. Public Health Infor-

matics conference participants recom-mended the following critical steps toachieve success in these efforts:

1. COLLECTIVE VISION_Create a shared senseof priorities for information and communication

18


technology (ICT) contributions. Adopt a broadecological approach to health, using a systemsview and framing the case for an integratednational public health information capability orfor national health enterprise system architec-ture. To create a collective vision, local accessto information tools and data is vital. Thisapproach requires understanding eHealth inrelationship to the needs of its primary users(health care workers) as well as of its second-ary users (public health officers).

2. ARCHITECTURE_Define the preferred publichealth information system architecture bytaking into account local, district/regionaland national needs. Include necessary com-ponents, connections, players, stakeholdersand human resources at each of these levels.This architecture will inform personal healthcare, population-based services, and healthpolicy at all levels. It will also leverage themost efficient ways to collect, organize andshare routine health information. Such archi-tectures are needed to guide countries instrengthening their own health systems andto guide developers in providing effectivetools to help countries achieve this aim.

3. ARTICULATE IMPERATIVES FOR GLOBAL COOP-

ERATION_Identify the essential contributionsthat can and should be made by global part-ners in public health informatics organization.

4. REGIONAL HEALTH INFORMATICS

CENTERS_Establish a Network of RegionalCenters in Health Informatics based in lead-ing health universities located in resource-constrained countries. Create a long-termfunded program plan for training, researchand development at these centers. In the United States and other developedcountries, these centers bring togetherresearchers, developers, educators andhealth practitioners to work on challengingproblems. Creating such centers at key healthuniversities in resource-constrained countrieswould ensure that training and developmentare contextually and culturally appropriateand relevant to the needs and priorities of thenations in question. Centers like these wouldalso provide a synergistic setting for faculty

(both from health schools and from comput-ers science and information technology pro-grams) to work collaboratively with ministriesof health, public health agencies, nongovern-mental organizations (NGOs), WHO pro-grams, foundations and the private sector.

Models for such health centers exist now orare currently being developed. One is in Peruat Cayetano University, which has a long-standing relationship with the University ofWashington’s division of biomedical andhealth informatics training. A second is anewly created Center for Public Health Infor-matics at Mahidol University, in Bangkok,Thailand. To build necessary synergies and totest various approaches to center develop-ment, five to seven geographically dispersedregional centers should be the goal for initialplanning and development.

Conclusion

Public health informatics tools are enablingpractitioners, regardless of their location andresource level, to obtain a more complete picture of a population’s health and risk sta-tus and gather information from disparatesources. Advancing public health informaticspartnerships and centers of learning—andputting informed and complete technologytools in place— represents the next phase inthe public-health revolution.

Notes

1 Becker SJ, Blank EC, Martin R, Skeels M. Public Health Laboratory Administration. In: Novick LF and Mays GP, eds.Public Health Administration. Gaithersburg, MD: Aspen Publishers; 2001: 623-645.

2 The Health Metric Network Framework 2nd Edition, January2008. Available at: www.healthmetricsnetwork.org.

3 Falkenberg T, Tomson G. The World Bank and Pharmaceuti-cals. Health Policy Plan. 2000 Mar; 15(1):52 8.

4 Disease Control Priorities Project. Available at:www.dcp2.org.

5 Bisson GP et al. Pharmacy Refill Adherence Compared withCD4 Count Changes for Monitoring HIV-Infected Adults onAntiretroviral Therapy. PLoS Medicine. May 2008; Availableat: http://medicine.plosjournals.org/perlserv/?request=get-document&doi=10.1371/journal.pmed.0050109.

19


Capacity building is defined broadly by the United Nations Development Pro-gramme (UNDP) as “the creation of an enabling environment with appropriatepolicy and legal frameworks, institutional development, including communityparticipation, human resources development and strengthening of managerialsystems.”1 There is a shortfall of 4.3 million health care workers worldwide.And capacity needs are often felt more acutely in those countries that have thegreatest health disparities and that are less economically viable. Sub-SaharanAfrica and Southeast Asia are unduly affected, plagued by workforce develop-ment issues, inadequate numbers of qualified health workers, the migrationand departure of skilled personnel, weak infrastructure and a lack of resources.

As health service capacity deficits widen, eHealth tools are increasingly employed to addresscapacity shortfalls. These technologies provide electronic information and training links to ruraland underserved areas and robust clinical data for informed decision making.

The American Medical Informatics Association (AMIA), in conjunction with the InternationalMedical Informatics Association (IMIA), convened eHealth Capacity Building, part of the Rocke-feller Foundation’s Making the eHealth Connection: Global Partnerships, Local Solutions Bella-gio Center conference series. Participants focused on visionary solutions to boost the globalhealth workforce and informatics capacity in the developing world.

Informatics and Capacity Building: Key Issues

Informatics is a scientific field that draws upon the information sciences and related technol-ogy to improve health care, biomedical and clinical research, education, management and pol-icy. Global experts agree that significant capacity-building hurdles must be scaled in thedeveloping world and that informatics and eHealth can be utilized to support these efforts. Intaking action, however, key questions must also be addressed across nations and disciplines:

} What is the current health service capacity and workforce situation in developing countries?

} Who is the workforce? Are they frontline workers, nurses, laypersons, community health workers,physicians, nurses, midwives, librarians or other individuals?

} Do any particular technologies—handheld devices, cell phones, computers with auxiliary memoryor the Internet—hold the key to a capacity leap? If so, what incentives can be employed to increasethe use of these technologies?

eHealth Capacity Building


Chapter 3

} What sectors need the highest level of capac-ity-boosting aid?

} How can eHealth be integrated into degree-granting public health programs and othermedical training opportunities?

} How should capacity-building opportunitiesand collaborative partnerships be targetedand prioritized in the developing world?

Informatics, eHealth and CapacityBuilding: A New Vision

A new model for capacity building in thedeveloping world is emerging that leveragesinformatics and eHealth. Key building blocksfor this new paradigm include the imaginativeuse of beneficial technologies in resource-con-strained environments, the involvement oflocal health professionals in shaping workablesolutions and the inclusion of workforce devel-opment imperatives into overarching strategicplans and policies. Executing this visioninvolves work by an international consortiumof eHealth informatics specialists who can 1)support practice, education, training, policyand research; and 2) educate governmental

and national leaders about the importance ofeHealth capacity and informatics.

A detailed road map for attaining this break-through capacity-building vision, recom-mended by eHealth Capacity Building

conference participants, follows (page 22).

1. Create an international network of eHealthinformatics practice, education, training, pol-icy and research. Fervent pockets of eHealthand informatics activity exist throughout boththe developed and the developing world, butexperts often do not engage in valuable dis-course and skills-sharing that is needed toharvest lessons and wisdom across experi-ments. Strategically growing an eHealth infor-matics network worldwide—but particularly in the developing world—will advance boththinking and practice. At the macro level, conversations between donors and fundersabout developing coordinated initiatives andcollaborative work are critical, as are innova-tive avenues to create a resource bank ofinformatics experts who can be called upon.Health care standards organizations are also

21


key venues for networking, which can pro-vide affordable standards access and invalu-able participation in standards activities.

Centers of Excellence are important anchorsin international eHealth informatics networks.A Center of Excellence is commonly knownas an exemplary academic program that pro-motes innovative research, teaching andlearning practices that distinguish and estab-lish it as a leader in its region and beyond.Because of strategic location and/or theabsence of similar programs within a region,Centers of Excellence are uniquely positionedto be leaders in conducting nationally recog-nized research and in forging partnershipsthat serve community needs.

In relation to international eHealth informat-ics networks, Centers of Excellence provideavenues to develop formal and collaborativeplans for education, training and research.This will create the next generation of leaderswho will spread informatics knowledge, skillsand values. In order to leverage these institu-tions, efforts should be made to accomplishthe following:

} Identify existing informatics Centers of Excel-lence and facilitate their development as cen-tral resources for disseminating informaticsknowledge and skills

} Establish relationships among Centers ofExcellence and develop mechanisms forNorth-South and South-South collaborationand networking to share ideas and resources

} Develop additional infrastructure and boostthe capacity of regional Centers of Excellencein informatics practice as well as applied infor-matics research

An international network of eHealth informat-ics can also be helpful in training. Network par-ticipants can work to develop core informaticssuccess profiles for use in training, in seedingmentored projects, and in building local capac-ity as rapidly as possible. This includes identify-ing people in resource-poor countries who canprovide mentoring and basic education ininformatics; expert consultation that enablesdecision makers to make wise policy choices;and acquisition of informatics tools.

Collective networking and group thinkingabout impact measurement is also an advan-tage of a global eHealth informatics practicenetworks. Together, experts can develop andshare ways to measure eHealth readiness andimpact, using these measures for research inconjunction with implementation projects.

“I would take the e

out of eHealth. eHealth

is just health.”

Paula Otero, MD, Department of MedicalInformatics, Hospital Italiano de Buenos Aires,Argentina

Global South Components of Needs and 20/20 Vision for Assuring eHealth CapacityFrom Silos to Systems

Policy andLeadership

Executive Seminars,

Leadership ID, Training, Advocacy

Human Capital(eHealth Workforce Capacity) Clinician/Public Health Champions

20/20 “Bits & Bytes” Knowledge and Skills Offerings

National Readiness Assessment Instrument, Other Tool Kits

PhD, Masters Informatics

State of ICTTechnology Infrastructure

COMPONENTS VISION FOR eHEALTH WORKFORCE

2. Educate government leaders about theimportance of eHealth capacity and informat-ics to national health and economic develop-ment goals, cultivating and sustainingsupport for eHealth capacity and informaticsactivities. To succeed, eHealth capacity andinformatics efforts must be a key nationalconsideration in an atmosphere of competingeconomic, political and policy priorities. Inachieving this, advocates must inform andteach government leaders about the impor-tance of eHealth strategies in reachingnational and regional health and economicdevelopment goals, while highlighting theoverriding value of a trained, well-educatedeHealth workforce that builds on whatalready exists. Political influence to secureeHealth support must be developed innational budgets. There must also be a grass-roots advocacy strategy to make the eHealthcapacity and informatics case to key stake-holders, politicians, rainmakers and seniorhealth care professionals.

Champions must be cultivated at all levels ina country to support wise policy and strategicdecisions. Effective strategies and policiesshould also be shared across national bor-ders, so that those who have not yet formu-lated policies and strategies can benefit fromthe building blocks developed in neighboringcountries. Business and industry must play avital role in cultivating and sustaining high-level government support for eHealth capac-ity and informatics activities.

3. Develop a blueprint for initiating and exe-cuting activities in resource poor countries to rapidly create eHealth initiatives. Clear yetflexible blueprints for individual countries and for global priorities should be developedto jump-start eHealth, capacity, and informat-ics activity. Health care professionals shouldbe actively engaged in the blueprint process.Blueprints should emphasize demonstrated,scalable solutions and the provision of work-ing tools from which people can derive benefit quickly. Rapid dissemination of les-sons learned in other projects and countries,while being sensitive to local needs, values,and personalities, must also be a priority.

Any eHealth, capacity and informatics blue-print should integrate with and add value to current programs directed toward eradicat-ing disease.

Conclusion

The role of eHealth and informatics in address-ing serious shortages of qualified health service professionals and in building healthsystem capacity cannot be underestimated.An explicit focus on health informatics andeHealth capacity building is critical for improv-ing health service quality and efficiency.Proper training and leveraging of lessonslearned by an international eHealth informat-ics network and the creation of Centers ofExcellence that are linked around the globewill immeasurably advance health care prac-tice, education, training, policy and research.

Notes

1 United Nations Development Programme. Available at:http://www.undp.org/

“I envision a day and

time in Africa when time

and space are irrelevant—

when it is possible to

deliver health services

without silos and address

a population exploding

at a faster rate than the

institutions that are set

up to take care of them.”

Egondu Onyejekwe, PhD, Founder and CEO, EARTHMAP Foundationfor African HIV/AIDS, Federal University of Technology, Nigeria

Information and communication technologies (ICT) combined with wirelessand mobile devices, are strengthening the production, dissemination andglobal use of health information. The increasing capacity of information pro-ducers, intermediaries and users is triggering the explosive growth of easilyaccessible information. However, to take advantage of opportunities created bythese technologies, it is imperative to overcome important inequities in access.Referred to as the digital divide, access inequalities dampen the power of openknowledge exchange and thwart improvements in health, health systems andhealth care, particularly in developing countries.

Key barriers inhibiting equitable health care information access, particularly in developingcountries, include connectivity, language, copyright, economics, visibility, technological literacy,and culture (the need for information to be culturally acceptable and relevant within differentsettings and domains).1

BIREME, the Latin American and Caribbean Center on Health Sciences Information, convenedAccess to Information and ICT, part of the Rockefeller Foundation’s Making the eHealth Connection: Global Partnerships, Local Solutions Bellagio Center conference series. Partici-pants identified catalytic ingredients for the establishment of equitable national and interna-tional policy. They also identified new strategies for promoting the inclusion of developingcountries in global information flows.

Access to Information and Knowledge Sharing: Key Issues and a New Paradigm

As e-solutions to better and more equitable knowledge sharing are identified, key questions areemerging. These include:

} How can information access inequalities best be addressed? Does this require focused priority set-ting or a multipronged strategy?

} How can open-access information resources be more optimally leveraged and promoted?

} What strategies result in quality and consistency when it comes to online health information?

} How can flexible, user-focused, access models and tools be developed that incorporate uniquenational, local and cultural needs?

Access to Information and Health: ICT’s Transformative Impact


Chapter 4

To address these and other challenges toenhancing eHealth, Access to Informationand ICT conference participants agreed that anew environment is needed. Such an environ-ment should enable producers, intermediariesand information users to develop and sharecontent, methods and technologies for theglobal public good. The essential ingredientsof such an environment include the following:

} Open-access tools

} Collaborative and social network-basedapproaches to information and knowledgesharing

} The development of greater national capacity,with recognition of culture and context

} Integration with primary health care activities

} Interoperability through the use of the mostappropriate standards, methodologies andtechnologies

This enabling environment must encouragecooperative development and operation glob-ally, increasing health information use andpromoting actionable knowledge. To do so, itmust include these elements:

1. OPEN-ACCESS INFORMATION AND KNOWLEDGE

TOOLS_Online information knowledgesources and tools developed and adapted byeHealth should be openly accessible and inter-operable in order to fully achieve the objectives

of improving health. The mass digitization ofinformation brought on by digital technologieshas been accompanied by an expansion inintellectual property rights, such as copyrights,patents and trademarks.2 This expansionmakes it difficult and complex to fulfill the idealof equitable access to information and knowl-edge. However, the growth of the open-accessmovement is managing this trend, helping tocreate a freer environment for innovation inhealth. Open access is defined as “free avail-ability on the public Internet, permitting anyusers to read, download, copy, distribute, print,search or link to the full texts of these articles,crawl them for indexing, pass them as data tosoftware, or use them for any other lawful pur-pose, without financial, legal, or technical barri-ers other than those inseparable from gainingaccess to the Internet itself.”3

An open-access article, which is available toanyone with an Internet connection, is highlyvisible because Web search engines indexopen-access repositories and journals.4

Open-access articles are therefore more likelyto be read and cited than articles in subscrip-tion-based journals that come with costsattached to them. This is particularly impor-tant for developing countries, whose scien-tific production faces barriers in becomingvisible and accessible in the classic main-stream indexes.

25


Several initiatives in the developed world pro-mote open access in the health-sciencesdomain, including the Biomed Central PublicLibrary of Science and PubMed Central, whichis spearheaded by the U.S. National Institutesof Health. Developing countries have also putinto practice initiatives that promote openaccess. For more than a decade, in LatinAmerica and the Caribbean, the Latin Ameri-can and Caribbean Center on Health SciencesInformation (BIREME) has been developingthe Virtual Health Library (VHL), whichincludes several networks based on openaccess. A prominent effort in this regard is theScientific Electronic Library on Line (SciELO)which enables developing countries to havefree, full text access to scientific journals.Another important initiative promoted by theWorld Health Organization (WHO) in coopera-tion with private publishers is the HINARI(Health InterNetwork Access to Research Ini-tiative) program, which provides free, or verylow cost, online access to major biomedical lit-erature related to local, not-for-profit institu-tions in developing countries. Nations entitledto free access to HINARI are those with a GNIper capita below US $1250 (World Bank fig-ures). Institutions in countries with GNI percapita between US $1250 and US $3500 paya fee of US $1000 per year per institution.

2. COLLABORATIVE AND SOCIAL-NETWORK

APPROACHES TO INFORMATION AND KNOWL-

EDGE SHARING_Traditionally, the processesof production, dissemination and utilization ofinformation and knowledge were developedseparately, in different locations, by diverseagents and institutions. A transition to a pro-posed social network-based enabling environ-ment with intensive utilization of ICTs isrecommended. This would:

} Allow a more effective integration of theseprocesses

} Promote the establishment of flexible cooper-ative networks among producers, intermedi-aries and users of information and knowledge

The impact on health of collaborative spacesand online communities of practice ismarkedly changing the face of knowledge

dissemination and ICT-enabled communica-tion.5 Knowledge is not static, but is a livingentity that is continually being refined, revisedand supplemented, requiring open accessand social interaction. Social intelligence andcollaborative spaces play a critical role in pro-moting knowledge exchange and knowledgebuilding, helping to develop and implementculturally sensitive and contextually appropri-ate health interventions. To move beyondstovepipe approaches to global healthimprovement will require a plurality of solu-tions in meaningful contexts, a weaving ofthe empirical with the experiential, an integra-tion of the vertical with the horizontal andvested community participation.

Among good examples of collaborative spacesand communities of practice for knowledgenetworking and exchange is the Global Alliancefor Nursing and Midwifery Community of Prac-tice (GANM), which includes more than 1,500nurses, midwives, birth attendants and othersfrom 132 different countries.6 Healthcare Infor-mation For All (HIFA), administered by theGlobal Healthcare Information Network basedin the United Kingdom, is another case in point.HIFA’s goal is to ensure that by the year 2015,every person in the world will have access to aninformed health service provider and that “peo-ple will no longer be dying for lack of knowl-edge.”7 Online Web conferences and meetingsare also becoming a practical solution to bringpeople together online regardless of their geo-graphic locations. Some solutions such as Ellu-minate Live!™ Web conferencing software havebeen used successfully even in contexts withlimited connectivity.

Each of these collaborative spaces has hadsignificant impact on knowledge dissemina-tion in the health realm.

3. DEVELOPMENT OF NATIONAL CAPACITIES_The complexity and diversity of health prob-lems in the developing world require a myriadof solutions. These challenges are local andcontext specific, strongly related to socialdeterminants, such as economic and culturalfactors, living and working conditions andindividual behaviors.

26


A one-way importation of knowledge, fre-quently from the developed world, will notachieve the desired health improvements indeveloping countries, since knowledge dis-semination as a unidirectional process fails to deal with diversity and disregards theimportance of cultural and societal context.Altering the behavior of individuals, commu-nities, and policy makers requires multi-direc-tional considerations and involves flexibilityand compromise.

The need to find adequate solutions accordingto local context requires developing countriesto strengthen national capabilities and insertthemselves in a conscious and sovereign wayin the global flow of information. It is impera-tive that these nations become involved ininternational cooperative networks to produce,analyze and adapt this information to their spe-cific needs. Access to health information, as a

social determinant of health, is a basic tenet of

national growth and development.

Instead of the unilateral transfer of knowl-edge, international and multilateral agenciesshould focus on technical cooperation activi-ties in supporting national efforts to developthese capacities.

4. INTEGRATION WITH PRIMARY HEALTH

CARE_Information and knowledge-sharinginitiatives that implement a social networkedenabling environment should be supportedby wide community participation, appropriatetechnology and the integration of health pro-motion, disease prevention and medical care.Together with universal access, equity andsocial justice, these are the basic principles ofprimary health care (PHC), making PHC set-tings, actors and activities an ideal environ-ment for the development of these initiatives.

The proposed social network-based enablingenvironment can help update the PHC strat-egy by supporting the following:

} The production and dissemination of informa-tion, knowledge and scientific evidence per-taining to local historical, geographic andcultural conditions

} Proactive participation by different segments ofsociety in defining public policies and in gener-ating, adopting and using health innovationsthrough new forms of social organization suchas networks of professionals and communities

As eHealth grows in its reach and sophistica-tion, the ability of these tools to supporthealth equity and to level the information andknowledge playing field is limitless. If usedthoughtfully and in a context that recognizesnational, regional, educational, cultural andother differences, knowledge sharing canexpand in the health care sector, improvingcare through international cooperation.

Notes

1 Pandita N, Singh S. Barriers to Equitable Access to QualityHealth Information with Emphasis on Developing Countries. In:at Making the eHealth Connection: Global Partnerships, LocalSolutions. Rockefeller Foundation's Bellagio Center in Bellagio,Italy, July 13 to August 8, 2008. [cited 2008 Nov 27]. Available from: http://www.ehealth-connection.org/files/conf-materials/Barriers%20to%20Equitable%20Access_0.pdf

2 Wilbanks J. Intellectual Property and Access to Information.In: Making the eHealth Connection: Global Partnerships, LocalSolutions. Rockefeller Foundation's Bellagio Center in Bellagio, Italy, July 13 to August 8, 2008. [cited 2008 Nov 27]. Available from: http://ehealth-connection.org/wiki/images/a/a3/WilbanksJohn--2008.pdf

3 Open Society Institute Budapest Open Access Initiative Definition. Available from:http://www.earlham.edu/~peters/fos/boaifaq.htm

4 Lyon B. Access to Equitable Access to Quality Health Infor-mation with Emphasis on Developing Countries (narrative,with case studies). In: Making the eHealth Connection: GlobalPartnerships, Local Solutions. Rockefeller Foundation's Bellagio Center in Bellagio, Italy, July 13 to August 8, 2008. [cited 2008 Nov 27]. Available from: http://ehealth-connection.org/wiki/images/2/21/RoyallJulia-LyonBecky--20080717.pdf

5 Abbott, P, Urra P. Knowledge Networking: Social Networks to Share, Create, Disseminate and Use Information, andKnowledge to Enhance Health. In: Making the eHealth Con-nection: Global Partnerships, Local Solutions. RockefellerFoundation's Bellagio Center in Bellagio, Italy, July 13 toAugust 8, 2008. [cited 2008 Nov 27]. Available from:http://ehealth-connection.org/wiki/index.php?title=Knowledge_Networking:_Social_networks_to_share_%2C_create%2C_disseminate_and_use_information%2C_and_knowledge_to_Enhance_Health

6 Abbott, P., Coenen, A. Globalization and Advances in Informa-tion and Communication Technologies: The Impact on Nurs-ing and Health. Nursing Outlook, 56:238-246.

7 Healthcare Information For All. Available at:http://www.hifa2015.org.

“Information is necessary

to make informed

decisions about health.

The importance of

technology to aggregate

information for the

patient is so important

for safety and efficiency.

This is not spending

money but investing

money [in technology]

to get a return in health

and efficiency.”

Alvaro Margolis, MD, MS,Vice President for Latin America and the Caribbean, International Medical Informatics Association, Uruguay

Making the eHealth Connection: Global Partnerships, Local Solutions, amonth-long conference series at the Rockefeller Foundation Bellagio Center

in Italy, in 2008, addressed key issues for advancing eHealth and improving healthin the developing world.

We, the participants of the conference on the theme of Access to Health Informa-tion and Knowledge-Sharing, organized by the Caribbean, the Latin American andCaribbean Center on Health Sciences Information (BIREME) with the support ofthe Rockefeller Foundation, during the week of July 20 to 24, agreed to the follow-ing summary report on the conclusions of the meeting.

Recognizing that:

1) Health information and knowledge are social determinants of health sinceinequities in access to information and knowledge generate and/or increasehealth inequities. This creates unjust, unnecessary and avoidable differencesin the health conditions of individuals and population groups.

2) Health information policies should be part of health policy in order to strengthenthe use of information, knowledge and evidence in decision making.

3) eHealth comprises health promotion, disease prevention and care to improvehealth conditions and equity. Involving different stakeholders with differentinterests and needs, this requires a plurality of solutions in meaningful contexts.

4) National and global research programs are essential to identify informationneeds, to recognize barriers to the access, translation and use of informationand to evaluate the impact of information and knowledge-sharing interven-tions on health outcomes.

5) The implementation of global eHealth initiatives should be based on partner-ships involving various national and international players.

6) eHealth must be used to overcome barriers to access and barriers to the useof quality health information. It must also be used to facilitate the conver-gence of initiatives, products and solutions.

28


Bellagio Center Declaration on Access to Information and Knowledge Sharing

7) Priority should be given to settings where the production of information andknowledge is weak, and where access to it is limited.

8) The information and knowledge sources and tools developed and adapted byeHealth should be openly accessible and interoperable via adequate methodsand technologies.

9) Information and knowledge sharing should be implemented through commu-nity participation, appropriate technology and the integration of promotion,prevention and care as a primary health care approach.

10) Human resource capabilities should be expanded to incorporate skills forhealth information and knowledge management and sharing that meet theneeds of different users, applying appropriate standards, methods and tech-nologies.

We commit ourselves to mobilizing efforts and resources toward the creation ofan environment that will serve the global public good and that will enable produc-ers, intermediaries and users to develop and share content, methods and tech-nologies. This new environment will increase the use of health information andpromote knowledge sharing with a focus on international cooperation for thedevelopment of health-information infrastructure and human resources.

We call for the creation of a task force with representatives from key stakehold-ers and donors. This task force should establish a plan of action for the implemen-tation of this health information and knowledge sharing.

We urge national and international organizations, funding agencies, the privatesector, governments and institutions to become our partners in this endeavor.

24 July 2008

29


Mobile electronic health tools such as cell phones and telemedicine technolo-gies are rapidly transforming the face and context of health service deliveryaround the world. Currently, there are more than 3.5 billion mobile phones inuse across the globe—a figure that is set to double in the next decade. At thesame time, telemedicine’s role in clinical care, education, research and trainingin the health sector continues to grow from continent to continent.

Mobile phone use, in particular, is exploding across the developing world, offering the opportu-nity to leapfrog other applications and services on both the health and technology fronts. AsUnited Nations Foundation President Timothy E. Wirth emphasizes, the power of these tech-nologies to improve health and the human condition cannot be underestimated: “Moderntelecommunications, and the creative use of it, has the power to change lives and help…solvesome of the world’s biggest challenges.”

Mobile health information technology (mHealth) typically refers to portable devices with thecapability to create, store, retrieve and transmit data in real time to improve patient safety andthe quality of care. The flow of mobile health information is characterized by portable hardwarecoupled with software applications and patient data that travels across wireless networks.Data transmission is realized by technologies common in everyday life, including Bluetooth,cell phone, infra-red, WiFi, and wired technologies, all of which operate as part of a network.mHealth deployment is diverse. A clinician can use a mobile device to access a patient’s elec-tronic health record (EHR), write and transmit prescriptions to a pharmacy, interact with patienttreatment plans, communicate public health data, order diagnostic tests, review labs, or accessmedical references, for example.

The United Nations Foundation, the Vodafone Group Foundation, and the Telemedicine Societyof India jointly convened mHealth and Mobile Telemedicine, part of the Rockefeller FoundationMaking the eHealth Connection: Global Partnerships, Local Solutions Bellagio Center conferenceseries. Participants focused on methods for harnessing the spread of mobile technology and itspower to transform health and information exchange.

mHealth and Mobile Telemedicine: Key Issues

Experts predict that the impact of mHealth is likely to be more far-reaching than other develop-ments, such as nanomedicine and genetic therapy, as it will create an urgent need to reviewthe way health care is financed and as it will blur the boundaries between professional medical

mHealth and the Future of Medicine


Chapter 5

help and so-called “do-it-yourself” medicine.Key issues as mHealth moves forward, partic-ularly in developing world settings, includethe following:

} mHealth markets and scaling

} Imperatives for national-level health data collection processes through mobile devices

} Exploring critical success factors and incen-tives for local implementations

} Given mHealth's rapid progression, the immediate seeding of a multi-sector partner-ship dedicated to designing, funding andadvancing mobile service projects

Also at play are these issues:

1. INFORMATION ACCESS AND USE_The management of information emerges as an important challenge. Key to the successfulimplementation of mHealth is the availabilityof the right information at the right place, at the right time and in the correct form. Medical practitioners and patients must befree to roam and to utilize different access devices (in terms of both communication

characteristics and display and processingcapabilities). New challenges will arise, how-ever, regarding the secure and reliable deliv-ery of information from a variety of sourcesand in a multitude of formats (from plain messages to multimedia content). Critical tothe successful handling of supporting infor-mation are monitoring devices, health caredatabases, communication networks andaccess devices.

2. COMMUNICATION NETWORK SOPHISTICA-

TION_The variety and complexity of mHealthapplication scenarios calls for the combineduse of wireless technologies (both short- andwide- range), wired communication back-bones and the Internet in a seamless, secureand reliable way. The employed wireless technologies include Bluetooth, wLAN, WiFi,GSM/GPRS, UMTS and satellite communi-cations (VSAT, DVB-RCS). The difficulty ofachieving operational compatibility betweenthe telecommunication services, terminalsand devices continues to be a challenge formHealth applications.

31


Although high-speed digital communicationinfrastructures are gradually gaining ground,it is often the case that the regions that wouldbenefit the most from electronically deliveredhealth care are underserved in termstelecommunication capabilities. High-speedcommunication networks are still far frombeing a reality in many remote rural areas indeveloping countries. This limits the optionsfor telemedicine, as many services can onlyfunction well under specific conditionsrelated to communication capabilities. Manytelehealth applications rely on high-speedbroadband IP networks to deliver high-quality,timely and converged voice, video and data.

3. ACCESS LIMITATIONS_mHealth employs amultitude of both wired and wireless-accessdevices, e.g. portable PCs, cellular phonesand personal digital assistants (PDAs). Eachone of these appliances has its own limita-tions, in screen size, processor power, mem-ory, bandwidth and battery life. The servicecapabilities of each device vary depending onthese characteristics.

Clinicians should be particularly aware of theaccess limitations of the devices employed,what amount of information they can provideand how well they can display it. Screen sizeand digital imaging technologies are particu-larly important in some highly visual telemedi-cine applications, such as tele-radiology,tele-dermatology and tele-pathology. Fortu-nately, technologies currently available pro-vide excellent pixel density and resolutionwith a high rate of diagnostic agreementbetween digital and real images, as demon-strated in the scientific literature.

4. UNIFYING INFORMATION SOURCES_Ideally,the entire medical profile of a patient (med-ical history, results of laboratory tests, etc.)should be retrievable at the point of care atthe touch of a button. Yet, the decentralizedmulti-actor nature of health care and the widedistribution of relevant data sources have pro-duced a patchwork, in terms of content anddatabase implementation, that makes accessto and retrieval of data from repositories areal challenge. Consequently, new mobilehealth applications must focus on the integra-tion and exploitation of heterogeneous scien-tific information databases in a seamless way.This will enable the storage, updating, searchand retrieval of useful information.

mHealth and the Transformation ofHealth Service Delivery

Telecommunications growth in developingcountries over the past five years has beentremendous. In 1998, India and China hadless than 1 million and 25 million mobile subscribers, respectively. By early 2008, both countries were adding 8 to10 millionsubscribers per month. This outpaces theUnited States, where growth is around 1.6million subscribers per month, and Japan,where the corresponding figure is less than 1 million. In fact, the majority of mobile-sub-scriber growth over the next 10 years willcome from the developing world. In 1998,developed nations accounted for more than 76 percent of mobile subscribers world-wide By 2018, only 19 percent of mobile subscribers are expected to come from developed nations.

One of the most important areas that mobiletechnologies are primed to affect in bothdeveloping and developed countries is healthcare. Mobile technologies do two things well:compress time and distance. Thus, they con-nect, enable, and empower participants in thehealth care ecosystem to reduce costs anderrors while increasing productivity, access,and efficiency. mHealth and Mobile Telemedi-

cine conference participants concluded thatmobility and mHealth will affect health caredelivery in the following critical areas:

32


1. GLOBALIZATION OF HEALTH SERVICE

DELIVERY_In an interconnected world, healthservice delivery will be much more decentral-ized and much more widely distributed. Thelocal clinic might be responsible for monitor-ing vital signs, but the analysis and prognosismight come from a physician thousands ofmiles away. You might be lying on a bed inKuala Lumpur, but your surgeon could be inStockholm on video conference with expertsfrom Cambridge and Chennai. Real-timetranslation capability would mean languagewill not be an issue in the future.

2. REMOTE CARE AND MONITORING_Given thecost of access and administration, there will besignificant investment in sensor technologynear or on the patient. There will also be signifi-cant funding of the communication infrastruc-ture that connects both medical data fromsensors and the patient to physicians and theirstaff. For example, the German firm Biotronichas developed a phone that communicateswith a pacemaker using close-range radio fre-quency and then transmits data over a cellularnetwork to the physician in real time.1,2,3

Remote care will revolutionize how expertiseand drugs are delivered in rural parts of theworld. They will also decrease the cost ofequipment and care.

3. ALERTING_The mHealth solutions that willbe most replicable will be those that are bothstraightforward and ubiquitous. A simplealerting capability can help reduce costs andincrease efficiency in every country. Fromreducing the number of missed appointmentsand missed medications through proactivepatient monitoring4 to alerting end-users inthe case of an epidemic or an emergency,messaging and alerting technologies willremain an integrated part of the health caresystem for years to come.

4. EARLY DISEASE DETECTION_There is plentyof research to show that if a disease isdetected and treated early, costs and morbid-ity rates are greatly reduced. If the impact ofthe therapy can be monitored in real time andadjusted as needed, markers in the humanbloodstream can allow physicians to follow

the disease and transform medical prognosesinto more evidence- and performance-basedtreatments.

5. DATA COLLECTION AND RECORD MAINTE-

NANCE_Current health care interactionsoften require that patients fill out countlessforms and other paperwork. By automatingdata collection for patient trials or monitoringand digitizing the medical records for furtherprocessing, significant cost savings can berealized. Enormous computing power andGbps (Gigabits/second) network connectionswould mean data can be collected, analyzed,and understood in real time from almost any-where on the planet.

6. WELLNESS AND INFORMATION AWARENESS_We now have the potential for instantaneousaccess to information and the capacity to usedevices to monitor and record vital signs atthe touch of a button. This ease of use canincrease the desire of individuals to stay fitand healthy as well as improve preventativeregimens. In addition, the ability to networkwith friends, family and patients with similarexperiences will help create a better environ-ment for sharing information.

7. GUIDANCE IN EMERGENCY RESPONSE_Theeffectiveness of medical responses to emer-gencies is determined by speed and by thelevel of clear communication. By coordinatingwith application platforms and operators, com-mand centers can issue very specific guidance,informing end users about what to do, whichroute to take, how to contact authorities, and,based on real-time modeling, what to expect inthe next few minutes or hours.

8. PREVENTING PHARMACEUTICAL COUNTER-

FEITING AND THEFT_A major challenge, especially in developing countries, is thatmedications are essentially a form of cur-rency for criminals. Sensors (monitoredremotely) placed on drug shipments can helpensure that a medication reaches its intendeddestination without tampering. Sensors canalso help maintain or monitor the environ-mental conditions necessary for certain drugsto be effective.

“The potential for devel-

oping countries to become

centers of innovation for

eHealth is exciting. They

don’t have to contend

with all the legacy issues,

can start with best prac-

tices and there is such

energy and talent devoted

to this problem. I think

the sky is the limit as far

as what the potential out-

comes will be.”

Karl Brown, MIA, Associate Director,Applied Technology, Rockefeller Foundation,United States

are installed and used depending on the dif-fering needs of various locations and situa-tions. In addition, the patient informationsystem records the name of the disease andthe findings of the physician, the diagnostictests used to measure the grade of illness, theresults of these tests and the type andmethod of treatment.

The system can also record information suchas the patient’s address, occupation, maritalstatus and age. In the hospital or doctor’soffice, data sent in various formats can now beprocessed collectively. Data exchange can beperformed via both pocket radio GSM/CDMAcellular phones and fixed-line telephones. Theexchange of information can occur with dedi-cated software based on the TransmissionControl Protocol/Internet Protocol (the basiccommunication language of the Internet), andthe means of communication can be adaptedto the local infrastructure.

This ongoing pilot project has allowed peoplein rural areas and other locales far from hospi-

9. MODELING AND PREDICTING DISASTERS_Significant effort must be put into modelingand predicting emergencies, from diseaseepidemics to terrorist attacks to wildfires toearthquakes. How will an evacuation plan bedirected? How will affected citizens beinformed? What if the sensor networks fail?And how will modeled data be fed into a real-time emergency response system?

mHealth in Practice: Indonesia’s Mobile Telemedicine System

The United Nations Development Programmehas endowed a new mobile-health initiative inSukabumi, Western Java, in Indonesia. It isrun by the Institute Teknologi Bandung, theHealth and Medical Bureau, district authori-ties, three hospitals and 71 community healthcenters. The system utilized in this projectemploys existing Internet communicationequipment and has been operating with theprimary objectives of telediagnosis, remoteconsultation and the collection and recordingof patient information. Medical instruments

34


tals to receive periodic medical examinationsusing cellular phones. Furthermore, the staffof small hospitals can now receive criticalinformation formerly available only in largermedical settings, such as specialists’ diag-noses of rare diseases or advice about thetreatment of advanced illnesses.

Conclusion

mHealth holds great promise for better publichealth and medicine in both the developedand developing worlds. There is a rapidlygrowing mhealth eco-system, but movingfrom proof of concept demonstrations toeffective deployment of these technologiesrequires overcoming a series of challenges.The conclusion of the mHealth week at Bella-gio was to establish an “mHealth Alliance,”which was announced in February, 2009, atthe Mobile World Congress. The purpose ofthe Alliance is to foster mHealth, build part-nerships, undertake advanced trials, andadvocate for appropriate public policies. Itsmission is to help drive mHealth to sustain-able scale at the farthest reaches of wirelessnetworks. The Rockefeller Foundation, theUnited Nations Foundation, Vodafone Foun-dation, and the U.S. President’s EmergencyPlan for AIDS Relief (PEPFAR) are the found-ing donors. The Alliance is rapidly attractingsupport from a wide variety of quarters as itbegins to implement its strategic focus onboth information and implementation.

Notes

1 The Emerging Personal Health Information Network, InsideEdge, September 2007, Volume 13, Number 8.

2 We will also see health care-specialized devices with wire-less connectivity like the ones from CardioNet, a UnitedStates-based company.

3 Many phones already have biometric sensors for authentica-tion. We will be using these same sensors and additionalones to monitor vital signs and transmit them. Some of theinnovative concepts being worked on are measuring heartrate with a cell phone and using the measurement forauthentication for other purposes like banking and payments.Pharma companies are likely to use bar codes and NFC(near-field communications) to provide more information onlabels and drugs so users can just scan the labels from theircell phones and get relevant information or instructions.

4 Research shows that poor adherence leads to increased drugresistance. For example, if a patient with tuberculosis takestreatment once a week rather than the prescribed regimen oftwice a week for the duration of the treatment, the risk of apositive culture at 12 months is five times greater. Source:The Role of Mobile Phones in increasing Accessibility andEfficiency in Healthcare, The Vodafone Policy Paper Series,Number 4, March 2006.

“All over Africa and

Asia, countries started

putting in networks with

high-density coverage

for voice and data. The

tables have turned. The

developing world has

very advanced infrastruc-

ture for communications

whereas many parts of

the developed world

are playing catch-up.”

Anand Narasimham, PhD,Co-Founder and Chief Technology Officer, Voxiva, Inc., United States

Electronic medical records (EMRs) are increasingly deployed in countries acrossthe globe. They enable critical, real-time information services that empowerboth patients and health care workers. Just a few years ago, the use of EMRs inresource-poor, developing nations was experimental at best. Few organizationsbelieved that using EMRs was realistic in these regions and fewer still haddeployed such systems. Times are rapidly changing. Information technology ismore widely available in resource-poor areas, and it is allowing health advocatesto tackle difficult challenges such as managing HIV/AIDS and drug-resistanttuberculosis. Successful EMR projects are now operating in such diverse localesas Zambia, Peru, Haiti, Rwanda, Kenya and Malawi. Future expansion is pre-dicted. The global market for electronic medical records is expected to grow anastounding 23.8 percent by 2012, including EMR projects in both the devel-oped and the developing world.

The Regenstrief Institute, Inc., and Partners In Health jointly convened The Promise of Elec-tronic Medical Records: An Overview, part of the Rockefeller Foundation’s Making the eHealthConnection: Global Partnerships, Local Solutions Bellagio Center conference series. Participantsmade recommendations for the broader use of EMRs in the developing world.

Electronic Medical Records: Key Issues

An electronic medical record is defined as a longitudinal collection of electronic health informa-tion that provides immediate, authorized access to person- and population-level data to supportefficient health service delivery processes.1

While EMRs hold great promise, few studies have been conducted to measure the actualimpact of using them to improve the quality, access or affordability of health care, particularlyin developing countries. And much work remains to determine the right mix of ingredients for a workable, culturally appropriate EMR. Other key questions also relate to electronic medicalrecord technologies used in developing countries. These are:

} What should be built into EMR systems (e.g., reports, patient summaries and analyses needed bylocal teams)?

} What is the appropriate level for EMR systems to be deployed—national, district or clinic?

The Promise of Electronic Medical Records


Chapter 6

} What collaborative EMR approaches can be used to improve data quality, collectionand tracking?

} How can EMRs be funded and what incentivescan increase their usage?

} How can EMR infrastructure, technical support and capacity-building challenges be overcome?

Open-Source EMRs and the Developing World

Open-source environments enable computerprogramming code for a technology to befreely available for everyone to use and tocustomize for their purposes. The intent is toencourage the development of products thatare more understandable, modifiable, replica-ble, reliable and accessible. Open-source soft-ware allows interested individuals to producea new software version, share it with others,and/or market it. Implementers use open-source strategies because they can be costeffective, adaptive in addressing local needsand flexible in design, development and distri-bution. They enable governments and com-munities to play a central role in meeting thedemands of health care services.

The Open Medical Record System (Open-MRS¨) is one example of how open-systemsoftware principles and tools can be success-

fully deployed in challenging environmentssuch as Africa and South America. OpenMRSis a multi-institution, nonprofit collaborativeled by the Regenstrief Institute, Inc., a world-renowned leader in medical informaticsresearch, and Partners In Health, a Boston-based philanthropic organization with a focuson improving the lives of underprivileged peo-ple worldwide through health service andadvocacy. These teams nurture a growingglobal network of individuals and organiza-tions all focused on creating medical recordssystems and implementation networks thatenable system development and self-reliancewithin resource-constrained environments.OpenMRS has been implemented in severalAfrican countries, including South Africa,Kenya, Rwanda, Lesotho, Zimbabwe, Mozam-bique, Uganda and Tanzania.

OpenMRS is an application that enables thedesign of a customized medical records sys-tem by those with no programming knowl-edge. It provides a common framework tobuild medical informatics efforts in developingcountries. OpenMRS is based on the principlethat information should be stored in a waythat makes it easy to summarize and analyze,with minimal use of free text and maximumuse of coded information. At its core is a con-cept dictionary that stores all diagnoses, tests,

37


procedures and drugs—as well as generalquestions and potential answers. OpenMRS isdesigned to work in environments wheremany client computers access the same information on a server. It aims to providecomprehensive information for programmers,developers, medical records implementersand users. When combined with standardsconsensus, consistency, clinical mapping andknowledge modeling, OpenMRS can achievepositive health care outcomes. It is just oneexample of EMRs successfully and efficientlyimproving health in the developing world.

Migrating Towards a Robust, Integrated EMR Framework: Essential Ingredients

Progress toward broader deployment of inte-grated, workable eHealth solutions in thedeveloping world requires many importantactions. These include creating an implementa-tion toolkit; developing adaptable, interopera-ble and scalable software; and fosteringcommunities to support local grassroots initia-tives, while linking them to other projects andorganizations that can provide technical, finan-cial and training support. A cradle-to-graveapproach supported by project tools is neces-sary to achieve effective results.

Participants in the Electronic Medical Records

conference made recommendations for thecreation of a new toolkit that could support theeffective assessment, implementation andongoing support of electronic medical records.Toolkit elements would be featured live on awiki-enabled Web site so that critiques andmodifications would be made and would bevisible online. Recommended tools include the following:

1. POLITICAL_Tools must address the politicalclimate of the environment so that key stake-holders and motivators are clearly identified.This includes assessing the regulatory envi-ronment and governmental issues. Any legalor political constraints need to be identifiedup front.

2. ENVIRONMENTAL_The physical environ-ment is a key constraint in the deployment oftechnology and could be a critical componentdefining or limiting the sophistication of thesolution to be tapped. Assessments for tap-ping and stabilizing energy or power sourcesare essential, as is gauging the accessibility ofthe community served. Other considerations,such as temperature and humidity, may havea major effect on the technical solution thatmay be utilized.

38


3. SOCIAL_Social tools assess human rela-tions and associated dependencies includingrequired staff. The project owner, along witheverything else that is needed to successfullyrun and manage the project, will be identified.Readiness of the users is a key success factor.The creation of a communications plan,regardless of how rudimentary it might be, isalso essential to the success of a project roll-out. The initiation of a training program is alsovital. Critical considerations include training,staffing and planning tools that take turnoverinto consideration.

Evidence in developed countries demon-strates that involving potential EMR usersfrom the beginning is crucial for gainingacceptance of the necessary changes. Thiscould be as simple as announcing the projectin the health care facilities as early as possi-ble. It could be as involved as inviting futureusers to be part of the system design andimplementation. By the time equipment andsoftware arrive at a health facility, futureusers should already have at least someknowledge of their benefits.

4. TECHNOLOGICAL_An information strategy isdeveloped, followed by a needs assessmentto help map what features and work flow are

“One of the biggest

challenges we face for

patients with HIV/AIDS

or tuberculosis is

continued care over

long periods of time.

Previously, there were no

tools to monitor across

sites and multiple visits.

But now, with open

source medical records,

we can bring all of this

information together in

a way we could not

have dreamed of before.”

Aamir Khan, MD, Executive Director, Interactive Research andDevelopment, Pakistan

needed. Required technology solutionsemerge once these activities are completed. A tool to perform a gap analysis must then be used, since customization of standard solutions is usually required. Tools needed for configuration, scaling, deployment andimplementation should be considered.

5. EVALUATION_Donors require confirmationand evidence that their investments are mak-ing a difference. Therefore, implementers willneed tools to measure the baseline (at theonset of the project) and the project’s progressagainst that baseline. They will also need amechanism for reporting results. Evaluationdata, even if only from an exploratory assess-ment, may also be crucial in winning from thesupport of local staff. Capacity-building educa-tion and training around evaluation methods isalso critical, as consistency in reporting is ofparamount importance.

6. PERCEIVED VALUE ASSESSMENTS_Assess-ment tools measuring success objectives areimportant for ongoing project viability. Unlessthe users see value for the systems that havebeen installed, they will not use them.

7. SUPPORT_Before, during and after the systems are installed, support for the users is required in the form of education and

training as well as technical support for creating patches, fixing bugs, and releasingnew initiatives.

Seeding and Sustaining EMR Solutions:Collaborative Action Networks

The most successful EMR projects prioritize adirect, supportive working relationship withdevelopers, implementers and end users inthe countries where systems are deployed.These community-based networks simultane-ously meet the specific needs of end usersand aim to teach proficiency in software andproject approaches in order to encourageself-maintenance.

The Health Information Systems Project(HISP), based largely in Norway and SouthAfrica, has particular experience with suchefforts. HISP describes the evolution of “col-laborative action networks” within its commu-nity as the focal points of implementationgrowth within a given country. The OpenMRScommunity has also had success with suchnetworked approaches, and has built a robustcommunity of worldwide developmentexpertise. Instead of exerting a primarily top-down approach to large-scale implementa-tion, these efforts enable communities toform around solving larger problems. A

40


Collaborative Action Network (CAN) such asthis could offer support for eHealth and EMRsin the developing world. A CAN approachacknowledges challenges in developing environments. These include:

} Insufficient human capacity—both from anexpertise and an ownership perspective

} Mistrust within developing environmentsabout the motivations of individuals/organizations who come in and deploy systems from “outside;”

} A legacy of failed top-down technologydeployment attempts

WE-CAN (World eHealth CollaborativeAction Network)

EMR conference participants envisioned theformation of a World eHealth CollaborativeAction Network (WE-CAN) to enable supportfor ideas to flow both from the bottom up andfrom the top down. CAN organizations can beformed at many different levels and are self-organizing around an idea, a work require-ment or a system. CANs can interlink and/orsubsume one another. They embody the concept of a community of communities.

Guidance and leadership for WE-CAN shouldincorporate developing world country repre-sentatives, existing or emerging collabora-tions (project level CANs), industry leaders,donors and others. The goal of WE-CANwould be to create a global marketplace foreHealth through collaboration, best practicesand standards-based interoperable systems.

What is needed to create and sustain the WE-CAN initiative includes:

} Governance body: A board of directors or secretariat to provide basic guidance and support of the community.

} Online technologies: A series of technologies(wikis, blogs, forums, mailing lists, etc.) thatallow communities to self organize.

} Face-to-face meetings: Opportunities for com-munities to meet with one another are centralto community growth and coordination.

} Community mandate: The notion of WE-CAN needs to be supported and understood

at the highest levels in order for it to succeed.Therefore, educating decision makers will be essential.

} Core support for CANs: As these self-formingorganizations are asked to serve greater func-tions for the world, they will need resourcesto properly scale their endeavors. They willneed appropriate management, financialresources and mentorship opportunities.

} Reference implementations: In-countrydemonstration projects or reference imple-mentation of one or more EMR systems usingstate-of-the-art techniques and principles willhelp facilitate the application of current think-ing and a harvesting of lessons learned. Theseshould be supported by in-country Centers ofExcellence.

Conclusion

Canadian eHealth pioneer Richard Alvarezobserved that “the last 12 months could bedubbed the international year of electronichealth records, as electronic health informa-tion systems have been identified as a criticalingredient for reinvigorating health care incountry after country.”2

The promise of electronic medical records inthe developing world is great. With coopera-tion for the greater good, innovative collabo-ration networks can abandon top-downapproaches in favor of workable, customizedsolutions built on lessons learned. Confer-ence participants noted an old African saying:“I am who I am because of who we all are.”Apply this principle to the promise of EMRand the number and intensity of initiativeswill continue to grow.

Notes

1 U.S. Institute of Medicine, Patient Safety: Achieving A NewStandard of Care, November 2003.

2 Alvarez, R. Health Care Has to Move into the Hi-Tech Age.Bull World Health Organ [online]. 2005; 83, 5: 323-323.

“We are facing a

generation in the Global

North and South that is

increasingly comfortable

with mobile phones and

computers. We need to

bring those who are

‘born digital’ into the

equation now. They

absolutely need to be at

the table.”

Sherrilynne Fuller, PhD,School of Public Healthand Community Medicine,University of Washington,United States


Chapter 7

eHealth is a now recognized as a key enabler for supporting health systems theworld over as they strive to deliver good health and wellness. Policy is a unify-ing element in eHealth. Developed appropriately, it can help clear a path forsound adoption of technological solutions and enable countries with similarchallenges to share resources and lessons learned across international borders.

eHealth policy is concerned with solutions that support capacity building and provide servicesthat improve health outcomes. Policy boundaries are defined by socio-economic, financial, cul-tural and institutional conditions; by human and material resources; and by organizational andmanagerial models. While health may be a domestic matter, the networked nature of eHealthcreates a new paradigm for it, as a global matter. Local and national development of eHealthpolicy must occur in a global context, and vice versa—or from a “Glocal” perspective.

To advance dialogue and consensus in the global eHealth arena, the World Health Organizationconvened National and Global eHealth Policy, part of the Rockefeller Foundation’s Making theeHealth Connection: Global Partnerships, Local Solutions Bellagio Center conference series.Participants were asked to form new ideas and frameworks that support the proliferation ofsound and sustainable eHealth policies in the developing world and internationally.

Glocal eHealth Policy: Key Issues

eHealth policy is a new and rapidly expanding field. Nearly 100 eHealth policy issues havebeen identified to date. Yet progress in resolving these issues in developing countries and onthe international stage lags far behind. Achieving needed consensus on these issues andadvancing to the next stage of eHealth policy development requires answering some key ques-tions:

} What eHealth policy issues and gaps exist?

} How can the full spectrum of eHealth policy issues, from local to global, be captured?

} What eHealth policies already exist? Are they applicable in developing-world contexts?

} Which global outcomes indicators can provide evidence and insight to guide policy development?

} Which organizations should take the lead in eHealth policy development on the regional, nationaland global level? How can cooperation between these bodies be encouraged?

“Glocal” eHealth Policy

eHealth Policy: Conquering the New Digital Divide?

eHealth policy has been defined as “a set ofstatements, directives, regulations, laws, andjudicial interpretations that direct and managethe life cycle of eHealth.”1 The idea of havingan eHealth policy is still relatively new, yetmore than half of the countries in the worldalready have some form of eHealth policy,strategic plan, road map or action plan, how-ever basic or nascent. This number is expectedto rise above 85 percent within three years.Early eHealth policy adopters include Australia,Canada, China, Croatia, Denmark, Finland, Iran,Malaysia, Malta, New Zealand, Russia, Singa-pore, South Korea, Sweden, Taiwan, Tanzania,Thailand, the United Kingdom, Vietnam andthe United States.2

eHealth policies, strategies, and road mapsalready drafted cover a wide range of issues,but there is little commonality in what the poli-cies aim to achieve. This is in part due to differ-ent levels of maturity in the eHealth field, thefact that issues that have already beenaddressed in one nation may still be a goal tobe achieved in another, and different interpre-tations of terms such as an electronic medicalrecord. Issues including standards, interoper-ability and data security are often stated asimportant components of eHealth policy, butin reality, these issues are being dealt with atan international level by other agencies andare ever-changing as technology evolves.

In the developing world, eHealth expectationsand requirements are somewhat different.The developed world looks to provide serviceslike eCards and grapples with how to reducethe health care costs of an aging populationby introducing home care and keeping peopleout of hospitals. Meanwhile, the developingworld is examining how to find ways of over-coming extreme shortages of health careworkers and improve rural health care, whileat the same time improving or implementingelectronic health information systems. Whatseems perfectly acceptable and correct in thedeveloped world, in terms of data quality andpatient confidentiality, may be major impedi-ments in the developing world.

Attention needs to be directed toward inter-jurisdictional policy issues that will enableand facilitate patient mobility, data mobilityand sharing, both across international bor-ders and regional boundaries within coun-tries.3 Developing countries already findthemselves disadvantaged in respect toaccess to eHealth, human resource capacityand economic capacity. They require assis-tance with the creation of relevant policiesand strategies. They also need standardsappropriate to their socioeconomic condi-tions and infrastructure. Crafted effectively,eHealth policy will draw developing countriesinto the fold and enable them to furtherengage with the international community and enjoy the benefits of global eHealth.

eHealth Policy Issues: Emerging Consensus

Discussions between ministers of health andtechnology on different continents are bring-ing common eHealth policy issues to the sur-face. A recent eHealth literature review alsobrings fundamental eHealth policy points intofocus. It reveals that eHealth policy elementsof concern to countries around the globe fallinto nine categories:

NETWORKED CARE: Enhances the ability ofproviders, departments, organizations andjurisdictions to work in a coordinated environ-ment to improve care of the population, by

} Creating an enabling environment

} Sharing information, knowledge and practice

} Making the transfer of information easier

} Making the transfer of information safer

} Overcoming challenges for networked care

INTER-JURISDICTIONAL PRACTICE: Deals withthe transfer of information and the provisionof care between different jurisdictions, by

} Addressing professional portability

} Tackling challenges and discrepancies ininter-jurisdictional practice

DIFFUSION OF eHEALTH ADDRESSING THE

DIGITAL DIVIDE: Supports the use of eHealthamong the neediest populations to improvehealth services, by

43


} Increasing penetration of services

} Developing “open” policies

INTEGRATION INTO EXISTING SYSTEMS: Enablesintegration of eHealth projects and programswith the regular services, by

} Achieving broader goals through integration

} Facilitating integration

} Identifying and involving the stakeholders

} Overcoming challenges with integration

HANDLING INNOVATION AT DIFFERENT LEVELS:

Grows the capability of institutions to imple-ment eHealth successfully, by

} Assigning definitive roles

} Managing change brought by new technolo-gies and ideas

} Assessing technologies

POLICY GOAL SETTING: Guides institutions indefining policies for eHealth, by

} Making eHealth feasible

} Making policies flexible

} Providing effective governance

} Creating guidelines for different stakeholders

EVALUATION AND RESEARCH: Generates evi-dence for adoption of eHealth, by

} Evaluating the impact of eHealth

} Assessing new technologies

INVESTMENT: Introduces business models foreHealth adoption, by

} Using eHealth for commercialization pur-poses: It is a natural phenomenon that manyinstitutions will use eHealth to increase theirclientele and thus grow their businesses.Proper policies are needed to regulate theseefforts so that the elements of care and bene-fit to the population are not lost.

} Engaging in public-private partnership: Realiz-ing the kind of investments required in imple-menting eHealth programs, it may be useful toexplore public-private partnership models foreHealth. Clear policies and guidelines to imple-ment such partnerships would be beneficial.

} Advertising cross-border sale of drugs: Theuse of eHealth has encouraged inter-jurisdic-tional provision of care, including the orderand sale of medicines. It is necessary for gov-ernments to design policies that could regu-late and guide the use of eHealth for suchpurposes, and control malpractice and fraud.

ETHICAL ISSUES: Fosters the adoption ofeHealth, by

} Addressing consent for care in eHealth: Lawsdiffer in many areas on obtaining consent forcare before transferring patient informationonline, or before arranging video-conferenc-ing sessions. Clear policies to guide such con-sent can benefit health care institutions andproviders.

} Dealing with liability issues (medical malprac-tice liability): Policies regarding liability issuesare extremely important, especially in thecases of inter-jurisdictional care.

} Figuring out medico-legal issues: Policiesregarding medico-legal issues in eHealth arealso crucial, and must be developed beforesuch programs are implemented.

} Affirming the patient’s right to access infor-mation: Policies regarding a patient’s right toaccess his or her own information is an impor-tant matter for eHealth decision makers.

Moving Forward: Planning for eHealth Policy Success

To address varied, complex and multi-jurisdic-tional eHealth policy challenges, a five-stepframework was developed by National and

Global eHealth Policy conference participants topush eHealth policy and better health forward:

1. GLOBAL eHEALTH CONVENTION_The goal is to swiftly prepare a global legal and regula-tory framework for eHealth, and to seek intergovernmental endorsement of the con-vention. The convention itself would establishhigh-level, core eHealth principles that couldthen be implemented in national legislationand international resolutions. The WorldHealth Organization is seen as a principalbody to move this initiative forward. Interop-erability and cross-border provision of med-ical services are the critical areas of focus forthe convention.

44


2. eHEALTH POLICY TOOLKIT_Conference par-ticipants recognized an urgent need for aneHealth toolkit that would offer relevant infor-mation to ministries of health on policy issues,such as standards and interoperability, datastewardship, governance and institutionalresponsibilities, finance and budget planningand human health resource needs. This toolkitshould be in both paper and online form andconsistently updated.

3. eHEALTH EDUCATION_There is a significantlack of understanding in relation to eHealth.Raising awareness among all stakeholdersabout what eHealth is, and what it can do, is acritical and urgent issue. Of equal importanceis consistency in the messaging. To addressthis need, an integrated advocacy, communi-cations and marketing plan should be estab-lished that will make the case for eHealth.

4. NATIONAL eHEALTH COUNCILS_There isgreat value to be gained from each countryhaving a resource that provides a broad per-spective on eHealth with representation fromdiverse stakeholders. This body could adviseor assist in eHealth policy development andthe provision of technical advice. It could alsohelp with implementation, evaluation andmonitoring. Conference participants agreedthat the formation of national eHealth coun-cils was the most appropriate mechanism.These could be national in scope for smallcountries, sub-national for large countries, oreven linked through the creation of regionalclusters or the joining of established regionalentities. Conference attendees recommendedforming networks of eHealth ambassadorswho are respected individuals at local,regional or national levels. These ambassa-dors could knowledgably promote the appli-cation and integration of eHealth solutions.

5. STAKEHOLDERS_Another highlight ofNational and Global eHealth Policy conferencediscussions was recognition of the complex-ity of the eHealth arena, and the number ofstakeholders that must be involved in deci-sions and actions related to implementationand integration of eHealth solutions. Stake-holders include:

} International agencies and bodies

} Community and community-based organizations (CBOs)

} Special-interest groups and religious groups

} Government and government-supportedorganizations at all levels and all sectors

} Politicians, legislators and parliamentarians

} NGOs /BINGOs (Big International NGOs)

} Donors

} Private-sector organizations

} Academia

} Professional associations

} Health service providers

} Regulatory bodies at various levels

} Standards development organizations

} Media and opinion makers

} Judicial bodies

} Research and development institutions at all levels

Addressing eHealth policy issues will be acomplex process. A common vision can unitediverse stakeholders.

Conclusion

In order for eHealth policy to progress,experts from around the globe must engagein an active dialogue that provides consen-sus-based answers to complex questions andputs conceptual policy frameworks into prac-tice. The overall goal is to speed the imple-mentation and integration of appropriateeHealth solutions into health care environ-ments, particularly within a developing worldcontext. Nothing could be more important forimproving global health, revamping healthsystems and supporting the United NationsMillennium Development Goals.

Notes

1 Scott RE, Chowdhury MFU, Varghese S. TeleHealth Policy:Looking for Global Complimentarity. Journal of Telemedicineand Telecare. 2002;8(Suppl 3 ):55-57.

2 Scott RE, Chowdhury MFU, Varghese S. TeleHealth Policy:Looking for Global Complimentarity. Journal of Telemedicineand Telecare. 2002;8(Suppl 3 ): 55-57.

3 Scott RE, Chowdhury MFU, Varghese S. TeleHealth Policy:Looking for Global Complimentarity. Journal of Telemedicineand Telecare 2002;8(Suppl 3 ): 55-57.

“People think of policy

very differently. Policy

can be law, regulation,

process or a way to put in

place incentives that drive

the private market. It is

not just government top-

down solutions. This is

good news for eHealth

because we have many

levers with which to effec-

tuate positive change.”

Ticia Gerber, MHS/HP,United States

Facilitating an ecosystem of well-functioning eHealth markets around the worldis a critical step in health improvement and system transformation. Unfortunately,cultivation is falling short, with information technology markets proving difficultto both quantify and catalyze, particularly in the developing world. Initial esti-mates by the Boston Consulting Group peg the global eHealth products andservices market at $96 billion, with 95 percent of this market in industrializedcountries. Nearly half of the developing world markets, estimated at $4 billion,are in only four countries: Brazil, Russia, India and China.

Definitional issues and fragmentation complicate efforts to nurture eHealth markets. eHealthcovers a broad swath of territory, from electronic medical records (EMRs) to telemedicine andmobile-health interventions. Health 2.0 technologies that enable user-generated content, SMSsocial networking tools, and peer-to-peer platforms are also increasingly placed under a widen-ing eHealth umbrella. And eHealth is perceived differently, depending on the audience. A well-functioning market may ultimately be described as one that facilitates a platform for integratingthe myriad of eHealth technologies, donors and systems into a coherent whole that drives effi-ciencies and improves health outcomes.

The Public Health Institute convened Catalyzing Markets for Global eHealth, part of the Rocke-feller Foundation’s Making the eHealth Connection: Global Partnerships, Local SolutionsBellagio Center conference series. Participants provided an overview of eHealth markets in the developing world and outlined novel collaborative approaches to leapfrog over the legacyeHealth environments found in many nations.

Catalyzing the Global eHealth Market: Key Issues

Successful eHealth markets enable better coordination of services, data integration and the devel-opment of evidence-based practices. In order for this to occur, however, eHealth entrepreneursmust possess a clear understanding of market size and key problems that proposed businessmodels will attempt to solve, and be able to formulate a vision of business model sustainability inmarkets where purchasing power is often perceived as too low to support eHealth enterprises.

Challenges in seeding and growing eHealth markets are notable and must be addressedthrough innovative partnerships that span the globe. When undertaking this task, key issuesand barriers must be considered:

Catalyzing Markets for Global eHealth


Chapter 8

Collaborative Markets for Global eHealth

Concerted action is needed to change thecurrent eHealth market environment in a waythat drives innovation and health systemtransformation. Catalyzing Markets for Global

eHealth conference participants concludedthat the open-source software communityand other e-commerce mechanisms can beadapted to develop new organizationalprocesses that may achieve breakthroughsmuch faster and with a more diverse group ofplayers. If the right system of solutions andinstitutions is put into place now, many of theeHealth difficulties encountered by devel-oped nations can be avoided in developingcountries and greater health benefits derived.

The challenge is to transcend the current ten-dency to create analog institutions appropri-ate to the non-digital problems of the past,and move toward new forms of networkedorganizations. Academics Elinor Ostrom andCharlotte Hesse highlight the concept of acommons, a shared resource governed by anew set of institutional relationships andethos.1 The recent theoretical work in thisarea, coupled with public-private partnershipexperiences, creates an important foundationfor new types of institutions and partnershipsthat can facilitate collaborative markets, meet

} Lack of awareness about the costs and bene-fits of eHealth solutions

} Absence of business-case studies demon-strating potential eHealth models and theirpromise for health system transformation

} Fragmentation of the eHealth market on boththe supply and the demand sides, with mostglobal health programs being driven by verti-cal or disease-driven programs that createnumerous silos

} Lack of a coherent, transparent enabling policy environment that supports eHealthmarket development (e.g., a process that supports funding, data handling, privacy andinteroperability)

} Shortage of private-sector involvement frommultinational and information technology (IT)companies based in the developing world duein part to perceptions of market inadequacy

While on the surface, market barriers appearto be formidable, businesses are successfullydeveloping products and services for eHealthmarkets in the developing world. A growingroster of players is working in the field.

47


the outstanding needs of entrepreneurs, andgenerate new opportunities downstreamfrom the commons.

Lessons from the IBM and Apache software’sexperience illustrate how an eHealth com-mons might work. When IBM recognized thatthe market for hardware had matured andwould not be the source of sustained revenuegrowth in the future, it began shifting its busi-ness model to focus on open-source softwaresuch as Linux and the Apache Software Foun-dation. Through the donation of approxi-mately $10 million of code and 400programmers’ labor, IBM accelerated thegrowth of open-source code, driving demandfurther downstream for higher-margin Web-based consultative services. In essence, IBMmade a strategic investment in the commonsto grow the overall market.

The global eHealth market might thereforeexplore the concept of the collaborative market,the notion of the commons for sharingresources, and expertise that might enable thegrowth of the market for everyone. The eHealthmarket might also explore foundational build-ing blocks, such as open standards, commonarchitectures and interoperability. This frame-work would allow both open-source and propri-etary systems to operate. The issue is not oneof open source versus proprietary, but ratherhow to build an eHealth commons that lays thenecessary conditions for the market to growand actually drive healthy outcomes.

eHealth Commons: Core Ingredients

An eHealth commons, Catalyzing Markets for

Global eHealth conference participants con-cluded, is needed to strategically bringtogether key actors around shared resources(common standards, shared vision on systemarchitectures, facilities for demand aggrega-tion, donor-aligned financing pools, etc.).Thiswould enable markets to grow and wouldsupport a vast ecosystem of eHealth players.A global eHealth commons would likely pos-sess these elements:

} Financing and matchmaking functionsbetween entrepreneurs and donors

} An architectural function that addresses open standards, architectures, interoperabilityand systems integration

} Smart social networking and an open-innovation portal to bring together disparateeHealth players

} A business model advisory and best practices repository

} Demand aggregation where the World HealthOrganization (WHO), ministries of health andother e-services could come together to coor-dinate platforms

} Research and evaluation tools that can informeHealth policymaking

} The global eHealth commons could addressusers or stakeholders in the global eHealthfield: entrepreneurs and companies, policy-makers, informatics professionals, publichealth professionals and citizens.

eHealth Commons: Developing World Framework

Catalyzing Markets for Global eHealth confer-ence participants emphasized that the follow-ing issues should be considered in thecreation of an eHealth commons:

1. CREATE VALUE PROPOSITIONS FOR DIVERSE

INDUSTRY PLAYERS, INCLUDING COMPETITORS_Operating in the eHealth arena entails coordi-nating the development of common standardsand architectures that enhance interoperabilityand help reduce uncertainties for industry andentrepreneurs while simultaneously giving poli-cymakers the necessary toolkits to make theright decisions with vendors and others.

2. STRUCTURE THE COLLABORATIVE MARKET AS

A THIRD PARTY WITH INDEPENDENT MANAGE-

MENT_This third party should adopt anagnostic but strategic view on eHealth mat-ters, with criteria framed around sustainingthe growth of the public good (i.e., health out-comes and transforming systems, sustainabil-ity of enterprises to drive innovation andhealth equity in the broadest sense.)

3. EXPECT THAT THE PRODUCT, TERMS OF

TRADE, AND MARKET STRUCTURE OF THE COL-

LABORATIVE MARKET WILL EVOLVE_A collabo-rative market and commons can be designed

There is a demand for

better health services

and technology and an

increasingly affordable set

of technologies to meet

that need. Unlocking the

eHealth markets is not

so much creating markets

as aligning the different

pieces and making

connections so that the

markets work.”

Chris Elias, President and CEO, Program for Appropriate Technologiesin Health, United States

with a focus on today’s problems and reali-ties. There is a strong need to exercise foresight and strategic thought to identifyleapfrog opportunities and an overall innova-tion strategy that can attract the best in thefield to the overall cause.

4. ALIGN DONORS_The eHealth commonsmust become a central space where a spec-trum of donors such as multi- and bi-lateraldonors, venture capitalists, foundations andgovernments can come together and buildshared investment platforms that reinforceeHealth goals for common standards, archi-tectures and interoperability. Donors areimportant agents in the eHealth value chain.They should be seen as having the founda-tional ability to enable eHealth markets. Onetangible donor alignment tool is softwaredevelopment that facilitates the integration of the eHealth value chain by focusing on aseries of strategic alignments, including thealignment of the following:

} Philanthropists to innovation

} Policymakers to entrepreneurs

} eHealth information with researchers, philanthropists, social/entrepreneurs, donors and the private market

5. INCREASE CAPACITY OF SOCIAL ENTREPRE-

NEURS_As with the public sector, there is aneed to build capacity among social entrepre-neurs to absorb capital, obtain information onavailable technology solutions, receive ade-quate technology training to manage softwaresystems, exchange business model insights,and be vocal in the policy arena so that policy-makers do not overlook local social entrepre-neurs when framing new policy agendas foreHealth. In addition, an eHealth promotionnetwork could integrate needs across thedemand and supply chains, acting as a clear-inghouse of tools, frameworks, and knowl-edge to facilitate market growth. Within theeHealth commons framework, the networkwould vet proposals from social entrepre-neurs and match their identified needs withthe right stakeholders in the network.

Conclusion

Experts estimate that a country-level invest-ment of 2 percent of health care expenditureson IT can generate a significant health-systembenefit. With the proper market and innovativefinancing solutions, developing countries havethe opportunity to cultivate some of theworld’s most innovative and effective eHealthsolutions. Collaborative markets, entrepreneur-ial commons, solid business case studies, bet-ter donor and financier matchmaking, smartsocial networking, and strategically addressingcurrent constraints in the eHealth supply anddemand chain are all keys to success.

Notes

1 Hess, C, Ostrom, E. Understanding Knowledge as a Commons:From Theory to Practice. Cambridge, Mass: MIT Press, 2006.

2 Ibid, p. 6.

“We must now be able to

share patient information

across the planet. To

think more globally, we

need donors who have

the ability to put people

together and channel

resources in the right

direction, governance

bodies that reflect what

is needed and integrate

different initiatives, and

technology that is sharable

and interoperable.”

Beatriz de Faria Leão, MD,PhD, Health Standards Architect, Zilics Health Information Systems, Brazil

50


51


The goal of the four-week Making the eHealth Connection conference was to fosterpartnerships among groups of thoughtful, committed participants—many of whomwere from the developing world—and to help them establish frameworks and agree-ments that will advance health systems by enabling a global eHealth movement.

With many new ideas sparked and strong ties formed among conference participants, most ofwhom had never met or collaborated before, the outcomes of the conference will inform bothnational and international eHealth agendas for years to come.

Many seeds for new partnership, business, funding and policy models grew out of conferenceconversations. Each day these new ideas are propelling eHealth and better health systems forward. Two imperatives were mentioned most ardently and frequently by conference partici-pants from all professional walks of life:

} The need to move from silos to systems—seeking out person-centered, user-driven, integrated, collaborative, sustainable, scalable, reusable and in-country demand-driven eHealth solutions

} The need to be daring in eHealth visions for the developing world, realizing that much can bedone with limited resources and a lot of ingenuity

By turning these ideas into practice, the eHealth movement truly can be a great equalizerbetween rich and poor, healthy and ill. We are already seeing examples of how the thoughtfulimplementation of eHealth around the world is leading to improved health systems and health,particularly for emerging economies.

As Making the eHealth Connection participant Nolwazi Gasa of the Development Bank ofSouthern Africa so eloquently put it during her time at the Rockefeller Foundation Bellagio Center conference, “The cost of doing nothing on eHealth is far greater than the cost of doingsomething. Be a facilitator and owner of the process.”

The Road Ahead

52


NATIONAL HEALTH INFORMATION SYSTEMSWeek 1: July 13–18, 2008Public Health Informatics andNational Health InformationSystems

} University of Washington’s Cen-ter for Public Health Informatics

} Health Metrics Network

Public health informatics is anarea of great growth and prom-ise in the developing world.This conference examined theuse of ICT in public health,enterprise architecture issues,user needs, functional require-ments, and the development ofa Partners in Global PublicHealth Informatics Initiative.

The Path to Interoperability

} Health Level Seven (HL7)

} World Health Organization

A key obstacle to sharing infor-mation is the lack of interopera-ble health systems andconsensus on data standards.This conference covered cur-rent standards developmentand implementation related tothe interoperability needs ofdeveloping countries. And, itidentified technologies, poli-cies, skills, and government andindustry leadership necessaryto achieve interoperability.

KNOWLEDGE AND CAPACITYFOR eHEALTHWeek 2: July 20–25, 2008Access to Health Information

} Latin American and Caribbean Center on Health Sciences Information (BIREME)

Making the eHealth Connection:Overview

Increasing access to healthinformation can greatly improvehealth care. Participants dis-cussed state of the art informa-tion access tools. They exploredthe role of social and virtualcommunities, seeding globalalliances, and networks on e-information access and policies.

Health Informatics andeHealth Capacity Building

} American Medical InformaticsAssociation

} International Medical InformaticsAssociation

One of the biggest challengesto eHealth capacity building indeveloping countries is theshortage of qualified healthcare professionals and trainingresources. This conference pri-oritized capacity-buildingopportunities in developingcountries and identified howeHealth technologies and toolscan support them.

CORE eHEALTH TECHNOLOGIESWeek 3: July 27–Aug 1, 2008Electronic Health and MedicalRecords

} Partners in Health

} Regenstrief Institute

Since fledgling efforts just fiveyears ago, several successfulmedical information systemsand electronic medicalrecords (EMRs) systems havenow been deployed in devel-oping countries, and informa-tion technology (IT) is much

more widely available inresource-poor areas. The coreobjective of this conferencewas to explore a plan for thecreation of a comprehensivehospital and ambulatory med-ical information system fordeveloping countries.

mHealth and Mobile Telemedicine

} United Nations Foundation

} Vodafone Group Foundation

} Telemedicine Society of India

Mobile electronic health toolsare rapidly transforming healthcare delivery. Mobile phoneuse in particular is explodingacross the developing world,offering the opportunity toleapfrog forward. Participantsassessed mHealth andtelemedicine priorities, dis-cussed market scaling, andseeded a multi-sectoral part-nership dedicated to design-ing, funding, and advancingmobile health projects in thedeveloping world.

POLICY AND MARKETS FOR eHEALTHWeek 4: Aug 3–8, 2008

Unlocking the market foreHealth

} Public Health Institute

eHealth is increasinglyemployed to address healthsystem challenges andimprove services, especiallyfor poor and vulnerable popu-lations. Yet a myriad of ques-tions linger on the money and

AMERICAN MEDICAL INFORMATICS ASSOCIATION(AMIA)www.amia.org

AMIA is a professional organi-zation of leaders shaping thefuture of biomedical and healthinformatics in the UnitedStates and over 50 othernations. AMIA is dedicated tothe development and applica-tion of informatics in support ofpatient care, public health,teaching, research, administra-tion, and related policy.

HEALTH LEVEL SEVEN (HL7)www.hl7.org

HL7 is a not-for-profit stan-dards development organiza-tion dedicated to providing acomprehensive framework andrelated standards for theexchange, integration, sharing,and retrieval of electronichealth information that sup-ports clinical practice and themanagement, delivery andevaluation of health services.

HEALTH METRICS NETWORK(HMN)www.who.int/healthmetrics/en

Health Metrics Network (HMN)is a global partnership that facil-itates better health informationat country, regional and globallevels. Partners include devel-oping countries, multilateraland bilateral agencies, founda-tions, other global health part-nerships and technical experts.

53


Making the eHealth Connection:Partners

INTERNATIONAL MEDICALINFORMATICS ASSOCIATION(IMIA)www.imia.org

IMIA provides leadership andexpertise to the multidiscipli-nary health focused commu-nity and policy makers toenable the transformation ofhealthcare in accord with theworld-wide vision to improvethe health of the world popu-lation. It plays a major globalrole in the application of infor-mation science and technol-ogy in the fields of healthcareand research in medical,health and bio informatics.

LATIN AMERICAN ANDCARIBBEAN CENTER ONHEALTH SCIENCES INFORMATION (BIREME)www.bireme.br

BIREME's mission is to con-tribute to the development ofthe health in the countries ofthe Latin America and theCaribbean by the promotionof the use of the scientific andtechnical health information.

PARTNERS IN HEALTH (PIH)www.pih.org

Partners In Health is a non-profit corporation based inBoston, Massachusetts, andactive in the Caribbean, LatinAmerica, Africa, Russia, andthe United States. Throughservice, training, advocacy,and research, and by estab-lishing long-term relationships

incentive side of the equation.These issues are particularlyacute for developing countries.This conference generatednew thinking about thefinance and business ofeHealth for the underservedand explore how to effectsocial and health care changesthrough eHealth investmentsin developing countries.

National eHealth Policies

} The World Health Organization

Common policy challenges areemerging for countries aroundthe globe embarking oneHealth implementations.Coordination between actorsat the local, regional, national,and trans-national level andrational alignment on eHealthdonor policy is increasinglyimportant. This conferencedefined a new process fordevelopment of nationaleHealth strategies, describeddistinct models for regulationof national and global eHealthinfrastructures, and began theprocess of drafting a five-yearglobal eHealth policy roadmap.

with sister organizations, PIHstrives to to bring the benefitsof modern medical science tothose most in need.

PUBLIC HEALTH INSTITUTEwww.phi.org

The Public Health Institute(PHI) is an independent, non-profit organization dedicatedto promoting health, well-being and quality of life forpeople throughout California,across the nation and aroundthe world. As one of thelargest and most comprehen-sive public health organiza-tions in the nation, it is at theforefront of research and inno-vations to improve the effi-cacy of public healthstatewide, nationally andinternationally.

REGENSTRIEF INSTITUTEwww.regenstrief.org

The Regenstrief Institute is aninternationally recognizedinformatics and healthcareresearch organization, dedicated to the improvementof health through research thatenhances the quality and cost-effectiveness of healthcare.

TELEMEDICINE SOCIETY OF INDIAwww.tsi.org.in

The Telemedicine Society ofIndia was created in 2006 withthe objectives to promote andencourage development,advancement and research inthe science of telemedicineand the application of telemed-icine technology in clinicalcare, education and research inthe health sector of India.

UNITED NATIONS FOUNDATION (UN FOUNDATION)www.unfoundation.org

The UN Foundation acts tomeet the most pressing health,humanitarian, socioeconomic,and environmental challengesof the 21st century throughthe support of the UnitedNations, new and innovativepublic-private partnerships,advocacy and grantmaking.

UNIVERSITY OF WASHING-TON’S CENTER FOR PUBLICHEALTH INFORMATICS (CPHI)www.cphi.washington.edu

The mission of CPHI is to linkpractitioners, faculty, staff,and students from a wide vari-ety of disciplines to enhancepublic health informaticsresearch, training and prac-tice. It is an interdisciplinaryenvironment that supportsinnovative re-search into infor-mation strategies and tech-nologies to improve the healthof the public.

VODAFONE GROUP FOUNDATIONwww.vodafone.com/start/foundation.html

The Vodafone Group Founda-tion makes social investmentsthat help the people of theworld to lead fuller lives by:sharing the benefits of devel-opments in mobile communi-cations technology as widelyas possible, supporting thelocal communities in whichVodafone operates, helping toalleviate suffering in disasterareas, supporting sport andmusic projects to benefityoung people and their com-munities, promoting thehealth and well-being ofyoung people; and protectingthe natural environment.

WORLD HEALTH ORGANIZATION (WHO)www.who.int/en

WHO is the directing and coor-dinating authority for healthwithin the United Nations sys-tem. It is responsible for provid-ing leadership on global healthmatters, shaping the healthresearch agenda, settingnorms and standards, articulat-ing evidence-based policyoptions, providing technicalsupport to countries and moni-toring and assessing healthtrends.

54


Making the eHealth Connection:Partners

55


Patrice CristofiniOrange/France Telcom

Walter CuriosoUniversidad Peruana CayetanoHeredia

Merceline Dahl-RegisCommonwealth of the Bahamas

Tao DaiInstitute of Medical Information and Library,Chinese Academy of MedicalSciences & Peking Union Medical College

Beatriz de Faria LeaoZilics Information Systems

Patrice DegouletParis Descartes University

Susan DentzerHealth Affairs

Don DetmerAmerican Medical Informatics Association

Brian DevoreIntel

Matt DiverBoston Consulting Group

Robert DolinSemantically Yours

Peter DruryHealthcare Practice, Emerging Markets, Cisco Internet Business Solutions Group

Hammad DurraniAga Khan Foundation

Julie CarandangRockefeller Foundation

Henry ChasiaNepad eAfrica Commission

Molly CheahPrimary Care Doctors’ Organization, Malaysia/OpenSource Health Care Alliance

Konstantin ChebotaevMedical Center for Informationand Analysis of the RussianAcademy of Medical Sciences

Jie ChenFudan University School of Public Health

Ngai Tseung CheungHospital Authority

Chris ChuteMayo Clinic

Michael ClarkeInternational DevelopmentResearch Centre

Jon James ConibearHearst Corporation

Thomas M. CookThe University of Iowa, Collegeof Public Health, Occupationaland Environmental Health

Nicholas CopNicholas Cop Consulting

Jillian CopelandBoston Consulting Group

Kevin CreanMicrofranchise/Social Entrepreneur/TomKat Foundation

Patricia A. AbbotJohns Hopkins University,School of Nursing

Savas AlpayCentre for Islamic Countries

Najeeb Mohamed Al-ShorbajiWHO, Regional Office for the Eastern Mediterranean

Barbara AronsonWHO

Diana Arsenian

Chris BaileyWHO

Ayelet BaronCisco Systems Inc./NetHope

Peter BenjaminCell Life

Paul BiondichRegenstrief Institute

Joaquin BlayaPartners In Health

Meryl BloomrosenAmerican Medical InformaticsAssociation

Gaetano BorrielloUniversity of Washington andGoogle/Seattle

Jorn BraaInformation Systems Program,University of Oslo

Bill Braithwate Anakam Inc.

Karl BrownRockefeller Foundation

Making the eHealth Connection:Participants

56


Chris EliasPATH

Tim ElwellMysis

Andre ErthalNokia Technology Institute

Amado EspinosaAportia Inc.

Tim EvansWHO

Alex EzehAfrican Population and HealthResearch Center

Bokai FofanaallAfrica.com

Hamish FraserPartners In Health

Sherrilynne FullerUniversity of Washington, Biomedical and Health Informatics

Richard GakubaKing Faisal Hospital, Rwanda

Hector GallardoCarso Health Institute

Krishnan GanapathyApollo Telemedicine Foundation

Patricia GarciaNational Inst. Of Health of Peruand School of Public Health,Universidad Peruana CayetanoHeredia

David GaretsHIMSS Analytics

Nolwazi GasaDevelopment Bank of Southern Africa

Pape GayeIntrahealth International

Berhane GebruAED

Antoine GeissbuhlerGeneva University

Ticia GerberManatt Health Solutions

Yvette GerransPATH

Dennis GiokasCanada Health Infoway

Roger GlassNational Institute of Health

Mzamose P. GondweTropIKA Reviews

Phil GormleyBoston Consulting Group

Robert GreenesArizona State University

Pat GuerraSanta Clara University

Ravi GuptaeIndia/Centre for Science,Development and Media Studies

Ana Estela HaddadMinistry of Health, Brazil

Ed HammondDuke University

Lyn HanmerHealth informatics R&D Coordination Division andSouth African MedicalResearch Council

Verle HarropAtlantic Health Sciences Corporation

Carleen HawnFound READ

William HershOregon Health and ScienceUniversity

Allen HightowerCDC Kenya

Carola HullinUniversity of New South Wales

Omer ImtiazuddinAcumen Fund

Gautam IvaturyCGAP

Charles JaffeHL7

Joseph JasinskiIBM Research

Darius JazayeriPartners In Health/OpenMRS

Macollvie Jean-FrancoisSouth Florida Sun-Sentinel

Pamela JohnsonVoxiva, Inc.

Claudia JuechRockefeller Foundation

President Paul Kagame Rwanda


57


James KahnUniversity of California, San Francisco

Clifford KamaraMinistry of Health and Sanitation, Freetown, Sierra Leone

Andy KanterMillenium Villages Project,Earth Institute at Columbia University

Simon KennedyBoston Consulting Group

Aamir KhanInteractive Research and Development

Shariq KhojaAga Khan University

Ann Marie KimballUniversity of Washington, Epidemiology and Health Services

Liza KimboCDC

Michio KimuraHamamatsu University

Jean-Baptiste KoamaVoxiva, Inc.

Sergio KönigIT & GS Consultores, Center forInformation, Technology, andManagement for Healthcare

Ramesh Krishnamurthy CDC

Rebecca KushCDIsC

Yun Sik Kwak Kyungpook University

S. Yunkap KwankamWHO

Holly LaddAED-SATELLIFE Center for Health Information andTechnology

Mark LandryPEPFAR, Office of the U.S.Global AIDS Coordinator(OGAC)

Larry LeisureiMetrikus

Les LenertNational Center for PublicHealth informatics, CDC

Neal LeshD-tree International; Dimagi, Inc.

Bill LoberUniversity of Washington

Nancy LorenziVanderbilt University, School of Medicine

David LubinskiWHO

Hoat Ngoc LuuHanoi Medical University

Becky LyonNational Library of Medicine

César Macias ChapulaNational Institute of PublicHealth, Mexico

Michael MadnickBill & Melinda Gates Foundation

Rachel MaguireIFTF

Michael MalteseMassachusetts Instittute of Technology

Burke MamlinRegenstrief Institute

Melissa MannLatin-American and CaribbeanCenter on Health SciencesInformation

Alvaro MargolisInternational Medical Informatics Association (IMIA)

Heimar MarinFederal University of Sao Paulo

Maurice MarsNelson R. Mandela School of Medicine, South Africa

Bob MartinCoordinating Office for Global Health, CDC

Strive MasiyiwaEconet Wireless International

Claire McCarthyKaiser Permanente

Clint McClellanQualcomm, Inc

Patricia MechaelEarth Institute at Columbia University


58


Lauri MedeirosUniversity of California, San Francisco

Michelle MeigsAssociation of Public Health Laboratories

Randy MillerJAMIA

Katherine Miller United Nations Foundation

Satyan MishraDrishtee

Moretlo MolefiTelemed Africa

Barend MonsUniversity of Rotterdam, Erasmus Medical Centre,Department of Medical Informatics

Jesse MooreGSM Association

Fidelis Nde’eh MorfawWHO

Lincoln MouraZilics Health Information Systems

Edward MukooyoUganda Ministry of Health

Fadwa MuradInformatics and Decisions Support Directorate, Ministry of Health

Maria Goretti MusokeMakerere University

Henry MwanyikaIfakara Health Institute

Brian NairnElsevier Health Sciences

Anand NarasimhanVoxiva, Inc.

Vung Nguyen DangHealth Policy Unit, Ministry of Health of Vietnam

Boris NikolicBill & Melinda Gates Foundation

Ivo NjosaWorld Bank

Patrick O'CarrollUSPHS

Esther OgaraMinistry of Health, Kenya

Catherine OmaswaMinistry of Health, Uganda

Egondu OnyejekweEarthmap Foundation forAfrican HIV/AIDS; Lead Visiting Professor, Futo,Owerri, Nigeria

Aida Opuku-MensahUNECA

Zulma OrtizCONAPRIS/Academy of Medicine

Paula OteroHospital Italiano de Buenos Aires

Judy OzboltNursing Informatics, University of Maryland

Ariel Pablos-MendezRockefeller Foundation

Abel L. PackerWHO, BIREME

Neil Pakenham-WalshGlobal Healthcare Information Network

Naina PanditaNational Informatics Centre,Department of InformationTechnology

Brooke PartridgeVital Wave Consulting

Surj Patel

Alberto PellegriniNational Commission of Social Health Determinants on Health

Ian PettUNICEF

Gustav PraekeltPraekelt Foundation

Ruben PuentesRockefeller Foundation

Octavian PurcareaMicrosoft

John QuinnHL7

Miriam RabkinColumbia University MailmanSchool of Public Health

Sumanth RamanTata Consulting Services

Jody RanckPHI

Eric RasmussenINSTEDD


59


Richard James RichardsonHealth Systems Group LTD

Giselle Ricur Institututo Zaldivar, Argentina

Dave RossPublic Health Informatics Institute

Thais RussomanoPUCRS University, Brazil

Sundeep SahayUniversity of Oslo, Norway

Shahida SaleemSehatFirst

Reijo Salmela WHO Regional Office for theWestern Pacific

David SasakiGlobal Voices on-Line

Rodrigo SaucedoCarso Health Institute

Andrea SaveriInstitute for the Future

Sophia SchletteBertelsmann Stiftung

Tim Charles SchwarzLinklaters LLP

Nina SchwenkMayo Clinic

Richard ScottUniversity of Calgary, Canada

Chris SeebregtsMedical Research Council

Tarun SeemMinistry of Health and FamilyWelfare, India

Joel SelanikioDataDyne.org

Jeong-Wook SeoSeoul National University, College of Medicine

Dave SessionsMicrosoft

Stephen SettimiUSAID Bureau of Global Health

Mitul ShahUnited Nations Foundation

Bern ShenHigh Tech Consultant

Augusto Paulo José SilvaMinistry of Public Health,Guinea-Bissau

Pratap SinghasivanonFaculty of Tropical Medicine,Mahidol University

Clive Smith

Mark SpohrWHO

Sally StansfieldWHO

Andy StergachisCenter for Public Health Informatics, UW

Jeff StringerThe CIDRZ Foundation

Abu Bakar Bin SuleimanInternational Medical University, Malaysia

Dianne SullivanVodafone Group Services Ltd

Adalberto TardelliWHO, BIREME

Mary TaylorBill & Melinda Gates Foundation

Sheila TeasdaleAmerican Medical Association

Claire ThwaitesUnited Nations Foundation

Jonathan TienBoston Consulting Group

William TierneyIndiana University,School of Medicine and Regenstrief Institute

Simbini TungamiriraiUniversity of Zimbabwe

Lo VeasnakiryCambodia Dir Planning

Neil VerselIndependent Journalist

Ndiba WairiokoMeridian Medical Centre

Kier WallisManatt Health Solutions

Norma WilsonRoutine Health InformationNetwork (RHINO)

Wendy WoodsBoston Consulting Group

Mohamed YoussoufAfrican Development Bank

Nihat YurtMinistry of Health, Turkey


60


We want to thank the following individuals for their contributions to “From Silos to Systems: An Overview of eHealth’s Transformative Power.”

EditorTicia Gerber, MHS/HP

ContributorsPatricia Abbott, PhDNajeeb Al Shorbaji, MDChristopher Bailey, MLSMeryl Bloomrosen, MBAKarl Brown, MIARachel Christmas DerrickDon Detmer, MDHamish Frasier, MDSherrilynne Fuller, PhD Ticia Gerber, MHS/HPMzamose Gondwe, BScW. Ed Hammond, PhDHolly Ladd, JD David Lubinski, MBAClaire MackAlvaro Margolis, MD, MSRobert Martin, MPH, PhDBarend Mons, PhDSaroj Mishra, MDVeronica Olazabal, MCRSAriel Pablos-Méndez, MD, MPHAbel L. Packer, MLSNaina Pandita, MSc, MPhilAlberto Pellegrini, MD, PhDJody Ranck, MD, PhDRichard Scott, PhDMitul Shah, MBAChetan Sharma, MSEEIndra Pratap Singh, MScSally Stansfield, MDAndy Stergachis, PhD, RPh

From Silos to Systems: Contributors

420 Fifth Avenue

New York, NY 10018

212.869.8500

www.rockefellerfoundation.org/THS/eHealth

null

Documents

rockefeller foundation

global ehealth

systems introduction

field of ehealth

community productions

contributors ehealth

health systems initiative

ehealth center of excellence