e-health

E-Health and the twenty-first century trends

Contact Details Cell Phone: 250-507-4343 Victoria , BC Canada [email_address] 15 years healthcare specialist experience and practice management consulting. Utilizing extensive industry experience within medical equipments, IT healthcare (PACS/RIS/CIS & CVIS), pharma, biotech, clinical research and healthcare to execute and implement certain process as well as methodology into diverse operational roles at all organizational levels.

Everybody talks about e-health these days, but few people have come up with a clear definition of this comparatively new term. Barely in use before 1999, this term now seems to serve as a general "buzzword," used to characterize not only "Internet medicine", but also virtually everything related to computers and medicine. The term was apparently first used by industry leaders and marketing people rather than academics. They created and used this term in line with other "e-words" such as e-commerce, e-business, e-solutions, and so on, in an attempt to convey the promises, principles, excitement (and hype) around e-commerce (electronic commerce) to the health arena, and to give an account of the new possibilities the Internet is opening up to the area of health care. What is e-health?

What is e-health? Intel, for example, referred to e-health as "a concerted effort undertaken by leaders in health care and hi-tech industries to fully harness the benefits available through convergence of the Internet and health care." Because the Internet created new opportunities and challenges to the traditional health care information technology industry, the use of a new term to address these issues seemed appropriate. These "new" challenges for the health care information technology industry were mainly (1) the capability of consumers to interact with their systems online (B2C = "business to consumer"); (2) improved possibilities for institution-to-institution transmissions of data (B2B = "business to business"); (3) new possibilities for peer-to-peer communication of consumers (C2C = "consumer to consumer").

What is e-health? Also eHealth refers to various information and services that is either shared or modified through technology such as the internet . The term itself emerged in the year 2000. It includes virtually all of the aspects associated with medical informatics but also sets the main focus around sending clinical data. A broad range of elements are covered by eHealth such as: 1-Telemedicine 2- EMR ( Electronic Medical Records ) 3- Health Informatics 4- MHealth 5- Evidence Based Medicine Of course these are certainly not every facet of eHealth and as time goes on and technology grows more will be added to this list.

E-Health: "E-health is a new term used to describe the combined use of electronic communication and information technology in the health sector" OR is the use, in the health sector, of digital data-transmitted, stored and retrieved electronically-for clinical, educational and administrative purposes, both at the local site and at a distance What is e-health? World Health Organization

Conclusion So, to recap; eHealth is an informative and interactive method that both patients and health care professionals can come together and share information with others in the profession from around the world. Regardless of location, medical issue, health concern, etc. health care physicians can discuss data as well as past experience to provide the best possible solutions for the patient.

I am a human being. I seek to enhance my quality of life. I am 53 years old and recently woke up with pain in my chest. My father died of a heart attack at 44 and my mother is living with diabetes. I have never smoked. I walk my dog in the park every day and try to watch my diet. I am 5' 9" tall and weigh 142 pounds. I know I must monitor my blood sugar. I am allergic to sulfa drugs and take two aspirin every day. I eat two eggs for breakfast daily. I have daughters and a grand daughter who are all healthy. My gallbladder was removed four years ago. I have green eyes. I have never had a stress test. I wish my doctor remembered our last visit, my hairdresser does. Enable my care team to provide the highest quality of care.

I am a doctor. I have more of everything these days, except time. More patients to see. More charts to complete. More data to interpret. I treated 70 patients today, followed up on 28 radiology reports and 44 lab reports, and wrote hundreds of orders. I must remember dozens of medications, protocols, dosages and guidelines. I have 6 months of medical journals sitting on my nightstand. I want to educate my patients, practice evidence-based medicine, offer preventative service and deliver good outcomes. I am a physician committed to my patients. Enable me to provide the best quality of care .

I am a nurse. I am devoted to the care of others. I have over 12 years of experience serving my patients and their care team. I coordinate the care of multiple patients, all at different stages of ill health. My pockets, stuffed full of reminders, work orders and pending tests are my only safeguard against missing charts and files. How am I supposed to document for the next care team? Room 207 got sick with her last dose of morphine, 209 needs teaching on her inhaler, I have vitals to check on everyone. I am a nurse who trained to work with people, not paper. Enable me to provide the best quality of care for my patients .

I am a CIO. I keep information flowing. I am responsible for a growing community health network with over 100 computing environments and 30 different vendors across 17 departments at 6 sites. I need stable systems, easy maintenance, no downtime, fast performance, implementation expertise and deep clinical functionality. I dream of a true partner who offers this in every department, helps me justify my IT investment and delivers on time and within budget. I seek to improve clinical outcomes, patient safety and productivity. With a true partner I can recruit the best talent, streamline information flow and employ the best technology. Help me make IT happen .

The Circle of Care Community Care Center From the EHRS Blueprint © Canada Health Infoway 2003-2005 Pharmacy Laboratory Diagnostic Hospital Emergency Homecare Clinic Emergency Services Specialist Clinic

The Patient Centric & Integrated View of Consolidated Information Pharmacy Laboratory Diagnostic Hospital Emergency Homecare Community Care Center Clinic Emergency Services Specialist Clinic From the EHRS Blueprint © Canada Health Infoway 2003-2005 QUALITY SAFETY ACCESSIBILITY Clients/Patients INTEGRATED VIEW Pharmacy Laboratory Diagnostic Hospital Emergency Homecare Clinic Emergency Services Specialist Clinic

An electronic health record (EHR) is a secure and private lifetime record of an individual’s health and care history, available electronically to authorized health providers . It facilitates the sharing of data – across the continuum of care, across healthcare delivery organizations and across geographies. Electronic Health Record (EHR) 6

The 10 e's in "e-health" 1-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. 2-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. 3-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.

The 10 e's in "e-health" 4-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. 5-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 of physicians through online sources (continuing medical education) and consumers (health education, tailored preventive information for consumers) 7-Enabling information exchange and communication in a standardized way between health care establishments. 8-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 a pharmaceuticals.

The 10 e's in "e-health" 9-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. 10-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.

The 10 e's in "e-health" In addition to these 10 essential e's, e-health should also be easy-to-use, entertaining (no-one will use something that is boring!) and exciting - and it should definitely exist!

Why is Ehealth important? In the twenty-first century the NHS in the UK, and health care providers in other developed countries face some major challenges. Three key challenges are identified below. Uniquely, Ehealth is seen as providing answers to each of these key challenges. Challenges facing UK health care at the start of the twenty-first century Providing for an ageing population with increasing prevalence of chronic illness, which is increasingly expensive to treat; Improving patient safety and reducing errors; Supporting patients to become informed consumers who take an active role in their own health care.

Why is Ehealth important? The demographic transition to an ageing population living longer with chronic disease, means that health care providers not only have to find the resources to care for these people but also have fewer younger people to provide informal care or to fund the welfare state through taxation. Pharmaceutical companies are investing heavily in developing new drugs for the major chronic conditions such as cancer, heart disease and dementia, and they need to recoup their investment. Information and communication technologies (in the various guises of Ehealth, telecare, telehealth, etc.) are seen as an answer to these conundrums. The discourse of telecare in particular has been one of technology being the answer to many of the problems social care currently faces. Ehealth solutions are posited as relatively cheap methods of delivering care and support both remotely, and with automation. This includes remote monitoring and remote consultation delivered by health care practitioners, as well as self-monitoring tools to support self-management. The goal is the maintenance of independent living for those with chronic illness, and a reduction in the use of secondary care.

Why is Ehealth important? The second challenge of twenty-first century health care for which Ehealth is seen as having a key role is patient safety. Ehealth is seen as being a key element in the knowledge management initiatives (for example lean health care) being implemented to improve safety. Technology is seen as having the potential to reduce errors, improve patient experience and reduce costs. Again the discourse here has predominantly been a positive one of technology solutions for human problems, and it is rare to find rhetoric critical of the Ehealth agenda. Little attention has been paid to the evidence that Ehealth interventions carry risks as well as benefits (Car et al. 2008). Similarly, Ehealth applications sometimes fail to work in practice due to problems with implementation and professional resistance (Car et al. 2008).

Why is Ehealth important? The third major theme in health care in developed countries at the start of the twenty-first century concerns consumerism and the empowerment of the patient. As discussed above, Ehealth in general and the internet in particular have been seen as playing a vital role in facilitating this. The quantum change in accessibility of information brought about by the internet revolution has coincided with the move to shift the balance of power from professionals to patients. Health information on the internet now allows consumers to make informed choices about their health and to access the esoteric knowledge previously only available to health professionals.

Checking and updating patient notes technology enabled Rapid patient updates or consultation Collaborating on patient diagnosis and care Test results sent instantly to multi-devices Online patient services and communications Patient discharge - wheelchair requested & room cleaned

Our Vision…….. Workflow Optimization Identifies key decisions and scope decisions: What processes are being impacted? Which applications are needed to support automating the impacted processes? What members of the care delivery team need to be involved? What are the interface or integration issues ? Identifies Sequencing of Automation

Organizational Strategy Organizational IM/IT Strategy Ensure priorities in the strategic plan are aligned with the organization’s overall goals Outline plan to achieve the IM/IT vision Establish a decision framework for future IM/IT projects that the organization pursues

What are the constraints? How do we get there? Where are we? Where do we want to be? How do we get started? What are the impacts? Strategic Planning Framework

Healthcare Projects Patients Registration Health Status Care Delivery Admission Area/ Location (Process) Access (Policy) Provider (Staff) Service Treatment Quality & Safety Productivity Technology

E- health Projects in Canada The eHealth industry is a crucial element in building the foundation for a robust health system infrastructure and infostructure. eHealth will play a critical role in the development and application of systems and processes that support quality patient care through evidence-based clinical decisions and in the provision of the right information to the right person at the right time. As the health system becomes more fully e-enabled, the roles of the various players within eHealth will become even more important. The three groups working within eHealth— health informatics (HI) professionals, health information management (HIM) professionals and technical specialists — will be required to provide the context and tools to organize a vastly increased amount of information and to integrate this information into health system tools that allow clinicians to use this information.

Health Informatic Those involved in eHealth need to understand both the information and communications technology (ICT) world and the health system: its context, vocabularies and ontologies, and how to use these to improve information and knowledge management. eHealth builds health infostructure capabilities by: 1. Improving access to health care services, information, and connecting clinicians; 2. Improving clinical practice through improved knowledge management; and 3. Improving health information for the care givers, patient, and public with the outcome of promoting improved.

Health Informatic As the health system becomes more fully e-enabled, the roles of the various players within eHealth will become even more crucial. The rate of discovery of new medical information on diseases and clinical interventions makes it very difficult for clinicians to keep up to date. This is coupled with the massive amount of information that will reside in patient health records. The three groups working within eHealth—health informatics professionals, health information management professionals and technical specialists— will play a crucial function in providing context and tools to organize all of this information and in integrating this information into health system tools that allow clinicians to use this information.

Definitions COACH (Canadian Organization for Advancement of Computers in Health): “ Health informatics (HI) is the intersection of clinical, IM/IT and management practices to achieve better health…Health Informatics Professionals develop and deploy information and systems solutions, drawing on expert knowledge from fields such as computer science, information management, cognitive science, communications, epidemiology, management sciences and health sciences.

Definitions Canadian Health Information Management Association (CHIMA): “ Health information management professionals provide leadership in all aspects of clinical information management at both the micro and macro levels. At the micro (or individual record level) HIM professionals support the collection, use, access and disclosure, to the retention and destruction of health information regardless of format… At the macro (or aggregate data level), HIM professionals deal with the information through the health system, analyze statistics, manage complex information systems including registries and work with public, private and key stakeholders in understanding and using health data to improve the health of Canadians.

Definitions Technical Specialists Technical specialists require strong information and communication technology competencies, and should also have some knowledge of the health care industry. These professionals are responsible for managing the health care organization’s ICT systems and for ensuring that these systems are available, used, maintained and upgraded as required. Some of the roles fulfilled by this group include database administration, application development and network and communications infrastructure.

E- health Projects in Canada There are numerous stakeholders in the eHealth industry, and each one plays an important role in advancing the eHealth agenda. They are as follows: Academic institutions; Health care provider institutions; Public health agencies; Industry associations; Clinicians; Consumers; Technology vendors; Canada Health Infoway ; Canadian Institute for Health Information (CIHI).

Canada Health Infoway CANADA HEALTH INFOWAY INC. INVESTS WITH PUBLIC SECTOR PARTNERS ACROSS CANADA TO IMPLEMENT AND REUSE COMPATIBL E HEALTH INFORMATION SYSTEMS THAT SUPPO RT A SAFER , MORE EFFICIENT HEALTH CARE SYSTEM . INFOWAY IS AN INDEPENDENT, NOT- FOR – PROFIT ORGANIZATION WHOSE MEMBERSARE CANADA’ S 14 FEDERAL , PROVINCIAL AND TERRITORIAL DEPUTY MINISTERS OF HEALTH .

Canada Health Infoway Since its inception in 2000, Canada Health Infoway (Infoway) has had the mandate to invest in and support the development of a pan-Canadian EHR infostructure to accelerate the use of electronic health records in Canada. The internationally recognized EHR blueprint architecture establishes the framework for the development and deployment of ICT to support an EHR system. Infoway works with various industry stakeholders—technology vendors, provincial eHealth agencies, industry associations and health care organizations—to provide leadership and investment in eHealth projects that support its objective.

EHRS BLUEPRINT The Electronic Health Record Solution (EHRS) Blueprint is a technology framework that enables the appropriate sharing of clinically relevant patient health information between health services providers across care settings and disciplines in Canada. The Blueprint provides a vision and direction for how information technology will be employed to allow the many different information systems used in health care to interoperate: allowing a health service provider to access information captured by other healthcare providers for the same patient/client.

HOW IT WORKS The Blueprint is an enterprise systems architecture that uses the well accepted principles of a Services Oriented Architecture to enable the applications at the many points of service to use one standards-based set of interfaces to exchange information through a shared EHR Infostructure (EHRi). Each jurisdiction in Canada will operate one or more instances of this standardized infostructure. The Blueprint describes how each point of service application can connect to the shared infostructure using a common set of interface standards, rather than connecting to each other directly. These interfaces are handled by the Health Information Access Layer (HIAL) which provides common services to support, for example, authorization and authentication of users and logging and auditing of all accesses. Point of service applications send distinct information about clients/patients to a set of shared information repositories that are managed by the Longitudinal Record Services. The applications (or an integrated viewer) can then request EHR information from the Infostructure using the same mechanisms, securely accessing relevant EHR information captured by many different health disciplines, in many different care settings, and potentially in many jurisdictions across Canada. Each infostructure can communicate with other infostructures, collaborating to deliver clinically relevant information where and when it is needed, regardless of where it was originally captured .

The building blocks include individual electronic health records (EHR), health information management systems in large and small healthcare settings called Point of Service applications (PoS), health information repositories and warehouses, and special service applications that screen and manage health information as it is transmitted from one point to another. These capabilities, combined with a supporting infostructure that connects them all, is called the EHRS.

The EHR Infostructure is made up of: • Registry systems to manage and provide the information required to uniquely identify the actors and resources in the EHR. These identified elements include the name of the patient/client (including a unique identifier), the provider of care, the location of care, the end users of applications and the terminologies used to describe diseases, acts or other clinically relevant information. Registries which hold patient/client consent information are part of the EHRi as well. Figure 1 The EHR Solution Concept Source: Canada Info Way

Figure 2 EHR as Network of HER infostructures Source: Canada Info Way

Figure 3 PoS Systems Source: Canada Info Way

Figure 4 EHRi Data Repositories Source: Canada Info Way

Figure 6 Registry Services Source: Canada Info Way

Figure 7 Longitudinal Record Services Source: Canada Info Way

Figure 8 The Health Information Access Layer (HIAL) Source: Canada Info Way

Figure 9 EHR Viewer Source: Canada Info Way

Figure 10 Communications Services in the HIAL Source: Canada Info Way

Figure 11 HIAL Common Services Source: Canada Info Way

The Benefit/Future of eHealth in Canada In 2005, Branham Group Inc. asked leading eHealth thought leaders and key decision makers to dust off their “ crystal ball” and offer their perspective on how eHealth would be used to deliver health care services in 2015. By combining these various predictions, a composite Picture emerges in which: The existing “silos” of information and expertise no longer exist. “ Patients” have become “consumers” of health care services and are taking a more active role in their care. “ Patient self-service” emerges as a viable option for routine tasks such as booking appointments or monitoring certain aspects of a chronic condition.

The Benefit/Future of eHealth in Canada Health care providers make extensive use of mobile devices to access the information they need, when they need it, wherever they might be located. Clinicians are shifting from a mindset of having to remember everything to routinely consulting handheld devices and on-line applications to order tests, review test results, refine a diagnosis, select the most appropriate care plan, schedule therapy and prescribe medication. Health care providers no longer need to be in the same room as the person they are treating in order to make a diagnosis or even deliver many aspects of care.

Canada Health Infoway has made significant contributions to eHealth initiatives across the country, through collaboration, funding and leadership. Infoway has developed an EHR systems architecture, which forms the basis for significant advancement in technology use across the country. According to the Canada Health Infoway 3 of 13 provincial and territorial jurisdictions will have the required fully interoperable EHR infostructure in place by the end of 2010. Alberta, Prince Edward Island, and the Northwest Territories are anticipated to have all the required elements of the EHR infostructure in place by 2010. Implementation in British Columbia and Quebec is forecast to extend into 2010. By this time, in these jurisdictions, a provider should be able to retrieve a patient’s health record within the region. The complete record contains historical drug, laboratory, diagnostic imaging, some hospital clinical reports, and immunization data regardless of where it originated. Combined, these five jurisdictions represent 47 per cent of the Canadian population.

Snapshot of the Vendor Market Share Source: Information and Communications Technology Council Report 2008

Is It worth to invest and start ?

It’s not just what you connect Equipment Public Health Organizations Laboratories Pharmacies Clinicians Clinics Emergency Responders S uppliers Payers After Care Imaging O.R.s & Beds

It’s planning holistically Infrastructure Information Finance & Utilities Mobility & Security Supply Chain People & Processes

It’s planning holistically for maximum design efficiency Infrastructure Information Finance & Utilities Mobility & Security Supply Chain People & Processes

Key points to consider Operational processes Clinician and Patient involvement Technology enablers & constraints Physical layout Think tomorrow

Healthcare & Project Management = Plan the work , then work the plan

Patient Management Technology Best Quality of Care 01

We want a system or a solution that enables us to provide the best quality of care to our patients and assist us in making decisions. We want a system or a solution modeled on how we work that provides access to comprehensive, real-time information from anywhere. We want a system or a solution that will help us reduce our costs and be easy to maintain and update. 02

Why Do Projects Fail? Changing scope Insufficient planning No risk or issues management Poor communication Lack of commitment and responsibility by stakeholders 03

P L A N N I N G F U N D I N G Step 0 Deafine Expected / Targeted Mission Statement M A N A G E M E N T O V E R S I G H T Time Step 1 Concept Definition Step 2 Concept Development Develop Process Time Step 3 System Definition Prototype and System Design Time Step 4 Process/ System Life Cycle Development and Testing Step 5 Production and Deployment Project Plan (P0, P1, P2 & P3) P 0 Issue : Planning Guidance Milestone 0 Project Initiation Approval P 1 Final Approves Project Funding 0 Fund Project Milestone 1 Prototype Development Approval P 2 Execution Funding 1 Fund 1 Status Review Funding 2 Fund 2 P 3 Closure Milestone 2 System Development Approval Funding 3 Fund 3 System Testing

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