WCIT 2014 Ramesh Krishnamurthy - Critical need for standardization of e-health systems and services

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Critical need for standardization of eHealth Systems and Services

Dr. Ramesh S. KrishnamurthyFocal Point, eHealth Standardization and Interoperability

WHO HeadquartersG S it l d

1 | WCIT 2014 - Guadalajara, Mexico - | September 30, 2014

Geneva, Switzerland

Workshop ‐ 30 September 2014 ‐ 15:30‐17:00

Joya 1 and 2, Business Center 1 – Expo Guadalajara

Key Messages


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Key Messages

• Reliable Health Information Systems are essential for better healthcare delivery and better health outcome

• Functional Health Information Systems depends on harmonized and interoperable data elements between and within systems through adoption of Health Data Standards and IT Standards

• Strengthening Health Information Systems depends ti l hi lti t l t


on national ownership, multisectoral engagement, appropriate use of ICT, and adequate human capacity

Outline

• Contextualizing the problem

• World Health Assembly Resolution 66 24• World Health Assembly Resolution 66.24

• Approach to strengthening Health Information Systems


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Two Relevant Documents

on Health Information Systems, eHealth, and prioritization of Health Data


Commission on Information and Accountability

Recommendation 3 ‐ Innovation:

1

By 2015, all countries have integrated the use of Information

and Communication Technologies in their national h l h f d


health information systems and health infrastructure.

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“The use of eHealth and mHealth should be strategic, integrated and support national health goals. In order to capitalize on the t ti l f ICT it ill b iti l tpotential of ICTs, it will be critical to agree on

standards and to ensure interoperability of systems. Health Information Systems must comply with these standards at all levels,

including systems used to capture patient data


at the point of care.”

Source: United Nations, 2011. Keeping promises, measuring Results, First report of the COIA, p14.

“Common terminologies and minimum data sets should be agreed on so that information can be

ll t d i t tl il d tcollected consistently, easily and not misrepresented. In addition, national policies on health‐data sharing should ensure that data protection, privacy, and consent are managed

consistently.”


Source: United Nations, 2011. Keeping promises, measuring Results, First report of the COIA, p14.

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2

|WHO | Global Fund | GAVI | UNFPA |


| WHO | Global Fund | GAVI | UNFPA | |World Bank | UNAIDS | UNICEF |

|Gates Foundation|

highlights the following key points

• Increase Levels and Efficiency of Investments in Health Information

• Develop Common Data Architecture

• Strengthen Performance Monitoring

Infrastructure

Services

Standards

Policy

Governance


g gand Evaluation

• Increase Data Access and UseGovernance

Protection

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fHealth Information System in the Context of

Health Data Standardization and Interoperability


An Example of Health Information SystemA Set of Complex Sub Systems

HIS Sub Systems

Monitoring Policy

Allocated Length-Of-Stay Utilization

500

600

700


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700

10%

20%

30%

10%

20%

30%

10%

20%

30%

10%

20%

30%

Data Warehouse

MonitoringEvaluationResearch

Extract, transform and load data into warehouse

Census Vital EventRegistry Surveys

Health Events & Risks

HealthServiceRecords

ResourceTracking

Policy

Resources

Processes

Information Services

0

100

200

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400

500

Pa

tien

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Status 143 221 412 574 325 172 68 145

25% 50% 75% 100% 125% 150% 175% 200%0

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Status 143 221 412 574 325 172 68 145

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Status 143 221 412 574 325 172 68 145

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Status 143 221 412 574 325 172 68 145

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Modified after Health Metrics Network, 2007.

Data Collection Forms & Methods

Statistical Systems

FinancialSystems

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Producers and Consumers of PH Data

Many Producers and Consumers of HIS Data

Ministries of Health, Finance, Education, Labour, Local Health Governments, Private Health Sector,Insurance Providers, Development Partners, etc…


Courtesy: HMN, 2007

Healthcare and PH D t

Country HIS Data Sources

PH Data


Courtesy: HMN

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UnpakingUnpaking Health Information Systems

The Functional Blocks and The Primary Engines (sub processes)



HIS Sub Systems

Monitoring Policy


500

600

700


600

700


500

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700


600

700

10%

20%

30%

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20%

30%

10%

20%

30%

10%

20%

30%

Data Warehouse






ResourceTracking

Policy

Resources

Processes


0

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200

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400

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Pa

tien

ts

Status 143 221 412 574 325 172 68 145

25% 50% 75% 100% 125% 150% 175% 200%0

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Status 143 221 412 574 325 172 68 145

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tien

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Status 143 221 412 574 325 172 68 145

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Status 143 221 412 574 325 172 68 145

25% 50% 75% 100% 125% 150% 175% 200%

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Statistical Systems

FinancialSystems

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Infrastructure

HumanResources

FinancialResources

Informationand

KnowledgeResources

StewardshipFunctions

Conceptual Functional Elementsof Country HIS

DiagnosticCommunity-

based

Resources


Health Facility-Based

Services

Services Services

Environmental(Monitoring)

Services

HealthCommodities

Courtesy: HMN

Relating HIS Functional Elements to HIS Primary Engines (sub processes)

Environmental Monitoring System

Patient Management System

Asset Management System

Alert and Response System

Knowledge Management System

Diagnostics Management System

Census System

Financial Management System

Further reviewLaboratory/

18 | WCIT 2014 - Guadalajara, Mexico - | September 30, 2014 Courtesy: HMN

Supply Chain Management System

Disease Surveillance System

Human Resources Management System

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Supply Chain Management System

Supply Chain Information System


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It is desirable that...

Health data systems should not beHealth data systems should not be developed as a stand‐alone vertical systems

that focus only on a particular process, instead, as an interoperable component

of national/sub‐national health information


f / fsystem

Multitude of Stakeholders

A Complex Landscape


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Multiple Stakeholders of National HIS


GW

S

Health Information Systems financially-supported vertical programs

GATES

FD

PEPFAR

ORLDBANK

STATE

FD

DONOR

1

DONOR

2

DONOR

N


Community Level Programs

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HD D D D

Health Information Systems disease-based vertical programs

MALARIA

HIV /AIDS

TB

ISEASE

1

ISEASE

2

ISEASE

3

ISEASE

N

Data Extraction


Community Level Programs

Movement of Data inNational Public Health Sector

Illustrative Example


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INDIA> 1.1 billion persons

Sub‐center

Public Health Sector Overview

District(640+ Districts)

Block(10,000+ Blocks)

(Representing several villages)


State(35 States)

Sub‐center

Sub Centeror Health Sub Center

Country ICT Infrastructure




Primary Health Center / B-PHCor Community Health Center

District Surveillance Unit

BroadbandConnectivity


State(35 States)

State Surveillance Unit

Broadband and Satellite-based Connectivity

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Sub‐center

Sub Centeror Health Sub Center(Auxiliary Nurse Midwife, or Male Health Worker)

Weekly householdvisits to collect data

PH Data Collection Process

Paper Forms

Consolidated Forms at Sub-center per week

Handdeliver




Primary Health Center / B-PHCor Community Health Center(Medical Doctor + helper)

District Surveillance Unit(District Surveillance Officer, Data Manager, Data Entry Operator)

Paper Forms

One consolidated forms

B-PHC or CHC data collected from

PHCs

Paper forms are converted to

electronic dataSpreadsheets

Email/Web Entry

deliver

Handdeliver


State(35 States)

State Surveillance Unit (State Surveillance Officer, Data Manager, Data Entry Operator)

Electronic data, kept in the form of formats

Surv.Database Spreadsheets

Data Standardization:Challenges of data acquisition and

management from disparate sources


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Registries of a

Primary Data Source

Primary Health Worker


Primary Data Source

Weekly Data, manually

computed by the data entry operator


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Minor Ailment R i

Primary Data Source

Registry

33 | WCIT 2014 - Guadalajara, Mexico - | September 30, 2014 Courtesy: US. CDC

OPD Registries

Primary Data Source


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Fever Registries

Primary Data Source


OPD / Fever Registries

Primary Data Source


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Primary Data Source

State Surveillance Registries


Primary Data Source

Data quality and validation issues


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Primary Data Source

Incomplete OPD Registries


Data Collection

Courtesy: US. CDC

Specimen Logbook

Primary Data Source


Data Collection

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Primary Data Source

Rumor Registries


Data Collection

Courtesy: US. CDC

Primary Data Source

Vertical Program Data


Data Collection

Courtesy: US. CDC

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Primary Data Source

Malaria Registries



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SurveillanceForms


Specimen Collection and Shipment

Forms

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47 | WCIT 2014 - Guadalajara, Mexico - | September 30, 2014 Slide 47

Patient File Recordkeeping


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Data Aggregation


Data Analysis and Reporting


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Information Management


E amples of comple it of data floExamples of complexity of data flowwithin disease‐specific

Health Information Systems


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HIV/AIDS Data Flow


Active Pneumonia Surveillance


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National Public Health Data Flow


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IDSR Data Flow

Courtesy: Voxiva Inc., 2008.


Justifying the Need for Appropriate Use of Standards in Health Data

Examples


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Need for Data ConsistencyPaper‐based System

Electronic System


Need for Standards

Example below illustrates lack of use of Standardized VocabulariesQuestion: Cause of Death; Answer: (free text)

Need for Data Consistency


Sample Extract of an analysis from over 10,000 electronic records

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A mixture of Techniques inA mixture of Techniques in Public Health Data Collection

and theNeed for Harmonization of Approaches


Scannable Data Forms


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Electronic Data Collection Methods


Surveillance Logbook

Rapid Data Collection Efforts

Data Transfer

ook

Surveillance

Tool


Data Collection

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Electronic Medical Records


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Mobile Computing Devices



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Sense of Urgency for establishing Interoperable

Health Information Systems usingHealth Data Standards


Sense of Urgency

• eHealth and HIS are essential for rapid detection and containment of infectious diseases respond to health emergencies anddiseases, respond to health emergencies, and delivery of healthcare to population at all levels

• Fragmented eHealth systems pose threat to health care delivery

• Multiple sectors within countries depend on


• Multiple sectors within countries depend on accurate and timely health information for decision making

eHealth ‐ Effective use of ICT to provide and support health service delivery

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HIS Sub Systems

Monitoring Policy


500

600

700


600

700


500

600

700


600

700

10%

20%

30%

10%

20%

30%

10%

20%

30%

10%

20%

30%

Data Warehouse






ResourceTracking

Policy

Resources

Processes


0

100

200

300

400

500

Pa

tien

ts

Status 143 221 412 574 325 172 68 145

25% 50% 75% 100% 125% 150% 175% 200%0

100

200

300

400

500

Pa

tien

ts

Status 143 221 412 574 325 172 68 145

25% 50% 75% 100% 125% 150% 175% 200%

0

100

200

300

400

500

Pa

tien

ts

Status 143 221 412 574 325 172 68 145

25% 50% 75% 100% 125% 150% 175% 200%0

100

200

300

400

500

Pa

tien

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Status 143 221 412 574 325 172 68 145

25% 50% 75% 100% 125% 150% 175% 200%

-40%

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0%

Variance 10% 4% -20% -21% 30% 8% 10% -17% -28% -13

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Statistical Systems

FinancialSystems

General State of Health Information Systems

Indicator‐based Records Individual/Patient Records

Lack of Reliable & Timely Data Exchange


RegistriesDiagnostics/Images Records

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eHealth


eHealth Innovation Areas ‐ Examples

o Electronic Medical Records

o Mobile Health

o Decision Support Systems

o Electronic Health Records

o Personal Health Records

o Telemedicine (telehealth)

o Electronic Medication Services

o Health Knowledge

o Chronic Disease Management Services

o Patient, and Clinical management Systems,

o Distance Learning for health Professionals


o Health Knowledge Resources

o Mobile Health

(eLearning)

o Health Information Systems

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Example of a Commonly Adopted Standard


International Standards Road Traffic LightsJoint ISO/CIEStandard

ISO 6508:1999

CIE S006.1/F‐1998

CIE S006/G‐1998


Example of a Widely Accepted Standard

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Standardization Process


Simplified Standardization Process

StandardsDevelopment

StandardsMaintenance

StandardsAdoption

StandardsDevelopment

Organizations (SDOs)

Standards SettingOrganizations (SMOs)

Designated Standards Maintenance

Organizations (DSMOs)

National Authorities(Implementation, Policy, Governance)


Identify Need andDevelop Standards

Review and Update Standards

Implementation of Standards

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Sample List of Standards

• ICD ‐ International Classification of Diseases

• SNOMED ‐ Systemized Nomenclature of Medicine

• DICOM ‐ Digital Imaging and Communications in Medicine

• HL‐7 ‐ Health Level Seven

• LOINC ‐ Logical Observation Identifier Names and Codes

• ISO ‐ International Organization for Standardization (TC 215 Health Informatics)


(TC 215 – Health Informatics)

Generalized Categories of Standards


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Generalized Categories of Standards

• Health Data Standards (Primary area of World Health Organization)

o Data Standards, Information Content Standards, Information Exchange Standards, Entity/Person Identifiers Standards, Privacy and Security Standards

• Information Technology Standards (Primary area of International Telecommunications Union)

o Telecommunication, Machine to Machine


Communications, and other Technical Standards related to ICT

Source: Public Health Data Standards Consortium; http://www.phdsc.org/; Accessed: June 3, 2012

Standards Relevant to Health Data


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Standards Relevant to Health Data

• Data Standards

• Information Content StandardsInformation Content Standards

• Information Exchange Standards

• Entity/Person Identifiers Standards

• Privacy and Security Standards

• (Functional Standards; Business Requirements)


Source: Public Health Data Standards Consortium; http://www.phdsc.org/; Accessed: June 3, 2012

Data Standards

• Disease Classification

• Drugs Classification

• Laboratory Data Standards

• Digital Images• Digital Images

• Medicinal Products, Pharmaceutical Doses, Units, Common Terminology Services


gy

Examples only(non exhaustive list)

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Data Standards

• Clinical Procedure Terminology

• Pharmacy Terminology

• Nursing/HRH Terminology• Nursing/HRH Terminology

• Payer Terminology

• Financial/Business Transactions Terminology



Information Content Standards

• Healthcare Content

• Pubic Health Card

• Medical Device CommunicationCommunication



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Information Exchange Standards

• Digital Images

• Pharmacy Business Transactions

• Country‐specific MandatedCountry specific Mandated Transactions Terminology

• Financial/Business Transactions Terminology



Entity/Person Identifier Standards

• Patient Identifier• Provider Identifier• Employer Identification

Number• Country Identifier• Health (Insurance) Card

Issuer Identifier



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Privacy andSecurityStandards

• Anonymization and PseudonymizationStandards

• Security Standards• Confidentiality Standards• Patient Consent Standards• Data Audit Trails



Example of standards adoption


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Example of Standards for Digital Images

“facilitate the interchange of information between digital imaging computer systems in

medical environments”


Source: http://medical.nema.org/standard.html; Accessed August 6, 2012


Digital InterfaceUltrasound Device

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WHA Resolution 66.24eHealth Standardization and Interoperability


Recognized the value of adoption of standards foradoption of standards for

interoperability

and Health on the Internet2013: Adoption of resolution on

eHealth Standardization and Interoperability by 66th World Health Assembly


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National efforts in eHealth


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National eHealth Strategy

Self Assessment Dimensions

• National e‐health strategy

• ICT Infrastructure

• Services for information sharing

• Standards for interoperability

• Governance and coordination mechanism

• Policies and legislation in place and enforced


H l heHealth Standardization and Interoperability

efforts at WHO


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Standardization & Interoperability

– Established the WHO Forum on eHealth Standardization and Interoperability, p y,December 2012; now adopted as an annual Forum.

– Adoption of resolution on eHealth Standardization and Interoperability by the 66th World Health Assembly (WHA66.24)


– Finalization of Minimum Data Set for Health Workface Registry


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Forum‐2012


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Forum‐2014

Rapidly changing global health landscape

and the avenue of possibilities for informaticians


f

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Example 1Health Informatics Practice

Geospatial Science, and National Planning and Global Health Security


Global Health Facilities Locator

DATA MANAGEMENT

CONCEPTCountry Ministries of Health+ WHO Validation Community Managed Data


Country/RegionalSpace Agency

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DATA DISPLAY


• Source: OpenStreetMap.org (data license: OpenStreetMap is open data, licensed under the Creative Commons Attribution‐ShareAlike 2.0 licence (CC BY‐SA); Special Recognition: Dr. Markus Neteler and his team, Fondazione E. Mach, Italy


DATA VISUALIZATION


• Source: OpenStreetMap.org (data license: OpenStreetMap is open data, licensed under the Creative Commons Attribution‐ShareAlike 2.0 licence (CC BY‐SA); Special Recognition: Dr. Markus Neteler and his team, Fondazione E. Mach, Italy

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Example of Global Mapping of Health Facilities. Source: Neteler, 2012

• Linking GPS Location, remote sensing imagery, thermal maps, th d t GIS h fil t ll H lth F iliti

Potential Space Technology Applicationsto Global Health Facilities Locator

weather data, GIS shape files, to all Health Facilities

• Developing advance visualization tool for tele‐epidemiology, telehealth, and health emergency response

• Linking Health Workforce (Human Resources) and Health Commodities data

• Link information on Public Safety and other Public Health and


Emergency Management entities

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Example 2Health Informatics Practice

and Mobile Computing Platforms


Mobile Computing in Healthcare

o Electronic Health Records

o Personal Health Records

o Decision Support Systems

o Distance Learning for h lth P f i l

Examples

o Telemedicine (telehealth)

o Electronic Medication Services

o Public Health Surveys and Surveillance

health Professionals (eLearning)

o Chronic Disease Management Services


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Mobile Computing Devices


Antenatal and Neonatal Care

iimprove access to quality

antenatal and neonatal care in

Ghana; Grameen

Foundation’s MOTECH project


Source: http://www.grameenfoundation.org/what‐we‐do/health/maternal‐and‐infant‐health

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Eye care


Source: http://www.1ohww.org/mhealth‐trends‐pairing‐needs‐challenges‐one‐healthcare‐worldwide/.

Dental care


Source: WHO, 2011. mHealth: new horizons for health through mobile technologies: second global survey on eHealth.

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Environmental Sampling


Source: CDC, 2007

Emergency ResponseChina, Sichuan Province


Source: US CDC, 2005

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mHealth for NCDs Toolkit


Source, WHO, 2013.

mHealth initiatives

*


Source: WHO, 2011. mHealth: new horizons for health through mobile technologies: second global survey on eHealth.

* WHO Member States (193 members during 2011)

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Harmonization and Interoperabilityof Data and Systems


Interoperability and Standards


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Example eHealth Architecture: ISO TR 14639

Framework, Architecture, and Standards


A need for systematic approach to HIS design, implementation, and management

Measuring HIS Progress Over TimeFigure depicting Countries at Various Levels of HIS Maturity

2

3


0

1

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H lth I f ti dHealth Informatics and the Science of Public Health

Need for common conversation amongSMEs and Informaticians


SMEs and Informaticians

Public Health Science

+

Informatics Domain

Public HealthInformatics=


Adoption of best practices from both domains

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Public Health Informatician Senior Public Health Informatician1. Supports development of strategic direction for public health informatics within the enterprise

1. Leads creation of strategic direction for public health informatics

2. Participates in development of knowledge management tools for the enterprise 2. Leads knowledge management for the enterprise

3. Utilizes standards 3. Assures utilization of standards

4. Assures that knowledge, information and data needs of project or program users and stakeholders are met

4. Assures that knowledge, information and data needs of users and stakeholders are met

5. Supports information system development, procurement, and implementation that meet Public Health program needs

5. Assures that information system development, procurement, and implementation meet Public Health program needs

6a. Manages Information Technology operations related to project or program (for public health agencies with internal IT operations)

6a. Assures effective management of Information Technology operations (for public health agencies with internal IT operations)

6b. Monitors Information Technology operations managed by external organizations

6b Assures adequacy of Information Technology Operations managed by external organizations

7. Communicates with cross‐disciplinary leaders and team members 7. Communicates with elected officials, policy makers, agency staff and the public

8. Evaluates information systems and applications 8. Assures evaluation of information systems and applications

9. Participates in applied public health informatics research 9. Conducts applied public health informatics research

10. Contributes to the development of public health information systems that are interoperable with other relevant information systems

10. Assures that public health information systems are interoperable with other relevant information systems

11. Supports use of informatics to integrate clinical health, environmental risk, and 11. Uses informatics to integrate clinical health, environmental risk, and


population health population health

12. Implements solutions that assure confidentiality, security, and integrity, while maximizing availability of information for public health

12. Develops solutions that assure confidentiality, security, and integrity, while maximizing availability of information for public health

13. Conducts education and training in public health informatics 13. Contributes to progress in the field of public health informatics

Slide Courtesy: Denise Koo, Herman Tolentino. CDC, 2008.

Approach to strengtheningApproach to strengthening Health Information Systems

aligning efforts and role of multi‐sectors


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Dependencies of Health Information Systems

HISStakeholder

HIS Data Use for Better Health

Outcomes

Need for Multi‐sectoralEngagement

HIS Policy andPlanning

Information &C i ti

HIS

HealthDomainExperts

HIS Governance

StakeholderAlignment


CommunicationTechnology

Human Resourcesfor HIS

Financing

Multi‐sectoral Engagement

• Ministry of Health

• Ministry of Finance

Examples of Partners within HIS Landscape

• Ministry of Finance

• Ministry of Education

• Ministry of Labor

• Ministry of ICT/Telecommunications

• Ministry of Infrastructure

P i t H lth S t

Coordinationis essential

to owning and sustainingHealth

Information Systems

t N ti l d


• Private Health Sector

• Donors and Implementing Partners

at National and Sub‐national Levels

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Alignment of HIS Stakeholders and Strategies


Alignment of Stakeholders

Health Information Activities

BetterHealth

Outcomes

(stakeholder’s positions vary depending on the model)


Value Chain of Solutionsdriven by Public Private Partnerships

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Alignment of Strategies

Health Information Activities

BetterHealth

Outcomes

(stakeholder’s positions vary depending on the model)


Value Chain of Solutionsdriven by Public Private Partnerships

Health Information System Alignments

Health Health

Science

Appropriate

InformaticsApproach

Impact

Reliable Data to Results


Human Capacity

Sustainable Approach

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Key Messages


Key Messages

• Reliable Health Information Systems are essential for better healthcare delivery and better health outcome

• Functional Health Information Systems depends on harmonized and interoperable data elements between and within systems through adoption of Health Data Standards and IT Standards

• Strengthening Health Information Systems depends ti l hi lti t l t


on national ownership, multisectoral engagement, appropriate use of ICT, and adequate human capacity

WCIT 2014 Ramesh Krishnamurthy - Critical need for standardization of e-health systems and services

Healthcare

health information systemin

dataministries of health

etc13 wcit

use governance10 wcit

key messages2 wcit

private health sector

local health governments

health metrics network