Demzy_CIT 403_Seminar on e-Health

NATIONAL OPEN UNIVERSITY OF NIGERIA
(NOUN)
SEMINAR ON
EMERGING TECHNOLOGIES
TOPIC
AN UNDERSTANDING OF THE HEALTH INDUSTRY
AND HOW ICT CAN BE USED TO ENHANCE
HEALTHCARE DELIVERY IN NIGERIA
SUBMITTED BY
NAME GEORGE UDEMEOBONG NTA
MATRICULATION NUMBER NOU110838829
SCHOOL SCHOOL OF SCIENCE AND TECHNOLOGY
DEPARTMENT COMPUTER SCIENCES
COURSE CODE CIT 403
COURSE TITLE SEMINAR ON EMERGING TECHNOLOGIES
JULY 2014

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I.C.T FOR BETTER HEALTH-CARE IN NIGERIA.
INTRODUCTION
Information and Communication Technologies (ICT) play an essential role in supporting daily life in today's
digital society. They are used everywhere now and play an important role in the delivery of better and
more efficient healthcare services.
This is how Information and Communication Technologies (ICTs) are helping you, your doctor(s), your
pharmacist and your hospital take better care of your health.
Thanks to e-Health as doctors can access patients’ medical records more easily, get immediate access to
test results from the laboratory, and deliver prescriptions directly to pharmacists. Patients with heart
problems can carry monitors which alert their doctor if their condition changes, yet allow them to
continue with their daily business.
At the Nigerian level, the introduction of e-Health services will facilitate access to healthcare, whatever the
geographical location is, thanks to innovative telemedicine and personal health systems.
e-Health is also breaking down barriers, enabling health service providers (public authorities, hospitals)
from different member States to work more closely together.
If a particular treatment can be provided to a patient more effectively in another country, e-Health
systems make it simpler to organize and carry out treatment abroad.

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Suppliers of e-Health tools – such
as databases for patient records,
mobile monitors which transmit
data automatically, or handling
systems for patient call centres
will also benefit from the
development of a Nigerian market
in the e-Health sector, which will
enable them to build a strong
base from which they can tackle
the global market.
In addition, ICT also plays a key
role in helping the elderly to
improve their quality of life, to live
more actively and independently
for longer, and to counteract
reduced capabilities which
become more prevalent with age.
BACKGROUND OF e-HEALTH
It is increasingly evident that Information and Communication Technology (ICT) can transform health
systems. the UK, United States of America have shown that the meaningful use of electronic health records
could improve the quality of diabetes care, irrespective of the type of health insurance held by the patient.
The Hospital Information System Project (HISP) is a province-wide initiative designed to improve access to
patient information through a central electronic information system, an electronic patient record (EPR).
HISP’s goal is to streamline patient information flow and its accessibility for doctors and other health care
providers. These changes in service will improve patient care quality and patient safety over time.
The Health Management Information System (HMIS) is considered to be a single biggest routine data system
that will be implemented under the Ministry of Health and Social Welfare. It is so because it collects its
information from more than 5,400 health facilities. According to the new health policy of having a dispensary
in each village, a health center for each ward and a hospital for each district it is anticipated that after ten
years the numbers of the current health facilities are expected to double. Also, HMIS through outreach
program do collect community based data which cover more than 10,000 villages in the country.
In this respect the entire system form a unit known as HMIS which is a key component of Health Information
and Research (HIR) Section. This section is operating under the Directorate of Policy and Planning. Other
units are: -
Health Research Systems and Surveys (HRS)
National Sentinel Sites Systems (NSSS) which run DSS and
Information Technology and Communication (ITC)

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These units either support HMIS operations like ITC or supplement data to HMIS.
The HMIS in its current form was conceptualized in the early 1990s. The main aim was to establish a
comprehensive and integrated routine data system using up to date technologies and approaches. This
system was established as a key tool for monitoring and evaluation of health sector reform performance in
the country. Therefore HMIS is a core system which provides management solutions to management
questions through developed indicators which are applied at all levels of health delivery systems. HMIS
indicators are in the form of rates, ratios and absolute numbers, and each has a threshold and target value
whereby assessment of performance is based upon. In this respect the information is very useful in
managing health delivery in the country at all levels of health delivery system in the country
Before HMIS came into existence, several systems were operating. Most of these existed in public and non-
governmental organization (NGOs) health facilities. In addition, programs such as the TB and Leprosy and the
National AIDS Control Program (NACP) had and continue to have their own separate reporting systems due
to special requirements that could not be handled through HMIS. In 1980s, several studies were undertaken
on existing systems. From those studies the followings were noted: -
Systems were fragmented since a lot of data were collected with little capacity for analysis, interpretation or
use at all levels of health delivery;
The flow of data was bottom up with no significant feedback between higher and lower levels;
Health facility workers were overburdened with several forms to fill from different reporting systems;
There was a lot of resources that were wasted due to duplication of efforts;
Strategies to Strengthen e-Health
To strengthen the e-health system, the government needs to increase availability and use of timely, reliable
health information through coordinated investment in eHealth application software. In this respect, the
following principle will be met:
Country ownership and stakeholders involvements;
Linking of health and statistical constituencies;
Harmonization and alignment; and
Comprehensive approach to health information
Proposed e-Health Application Software
The overall objective of the proposed HMIS Program is to improve and strengthen the HMIS and information
usage at all levels of health delivery system in Nigeria. This would contribute to overall strategy of improving
HIS (Health Information System) in this country.
In this respect the specific objectives of the proposed HMIS Program are to: -
Ensure that the HMIS provides and disseminate quality essential indicators such as monitoring the
Millennium Development Goals – with a particular focus on MDG 4 & 5

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Improve and strengthen the HMIS and information usage at health facilities, districts, and regional and at the
national levels.
The HMIS will be strengthened according to specific criteria regarding data completeness, timeliness and
quality, as well as the analysis, dissemination and use of information. These criteria will be monitored and
evaluated for each facility, district and region taking part in the program – as well as for the national level.
The criteria are specified in the Tool for Assessing Information Usage:
Strengthen the HMIS capacity of the Ministry of Health at all levels (national, regional, district and facility)
and thereby ensure sustainability of the HMIS
System Components
There are five key components or “modules” in the system.
1. Registration: The system captures and records patient demographics and visits at the point-of-care.
Registration data will be displayed consistently and automatically on screens in the clinical system.
2. Order Entry & Results Reporting: All clinical orders will be listed with indications of what has been
completed and what is pending. Electronic alerts will appear for orders duplication and errors and
provide information to assist clinical decision-making. All test results in the patient’s electronic chart
will be filed with alerts for abnormal results.
3. Clinical Documentation: This module provides on-line documentation of clinical encounters such as
flowcharts and structured notes. Eventually this information will be shared across health care facilities
within the defined areas.
4. Scheduling: Patient scheduling schedules patients for appointments with clinicians or for tests and
procedures.
5. Patient Billing: All billable health services will be accessible and processed in this system. Examples:
private rooms, out-of-country coverage.
Who Benefits
Physicians
 Introduces Computerized Provider Order Entry (CPOE)
 Improves accuracy & legibility of, and access to, the required patient medications
 Improves clinicians’ efficiency & effectiveness through provision of key patient information (e.g.,
allergies) at time of ordering, plus conflict checking, order checking and online access to best practice
information
 Improves care through the logging of all orders
 Reduces medication error rates
Nurses
 Will allow immediate access to orders and results
 Will provide immediate access to patient demographics, medication and test results
 Will provide improved access to information on line (ie: suggested medications or drug alerts)
 Will decrease the need for paper, decrease errors and increase patient safety
Allied Health Professionals
 Will allow immediate access to orders and results
 Will provide immediate access to patient demographics, medication and test results

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 Will provide improved access to information online (ie: suggested medications or drug alerts)
Ward and Registration Clerks
 Will provide a single point of contact for patient registration information and reduce duplication of
effort
Clinical Benefits
 Provide a common source of information about a person’s health history
 Enhance the ability of health care professionals to coordinate care by providing a person’s health
information and visit history at the place and time that it is needed to Link information from
diagnostic information systems such as X-ray and laboratory into the EPR
 Strengthen internal and external communication among health care providers
 Eventually be accessible for use in all of Manitoba’s academic and community hospitals, as well as
long term care facilities
 Allow care providers access to the patient’s health history and results between facilities
 Will provide improved access to information on line (ie: suggested medications or drug alerts)
Administrative Benefits
 Will provide improved access to information on line (i.e. suggested medications or drug alerts)
 Strengthen internal and external communication among health care providers
 Will decrease the need for re-registrations of patients across multiple sites
Computer Provider Order Entry (CPOE)
Systems perform checks in the background when providers write orders. These checks include whether the
patient is allergic to the drug, whether there are interactions with other drugs the patient is taking, whether
the dosage ceiling for the drug is being exceeded, and so forth. When orders are entered that are
contraindicated for the patient, alerts and reminders pop up. These give the provider options to change the
order or document a reason for overriding the alert.
Importance Of Implementation Of E-Health Systems
e-Health application software enable the administrator to obtain data for billing, the physician to see trends
in the effectiveness of treatments, a nurse to report an adverse reaction, and a researcher to analyze the
efficacy of medications in patients with co-morbidities. If each of these professionals works from a data silo,
each will have an incomplete picture of the patient’s condition. An e-health integrates data to serve different
needs. The goal is to collect data once, then use it multiple times.
Components of an e-Health
An electronic record may be created for each service a patient receive from an ancillary department, such as
radiology, laboratory, or pharmacy, or as a result of an administrative action (e.g., creating a claim). This
clinical system may also allow electronic capture of physiological signals (e.g. electrocardiography), nurse
notes, physician orders, etc. often, these electronic records are not integrated, they are captured and remain
in silo systems, where each have their own user log-ins and their own patient identification systems.

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This proposed e-Health application software will address the solutions in three (3) distinct levels through
which the ministry of health could decide which of the level to implement: We are going to look at the level
in phases;
PHASE I
This is a situation where by an e-Health application software is running on a single computer system, so when
a patient arrives at the clinical system, the nurse or administrator in charge will register the patient base
using the e-Health registration form and then use the interactive form there to know what is wrong with the
patient, at the end of the process, he/she send the information gotten from the patient to the doctor or
consultant in charge to go through it and make subscription of drug to the desired patient and send it the
same way back to the nurse or the consultant or doctor might send a message back to the nurse to have an
audience with the patient.
See flowchart below for the flow of information and communications in this process:
Fig2: e-Health Application Software running from a local area network in a clinical section.
PHASE 2
In this scenario, this is a complicated section that has all the arms of operations and apart from that each of
the departments carries out a thorough check on the patient and sends to the server where the doctor will
have a message alert about all the information concerning the patient. Apart from that, there will be only of
section for registration which is the administrative department. When the administrator is done with the
registration, then the patient can then be referred to the nurse section where the patient will be cross
examine to know the actual situation with the patient.

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See Fig 3 below for the information flow:
Fig 3: The level of organization in the second phase
The entire system on how they interact using the newly proposed eHealth application software from
administrator to the coeditor which can be ether the consultant or a doctor is as shown below:

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PHASE 3
This is an advance phase of the e-health application software that can be implemented on a national level
through which the power of the internet will be used. In this case, there will be a lot of devices in each of the
terminal in every state or local government area where the patient can go if the health situation is critical but
in a scenario whereby is not critical, the patient can login into the e-health application software online, chat
with the nurse online and report the health issues, then the nurse will report immediately to the doctor or
consultant in charge for prescription to be made and the patient will receive a message alert for the
particular supplement to take and location where the supplement can be bought. In another way, the
pharmacy department can be contacted to supple the necessary supplement to the location where the
patient is at that particular point in time.
In this phase of e-Health implementation, the patient can have a one on one live video chat with the
consultant or doctor in charge and apart from that, some devices will be put in place to automatically
perform a check in each of the terminal then the result will be sent to the consultant or doctor immediately
for response.
With the help of the live video application software we are going to embed in the e-health application
software, the doctor can also monitor the test as it is being carried out and also have the report of the test
immediately and make a comment and all the necessary prescription of drug.
The features of the e-Health implementation of this phase are:
 Live video charge
 Biometry device to conduct test on patent
 Biometry device to conduct scan on patient
 Live chat with nurses and doctor
 Online payment platform
 POS on each of the terminal
Below are all the stages of the phase 3 of e-health implementation and which is the future of e-Health in the
world and this is meant to give personalities a self-help medical and health information platform that will
allow people to communicate with their health consultant 24/7 365 days a year.

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e-Health Operational Base and Responsibilities
The Ministry of Health is the owner of the HMIS and the Health Information and Research section of the
Ministry of Health is the operational base of the HMIS Program. In order to render the HMIS sustainable, the
HMIS Program will focus on developing capacity within the Ministry of Health in all aspects of the
management of the HMIS and data analysis and dissemination.
In order for this to be possible, it is the responsibility of the Ministry of Health to priorities the HMIS and give
it high level support, which will entail the allocation of sufficient resources. For the HMIS Program to succeed
the following actions are needed:
Health Information and Research section & HMIS unit need to be strengthened in the areas of database
management and epidemiology.
Regional and districts need information officers responsible for the HMIS and data reporting, analysis and
dissemination across programs and staff responsible for the database.
 All facilities need identified person responsible for the HMIS.
 The identification and allocation of HMIS staff is the responsibility of the Ministry of Health.
 Training and supporting these HMIS staff is the responsibility of the HMIS Program.
 Situation Analysis of e-Health
 Need for quality information recognized and prioritized by Ministry of Health
 System implemented across whole country at health facilities and district hospitals
 All role-players involved (Ministry of Health, NGOs, Bilateral Agencies, Development partners)
 Data collection and reporting tools in place
 Reports standardized Annual reports produced for country through Health Statistical.

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BACKGROUND INFORMATION ON TELECOMMUNICATIONS IN NIGERIA
The Federal Republic of Nigeria is a tropical country on the West African Coast along the Gulf of Guinea, with
the Republic of Benin to the West, Niger to the North, Chad to the North-East and Cameroon to the East and
South-East.
The climate is tropical. In the South, the average annual temperature is about 32oc, with high humidity and
the average annual rainfall above 3,800mm in parts of the South-East. It is drier and semi-tropical in the
North and the average annual rainfall may be as low as 625mm.
Nigeria covers an area of some 923,769 sq.km, and situated between latitudes 4o and 14oN of the equator. In
some parts of the country, latitude tends to modify the high humid and hot temperature associated with
tropical rain-forest regions.
The vegetation ranges from rain forest in the south, through deciduous forest to grasslands dotted with
shrubs which finally shades into the dry desert regions. Within the past few decades, desert encroachment
has threatened human and cattle life in the northern - most parts of the country. The southern part is
characterized by undulating hills, occasionally rising to as high as 3000 to 5,000 meters in some places. The
northern part shows the same features but rising to a plateau in the center and north-eastern part of the
country to about 8,000 meters above sea level.
The two major rivers transversing the country are Rivers Niger and Benue, in a confluence at Lokoja, from
where they flow through a series of creeks in the delta region into the Atlantic Ocean. Other inland drainage
areas and important rivers are Cross-River, Imo River, Kaduna River, and Lake Chad.
DEMOGRAPHIC AND CULTURAL DIVERSITY
The peoples of Nigeria are many and varied. They include the Fulanis, the Yorubas, Hausas, Igbos and a large
number of Northern and Southern ethnic groups. These variations have combined to produce a very rich
admixture of cultures and art, which form the heritage of modern Nigeria.
The Nigeria census in 1963 recorded a total of 55.670.055. There was another census in 1973, but the results
were never published. In 1984, the population of Nigeria was officially estimated at over 94 million. Nigeria's
population today is put at about 100,000,000 on a land mass of approximately 930,000sq kms. It is a
Federation of thirty six states and Abuja, the Federal Capital Territory. The climatic conditions range from wet
and humid in the South to dry and hot in the North.
There have been suggestions that more than 45% of the Nigerian populace are under 20 years old and are still
of school going age. This has put a lot of pressure on the educational systems of the country, and eventually
on the labour market. The economy is therefore being planned to grow fast enough to provide jobs for the
many school leavers annually.
Furthermore, the rural-to-urban migration has been found to be growing daily and thus creating
unprecedented problems of health and housing, transportation, law and order. This puts a lot of pressures
on the delivery systems for these social services. In spite of this, majority of Nigerians still live in rural areas,
living on subsistence farming, trading, rural industries, and crafts.

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SOME TELECOMMUNICATION INFORMATION ON NIGERIA
The total number of subscribers to telephone lines as at the end of December 1986 was put at around
230,000 while Telex subscribers were only 5,300 in number. Total installed capacity for telephone then was
320,834 and telex 11,577. The percentage utilization for telephone therefore was 71.6 per cent while telex
was approximately 45.7 per cent. However, modernity in telecommunications has provided facilities that
make for new class of service, improved revenue generation with properly reviewed tariff policy. Now, in
1996, the country has almost 1,000,000 subscribers to telephone lines all of which are handled by standard A
antennae facing both the Indian and the Atlantic Ocean Regions installed at four (4 NO.) different
geographical locations across the country. Nigeria operates a Domestic Satellite System by leasing three (3
No.) transponders from INTELSAT which are accessed by nineteen (19 No.) Standard B earth stations in some
state capitals of the Federation. There is a Territorial Manager responsible for Telecommunications
Administration in each state except Lagos state where because of the relatively large number of switching
centers and subscribers in the metropolis, it was considered prudent to have at least two (2No.) Territorial
managers.
Nigeria embraced Digital Technology since the 1980s with the introduction of Digital Switches and
Transmission Systems (Radio and Optic fibre) into the network. Since the beginning of the 90s, Mobile
Telephone Services (Cellular), Paging and Electronic Mail have also been part of the services offered by NITEL
(Nigerian Telecommunications Plc). NITEL now has an X.25 and X.40 switching facilities in its network. Today
however, to a population of One hundred million (100m), the figure of more than half a million telephone
lines in the country means in effect, a very low telephone density ratio; though the country has the largest
number of telephones in any one country in Africa.
ELECRONIC COMMUNICATIONS AND THE TELECOMMUNICATIONS SYSTEM
While the existence of information does not necessarily ensure its use, the real value of an information
system lies in the servicing of specific user needs. In order to solve this problem, and hoist the country on the
path of greater technological and overall socio-economic development as well as create a new lease of life
for the citizenry, a planned increase in penetration of telecommunications services has been seen as a
welcome development for national growth.
Every human society, from the most primitive to the most advanced, depends on some form of
telecommunications network. It will be virtually impossible for any group of people to define their collective
identities or make decisions about their common and binding interests, without communications.
Communication networks make society a reality.
It makes it possible for people to cooperate, to produce and exchange commodities, to share ideas and
information and to assist one another in times of need.
Indeed, every facet of the basic rights is dependent on telecommunication. Such basic rights of the individual
as the right to life, the right to personal liberty and dignity, the right to free expression and information and
the right to free movement, all of which enhance the quality of life of the individual, are facilitated by
telecommunications.

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Electronic Communications involve the process by which messages are sent across the globe through the use
of the computer, telephone line and a modem. Unlike the fax system which allows one page of text to be
transmitted at a time, electronic communication facility allows several pages to be processed off-line and
through a single dialing, it allows these several pages of messages to be transmitted to a gateway where
they can be distributed to their various destinations.
Furthermore, electronic communication involves any of several forms of information exchange between two
or more computers through any of several methods of interconnection such as telephone line, optical fibre,
satellite or radio. This communication mode is rapidly spreading throughout the world as a fast, reliable and
in most applications, an inexpensive form of communication. It is fast and inexpensive because it can use
existing public telephone lines, a dedicated (leased) line or via microwave radio frequency.
The foregoing is indicative of the requirements necessary to induce a meaningful development of
telecommunications infrastructure in Africa.
IMPORTANCE OF e-HEALTH
 Efficiency: One of the promises of e-health is to increase efficiency in health care, thereby decreasing
costs. One possible way of decreasing costs would be by avoiding duplicative or unnecessary
diagnostic or therapeutic interventions, through enhanced communication possibilities between
health care establishments, and through patient involvement.
 Enhancing quality of care: 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.
 Evidence based: 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. Much work still has
to be done in this area.
 Empowerment: of consumers and patients - by 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.
 Encouragement: of a new relationship between the patient and health professional, towards a true
partnership, where decisions are made in a shared manner.
 Education: of physicians through online sources (continuing medical education) and consumers
(health education, tailored preventive information for consumers)
 Enabling: Information exchange and communication in a standardized way between health care
establishments
 Extending: 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.

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 Ethics - e-health involves new forms of patient-physician interaction and poses new challenges and
threats to ethical issues such as online professional practice, informed consent, privacy and equity
issues.
 Equity: 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.
POLICY IN IMPLEMENTING e-HEALTH
Nigeria reports that the majority of the listed actions to promote an enabling environment for information
and communication technologies (ICT) in the health sector has been taken between 2000 and 2005, and is
likely to continue. The implementation of procurement policies or strategies to guide software, hardware
and content acquisition was planned to start by 2008. And Norms and standards for e-Health systems,
services or applications said to be adopted in the next two years as of then. Regulations to protect the
privacy and security of individual patient data where e-Health is used will be enacted by 2008 as well. Nigeria
highlights a psychiatric patient information system developed in some of the country’s tertiary health
institutions as another important initiative in the introduction of electronic patient management systems.
The following are described as the most e_ active projects in building an enabling environment for the use of
ICT in the health sector:
A health sector reform programme, which addresses the need to deploy ICT in the health sector;
The free _ own of ICT hardware and software into the country; and the government’s promotion of locally-
developed hardware and software, as well as the local assembly of computers.
Policy, technical issues, human resources and funding are mentioned as challenges, which are being
addressed where possible by government initiatives prove its success through improvement in services and
change in the health status of the population.
The objective of this expression is to indicate a detailed review of the literature to determine the scope of
policy issues faced by individuals, institutions, or governments in implementing e-Health programs.
We extracted data according to recurring themes, defined below. We summarized these findings using
tabular techniques and descriptive statistics. Reported analyses were too disparate to be pooled in a meta-
analysis.
The systems described in this document were placed into one of eight categories corresponding to the
typical applications used in developing countries. The order of these categories does not infer any priority:

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1. Electronic health record: an electronic record of health-related information on an individual that can
be created, managed, or consulted by clinicians or staff. Which can accessible all over the country any
were you are.
2. Laboratory information management system: a system for laboratory-specific activities or for
reporting results to administrators and health care personnel.
3. Pharmacy information system: any system used to order, dispense, or track medications or
medication orders including computerized order entry systems.
4. Patient registration or scheduling system: any system used to monitor and manage the movement of
patients through multistep processes or to maintain a census twenty four hours. An example is
admissions-discharge-transfer systems.
5. Monitoring, evaluation, and patient tracking system: any system used for aggregate reporting of
information, program monitoring, and tracking of patients’ status. Examples include district health
information systems or health management information systems.
6. Clinical decision support system: system designed to improve clinical decision making, in which
characteristics of individual patients are matched to a computerized knowledge base and software
algorithms generate patient-specific recommendations.
7. Patient reminder system: a system used to prompt patients to perform a specific action—for
example, take medications or attend the clinic.
8. Research/data collection system: any system used for collecting data from different locations or for
storing, managing, or reporting on data used for research purposes.
And also identified the following themes for e-Health policies
 Networked care,
 Inter jurisdictional practice,
 Diffusion of e-Health/digital divides,
 e-Health integration with existing systems,
 Response to new initiatives,
 Goal-setting for e-Health policy,
 Evaluation and research,
 Investment, and
 Ethics in e-Health.
e-Health policy issues were also divided on the basis of the levels where policies should be developed to deal
with a particular issue. The levels:

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a) Global: this level deals with the policies of global complementarity, such as standardization and inters
jurisdictional care,
b) Jurisdictional (national and provincial/subnational): this level deals with the policies required to
facilitate care within a health jurisdiction—that is, national or provincial/subnational governments,
and
c) Individual Institutions: this level deals with the policies required to facilitate e-Health at the local
level—that is, individual institution or practice.
Below we describe the distribution of e-Health policy issues according to the themes and the levels of policy
development.
Networked Care
The networked care theme includes policy categories and issues that can enhance the ability of providers,
departments, organizations, and jurisdictions to work in a coordinated environment to improve care of the
population. Networked care covers the issues of interoperability, standardization, and intellectual property
rights on material produced as a result of networked services, which need to be dealt with at the global level.
This theme also covers issues related to the use of acceptable, user-friendly, affordable, and reliable
technology via internet in solving related health issue.
Issues related to change management, such as distribution of user workloads, improvement in readiness at
the individual and institutional levels, and selection of simple and user-friendly technologies; financial
matters, such as insurance requirements and reimbursement; guidelines related to sharing of information,
knowledge, and services; cultural issues around communication and networking; and risk management.
Inter-jurisdictional Practice
The inter-jurisdictional practice theme includes policy categories and issues that deal with the transfer of
information and provision of care between different jurisdictions. Inter jurisdictional practice includes issues
related to management of health information in shared environments, policies for privacy, confidentiality,
and intellectual property rights, and guidelines for sharing knowledge and services, which can be dealt with
globally. Inter jurisdictional practice also deals with policies at the jurisdictional and individual levels, such as
liability of care, proper licensing of health care providers, accreditation of individuals and institutions, and the
defining of processes for coordinated services.
Diffusion of e-Health and Addressing the Digital Divide
The diffusion of e-Health and digital divide theme includes policy categories and issues that enhance the use
of e-Health among populations who most need improved health services. These include policies and
guidelines to allow greater penetration of telecommunication companies, such as mobile companies,
Internet service providers, integrated services digital network providers, and satellite vendors, to reach the
poorest communities, reduce the cost of telecommunication, provide universal and unlimited access to the
Internet, and allow for appropriate use of e-Health for commercial and humanitarian purposes. Other policy
issues with a jurisdictional and individual focus, such as encouraging development and use of open-source

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technologies, increasing access to technology, reducing cost, and building local capacity, are also included
under this theme.
Integration with Existing Systems
The theme of integration with existing systems includes policy categories and issues that enable integration
of e-Health projects and programs into regular services. The theme of integration includes jurisdictional
policy issues such as setting targets for increasing interaction between different groups of providers and
users, introducing decision-support systems to reduce the chance of errors, improving quality of care
through e-Health and creating a learning environment, and changing business rules and models for
integrating e-Health. This theme also includes policies at the institutional level, such as defining the roles and
responsibilities of different players, and creating guidelines on issues such as access to different gender and
sociocultural groups, transfer and storage of information, patient consent, confidentiality, and privacy, which
will help integrate e-Health with regular services.
Response to New Initiatives
The response to new initiatives theme includes policy categories and issues that can enhance the capability
of institutions to implement e-Health successfully. This theme includes jurisdictional policy issues, such as
guidelines for identifying and including stakeholders from different user and support groups in the planning
of e-Health programs. This theme also covers policy issues at the institutional level, such as defining the roles
and responsibilities of different players such as local providers and specialists, defining the processes for
change management, ensuring training and support to all users, defining the rules for procurement of
equipment, distribution of bandwidth, and distribution and security of wireless networks, maintaining
doctor–patient relationship, and evaluating new technologies in local environments before implementation
to avoid difficulties and failure.
Policy Goal-Setting
The policy goal-setting theme includes policy categories and issues that can guide the process of defining
policies for e-Health. Key global considerations in this regard include recognition of e-Health as part of the
broader development effort, in terms of assisting national health systems and recognizing e-Health as part of
the global health agenda, and encouraging a global commitment for funding e-Health programs. This theme
also includes jurisdictional considerations, such as developing policies to encourage growth of the
telecommunications sector and to increase connectivity in remote areas; increasing flexibility between
governments and private institutions to align with changing information technology environments and
policies; encouraging innovation and development; covering the costs of equipment and time needed for
health care providers to bring e-Health services into broad acceptance; and developing governance and
management structures. Institutional policy issues, such as ensuring universal standards of care, and allotting
and distributing the workload for health care providers and technical and managerial staff, are also included
under this theme.
Evaluation and Research
The evaluation and research theme includes policy categories and issues that can guide the process of
evaluation and research to generate evidence for the adoption of e-Health. These policy issues include
measurement of the time spent during tele-consultations and justification of the resources spent on setting

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up e-Health services, cost effectiveness, impact on health care management, demonstration of improvement
in health outcomes, and enhancement of clinical effectiveness and learning. Other issues at the level of
individual institutions include providing an environment for testing and simulating e-Health initiatives,
encouraging interdisciplinary research, and disseminating results for policy making and the benefit of users.
Investment
The investment theme includes policy issues that can suggest business models for e-Health adoption. This
theme includes encouraging the use of e-Health by health care institutions to increase the number of clients
and to grow their businesses and encouraging partnerships between public and private institutions, or within
the same sector. It also includes cross-jurisdictional advertisement and sale of drugs and services.
Ethics and Legal Issues in e-Health
The theme of ethics and legal issues in e-Health includes the ethical issues that must be considered during
adoption and implementation of e-Health. These include global policy issues, such as managing health
information on the Internet and ensuring privacy of health information. This theme also includes
jurisdictional and institutional policy issues, such as patient consent, liability of care, medico legal issues,
patients’ rights to access their own health information, security of information during portability,
maintenance of quality of care, and cultural issues in communication.
OUR NEWORK STRUCTURE ON e-HEALTH TECHNOLOGY
TRADITIONAL DIGITAL
SALES REPS INTERNET
DIRECT MAIL TABLET PCS
PROMOTIONAL MATERIALS VIDEO
MEETINGS MOBILE
CONFERENCES EMAIL
e-CME

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The nature of our Network structure allows us to create intelligent digital programs that incorporate
different combinations of targeting approaches based on objectives. For each customer solution, we follow
three main steps:
•Define different audience profiles based on various targeting criteria
•Align cookies to various profile segments
•Deliver messaging based on segments
Proposed Framework for e-Health
A basic conceptual framework for the e-health infrastructure in any country (Fig. 1) has been developed by
the International Society for Tele-medicine and e-Health (ISfTeH). If e-Health is to have its maximum positive
impact on a country’s entire health system, the institutions shown in Fig. 1 need not only to exist but also to
work closely together so that the e-Health profession in the country is adequately supported, well organized
and efficient.

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Fig. 1. A Proposed Framework for a National e-Health Infrastructure
National e-Health Councils
A National e-Health council in each country should be an instrument for giving relevant policy advice to the
national government. As such, it should include all major stakeholder groups. In many countries, a national
AIDS council has been a key instrument in the successful fight against the Human Immune Deficiency Virus
(HIV) and Acquired Immune Deficiency Syndrome (AIDS), partly by encouraging multi-sectoral support for
the effort. National e-health councils could similarly facilitate the multi-sectoral support of e-health in matters
beyond the current purview of the national health authority.
e-Health Corps
An e-health Corps composed of a professional category of health worker should be formed in each country.
Such “e-health workers” could supplement and facilitate the work of other health professionals, such as
doctors, nurses and pharmacists. As an enticement to remain in the health sector, the members of the corps
should have career prospects through schemes of service in employing institutions, such as ministries of
health.
e-Health Steering Committees
An e-health steering committee in each country should advise the National Health Authority on setting e-
Health policy and determining strategic direction. It should also oversee all e-Health projects and
programmes in the country and be responsible for their efficient coordination.
Centers/Networks of e-Health Excellence
In 2005, the Fifty-eighth World Health Assembly recommended the creation of national centers or networks
of excellence for e-health with the aim of encouraging best practices in, and providing policy coordination
and technical support for, health-care delivery, health service improvement and capacity building, and health
education and surveillance. Such centers or networks could also gather and analyze relevant information,
both nationally and internationally, and then distribute the results nationally to support e-health activities.
National e-Health
Council
e-Health Corps e-Health Steering
Committee
e-Health Center/Network
of Excellence
National e-Health Society

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e-Health Professional Societies
A national e-Health society should be created in each country to act as a forum for e-Health professionals to
exchange ideas and share knowledge. It should be an independent not-for-profit, non-governmental body.
Such a society could develop and store resources for e-Health and raise the profiles of e-Health experts. To
facilitate the sharing of experience with e-Health professionals outside the country, to the mutual benefit of
all involved, the society should be affiliated with international e-Health federations.
Civil Society’s Contribution
Research has shown that the failure of ICT projects in developing countries most often stemmed from
generic differences between two key stakeholder groups namely:
1. The Designers.
2. The Users.
In an attempt to address this issue, the ISfTeH framework added a “fourth dimension”, civil society, to
previous models of e-health collaboration. The earlier models, such as the Triple Helix Innovation model,
tended to focus on
The ISfTeH framework not only incorporates users but also extends their role beyond transformation to the
three preceding stages in the “innovation value chain”:
(i) Identification of the challenges to be resolved (facilitation)
(ii) Research to find solutions (discovery)
(iii) Dissemination of the results (diffusion).
e-Health’s Grand Challenges
The ISfTeH framework is particularly relevant to health systems that have strong central governing
structures. Although such health systems are found predominantly in developing countries, the framework
can act as an instrument to address the major challenges to efficient e-Health activities in any country. The
following can be considered e-health’s grand challenges:
o Creating a knowledge commons for e-Health (i.e. a widely available repository of knowledge and
information on e-health that is global in scope).
o Scaling-up e-health interventions to a size that is commensurate with the magnitude of the problem
to be addressed;
o Creating integrated e-health systems to resolve the perennial issues of siloed systems and lack of
interoperability;
o Transforming all health workers into e-health practitioners, thereby developing individual and
institutional capacity to use e-health tools and services;
o Developing ICT for health by viewing health as a production function and investigating where ICT can
support such production (not just through care but also at other points along the pathways
influencing health, such as by modifying the social determinants of health);
o Building ICT for the health system of the future by anticipating future needs (unfortunately, today’s
interventions are often designed in response to yesterday’s challenges and will not take effect until
tomorrow).

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Executive Summary
The economic pressures of ever-increasing healthcare costs and suboptimal health outcomes are driving the
search for new approaches to health management. Policymakers now speak of the National Health
Information Network and interoperable electronic health records as necessary elements of health care for
the entire population. Based on multiple studies and reports on the need for patient-centered health care,
public policy is attaching growing importance to the role of consumers in managing their own health, in
partnership with healthcare providers.
Consumer-oriented e-health resources are meant to help consumers manage the heavy demands of health
management. Indeed, it may be difficult for consumers to meet some of the demands without e-health tools.
“e-Health” is a broad term for the heterogeneous and evolving digital resources and practices that support
health and health care. e-Health resources enable consumers, patients, and informal caregivers to gather
information, make healthcare decisions, communicate with healthcare providers, manage chronic disease,
and engage in other health-related activities. Most, although not all, of these resources are available through
the Internet. e-Health tools offer consumers a broad range of integrated, interactive functions including
those listed below. Most tools support several of these functions, generally structured around a primary
purpose such as disease management.
 Health information—either a spectrum of searchable information or more narrowly defined content
 Behavior change/prevention—support for a specific behavior change such as smoking cessation
 Health self-management—tools for achieving and maintaining healthy behavior in lifestyle areas such
as diet and exercise
 Online communities—Internet-based communities for interaction among consumers, patients, or
informal caregivers about shared health concerns
 Decision support—structured support for making treatment decisions, choosing and evaluating
insurance programs or healthcare providers, or managing healthcare benefits
 Disease management—monitoring, recordkeeping, and communication devices for managing a
chronic disease, usually in conjunction with healthcare providers
 Healthcare tools—means of maintaining or accessing health records and interacting with healthcare
providers. This category includes personal health records.
These tools show great promise for enhancing the health of users; at present, however, they fall short of
offering population-wide benefits. The national commitment to eliminating health disparities and improving
health literacy intensifies the need for a thorough understanding of consumers and their requirements for e-
health tools. Some of the most important benefits of e-health tools—if properly designed and
disseminated—could potentially extend to underserved Nigerians, who often bear the greatest health
burdens with the least support. Even as more consumers become comfortable with the Internet as a health
resource, questions remain about the value of e-health tools for many segments of the nation’s diverse
population. This study found that there do not appear to be intrinsic deficiencies in technology or
insurmountable access obstacles; rather, the issue is that not enough tools have yet been designed and
disseminated with an eye to the diverse experiences, requirements, and capacities of end users.
This study treats diversity as a key concept in analyzing the e-health phenomenon. Its purpose is to identify
and analyze the critical factors influencing the reach and impact of consumer e-health tools for a diverse
population. It addresses questions about what motivates and engages different users, reviews the research
literature, examines e-health dissemination models, and identifies gaps and opportunities in policy, tool
development, research, and dissemination. The following vision provides the guiding principles and the
yardstick against which current conditions are assessed:

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 Consumers with diverse perspectives, circumstances, capacities, and experiences are included in the
design of, and have meaningful access to, evidence-based e-health tools with strong privacy and
security protections.
 Diverse consumers have the skills and support to evaluate, choose, and use e-health tools to derive
benefits for themselves and those they care for.
 Healthcare organizations and practitioners use the full range of e-health tools to engage and support
diverse consumers in their own health management as a routine element of care.
 Local, state, and national policies and programs support the sustainable development and
dissemination of evidence-based consumer e-health tools to diverse individuals and communities,
including those served by safety net providers.
 Alliances and partnerships facilitate sustained consumer access to and use of e-health tools,
consistent with the value propositions and perspectives of each participating stakeholder.
 Appropriate funding and incentives exist in public policy and the market to enable sustainable
business models for tools with demonstrated effectiveness.
This executive summary stresses that e-health practices have the potential to be part of the solution to
health disparities and other health policy challenges if appropriate and useful e-health resources are made
available to a larger proportion of the Nigerian population than is now the case. So far, market forces and
fragmented public-sector efforts have failed to harness technological innovation to improve population
health. Some observers worry that an uneven distribution of high-quality e-health tools or consumers’
varying ability to use such tools could worsen health disparities. The Executive summary proposes that
extending the benefits of these technologies to diverse users requires public leadership, robust public-
private partnerships, and consumer-centric research, analysis, and strategies. The entire effort must be
connected both to the disease prevention and health promotion objectives for the nation and to the goals
for the emerging National Health Information Network.
This proposal on e=Health explored the following questions:
 What is known about population diversity that can inform the creation of appropriate e-health tools
and enhance understanding of their uses?
 How is the research base for consumer-centric e-health tools evolving?
 What factors in public policy and the marketplace are influencing the development and dissemination
of e-health tools?
 What gaps are not likely to be filled by market-driven solutions and should be addressed by public
policy and public-private collaborations?
 What approaches exist and might be expanded to connect diverse groups of consumers with e-health
tools?
The proposal team took a critical approach, searching below the promising surface of e-health, to examine
gaps between promise and reality. The proposal draws on many earlier studies, reports, and articles. In
particular, it builds on the work of the Federal Ministry of Health.
The present study identified or confirmed several encouraging trends in the consumer e-health arena and
identified several issues raised in earlier reports that still have not been adequately addressed. Literature
reviews of published and unpublished studies, an environmental scan, interviews, and meetings with e-health
researchers and developers, public health officials, community technology professionals, and other experts
led to the following five findings:

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Finding 1.
Achieving broad public acceptance of personal health management and e-health tools will require greater
attention to the intended users’ diverse perspectives, circumstances, and experiences regarding health
information and digital technologies, as well as their differing capacities for health management.
Finding 2.
A large body of evidence suggests the effectiveness and utility of many consumer e-health tools. The
evidence is uneven across categories of tools and user groups, however. Often, the tools are developed as
research projects and not easily available in the marketplace; conversely, many tools in the marketplace do
not have an explicit evidence base. Consumers may not be able to access many evaluated e-health tools that
would be beneficial to their health, particularly given the increasing demands related to personal health
management.
Finding 3.
In addition to the lack of alignment between evidence-based and popular tools, other significant gaps include
the shortage of viable and sustainable business models, the need to protect health information privacy and
nurture public trust, and the need for ongoing quality assurance.
Finding 4.
The e-health arena comprises many stakeholders besides consumer end users, including healthcare
organizations, purchasers, public health entities, employers, community-based organizations, and others.
Many are already engaged in partnerships around funding, dissemination, research, development, and
advocacy. The personal health record arena has generated early collaborations around a tool that may prove
useful to diverse user groups and provide a platform for multiple e-health functions. Both coordination and
Federal leadership are needed to achieve the vision proposed in this proposal, possibly modeled on these
activities related to personal health records.
Finding 5.
Strategies for reaching diverse audiences have been developed and have proven effective in communities
outside the digital and economic mainstream. These strategies could provide models for new efforts to reach
diverse, often underserved audiences, complementing more standard market approaches and widening the
reach and impact of e-health tools. In addition, future e-health dissemination efforts may be able to leverage
the networks they have already created.
Conclusion
A well-organized national infrastructure for e-health can help make efficient national e-health systems a
reality and develop careers in e-health, particularly through capacity building, the promotion and
development of e-health tools and services, and the resolution of e-health’s grand challenges.
In any country, the ISfTeH framework could be a powerful tool for supporting the internal transformation of
e-Health into a mainstream activity of the entire national health system.

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GLOSSARY OF TERMS
:: e-Health means the use of modern information and communication technologies (ICT) in support of health
and health-related fields, and to meet needs of citizens, patients, healthcare professionals, healthcare
providers as well as policy makers. E-Health covers the interaction between citizens/patients and health-
service providers, institution-to-institution transmission of data, or peer-to-peer communication between
citizens/patients and/or health professionals.
:: e-Health solutions include products, systems and services that go beyond simply Internet-based
applications and encompass tools for both health authorities and professionals as well as personalized health
systems for patients and citizens. Examples include health information networks, electronic health records,
telemedicine services, personal wearable and portable communicable systems, health portals, and many
other ICT-based tools assisting prevention, diagnosis, treatment, health monitoring, and lifestyle
management.
:: e-Health Interoperability means the ability of two or more e-Health systems to exchange both computer
interpretable data and human interpretable information and knowledge.
:: Technical Interoperability means the ability of two or more applications, to accept data from each other
and perform a given task in an appropriate and satisfactory manner without the need for extra operator
intervention.
:: Semantic Interoperability means ensuring that the precise meaning of exchanged information is
understandable by any other system or application not initially developed for this purpose.
:: e-Health Info-structure should be understood as the foundation layer containing all data structures,
codifications, terminologies and ontologies, data interoperability and accessibility standards, stored
information and data as well as rules and agreements for the collection and management of these data and
the tools for their exploitation. At European level, such a European info-structure may be composed of
biomedical and health/medical research and knowledge databases, public health data repositories, health
education information, electronic patient and personal health records systems, data warehouses, etc.
:: Electronic Health Record (eHR) means a comprehensive medical record or similar documentation of the
past and present physical and mental state of health of an individual in electronic form, and providing for
ready availability of these data for medical treatment and other closely related purposes.
:: Telemedicine is the provision of healthcare services, through use of ICT, in situations where a health
professional and a patient (or two professionals) are not in the same location. It involves secure transmission
of medical data and information, through text, sound, images or other forms needed for the prevention,
diagnosis, treatment and follow-up of patients. Telemedicine services can encompass tele-radiology, tele-
pathology, tele-dermatology, tele-consultation, tele-monitoring, tele-surgery and tele-ophthalmology as well
as online information centers for patients, remote consultation/e-visits or videoconferences between health
professionals.
:: e-Prescription means an electronically issued and transmitted medicinal prescription.

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:: Virtual Physiological Human (VPH) is a methodological and technological framework, targeting multi-scale
models and simulation aiming at personalized, predictive and integrative medicine and information
infrastructures. Once established, it will enable collaborative investigation of the human body as a single
complex system.
:: Personal Health Systems (PHS) assist in the provision of continuous, quality controlled, and personalized
health services, including diagnosis, treatment, rehabilitation, disease prevention and lifestyle management,
to empowered individuals regardless of location. PHS consist of: intelligent ambient and/or body devices
(wearable, portable or implantable); intelligent processing of the acquired information; and active feedback
from health professionals or directly from the devices to the individuals.

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