Mustafa Degerli - 2016 - e-Health and e-Pulse - Report

E-HEALTH AND E-PULSE
Summary: This report gives information about e-Health [Definition of e-Health,
Main Players in the Field of e-Health, Success Factors for e-Health Projects, The 10 e’s in e-Heath,
Current e-Health Projects or Services of Turkey, Statistics Regarding the Health and e-Health
Industries of Turkey, Comparative Statistics regarding Health, Metrics related with Health and e-
Health, EU Citizen’s Use of e-Health Services, and European Funded Projects in the field of ICT
for Health and Wellbeing (e-Heath)], e-Pulse (e-Nabız) [e-Pulse (e-Nabız), Features and
Functionalities of e-Pulse (e-Nabız), Future Functionalities of e-Pulse (e-Nabız), and Security and
Privacy related with e-Pulse (e-Nabız), Legal Case related with e-Pulse (e-Nabız), Infrastructure
of e-Pulse (e-Nabız), and Integration of e-Pulse (e-Nabız) with Other Systems], Comparing
epSOS (EU), NHS (England), HealtheVet (USA), HealthHub (Singapore), and e-Pulse
(Turkey) [epSOS (EU), NHS (England), HealtheVet (USA), HealthHub (Singapore), Results of
Comparison regarding epSOS (EU), NHS (England), HealtheVet (USA), HealthHub (Singapore),
and e-Pulse (Turkey)], and Future Works.
Mustafa Değerli
METU Informatics Institute
June 2016
Ankara, Turkey

Mustafa Değerli – 2016 1
Table of Contents
Table of Contents........................................................................................................................ 1
List of Tables ............................................................................................................................... 3
List of Figures.............................................................................................................................. 4
1. Introduction ......................................................................................................................... 5
1.1 Scope .................................................................................................................................... 5
1.2 Definitions and Abbreviations ........................................................................................... 5
1.3 References ........................................................................................................................... 7
2. e-Health.............................................................................................................................. 10
2.1 Definition of e-Health ....................................................................................................... 10
2.2 Main Players in the Field of e-Health ............................................................................. 11
2.3 Success Factors for e-Health Projects............................................................................ 12
2.4 The 10 e’s in e-Heath....................................................................................................... 12
2.5 Current e-Health Projects or Services of Turkey.......................................................... 14
2.6 Statistics Regarding the Health and e-Health Industries of Turkey.......................... 16
2.7 Comparative Statistics regarding Health ....................................................................... 17
2.8 Metrics related with Health and e-Health...................................................................... 18
2.9 EU Citizen’s Use of e-Health Services ............................................................................ 20
2.10European Funded Projects in the field of ICT for Health and Wellbeing (e-Heath) 21
3. e-Pulse (e-Nabız)............................................................................................................... 28
3.1 e-Pulse (e-Nabız)............................................................................................................... 28
3.2 Features and Functionalities of e-Pulse (e-Nabız) ....................................................... 29
3.3 Future Functionalities of e-Pulse (e-Nabız)................................................................... 30
3.4 Security and Privacy related with e-Pulse (e-Nabız).................................................... 30
3.5 Legal Case related with e-Pulse (e-Nabız) .................................................................... 31
3.6 Infrastructure of e-Pulse (e-Nabız) ................................................................................ 32
3.7 Integration of e-Pulse (e-Nabız) with Other Systems ................................................. 32

4. Comparing epSOS (EU), NHS (England), HealtheVet (USA), HealthHub (Singapore),
and e-Pulse (Turkey)................................................................................................................ 34
4.1 epSOS (EU)........................................................................................................................ 34
4.2 NHS (England)................................................................................................................... 35
4.3 HealtheVet (USA).............................................................................................................. 36
4.4 HealthHub (Singapore) .................................................................................................... 41
4.5 Results of Comparison regarding epSOS (EU), NHS (England), HealtheVet (USA),
HealthHub (Singapore), and e-Pulse (Turkey)..................................................................... 42
5. Future Works..................................................................................................................... 47

List of Tables
Table 1 - Comparative Statistics regarding Health (Health Workforce and Infrastructure
& Technologies)...................................................................................................18
Table 2 - Comparative Statistics regarding Health (Total Expenditure on Health and
General Government Expenditure on Health)..........................................................18
Table 3 - Health Metrics........................................................................................19
Table 4 - Systems Integrated with e-Pulse (e-Nabız) and Rationales for Integration...32
Table 5 - Results of Comparison regarding epSOS (EU), NHS (England), HealtheVet
(USA), HealthHub (Singapore), and e-Pulse (Turkey) with respect to General
Characteristic.......................................................................................................42
Table 6 - Results of Comparison regarding epSOS (EU), NHS (England), HealtheVet
(USA), HealthHub (Singapore), and e-Pulse (Turkey) with respect to Functionalities ..43

List of Figures
Figure 1 - e-Health Journey...................................................................................11
Figure 2 - e-Pulse (e-Nabız) Web Page...................................................................28
Figure 3 - e-Pulse (e-Nabız) Application..................................................................28

1. Introduction
1.1 Scope
This report gives information about
 e-Health [Definition of e-Health, Main Players in the Field of e-Health, Success
Factors for e-Health Projects, The 10 e’s in e-Heath, Current e-Health Projects or
Services of Turkey, Statistics Regarding the Health and e-Health Industries of
Turkey, EU Citizen’s Use of e-Health Services, Comparative Statistics regarding
Health, Metrics related with Health and e-Health, and European Funded Projects
in the field of ICT for Health and Wellbeing (e-Heath)],
 e-Pulse (e-Nabız) [e-Pulse (e-Nabız), Features and Functionalities of e-Pulse (e-
Nabız), Future Functionalities of e-Pulse (e-Nabız), Security and Privacy related
with e-Pulse (e-Nabız), Legal Case related with e-Pulse (e-Nabız), Infrastructure
of e-Pulse (e-Nabız), and Integration of e-Pulse (e-Nabız) with Other Systems],
 Comparing epSOS (EU), NHS (England), HealtheVet (USA), HealthHub
(Singapore), and e-Pulse (Turkey) [epSOS (EU), NHS (England), HealtheVet
(USA), HealthHub (Singapore), Results of Comparison regarding epSOS (EU),
NHS (England), HealtheVet (USA), HealthHub (Singapore), and e-Pulse
(Turkey)], and
 Future Works.
1.2 Definitions and Abbreviations
€ Euro
CHRMS Core Health Resources Management System
CT Computed Tomography
DoD Department of Defense
ECHO Echocardiogram
EHIC Integration of the European Health Insurance Card
epSOS European Patients - Smart Open Services
EU European Union

EUROSTAT European Statistics Office
FMIS Family Medicine Information System
GP General Practitioner
ICS Integrated Care Services
IT Information Technology
ICT Information and Communication Technologies
MoH Ministry of Health
MRI Magnetic Resonance Imaging
N No
NHS National Health Services
No. Number
NY Not Yet
OECD Organization for Economic Co-operation and Development
PHR Personal Health Record
SCR Summary Care Record
SMS Short Message Service
USD United States Dollar
VA Veteran Affairs
VA CCD VA Continuity of Care Document

WHO World Health Organization
Y Yes
1.3 References
Akdağ, R.
Health Transformation Program in Turkey September 2010
PROGRESS REPORT, Republic of Turkey, Ministry of Health
Publication No: 807 ISBN: 978-975-590-336-1
Altınok, R.
Turkey’s e-Health Activities, 2013.
http://css.escwa.org.lb/ictd/2094/2.pdf
Andreassen, H.
K., Bujnowska-
Fedak, M. M.,
Chronaki, C. E,
Dumitru, R. C.,
Pudule, I,
Santana, S., Voss,
H., and Wynn, R.
European citizens’ use of E-health services: A study of seven
countries, BMC Public Health, 7-53, 2007.
epSOS
About epSOS, No Date. http://www.epsos.eu/home/aboutepsos.
Html
epSOS
Frequently Asked Questions (FAQ), No Date.
http://www.epsos.eu/faqglossary/faq.html#c91
Erciyas, S. S. and
Geçgil, T. A.
Turkish citizens to manage their own health data, eHealth Law &
Policy, 2-5, 2015.
European
Commission
eHealth projects - Research and Innovation in the field of ICT for
Health and Wellbeing: An overview, EUROPEAN COMMISSION
Directorate-General for Communications Networks, Content and
Technology, 2014.
Eysenbach, G.
What is e-health?, Journal of Medical Internet Research
2001;3(2):e20. doi:10.2196/jmir.3.2.e20
HealthHub HealthHub, No Date. http://www.healthhub.sg/
HealthHub HealthHub, About Us, No Date. http://www.healthhub.sg/aboutus

Maurice Mars
eHealth Economics: The Need For Standardized Metrics and
Frameworks. 2011.
https://www.medetel.eu/download/2011/parallel_sessions/
presentation/day2/eHealth_Economics.pdf
Müezzinoğlu, M.
2016 YILI BÜTÇE SUNUMU 10 Şubat 2016 TBMM Plan ve Bütçe
Komisyonu, 2016. http://www.saglik.gov.tr/TR/dosya/1-
101400/h/tbmm.pdf
The College for
Behavioral Health
Leadership
Health Metrics. No Date.
http://www.change4health.org/technologies/consumer-e-health-
and-health-metrics/frameworks/
The NHS in
England
Your health, your choices - Your health and care records, 2016.
http://www.nhs.uk/NHSEngland/thenhs/records/
healthrecords/Pages/overview.aspx
T.C. Danıştay 15.
Daire
2015-2900. http://www.ttb.org.tr/images/stories/haberler/
file/danistay_10_daire_2015_karar.pdf
T.C. Sağlık
Bakanlığı
T.C. Sağlık Bakanlığı Sağlık İstatistikleri Yıllığı – 2014, Ankara,
Turkey, 2015. http://www.saglik.gov.tr/TR/belge/1-2952/istatistik-
yilliklari.html
T.C. Sağlık
Bakanlığı eNabız
Portalı
e-Nabız, no date. https://enabiz.gov.tr/Yardim.html
T.C. Sağlık
Bakanlığı Sağlık
Bilgi Sistemleri
Genel Müdürlüğü
Kişisel Sağlık Sistemi Platformu “e-Nabız” Tanıtım Dokümanı, 2015,
https://enabiz.gov.tr/klavuz-magazine/
T.C. Sağlık
Bakanlığı Sağlık
Bilgi Sistemleri
Genel Müdürlüğü
Sağlık.NET Hakkında. No Date. http://www.e-saglik.gov.tr/belge/1-
33811/sagliknet-hakkinda.html
Türk Tabipleri
Birliği
e-Nabız Projesinin yürütmesi durduruldu, 2016.
http://www.ttb.org.tr/index.php/Haberler/e-nabiz-5957.html
Türkiye İstatistik
Kurumu
Temel İstatistikler, 2015.
http://www.tuik.gov.tr/UstMenu.do?metod=temelist

U.S. Department
of Veterans
Affairs
My HealtheVet The Gateway to Veteran Health and Wellness, 2014.
https://www.myhealth.va.gov/index.html
U.S. Department
of Veterans
Affairs
My HealtheVet Account Types, 2014.
https://www.myhealthevet.va.gov/mhv-portal-
web/anonymous.portal?_nfpb=true&_nfto=false
&_pageLabel=spotlightArchive&contentPage=
ipa/mhv_account_status-definitions.html
WHO Trade, foreign policy, diplomacy and health, EHealth, No Date.
http://www.who.int/trade/glossary/story021/en/
WHO
World Health Statistics 2015. 2015.
http://apps.who.int/iris/bitstream/10665/
170250/1/9789240694439_eng.pdf?ua=1&ua=1

2. e-Health
2.1 Definition of e-Health
E-health is still another popular application area of e-transformation and management.
The World Health Organization (WHO) defines e-health as the transfer of health resources
and health care by electronic means. It encompasses three main areas:
 The conveyance of health information, for health professionals and health
consumers, by means of the Internet and telecommunications.
 Using the power of information technology (IT) and e-commerce to improve
public health services, e.g. through the education and training of health workers.
 The use of e-commerce and e-business practices in health systems management.
For a while but particularly in recent times, e-health concept and applications is a
developing field in the juncture of medical informatics, public health and business,
referring to health services and information delivered and/or improved through the
Internet and/or related technologies.
In a broader sense, the term of e-health characterizes not only a technical development,
but also a state-of-mind, a way of thinking, an attitude, and a commitment for networked,
global thinking, to improve health care locally, regionally, and worldwide by using
information and communication technology (ICT).
Unquestionably, the term e-health, referring to all digital health-related information, is
exceedingly all-purpose as it covers:
 Products, like instruments to ensure the constant monitoring of blood pressure
in ambulatory patients,
 Systems, like computer-assisted surgery systems, and
 Services, like:
o Operating surgical and intensive care units, with interconnected
instruments and surveillance services ensuring continuous patient
monitoring;
o Computer-assisted prescription services, where the software checks for
incompatible drugs, contraindications and dosage levels;
o Information services for patients and consumers, including individual
electronic health records.
Furthermore, e-health can be defined as the introduction of information technologies in
the field of health on the internet for effective and efficient provision of healthcare
services, ensuring rapid access and sustainability of data exchange among all relevant
stakeholders.
In today’s settings, generally, e-health products, systems and services are mostly location
independent, in that they can be used locally (doctors’ surgeries, hospitals) or remotely,
as is inherent in the term “tele” (tele-dermatology, tele-surgery, tele-diagnosis, tele-
medicine, and etc.).
E-health has a very definitive journey for nearly all countries. The e-health journey can
be figured as in Figure 1.

Figure 1 - e-Health Journey
In this context, specifically for Turkey, the e-Health vision of the Ministry of Health of
Turkey is to establish a national health information system, which may be accessed only
by the authorized persons and institutions, in which all persons can access their own
health data, which complies with international standards and is supported by decision
support systems, which has large band width and covers the whole country; and which
is based on the utilization of technologies such as tele-medicine and tele-health in
practice.
2.2 Main Players in the Field of e-Health
In contradiction of the old-fashioned health sectors, e-health solutions firmly necessitate
coordination with dissimilar players whose philosophies, purposes and backgrounds are
to a certain extent miscellaneous.
These players can be enumerated as:
 United Nations agencies and other international bodies dealing with health,
telecommunications, and trade,
 Government authorities, health and telecommunication decision-makers at the
national and regional levels, as well as the regional bodies to which they belong,
 Academic and research institutions,
 Local health professionals, and their associations,
 Consumers, patients, and their associations,
 Donors,

 Relevant non-governmental organizations,
 The private sector, including foundations and industries related to health and
ICTs, and
 The media.
For sure, each of these groups has a dissimilar scholastic experience and convention, as
well as by some means contradictory responsibilities and constraints. Nevertheless, all of
these have to be well analyzed, respected, mobilized, and coordinated to achieve the
success.
2.3 Success Factors for e-Health Projects
To be legitimately effective and successful regarding the e-health, the implementation
efforts related with e-health settings must be based on a clear appreciation of the
country’s current and future public health and healthcare issues and opportunities, with
a characterization of the corresponding national priorities, and on a medium- to long-
term accomplishment plans for the use of e-health technologies to meet healthcare
priorities, with fragmentary renovation and restoration of the health systems themselves.
For better accomplishment, the related strategy must:
 bring together players from the public sector, not-for-profit organizations and the
private sector,
 be structured in the form of a business plan, approved by the stakeholders,
 be sponsored by a strong commitment on the part of all players, and
 include a comprehensive plan for ongoing education and communication with the
partners.
2.4 The 10 e’s in e-Heath
Intended for an effective and efficient e-health content and context, there must be 10 e’s
attained and sustained. Each of these 10 e’s is elaborated below:
1. Efficiency
e-health must be efficient.
One of the aptitudes of e-health is to increase efficiency in health care, thereby decreasing
costs. One conceivable way of decreasing costs would be by avoiding duplicative or
unnecessary diagnostic or therapeutic interventions, by dint of enhanced communication
possibilities among health care establishments, and through patient involvement.
2. Enhancing
e-Health should be enhancing quality of care.
Specifically, increasing efficiency involves not only reducing costs, but at the same time
improving quality. E-health may enhance the quality of health care for example by

allowing comparisons between different providers, involving consumers as additional
power for quality assurance, and directing patient streams to the best quality providers.
3. Evidence-based
e-Health ought to be evidence based.
That is to say, e-health interventions should be evidence-based in a sense that their
effectiveness and efficiency should not be assumed but proven by rigorous scientific
evaluation.
4. Empowering
e-Health must be empowering.
e-Health should lead to empowerment of consumers and patients by means of making
the knowledge bases of medicine and personal electronic records accessible to consumers
over the Internet, e-health opens new avenues for patient-centered medicine, and
enables evidence-based patient choice.
5. Encouraging
e-Health should be encouraging.
Specifically, encouragement of a new relationship between the patient and health
professional, towards a true partnership, where decisions are made in a shared manner.
6. Education
e-Health ought to be provided with education.
Education should be provided and repeated as required regarding e-health. It consists of
education of physicians through online sources (continuing medical education) and
consumers (health education, tailored preventive information for consumers).
7. Enabling
e-Health must be an enabler.
It should enable information exchange and communication in a standardized way
between health care establishments.
8. Extending
e-Health should have an extending attribution.
E-health ought to extend the scope of health care beyond its conventional boundaries.
This is meant in both a geographical sense as well as in a conceptual sense. e-health
enables consumers to easily obtain health services online from global providers. These
services can range from simple advice to more complex interventions or products such
as pharmaceuticals.

9. Ethics
e-Health should be blended with ethical concerns.
Ethics should be achieved and sustained as e-health involves new forms of patient-doctor
interaction and poses new challenges and threats to ethical issues such as online
professional practice, informed consent, privacy, and/or equity issues.
10. Equity
e-Health ought to be providing equity.
Equity should be ensured to make health care more equitable is one of the promises of
e-health, but at the same time there is a considerable threat that e-health may deepen
the gap between the “haves” and “have-nots”. People, who do not have the money, skills,
and access to computers and networks, cannot use computers effectively. As a result,
these patient populations (which would actually benefit the most from health information)
are those who are the least likely to benefit from advances in information technology,
unless political measures ensure equitable access for all. The digital divide currently runs
between rural vs. urban populations, rich vs. poor, young vs. old, male vs. female people,
and between neglected/rare vs. common diseases.
2.5 Current e-Health Projects or Services of Turkey
Turkey’s Ministry of Health (MoH) executes fairly large projects in the e-health domain.
Each of these projects are exceedingly funded and rigorously managed. These projects
are: Health-NET, Family Medicine Information System, Core Health Resources
Management System, Green Card Information System, Tele-Medicine Project, Decision
Support System, e-Pulse (e-Nabız), e-Training, and Other Projects.
Brief information for each of these major and fundamental projects executed by Turkey’s
MoH are given below.
1. Health-NET
Health-NET is an integrated, safe, fast and expandable information system which aims to
improve efficiency and quality of health services by collecting all kinds of data produced
in the health institutions in line with the standards and generating information adequate
for all stakeholders out of the collected data.
2. Family Medicine Information System
Family Medicine practice, initiated under the Health Transformation Program, has
introduced innovations both in terms of healthcare service provision and primary health
care data collection discipline of Turkey’s MoH. The most important innovation in this
context is the Family Medicine Information System (FMIS).

3. Core Health Resources Management System
This project, realized by the Central Organization of the MoH and 81 Provincial Health
Directorates has ensured the provision of accurate and updated information support to
managers of all levels in order for the human, material and financial resources to be
monitored and directed as required. Core Health Resources Management System
(CHRMS) is integrated with other projects and implementations and has become
indispensable for the Ministry with its database.
4. Green Card Information System
Through the Green Card Information System, green card entitlement of the citizens
holding green cards is monitored and this information is shared with other stakeholders
through web service.
5. Tele-Medicine Project
Through the Tele-medicine Project, distant reporting service was introduced in the field
of imaging with the use of information and communication technologies; and a total of
68 hospitals, consisting of 58 sender and 10 receiver hospitals, have been integrated in
the field of tele-radiology, tele-pathology and the roll-out works are continuing.
6. Decision Support System
Decision Support System, which provides analysis, reporting and statistics support for the
Health Policy makers, planners and decision makers was put into service. This way, it will
be possible to carry out epidemiologic and demographic analysis about the burden of
disease.
7. e-Pulse (e-Nabız)
e-Pulse (e-Nabız) is a personal health records system that allows users to manage all
health information and to access to the health history from a single point, regardless of
where the examinations and treatments are completed. Further details are given in
Section 3 of this report.
8. e-Training
E-training portal has been devised in order to support graduate in-service training of MoH
personnel and to provide them training at any place and time they wish. The project was
initiated in May 2009 and Microsoft Office 2007 and Information Safety Training have
been provided to around 2500 health personnel by way of distant training.

9. Other Projects
Through the MoH Tender Information System, it is possible to see the tender results for
the procurement of medicines, devices, materials and services in all MoH Provincial Health
Directorates, all hospitals, and Hygiene Regional Directorates.
Moreover, Pharmaceutical and International Classification of Diseases codes started to be
implemented. Within the framework of health informatics, National Health Data Dictionary
and Healthcare Minimum Data Sets were prepared for the first time and Health Coding
Reference Server was put into service.
Again for the first time, Organ Transplantation and Tissue Data Bank were established in
order to find the most suitable organ for the citizens waiting for organ transplantation;
and to prevent illicit organ transplantation. Through the Physician Data Bank, the diploma
and the specialty information of all physicians in the Republic Period are fettered into
records.
2.6 Statistics Regarding the Health and e-Health Industries
of Turkey
In order to understand and appreciate the size and promise of the related market with
respect to heath and e-health industries of Turkey, some statistics were gathered. These
numbers clearly show that health and e-health industries in Turkey are really promising
and they have high potential.
Collected statistics:
 Number of mobile phone subscriptions in Turkey: 72,174,826 [June, 2015]
(Turkish Statistical Institute)
 Number of Internet subscriptions in Turkey: 44,395,360 [June, 2015] (Turkish
Statistical Institute)
 Computer usage in households and individuals in Turkey: 54.8% [2015] (Turkish
 Internet usage in households and individuals in Turkey: 55.9% [2015] (Turkish
 Households with access to the Internet in Turkey: 69.5% [2015] (Turkish
 Number of physicians in Turkey: 135,616 [2014] (Turkish Statistical Institute)
 Number of persons per physician in Turkey: 573 [2014] (Turkish Statistical
Institute)
 Number of patient hospital visits per physician in Turkey: 4648 [2014] (Turkish
 Total number of visits to physicians in all healthcare facilities in Turkey:
643,992,030 [2014] (MoH, Republic of Turkey)
 Total number of visits to physicians in hospitals in Turkey: 396,577,644 [2014]
(MoH, Republic of Turkey)

 Number of hospitals in Turkey: 1528 [2014] (MoH, Republic of Turkey)
 Number of public hospitals in Turkey: 866 [2014] (MoH, Republic of Turkey)
 Number of private hospitals in Turkey: 556 [2014] (MoH, Republic of Turkey)
 Number of university hospitals in Turkey: 69 [2014] (MoH, Republic of Turkey)
 Number of other hospitals in Turkey: 37 [2014] (MoH, Republic of Turkey)
 Number of MRI devices in Turkey: 757 [2014] (MoH, Republic of Turkey)
 Number of CT devices in Turkey: 1071 [2014] (MoH, Republic of Turkey)
 Number of ultrasound devices in Turkey: 5286 [2014] (MoH, Republic of Turkey)
 Number of Doppler ultrasonography devices in Turkey: 3151 [2014] (MoH,
Republic of Turkey)
 Number of ECHO devices in Turkey: 1793 [2014] (MoH, Republic of Turkey)
 Number of mammography devices in Turkey: 903 [2014] (MoH, Republic of
Turkey)
 Number of MRI devices in private hospitals in Turkey: 403 [2014] (MoH, Republic
of Turkey)
 Number of CT devices in private hospitals in Turkey: 484 [2014] (MoH, Republic
of Turkey)
 Number of ultrasound devices in private hospitals in Turkey: 1865 [2014] (MoH,
Republic of Turkey)
 Number of Doppler ultrasonography devices in private hospitals in Turkey: 666
[2014] (MoH, Republic of Turkey)
 Number of ECHO devices in private hospitals in Turkey: 666 [2014] (MoH,
Republic of Turkey)
 Number of mammography devices in private hospitals in Turkey: 517 [2014]
(MoH, Republic of Turkey)
 Current health expenditure in Turkey: USD 72,456 M [2013] (MoH, Republic of
Turkey)
 Health investment expenditure in Turkey: USD 4262 M [2013] (MoH, Republic of
Turkey)
2.7 Comparative Statistics regarding Health
In order to understand the whole-picture in the context of health and pertinent practices
in the related field, it is a must to have a look at the comparative statistics regarding the
health.
Table 1 gives the comparative statistics regarding health (health workforce and
infrastructure & technologies). Table 2 gives the comparative statistics regarding health
(total expenditure on health as %).
Table 1 highlights that, when compared with United Kingdom, United States of America,
Singapore, and France; Turkey needs to improve its health workforce and health
infrastructure and technologies.
Additionally, Table 2 reveals that, when compared with United Kingdom, United States of
America, and France; Turkey needs to improve its total expenditure on health as % of
gross domestic product and general government expenditure on health as % of total
government expenditure.

Table 1 - Comparative Statistics regarding Health (Health Workforce and Infrastructure & Technologies)
Country
Density of health workforce
(per 10,000 population)
Density of health
infrastructure and
technologies
Physicians
Nursing and
midwifery
personnel a
Hospitals
(per
100,000)
Psychiatric
beds (per
100,000)
Turkey 17.1 24.0 1.5 9.3
United Kingdom 28.1 88.0 No Data 34.1
United States of
America
24.5 No Data No Data 50.2
Singapore 19.5 57.6 0.5 44.3
France 31.9 93.0 No Data 89.6
Table 2 - Comparative Statistics regarding Health (Total Expenditure on Health and General Government
Expenditure on Health)
Country
Total expenditure on health
as % of gross domestic
product
General government
expenditure on health as % of
total government expenditure
2000 2012 2000 2012
Turkey 4.9 5.4 9.8 10.7
United Kingdom 6.9 9.3 15.1 16.2
United States of
America
13.1 17.0 16.8 20.0
Singapore 2.7 4.2 7.1 11.1
France 10.1 11.6 15.5 15.8
2.8 Metrics related with Health and e-Health
Table 3 shows the generic metrics for the context of health.

Table 3 - Health Metrics

Additionally, for the context of e-health, following evaluation methods can be used to
monitor and control process and/performance:
 Cost analysis
 Marginal net present value calculation
 Cost effectiveness analysis
 Total absorption costing
 Cost minimization
 Cost minimization analysis
 Payback period and breakeven point
 Cost consequence analysis
 Affordability gap analysis
 Cost benefit analysis
 Utilization review
 Cost utility analysis
 Cost utility analysis
 Value chain analysis
 Willingness to pay
 eHealth utilization
 Contingent valuation method
 Activity based costing
On the other hand, both of these approached should be agreed on related parties for
employment.
Organizations need to blend these two category of metrics and methods to monitor and
fine-tune their efforts and practices related with health practices. Health metrics and e-
health metrics are determined by related organizations to evaluate the effectiveness and
efficiencies of related systems.
2.9 EU Citizen’s Use of e-Health Services
There is a study that investigated patterns of health-related Internet use, its
consequences, and citizens’ expectations about their doctors’ provision of e-health
services (Andreassen, Bujnowska-Fedak, Chronaki, Dumitru, Pudule, Santana, Voss, and
Wynn, 2007).
In the subject study, representative samples were obtained from the general populations
in Norway, Denmark, Germany, Greece, Poland, Portugal and Latvia. The total sample
consisted of 7934 respondents. Interviews were conducted by telephone.
44% of the total sample, 71% of the Internet users, had used the Internet for health
purposes.
Factors that positively affected the use of Internet for health purposes were youth, higher
education, white-collar or no paid job, visits to the GP during the past year, long-term
illness or disabilities, and a subjective assessment of one’s own health as good.
Women were the most active health users among those who were online. One in four of
the respondents used the Internet to prepare for or follow up doctors’ appointments.

Feeling reassured after using the Internet for health purposes was twice as common as
experiencing anxieties. When choosing a new doctor, more than a third of the sample
rated the provision of e-health services as important.
As a result of the subject study, it is concluded that the users of Internet health services
differ from the general population when it comes to health and demographic variables.
The most common way to use the Internet in health matters is to read information,
second comes using the net to decide whether to see a doctor and to prepare for and
follow up on doctors’ appointments.
Henceforth, health-related use of the Internet does affect patients’ use of other health
services, but it would appear to supplement rather than to replace other health services.
2.10 European Funded Projects in the field of ICT for Health
and Wellbeing (e-Heath)
In this part of the report, an overview of some of the most current (on-going or recently
finished) European funded projects in the field of ICT for health and wellbeing (e-Health)
are provided.
These are provided to reflect the current project examples in the e-health in the European
zone.
1. eHealthMonitor
Development of a platform for individualized personal healthcare services, design of
knowledge sharing methods which consider privacy protection requirements, and include
all stakeholders in the decision making process.
More information is available at the following webpage: www.ehealthmonitor.eu
Duration: 2011-2014
2. Mobiguide
The aim of the MobiGuide project (www.mobiguide-project.eu) is to develop an intelligent
decision support system for patients with chronic illnesses. The system accompanies the
patients wherever they go and helps them and their care providers in managing their
illness, whether they are at home, at work, out and about or travelling abroad on holiday
or for business. The MobiGuide tool analyses bio signals from body-worn sensors and
gives advice 24/7.
Duration: 2011-2015
3. MyHealth Avatar
Digital representation of patient health status.
More information is available at the following webpage: www.myhealthavatar.eu
Duration: 2013-2016

4. p-Medicine
p-Medicine (‘Personalised Medicine’) is working on an infrastructure that will facilitate the
translation from current practice to personalized medicine.
More information is available at the following webpage: www.p-medicine.eu
Duration: 2011-2015
5. DAPHNE
With DAPHNE, researchers and businesses join forces to help people manage their weight
and increase physical exercise using emerging technologies and information systems. The
project will use a new generation of sensors to detect how much energy a person expends
– including how much time they have been sitting still, walking, standing, doing
housework, etc. - and can monitor their overall fitness.
More information is available at the following webpage: www.daphne-fp7.eu
Duration: 2013-2016
6. BeatHealth
Better at sports while listening to music? BeatHealth wants to exploit this link between
music and movement for boosting individual performance and enhancing health and
wellness. It aims to create an intelligent portable tool and IT network for rhythmical
stimulation adapted to the individual’s skills. The beneficial effects of BeatHealth will be
evaluated both in patients with movement disorders (i.e., Parkinson’s disease), and in
healthy citizens of various ages with moderate physical activity.
More information is available at the following webpage: www.euromov.eu/beathealth
Duration: 2013-2016
7. PEGASO Fit for Future
Promoting healthy lifestyles and food awareness among teenagers through games and
technology - this is the goal of the "PEGASO Fit for Future" project.
More information is available at the following webpage: www.pegasof4f.eu
Duration: 2013-2017
8. SPLENDID
This project will develop hi-tech sensors aiming to prevent obesity: By measuring food
intake and activity these sensors can assess obesity risks. In the fight against obesity,
SPLENDID also developed special programs for guiding both school children and adults.
More information is available at the following webpage: splendid-program.eu
Duration: 2013-2016

9. PRECIOUS
To maintain a healthy lifestyle, PRECIOUS aims to improve motivation using a
combination of motivational interview and gamification principles, as well as creating a
personalized system that adapts to the users’ goals and preferences. The system will
measure food intake, physical activity, stress levels and sleep patterns.
More information is available at the following webpage: www.thepreciousproject.eu
Duration: 2013-2016
10. SEMEOTICONS
The central idea of SEMEOTICONS (SEMEiotic Oriented Technology for Individual’s
CardiOmetabolic risk self-assessmeNt and Self-monitoring), is to exploit the face as a
major indicator of individual’s wellbeing by tracing traits of physical and expressive status.
To map and assess these face signs, SEMEOTICONS will design and construct a multi-
sensory system integrated into a hardware platform having the exterior aspect of a
mirror: the so-called "Wize Mirror". This will easily fit into users’ home or other sites of
their daily life.
More information is available at the following webpage: www.semeoticons.eu
Duration: 2013-2016
11. eHealth Innovation
This thematic network wants to develop a European roadmap for sustained eHealth
innovation. The focus is on personalized health services and a supportive eHealth
infrastructure. Special emphasis will be put on chronic disease management for an ageing
population. The network involves 22 partners: 20 from 10 Member States and 2 from
Switzerland representing a broad range of stakeholders: national and regional authorities,
industry (ICT and pharma), national solution providers, researchers and users (health
professionals, patients, healthcare providers and insurers/third party payers), European
and national associations.
More information is available at the following webpage: www.ehealth-innovation.eu
Duration: 2011-2013
12. CLEAR
This project proposed the implementation of a "Tele-rehabilitation service" in four
Member States of the European Union. The ambition was to convert the project, after its
completion, to a European platform for Tele-rehabilitation, and to contribute to the
harmonization of eHealth services in the EU. CLEAR was a fundamental step in helping
doctors treating patients who seek health treatment in a comfortable environment,
including home, under supervision of a specialized team.
More information is available at the following webpage: www.habiliseurope.eu
Duration: 2008-2012

13. CommonWell
The CommonWell project (commonwell.eu) delivered integrated telecare and telehealth
services among social care providers and hospitals on open platforms. The developed
services were targeted mainly for patients suffering from chronic diseases and
professionals dealing with these conditions. The system collects and makes sure health
parameters are monitored and health care providers receive up-to-date information about
patients. The main advantage with this ICT solution is that it prevents unnecessary
admissions to hospitals and patients can go on living actively and independently.
The project implemented a platform which tested 4 different services in the pilot sites:
 Telecare integration for better emergency care;
 Managed hospital admission for care providers;
 Early intervention and telehealth for patients;
 Integrated support for heart failure patients.
The project ended in early 2012 and integrated services are now in real-life operation at
the four pilot sites established in Spain, Germany, England and the Netherlands.
Duration: 2008-2012
14. MOMENTUM
A European telemedicine "Blueprint" to mainstream telemedicine into daily practice and
make it sustainable.
More information is available at the following webpage: www.telemedicine-
momentum.eu
Duration: 2012-2014
15. NEXES
The NEXES project (www.nexeshealth.eu) moved the focus from hospital care to primary
and home care using ICT support. To this end, the project assessed deployment of 4
innovative Integrated Care Services (ICS) for chronic patients (respiratory, cardiac and
type II diabetes mellitus) including well standardized patient-centered interventions:
home-based wellness and exercise-training; enhanced care for frail patients; home
hospitalization and early discharge and remote support to primary care for diagnosis and
therapy. The pilot was carried out in three different sites – Spain, Greece and Norway –
where it developed insights into local structural and operational barriers which have to
be overcome for further development of Integrated Care Services.
Specific achievements of the project have been:
 Development of Integrated Care Services for chronic patients with enhanced
effectiveness and reduced costs,
 Consolidation of an open source modular Health Information Sharing Platform
supporting organizational interoperability among actors and clinical decision
support systems, and
 Strategies for scalability of the ICT services at regional level.
Duration: 2008-2012

16. RenewingHealth
This project has sought to deliver telemedicine and personal health services (PHS) to the
many people suffering from Chronic Obstructive Pulmonary Diseases (COPD), diabetes
and cardiovascular diseases.
The project has implemented large scale real-life pilots to validate and evaluate innovative
patient-centered personal health systems and telemedicine services.
The ultimate goal is to demonstrate what PHS and telemedicine services can deliver:
 More effective and efficient care and
 Improving of the quality of life and enhancing patients’ involvement and
empowerment.
More information is available at the following webpage: www.renewinghealth.eu
Duration: 2010-2013
17. United4Health
The United4Health project aims to exploit and further deploy innovative telemedicine
services implemented and trialed under the Renewing Health project. All included service
solutions adopt a patient centered approach, and involve the telemonitoring and the
treatment of chronic patients with diabetes, COPD or CVD diseases.
More information is available at the following webpage: www.united4health.eu and
ec.europa.eu
Duration: 2013-2015
18. THALEA
Through the THALEA project, five hospitals from Germany, Netherlands, Spain, Belgium
and Finland will initiate a joint Pre-Commercial Procurement (PCP) focusing on getting a
highly interoperable telemedicine and tele monitoring platform (a central ‘monitoring
cockpit’) for improving the care of acutely live threatened patients at intensive care units.
THALEA intends to launch a European wide published PCP call for tender for the value of
around €1,55M.
More information is available at the following webpage: www.thalea-pcp.eu and THALEA
factsheet
Duration: 2013 - 2016
19. INSPIRE
An EU-network to bring together experts and procurers interested in developing and
implementing innovative procurements in the eHealth, Active Aging and Independent
Living areas.
More information is available at the following webpage: www.nhg.fi
Duration: 2013 – 2015

20. CARRE
To help patients manage their chronic heart and kidney disease, CARRE will develop
personalized alerting, planning and educational services. This will empower patients, and
both professionals and patients will be able to make shared informed decisions on the
disease. The CARRE consortium consists of 6 partners from 4 countries (Greece, United
Kingdom, Lithuania and Poland) and is coordinated by the Democritus University of
Thrace in Alexandroupoli, Greece.
More information is available at the following webpage: www.carre-project.eu
Duration: 2013 – 2016
21. MovingLife
MovingLife ("MObile eHealth for the VINdication of Global LIFEstyle change and disease
management solutions") has delivered a set of roadmaps for mHealth ("mobile health").
These include technology and application research and innovation, implementation
practice and policy support. The roadmaps are supposed to accelerate the establishment,
acceptance and wide use of mHealth solutions at a global scale.
More information is available at the following webpage: www.moving-life.eu
Duration: 2011-2013
22. DECIPHER PCP
DECIPHER PCP (www.decipherpcp.eu) deals with mHealth procurement. It is developing
a mobile solution which enables secure cross-border access to existing patient healthcare
portals.
Duration: 2012-2016
23. UNWIRED Health
UNWIRED Health also deals with mHealth procurement for the transformation of
healthcare services. In this case, the Pre-Commercial Procurement (PCP) focuses on apps
offering services: to improve vaccination coverage and adherence and to coach patients
with heart failures enabling education, motivation, remote monitoring and other
functionalities, integrating and coordinating care provided by a hospital and the primary
care physician.
Both of these apps will be innovative, fully integrating the apps in the regional public
health systems and can be prescribed by GPs. These services will be implemented in open
platform infrastructures that will make the apps platform-agnostic, suitable to any
smartphone and any participating operator. The consortium consists of three procurers
introducing the innovation into their territories in Catalonia, Scotland and Southern
Denmark and three vendor independent non-profit associations that will act as catalyst
to foster the development of open platforms and interoperable solutions.
Duration: 2014-2016

24. PALANTE
PALANTE (www.palante-project.eu) focusses on patient empowerment: Maximize the
potential of ICT technologies in health care by validating pilots that address mechanisms
involved in patient empowerment. Currently there are 9 ongoing pilots: in Andalusia
(Spain), Lombardy (Italy), Turkey, Norway, Austria, Czech Republic, Basque Country
(Spain), France, Denmark. All of these pilots address the issue of patient’s secure access
to their own health information.
Duration: 2012-2015
25. SUSTAINS
To empower patients, SUSTAINS ("Support User Access to Information and Services")
comprises a basket of services based on giving citizens online access to their Electronic
Health Records (EHR). The services proposed have been distilled from the experience of
regions which have already pioneered such access. The regions of the SUSTAINS
Consortium share their experiences and achievements to speed up the implementation
of the SUSTAINS outcomes.
More information is available at the following webpage: sustainsproject.eu
Duration: 2012-2014
26. epSOS
epSOS (www.epsos.eu) is short for European Patient Smart Open Services.
This large scale project provides:
 Patient Summary: a digital summary of medical status to make abroad care better
and more efficient, especially helpful in an emergency situation.
 ePrescription: a digital drug prescription, so users can pick up medication in a
participating pharmacy abroad.
Duration: 2008-2014
27. Trillium Bridge
What if someone, while visiting the US, need urgent medical help and the doctor doesn’t
know medical history? The Trillium Bridge project wants to align the use of standards
between the EU and the US to share basic patient data between EU and US health
professionals. Of course only when the patient has given his consent.
By helping to create a transatlantic interoperability bridge for health data, Trillium Bridge
is implementing the EU-US Roadmap on eHealth.
More information is available at the following webpage: www.trilliumbridge.eu
Duration: 2013-2015

3. e-Pulse (e-Nabız)
3.1 e-Pulse (e-Nabız)
e-Pulse (e-Nabız) is a personal health records system that allows users to manage all
health information and to access to the health history from a single point, regardless of
where the examinations and treatments are completed. e-Pulse (e-Nabız) can be
accessed via a web-page (Figure 2) or devoted mobile applications (Figure 3) available
for mobile devices.
Figure 2 - e-Pulse (e-Nabız) Web Page
Figure 3 - e-Pulse (e-Nabız) Application

According to the Minister of Health of Turkey, Dr. Mehmet Müezzinoğlu, in less than one-
year period, since the introduction of the e-Pulse (e-Nabız), the number of users reached
to 3-million, and it is estimated that this number will be about 25-million in next five
years.
e-Pulse (e-Nabız) is the world’s largest and most comprehensive health informatics
infrastructure which can be securely accessed on the internet.
e-Pulse (e-Nabız) provides
 health records are reviewed by the doctors to the extents that are allowed by
users,
 enhancements in the quality and speed of diagnosis and treatment process as
previous records are accessible, and
 a powerful communications line between patients and doctors.
3.2 Features and Functionalities of e-Pulse (e-Nabız)
Functions of the e-Pulse (e-Nabız) can be listed as:
 Users can view the details about health facilities they visited with branch, time,
receipts, doctor details, and medicines information.
 Users can record and update side effects information about the medicines that
they used.
 Users can view test results, reports, and medical images with their reports.
 Users are able to record and update medicine allergies and other allergies that
they have, if any.
 Users are able to make appointments by using the e-Pulse (e-Nabız) as the
system is integrated to the central hospital appointment system.
 It is possible users to add notes to their appointments.
 There is an integrated calendar in the e-Pulse (e-Nabız), and users may use this
to track their appointments.
 Users can share their records with others or doctors as they wish with the
conditions they set.
 Users can track when the records that they shared are accessed with related
people.
 In the system, there is a messaging capability that users can use to communicate
with the contact networks that they created.
 Users can evaluate and rate on the health services that they take and comment
on these.
 By using the adding data module, users are able to either manually or
automatically add, modify, and delete their blood pressure, blood sugar, pulse,
and weight data.
 Mobile application of the e-Pulse (e-Nabız) sends reminders to the patients
regarding their medicines to take.
 By using the 112 emergency button, users can call emergency services with the
exact location that is shared by the application.
 Users are the only ones to control their records on the e-Pulse (e-Nabız) and they
can delete or share the records of their own, or they can pause or completely
terminate/remove their accounts on the e-Pulse (e-Nabız) system.

Smart-wristbands that measure steps, pulses, and calories, blood pressure and blood
sugar monitoring devices with Bluetooth capabilities, and certain mobile devices and
applications can be integrated to the e-Pulse (e-Nabız) profile and all health records can
be stored in a single place via the e-Pulse (e-Nabız).
Users can use the e-Pulse (e-Nabız) to access the details of their all examinations and
treatments. Users can update their profile information by using the profile section and
review last activities, last access details, and health facility visits of the related account
by using the notifications section. Users can either manually add their blood pressure,
blood sugar, and weight information to the system or authorize their devices to
automatically send these data to the system.
Regardless of in which health facilities they are completed, all test results and medical
images with their reports are recorded in the e-Pulse (e-Nabız) system. As long as these
are shared with the doctor by the patient, there is no need to repeat all these.
e-Pulse (e-Nabız) does not share any of the records without the consents of the users,
unless these are requested or required by laws or courts. e-Pulse (e-Nabız) uses
encryption for all records to protect them.
There is a SMS verification system for all update and delete operations. The system sends
a verification code to the users to complete the update and delete operations.
3.3 Future Functionalities of e-Pulse (e-Nabız)
In the future, following functionalities are planned to be integrated to the system:
 All notifications and reminders regarding pregnancy monitoring will be available
with the e-Pulse (e-Nabız).
 Users will be able to see their children’s vaccine follow-ups and growth curves.
 Patients with chronic diseases will be able to track their doctor visits and they will
be reminded by the e-Pulse (e-Nabız) as their appointments approach.
 Deaf citizens will be able to ask for ambulances by using the 122 emergency
button.
3.4 Security and Privacy related with e-Pulse (e-Nabız)
It is seen that confidentiality is an important component of the e-Pulse (e-Nabız) and the
MoH has duly set an encrypted platform on the website. In the system, only people
owning the data and authorized physicians can access the related data; the authorization
can be withdrawn at any time. These systems of electronic access have so far proved a
success in terms of the security of access.
Nevertheless, particularly for mobile signatures or one-time codes sent to GSM numbers,
loss or theft of mobile devices may lead to compromised security for the individual.
However, in terms of system infrastructure the e-government and electronic signature
systems have proven to be reliable in terms of addressing security concerns.

As this system (e-Pulse/e-Nabız) involves a separate website and access by authorized
individuals other than the owner of the health data, we will need to wait and see the
system in action in order to weigh whether the security risks are adequately addressed.
Critically though, Turkey currently does not have a finalized data protection law.
Accordingly, data protection is regulated in a piecemeal fashion by a combination of the
Turkish Constitution and the Turkish Criminal Code.
The Turkish Criminal Code has criminalized unauthorized access to and use of personal
data, therefore if any personal data is accessed or used outside the intended scope of
the e-Pulse (e-Nabız), those identified as the offenders would be sued under the Turkish
Criminal Code.
Nonetheless, as Turkey does not have a data protection law, there are also no separate
provisions defining sensitive data, such as race, ethnicity, sexual orientation or health. As
the data that will be stored within the scope of the e-Pulse (e-Project) will be mostly
regarded as sensitive data, Turkish citizens will not have the additional safeguards that
are afforded to such data in places like the European Union. This, in turn, may lead to
such data being insufficiently safeguarded.
Except for the above facts, in the conditions of use of the platform, the MoH noted that
some data may be used in national or international health research or analysis conducted
for Decision Support Systems but that only authorized MoH personnel will be able to
access the data and that the data itself will be anonymized. This means that there might
be exceptions to the authorized access to personal data.
Finally and disappointingly, the MoH claims a non-liability clause for missing information,
errors or delays in the data, software viruses etc. The MoH notes that the service and
application is provided by the MoH but the data is the responsibility of the institutions,
their personnel and people who update their own data. Such a non-liability clause may
cause problems in the application and implemented infrastructure of the system.
Additionally, coupled with the fact that Turkey does not have a data protection regime,
such a non-liability clause may limit the right of redress of those whose data is affected
by any such incident.
3.5 Legal Case related with e-Pulse (e-Nabız)
The Turkish Medical Association applied to the State Council and filed a lawsuit for the
cancellation of the MoH’s Communiqué, claiming that collecting personal health data with
patient names and identity numbers is against the general terms of data privacy.

The Association supported its claims through a precedent decision of the Constitutional
Court on the cancellation of the provisions of Decree Law no. 663, which authorized the
MoH to collect personal health data.
The State Council made a decision to cancel the Communiqué of MoH of Republic of
Turkey on that as there is no existing pertinent legal structure, particularly considering
the lack of a national law protecting personal data in Turkey.
Current situation is that all related data can be collected and maintained if and only if the
patients clearly permit to do so before any recording and maintenance.
Most probably this issue is to be evaluated when finalizing the Turkish national law
protecting personal data.
3.6 Infrastructure of e-Pulse (e-Nabız)
The e-Pulse (e-Nabız) uses the infrastructure of the Health.NET (Sağlık.NET). Certain
characteristics of the Health.NET are:
 An infrastructure based on web technology that transfer standards data from the
first, second, and third step independent software.
 A decision support system taking role in decision mechanisms which provides
related information from the center.
 A reporting system which provides an ability to track indicators requested from
international organizations, like WHO, EUROSTAT, and OECD.
 An infrastructure which enables lawful international data exchange.
 Providing citizens ability to let them access and manage their records.
 Applications to support national surveillance systems to reach data by using early-
warning systems.
3.7 Integration of e-Pulse (e-Nabız) with Other Systems
Systems integrated with e-Pulse (e-Nabız) and rationales for the pertinent integrations
are given in Table 4.
Table 4 - Systems Integrated with e-Pulse (e-Nabız) and Rationales for Integration
Integrated System Rationale for Integration
Central Doctors Appointment
Systems
To let users make appointments by using the e-
Pulse (e-Nabız).
Tele-medicine and Tele-radiology
To let users access radiological images and
reports.

Integrated System Rationale for Integration
Central Census Management
System
To access citizens’ specific data and information.
Health Management System
(Health-NET)
To facilitate the collection of data collected in
health facilities.
e-Government Website
To provide user authentication to the e-Pulse (e-
Nabız).
Family Medicine Information
System
To access data collected in related health
facilities.
Core Health Resources
Management System
To access data related with doctors and health
facilities.

4. Comparing epSOS (EU), NHS (England), HealtheVet
(USA), HealthHub (Singapore), and e-Pulse (Turkey)
4.1 epSOS (EU)
epSOS is aimed to design, build and evaluate a service infrastructure that demonstrates
cross-border interoperability between electronic health record systems in Europe.
epSOS attempts to offer seamless healthcare to European citizens. Key goals are to
improve the quality and safety of healthcare for citizens when travelling to another
European country. Moreover, it concentrates on developing a practical eHealth framework
and ICT infrastructure that enables secure access to patient health information among
different European healthcare systems. epSOS can make a significant contribution to
patient safety by reducing the frequency of medical errors and by providing quick access
to documentation as well as by increasing accessibility of ones prescribed medicine also
abroad. In emergency situations, this documentation provides the medical personnel with
life-saving information and reduces the (sometimes needless) repetition of diagnostic
procedures.
The goal of the epSOS Large Scale Pilot project is to develop and test (“pilot”) services
that
 enable patients to receive medication (ePrescriptions) when they are in another
European country. The medication must initially be prescribed in one of the
epSOS health professional in the patient's home country.
 permit health professionals to receive the relevant, translated clinical information
stored in the patient’s home country (“Patient Summary”). This is only possible
in the case of consultation and when the patient gives his/her consent.
epSOS Services are
 ePrescription
 Patient Summary
 Integration of emergency services
 Integration of the European Health Insurance Card (EHIC)
 Patient access to data
The project partners in cooperation with the eHealth Governance Initiative and other
Large Scale Pilots will disseminate the results to all European member states as well as
non-EU countries. Everyone interested will be able to access the results free of charge.
The epSOS pilot project is open to all citizens, physicians, hospitals, healthcare centers
or pharmacists that are living/located in those European countries participating in the
pilot project.

4.2 NHS (England)
Wherever someone visits an NHS service in England a record is created. This means
medical information can be held in various places, including GP practice, any hospital
where someone has had treatment, dentist practice, and so on. At times, this can delay
information sharing which can affect decision making and slow down treatment.
To help improve the sharing of important information about someone, the NHS in England
is using an electronic record called the Summary Care Record (SCR). Since April 2015 all
GPs should offer their patients online access to summary information of their GP records.
A health record (sometimes referred to as medical record) should contain all the clinical
information about the care received. This is important so every healthcare professional
involved at different stages of care has access to medical history, such as allergies,
operations or tests. Based on this information, healthcare professionals can make
judgements about the care going forward.
Health records should include everything to do with care, including x-rays or discharge
notes. The data in records can include:
 treatments received or ongoing
 information about allergies
 medicines
 any reactions to medications in the past
 any known long-term conditions, such as diabetes or asthma
 medical test results such as blood tests, allergy tests and other screenings
 any clinically relevant lifestyle information, such as smoking, alcohol or weight
 personal data, such as age, name and address
 consultation notes, which doctor takes during an appointment
 hospital admission records, including the reason admitted to hospital
 hospital discharge records, which will include the results of treatment and
whether any follow-up appointments or care are required
 X-rays
 photographs and image slides, such as magnetic resonance imaging (MRI) or
computerized tomography (CT) scans
If someone is registered with a GP practice in England, she/he will have a Summary Care
Record (SCR) unless she/he have chosen not to have one. SCR contains the following
basic information:
 the medicines
 allergies
 bad reactions to certain medicines

It also includes name, address, date of birth and unique NHS Number which helps to
identify person correctly.
An SCR is used in a number of healthcare settings and will provide healthcare
professionals with any information they wouldn't otherwise have. For example, when
someone is visiting an urgent care center or being admitted to a hospital, staff could view
her/his SCR and discover if someone is on a particular medication or has allergies.
Users can choose to add any information to their SCR that they think will help improve
their care. This can be of particular benefit to patients with detailed and complex health
problems.
If users are a parent or guardian of a child under 16 and feel that their child is able to
understand this information they should show it to them. They can then support them in
the decision to maintain an SCR and whether to include additional information.
Only authorized healthcare professionals directly involved in users’ care can access their
SCR. SCR will not be used for any other purposes. The person viewing SCR:
 Needs to have an NHS Smartcard with a chip and passcode,
 Will only see the information they need to do their job, and
 Will have their details recorded every time they look at record.
In addition, the healthcare professional must seek user’s permission if they need to look
at SCR. If they cannot ask users because they are unconscious or otherwise unable to
communicate, they may decide to look at record because doing so is in best interest. This
access is recorded and checked by the Privacy Officer of the organization to ensure it is
appropriate. Users can choose to opt out of having an SCR at any time. If someone do
opt out, she/he need to let her/his GP practice know by filling in an opt-out form.
4.3 HealtheVet (USA)
Using My HealtheVet can help users gain a better understanding of their health status. It
allows users to explore different ways they can monitor and improve their health.
When users use the tools on My HealtheVet, they become a more active partner with
their health care team. Working hand in hand with health care team and sharing
information may help them better understand personal healthcare needs.
The great benefit is that users can easily access their personal health information in their
My HealtheVet account - anytime and anywhere they have Internet access. Their
information is available to them at their convenience, 24/7.

My HealtheVet is VA’s online personal health record. It was designed for Veterans, active
duty Service members, their dependents and caregivers. My HealtheVet helps users
partner with their health care team. It provides opportunities and tools to make informed
decisions and manage health care
Specific features in My HealtheVet are available to users based on their account type. All
users who have a Basic account are able to view their self-entered information. If user is
a VA patient, she/he can upgrade account to Advanced or Premium.
Among the newest features available to Veterans with a Premium Account include VA
Notes. These are clinical notes that health care team records during appointments or
hospital stays. Also available are VA Immunization records, more detailed lab reports and
a list of current medical issues. These features are in addition to prescription refills, VA
Appointments and Secure Messaging.
My HealtheVet’s Blue Button feature allows users to view, print, or download and store
information from their personal health record (PHR). Then everything is all in one place
and viewable whenever they need.
By organizing and accessing medical records, the VA Blue Button helps users better
manage their health care needs and communicate with health care team. With the Blue
Button, users can download PHR and share it with VA and non-VA providers. This helps
them get the big picture of health and inform them how doing in reaching treatment
goals. Users can download record either as a PDF, text file or customizable Blue Button
file. Users can select the date range and the categories of information they wish to
include.
Users can start building their PHR by self-entering personal information, such as their
health history, emergency contacts and medications. They can monitor vital signs and
use the journals to track their diet and physical activity.
Then when users click the VA Blue Button, they can view all the data. If user is a Veteran
who receives care from VA, she/he can set preferences so that some VA and/or DoD
records feed into VA Blue Button copy of PHR, such as military service information.
Downloadable PHR can show:
 Information for emergency contacts, health care teams and insurance providers,
 Over-the-counter medications, allergies, military health history, medical events
and lab tests,
 Daily records in diet and physical activity (exercise) journals, and
 Recorded Vitals & Readings (blood pressure, blood sugar, cholesterol, heart rate,
body temperature, weight, pain level, etc.).

My HealtheVet users who are registered as a ‘VA Patient’ can also see:
 Military service information from VA and/or DoD records and
 Prescription history.
Users can make their PHR even more beneficial by upgrading to a Premium Account. This
level gives them full access to My HealtheVet features, including Secure Messaging with
VA health care team. When users download their data with the VA Blue Button, they can
also view information that VA/DoD has added into health record, such as:
 VA Chemistry/Hematology/Microbiology Lab results – the results from lab tests
 Information on VA Appointments– the details of recent and future appointments
at VA medical centers
 VA Immunizations – a history of the immunizations received through VA
 VA Problem List – a list of active health conditions and symptoms
 VA Notes – the clinical notes that health care team records during appointments
or hospital stays
 VA Admissions and Discharges including discharge summaries-a list of admissions
and discharges plus the detailed summary documented by health care provider
when discharged from the hospital
A number of smartphone apps are also available through a variety of non-VA sources.
While VA doesn’t endorse specific apps, there are now creative, secure and easy-to-use
ways of viewing Blue Button data. Search for “Blue Button” in smartphone apps library to
learn more.
My HealtheVet offers three account types:
 Basic
 Advanced
 Premium
Basic Account - Anyone who registers on My HealtheVet starts with a Basic Account. This
account does not require that users have their identity Authenticated. A Basic Account
provides limited access to features in My HealtheVet that users self-enter. Users may use
the journals and other tools to track their health measures. However, users cannot see
their personal information located in VA or DoD systems.
With a Basic Account users may use My HealtheVet to:
 Add information to a personal health journal about over-the-counter medications,
allergies, military health history, medical events, tests and allergies
 Record and track personal information such as contact information, emergency
contacts, health care doctors and providers, and health insurance information
 Record and track personal health measurements (blood pressure, blood sugar,
cholesterol, heart rate, body temperature, weight, pain level, etc.) in Vitals &
Readings

 Print a wallet ID card with the personal information entered into the personal
health record
 Set personal goals. My Goals makes it easy for users to set Goals, identify their
Strengths and Tasks, to overcome Obstacles, and track their progress. My Goals
can be used to help user’s health care team understand what is important to
them.
 Users can use the VA Blue Button (Download My Data) to view, save, print or
download and save self-entered information; then share this with caregiver, non-
VA provider or others they trust. Self-entered information may include:
o Activity Journal, Self Reported
o Allergies, Self Reported
o Family Health History, Self Reported
o Food Journal, Self Reported
o Health Care Providers, Self Reported
o Health Insurance, Self Reported
o Immunizations, Self Reported
o Labs and Tests, Self Reported
o Medical Events, Self Reported
o Medications and Supplements, Self Reported
o Military Health History, Self Reported
o My Goals: Current Goals, Self Reported
o My Goals: Completed Goals, Self Reported
o Treatment Facility, Self Reported
o Vitals and Readings, Self Reported
Advanced Account - This account is only for Veterans and/or VA Patients. It is a higher
level of access to features offered in My HealtheVet. It provides users the ability to view
some information in VA and/or DoD records. This account does not require that users
have their identity authenticated. However, when users register as a VA Patient, their
profile information is linked to VA/DoD records. When this happens, users are given an
Advanced Account. If users are a VA patient, this type of account lets users refill their VA
prescriptions online using My HealtheVet.
Premium Account - This account is only for Veterans and/or VA Patients. It gives users
the highest level of access to My HealtheVet features. To get this type of account users
need to go through authentication and have their My HealtheVet profile information (full
name, Social Security Number (SSN), date of birth (DOB) and gender) linked to VA/DoD
records. After users register, users’ account type will be displayed in the Member Login
box. Those with a Premium Account will have Premium Account Icon after their name.
With a Premium Account users may use My HealtheVet to view key portions of VA health
record, such as:

 VA Admissions and Discharges (including discharge summaries) - Discharge
Summaries are available 3 calendar days after they are completed.
 VA Allergies
 VA Appointments (future)
 VA Appointments (limited to past 2 years)
 VA Demographics, VA Electrocardiogram, and VA Immunizations
 VA Laboratory Results: Chemistry/Hematology/Microbiology - VA Laboratory
Results
 VA Medication History
 VA Notes - VA Notes written from January 1, 2013 forward are available 3
calendar days after they have been completed and signed by all required
members of VA health care team.
 VA Pathology Report: Surgical Pathology/Cytology/Electron Microscopy. VA
Pathology Reports are available 14 calendar days after they have been
completed. Some studies done at a non-VA facility may not be available or they
may not necessarily include an interpretation.
 VA Problem List - VA Problem List contains active health problems VA providers
are helping to manage. This information is available 3 calendar days after it has
been entered. It may not contain active problems managed by non-VA health
care providers.
 VA Radiology - Report is available 3 calendar days after it has been verified by
members of the VA health care team
 VA Vitals and Readings and VA Wellness Reminders
 VA electronic health record information such as VA Continuity of Care Document
(VA CCD) and other information as it becomes available
 Department of Defense (DoD) Military Service Information
In addition users may be able to:
 Use the VA Blue Button to view, save download and/or print VA health and DoD
Military Service Information. Users can also share this with their caregiver, non-
VA provider or others they trust.
 Download user’s VA Continuity of Care Document (VA CCD). This is a standard
electronic exchange document, used for sharing patient information. The VA
CCD will be a summary of important health information from the Veterans VA
Electronic Health Record.
 Use Secure Messaging to communicate online with VA health care team. Users
may send messages to request or cancel VA appointments. Use it to ask about
lab results or find out about a medication or health issue. Or simply to discuss
other general health matters.

4.4 HealthHub (Singapore)
HealthHub is a one-stop portal and mobile app for Singaporeans to access a wide range
of health content, deals, rewards and e-services.
HealthHub designed to empower Singaporeans to take greater ownership of their health
and wellness through the online access of personalized health records, better health
literacy and adoption of healthy lifestyle practices.
HealthHub is an initiative by the Ministry of Health, and Health Promotion Board,
supported by Ministry of Health Holdings, Integrated Health Information Systems and
public healthcare institutions including:
 Agency for Integrated Care
 Alexandra Health System
 Eastern Health Alliance
 Health Science Authority
 Jurong Health Services
 National Healthcare Group
 National University Health System
 Singapore Health Services
HealthHub allows users to access their health records, and the health records of their
children's information. Apart from viewing their screening and lab test results, users can
view their children’s school health and immunization records.
HealthHub provides:
 Immunizations records
 Health screening
 Lab test results
 Discharge information
 Medical appointments
 School health assessments
HealthHub lets users look up the health information they need. A-Z takes users to the
glossary displaying information on local health topics. Users can locate nearby healthcare
and lifestyle facilities, providers and suppliers in Singapore with the Directory.
HealthHub provides users to discover interesting and useful health information for the
stage of life they are in. HealthHub pulls together articles and features about health
concerns relevant to user’s age, gender, and role. Users can check out current events
and news with What’s On. HealthHub Deals brings together deals for activities, health
equipment, meals, exercise facilities, and classes.

4.5 Results of Comparison regarding epSOS (EU), NHS
(England), HealtheVet (USA), HealthHub (Singapore),
and e-Pulse (Turkey)
Regarding epSOS (EU), NHS (England), HealtheVet (USA), HealthHub (Singapore), and
e-Pulse (Turkey), specific features and function of each are listed in detail in above
sections. However, Table 5 provides the overall comparison results of these. Additionally,
Table 6 provides the comparison results of these with respect to functionalities.
Table 5 - Results of Comparison regarding epSOS (EU), NHS (England), HealtheVet (USA), HealthHub
(Singapore), and e-Pulse (Turkey) with respect to General Characteristic
Dimension epSOS NHS Healthe
Vet
Health
Hub
e-Pulse
Free of charge Y Y Y Y Y
In full operation NY Y Y Y Y
Users can view
and manage
records
Y Y Y Y Y
Users can
manually enter
records
Y Y Y Y Y
Users can delete
records
Y N Y N Y
Mobile application
is available
N N Y Y Y
Privacy and
security
addressed
Y Y Y Y Y
Integration with
other health
services
NY Y Y Y Y

Dimension epSOS NHS Healthe
Vet
Health
Hub
e-Pulse
Owned and
maintained by
government
NY Y Y Y Y
Conforms a
relevant Data
Protection Act
N Y Y Y NY
Offers different
account types for
users (patients)
N N Y N N
Provides opt-out
option
Y Y Y Y Y
Integration with
sport, fitness, and
health devices
N N N N Y
Table 6 - Results of Comparison regarding epSOS (EU), NHS (England), HealtheVet (USA), HealthHub
(Singapore), and e-Pulse (Turkey) with respect to Functionalities
Functionality epSOS NHS Healthe
Vet
Health
Hub
e-Pulse
View the details
about health
facilities visited
with branch, time,
receipts, doctor
details, and
medicines
information
+ + + + +
Record and
update side
effects
information about
the medicines
+ + + + +

Vet
Health
Hub
e-Pulse
View test results,
reports, and
medical images
with their reports
+ + + + +
Record and
update medicine
allergies and
other allergies
+ + + + +
Make
appointments
- - + + +
Add notes to their
appointments.
+ - + - +
Integrated
calendar
+ + + + +
Share records
with others or
doctors with the
conditions set
- - + - +
Track when the
records that
shared are
accessed with
related people
- - - - +
Messaging
capability that
users can use to
communicate
- - - - +
Evaluate and rate
on the health
services and
comment on
these.
- - - - +

Vet
Health
Hub
e-Pulse
Either manually or
automatically add,
modify, and
delete their blood
pressure, blood
sugar, pulse, and
weight data.
- - + + +
Sends reminders
to the patients
regarding
medicines to take
- - - - +
Emergency button - - + - +
Pause or
completely
terminate/remove
accounts
+ + + + +
Certain mobile
devices and
applications can
be integrated
- - + - +
Encryption for all
records to protect
+ + + + +
SMS verification
system for
operations
- - - - +
ePrescription + + + + +
Patient Summary + + + + +
Integration of
emergency
services
- - + - +

Vet
Health
Hub
e-Pulse
Integration of the
European Health
Insurance Card
(EHIC)
+ + - - -
Set personal goals - - + - -
School health
assessments
- - - + -
Articles and
features about
health
- - - + -

5. Future Works
Following works can be done in the future in the direction of improving the information
and knowledge distilled and presented in this report:
 Searching for the international standards and regulations, and evaluating the
related systems (epSOS, NHS, HealtheVet, HealthHub, and e-Pulse) with respect
to clauses covered in the related standards and/or regulations.
 Searching for the data protection laws in the context of health data and
information of certain countries, and comparing and contrasting them.
 Gathering statistics about the usage and benefits of the related systems (epSOS,
NHS, HealtheVet, HealthHub, and e-Pulse), and comparing and contrasting them.
 Searching for an inclusive answer for the question of how different countries find
solutions regarding the privacy and confidentiality of the systems in the context
of e-health.
 Searching for security breaches in healthcare and theoretically testing these for
related systems (epSOS, NHS, HealtheVet, HealthHub, and e-Pulse), and
comparing and discussing results.

Mustafa Degerli - 2016 - e-Health and e-Pulse - Report

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