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

e-Health
&
e-Pulse
Mustafa Değerli
June 2016

Outline (1/3)
• 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
• European Funded Projects in the field of ICT for Health and Wellbeing

Outline (2/3)
• 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)
• Integration of e-Pulse (e-Nabız) with Other Systems

Outline (3/3)
• 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)
• Future Works

Definition of e-Health (1/3)
• The transfer of health resources and health care by
electronic means (The World Health Organization - WHO)
• 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

Definition of e-Health (2/3)
• Products, like instruments to ensure the constant monitoring of blood
pressure in ambulatory patients
• Systems, like computer-assisted surgery systems
• Services, like:
• Operating surgical and intensive care units, with interconnected
instruments and surveillance services ensuring continuous patient
monitoring
• Computer-assisted prescription services, where the software checks
for incompatible drugs, contraindications and dosage levels
• Information services for patients and consumers, including individual
electronic health records

Main Players in the Field of e-
Health
• e-Health solutions firmly necessitate coordination with dissimilar players whose philosophies, purposes
and backgrounds are to a certain extent miscellaneous.
• 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
• The media

Success Factors for e-Health
Projects
• 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
• include a comprehensive plan for ongoing education and communication with the partners

The 10 e’s in e-Heath
Efficiency
Enhancing
Evidence-based
Empowering
Encouraging
Education
Enabling
Extending
Ethics
Equity

Current e-Health Projects or
Services of Turkey (1/4)
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
Other Projects

• Health-NET
• 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
• Family Medicine Information System
• Healthcare service provision and primary health care data collection
discipline of Turkey’s MoH
• Core Health Resources Management System
• Provision of accurate and updated information support to managers of all
levels in order for the human, material and financial resources

• Green Card Information System
• Green card entitlement of the citizens holding green cards is
monitored and shared
• Tele-Medicine Project
• Distant reporting service in the field of imaging with the use of
information and communication technologies
• Decision Support System
• Analysis, reporting and statistics support for the Health Policy
makers, planners and decision makers

• 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-Training
• Support graduate in-service training of MoH personnel and to provide them
training at any place and time they wish
• Other Projects
• MoH Tender Information System
• Pharmaceutical and International Classification of Diseases Codes s
• Organ Transplantation and Tissue Data Bank

Statistics Regarding the Health and
e-Health Industries of Turkey (1/3)
• Health and e-health industries in Turkey are really promising and they have high potential
• Number of mobile phone subscriptions in Turkey: 72,174,826 [June, 2015]
• Number of Internet subscriptions in Turkey: 44,395,360 [June, 2015]
• Computer usage in households and individuals in Turkey: 54.8% [2015]
 Internet usage in households and individuals in Turkey: 55.9% [2015]
• Households with access to the Internet in Turkey: 69.5% [2015]
• Number of physicians in Turkey: 135,616 [2014]
• Number of persons per physician in Turkey: 573 [2014]
• Number of patient hospital visits per physician in Turkey: 4648 [2014]
 Total number of visits to physicians in all healthcare facilities in Turkey: 643,992,030 [2014]
• Total number of visits to physicians in hospitals in Turkey: 396,577,644 [2014]

• Number of hospitals in Turkey: 1528 [2014]
• Number of public hospitals in Turkey: 866 [2014]
• Number of private hospitals in Turkey: 556 [2014]
• Number of university hospitals in Turkey: 69 [2014]
• Number of other hospitals in Turkey: 37 [2014]
• Number of MRI devices in Turkey: 757 [2014]
• Number of CT devices in Turkey: 1071 [2014]
• Number of ultrasound devices in Turkey: 5286 [2014]
• Number of Doppler ultrasonography devices in Turkey: 3151 [2014]
• Number of ECHO devices in Turkey: 1793 [2014]
• Number of mammography devices in Turkey: 903 [2014]

• Number of MRI devices in private hospitals in Turkey: 403 [2014]
• Number of CT devices in private hospitals in Turkey: 484 [2014]
• Number of ultrasound devices in private hospitals in Turkey: 1865 [2014]
• Number of Doppler ultrasonography devices in private hospitals in Turkey:
666 [2014]
• Number of ECHO devices in private hospitals in Turkey: 666 [2014]
• Number of mammography devices in private hospitals in Turkey: 517 [2014]
• Current health expenditure in Turkey: USD 72,456 M [2013]
• Health investment expenditure in Turkey: USD 4262 M [2013]

Comparative Statistics regarding
Health (1/3)
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

Health (2/3)
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

Health (3/3)
• When compared with United Kingdom, United
States of America, Singapore, and France;
Turkey needs to improve its health workforce and
health infrastructure and technologies
• 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

Metrics related with Health and e-
Health (1/4)

Health (2/4)

Health (3/4)
• 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

Health (4/4)
• 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

EU Citizen’s Use of e-Health
Services
• Factors that positively affected the use of Internet for health
purposes: 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.
• 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
• 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

European Funded Projects in the field of
ICT for Health and Wellbeing (e-Heath)
HealthMonitor
Mobiguide
MyHealth Avatar
p-Medicine
DAPHNE
BeatHealth
PEGASO Fit for Future
SPLENDID
PRECIOUS
SEMEOTICONS
eHealth Innovation
CLEAR
CommonWell
MOMENTUM

European Funded Projects in the field of
ICT for Health and Wellbeing (e-Heath)
NEXES
RenewingHealth
United4Health
THALEA
INSPIRE
CARRE
MovingLife
DECIPHER PCP
UNWIRED Health
PALANTE
SUSTAINS
epSOS
Trillium Bridge

e-Pulse (e-Nabız)
• 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
• 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) 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
• a powerful communications line between patients and doctors

Features and Functionalities of
e-Pulse (e-Nabız) (1/3)
• 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 used
• View test results, reports, and medical images with their reports
• Record and update medicine allergies and other allergies
• Make appointments by using the e-Pulse (e-Nabız)
• Add notes to their appointments.
• Integrated calendar in the e-Pulse (e-Nabız) to track their appointments.
• Share records with others or doctors
• Track when the records that shared are accessed with related people

• Messaging capability that users can use to communicate with the contact
networks that they created
• Evaluate and rate on the health services and comment on these
• 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, 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
• 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

Future Functionalities of e-Pulse
(e-Nabız)
• All notifications and reminders regarding pregnancy
monitoring
• See 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

Security and Privacy related
with e-Pulse (e-Nabız)
• 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
• Turkey currently does not have a finalized data protection law
• In Turkey, data protection is regulated in a piecemeal fashion by a
combination of the Turkish Constitution and the Turkish Criminal Code
• No separate provisions defining sensitive data, such as race, ethnicity,
sexual orientation or health
• The MoH noted that some data may be used in national or international
health research or analysis conducted for Decision Support Systems
• The MoH claims a non-liability clause for missing information, errors or
delays in the data, software viruses , etc.

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 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

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.

Integration of e-Pulse (e-Nabız)
with Other Systems
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
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

Comparing
epSOS (EU),
NHS (England),
HealtheVet (USA), HealthHub
(Singapore), and e-Pulse
(Turkey)

epSOS (EU) (1/3)
• To design, build and evaluate a service infrastructure that
demonstrates cross-border interoperability between
electronic health record systems in Europe
• Goals are to
• improve the quality and safety of healthcare for citizens
when travelling to another European country
• develop a practical eHealth framework and ICT
infrastructure that enables secure access to patient
health information among different European healthcare
systems

epSOS (EU) (2/3)
• 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
• permit health professionals to receive the relevant, translated clinical information stored
in the patient’s home country (“Patient Summary”)
• epSOS Services are
• ePrescription
• Patient Summary
• Integration of the 112 emergency services
• Integration of the European Health Insurance Card (EHIC)
• Patient access to data

epSOS (EU) (3/3)
• 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
• 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

NHS (England) (1/3)
• 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
• 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

NHS (England) (2/3)
• 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 your doctor takes during an appointment
• hospital admission records, including the reason admitted to hospital
• hospital discharge records
• X-rays
• photographs and image slides, such as magnetic resonance imaging (MRI) or computerized tomography (CT) scans

NHS (England) (3/3)
• 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 your record because doing so is in your best
interest
• 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

HealtheVet (USA) (1/3)
• Users can easily access their personal health information in their My
HealtheVet account - anytime and anywhere they have Internet access
• Designed for Veterans, active duty Service members, their dependents
and caregivers
• My HealtheVet helps users partner with their health care team
• Provides opportunities and tools to make informed decisions and
manage health care
• 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

• 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
• 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

• My HealtheVet offers three account types:
• Basic
• Advanced
• Premium
• 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.
• 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.
• 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.

HealthHub (Singapore) (1/3)
• One-stop portal and mobile app for
Singaporeans to access a wide range of health
content, deals, rewards and e-services
• 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 allows users to access their health records, and the health records of
their children's information
• 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
• Provides users to discover interesting and useful health information for the
stage of life they are in
• 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

Results of Comparison regarding epSOS (EU),
NHS (England), HealtheVet (USA), HealthHub
(Singapore), and e-Pulse (Turkey) (1/6)
Dimension epSOS NHS HealtheVet HealthHub 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

Dimension epSOS NHS HealtheVet HealthHub e-Pulse
Integration with other
health services
NY Y Y Y Y
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

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.

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Mustafa Değerli

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

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