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

9/30/2014
1
Critical need for standardization of
eHealth Systems and Services
Dr. Ramesh S. Krishnamurthy
Focal Point, eHealth Standardization and Interoperability
WHO Headquarters
G S it l d
Geneva, Switzerland
Workshop ‐ 30 September 2014 ‐ 15:30‐17:00
Joya 1 and 2, Business Center 1 – Expo Guadalajara
1 | WCIT 2014 - Guadalajara, Mexico - | September 30, 2014
Key Messages

9/30/2014
2
Key Messages
• Reliable Health Information Systems are essential for
better healthcare delivery and better health
outcome
• Functional Health Information Systems depends on
harmonized and interoperable data elements
between and within systems through adoption of
Health Data Standards and IT Standards
• Strengthening Health Information Systems depends
on national ti l ownership, hi multisectoral lti t l engagement,
t
appropriate use of ICT, and adequate human
capacity
Outline
• Contextualizing the problem
•• World Health Assembly Resolution 66.24
• Approach to strengthening Health
Information Systems

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3
Two Relevant Documents
on Health Information Systems,
eHealth, and prioritization of Health Data
1
Commission on Information and Accountability
Recommendation 3 ‐ Innovation:
By 2015, all countries have
integrated the use of Information
and Communication
Technologies in their national
h health lh information f systems and
d
health infrastructure.

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“The use of eHealth and mHealth should be
strategic, integrated and support national
health goals. In order to capitalize on the
potential of ICTs, it will be critical to agree on
standards and to ensure interoperability of
systems. Health Information Systems must
comply with these standards at all levels,
including systems used to capture patient data
at the point of care.”
Source: United Nations, 2011. Keeping promises, measuring Results, First report of the COIA, p14.
“Common terminologies and minimum data sets
should be agreed on so that information can be
collected consistently, easily and not
misrepresented. In addition, national policies on
health‐data sharing should ensure that data
protection, privacy, and consent are managed
consistently.”
Source: United Nations, 2011. Keeping promises, measuring Results, First report of the COIA, p14.

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Health Information System
in the Context of
Health Data Standardization and
Interoperability
An Example of Health Information System
A Set of Complex Sub Systems
HIS Sub Systems
Allocated Length-Of-Stay Utilization
700
700
30%
30%
20%
600
Monitoring
500
Policy
600
20%
10%
10%
Data
Warehouse
Evaluation
Research
400
300
200
100
25% 50% 75% 100% 125% 150% 175% 200%
500
400
300
200
100
0
25% 50% 75% 100% 125% 150% 175% 200%
0%
0%
-10%
-10%
-20%
-20%
-30%
B02 E02 E04 E15 H01 H02 H03 H04 H10 J03
-30%
-40%
B02 E02 E04 E15 H01 H02 H03 H04 H10 J03
Extract, transform and load data into warehouse
Census Vital Event
Registry Surveys
Health
Events
& Risks
Health
Service
Records
Resource
Tracking
Resources
Processes
Information
Services
0
Patients
Status 143 221 412 574 325 172 68 145
Patients
Status 143 221 412 574 325 172 68 145
-40%
Variance 10% 4% -20% -21% 30% 8% 10% -17% -28% -13
Variance 10% 4% -20% -21% 30% 8% 10% -17% -28% -13%
Modified after Health Metrics Network, 2007.
Data Collection Forms & Methods
Statistical
Systems
Financial
Systems

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Producers and Consumers of PH Data
Many Producers and Consumers of HIS Data
Ministries of Health, Finance, Education, Labour,
Local Health Governments, Private Health Sector,
Insurance Providers, Development Partners, etc…
Courtesy: HMN, 2007
Country HIS Data Sources
Healthcare and
PHD PH Data
t
Courtesy: HMN

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Unpaking
Health Information Systems
The Functional Blocks and
The Primary Engines (sub processes)
HIS Sub Systems
700
700
30%
20%
30%
600
Monitoring
500
Policy
600
10%
20%
10%
Data
Warehouse
Evaluation
Research
400
300
200
100
25% 50% 75% 100% 125% 150% 175% 200%
500
400
300
200
100
0
25% 50% 75% 100% 125% 150% 175% 200%
0%
0%
-10%
-10%
-20%
-20%
-30%
B02 E02 E04 E15 H01 H02 H03 H04 H10 J03
-30%
-40%
B02 E02 E04 E15 H01 H02 H03 H04 H10 J03
Census Vital Event
Registry Surveys
Health
Events
& Risks
Health
Service
Records
Resource
Tracking
Resources
Processes
Information
Services
0
Patients
Status 143 221 412 574 325 172 68 145
Patients
Status 143 221 412 574 325 172 68 145
-40%
Variance 10% 4% -20% -21% 30% 8% 10% -17% -28% -13
Variance 10% 4% -20% -21% 30% 8% 10% -17% -28% -13%
Statistical
Systems
Financial
Systems

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Infrastructure
Human
Resources
Financial
Resources
Information
and
Knowledge
Resources
Stewardship
Functions
Conceptual Functional Elements
of Country HIS
Diagnostic
Community-based
Health
Facility-
Based
Services
Services Services
Environmental
(Monitoring)
Services
Health
Commodities
Courtesy: HMN
Relating HIS Functional Elements to
HIS Primary Engines (sub processes)
Environmental
Monitoring System
Patient
Management System Asset
Management System
Alert and
Response System
Knowledge
Management System
Diagnostics
Management System
Census System
Financial
Management System
Laboratory/ Further review
Supply Chain
Management System
Disease
Surveillance System
Human Resources
Management System
18 | WCIT 2014 - Guadalajara, Mexico - | September 30, 2014 Courtesy: HMN

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Supply Chain
Management System
Supply Chain Information System

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It is desirable that...
Health data systems should not be
developed as a stand‐alone vertical systems
that focus only on a particular process,
instead, as an interoperable component
of f national// sub‐national health information
f
system
Multitude of Stakeholders
A Complex Landscape

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Multiple Stakeholders of National HIS
G
financially-supported vertical programs
W
S
GATES
FD
PEPFA
R
ORLDB
A
NK
STATE
FD
DONOR
1
DONOR
2
DONOR
N
Community Level Programs

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13
H
disease-based vertical programs
D D D D
MALA
RIA
HI
V
/AIDS
TB
ISEASE
1
ISEASE
2
ISEASE
3
ISEASE
N
Data Extraction
Community Level Programs
Movement of Data in
National Public Health Sector
Illustrative Example

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14
Public Health Sector Overview
INDIA > 1.1 billion persons Sub‐center
(Representing several villages)
Block
(10,000+ Blocks)
District
(640+ Districts)
State
(35 States)
Sub‐center
Country ICT Infrastructure
Sub Center
or Health Sub Center
Block
(10,000+ Blocks)
District
(640+ Districts)
Primary Health Center / B-PHC
or Community Health Center
District Surveillance Unit
Broadband
Connectivity
State
(35 States)
State Surveillance Unit
Broadband and Satellite-based
Connectivity

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15
Sub‐center
PH Data Collection Process
Weekly household
visits to collect data
Sub Center
or Health Sub Center
(Auxiliary Nurse Midwife, or Male Health Worker)
Consolidated Forms at Sub-center
per week
Paper Forms
Hand
deliver
Block
(10,000+ Blocks)
District
(640+ Districts)
Primary Health Center / B-PHC
or Community Health Center
(Medical Doctor + helper)
District Surveillance Unit
(District Surveillance Officer,
Data Manager, Data Entry Operator)
One consolidated forms
Paper Forms
B-PHC or CHC
data collected from
PHCs
Paper forms are
converted to
electronic data
Spreadsheets
Email/Web Entry
Hand
deliver
State
(35 States)
State Surveillance Unit
(State Surveillance Officer,
Data Manager, Data Entry Operator)
Electronic data, kept in the
form of formats
Surv.
Database Spreadsheets
Data Standardization:
Challenges of data acquisition and
management from disparate sources

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16
Primary Data Source
Registries of a
Primary Health
Worker
Primary Data Source
Weekly Data,
manually
computed by the
data entry operator

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Primary Data Source
Minor Ailment
R Registry
i
33 | WCIT 2014 - Guadalajara, Mexico - | September 30, 2014 Courtesy: US. CDC
Primary Data Source
OPD Registries

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Primary Data Source
Fever Registries
Primary Data Source
OPD / Fever Registries

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Primary Data Source
State Surveillance Registries
Primary Data Source
Data quality and
validation issues

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Primary Data Source
Incomplete OPD Registries
Data Collection
Courtesy: US. CDC
Primary Data Source
Specimen Logbook
Data Collection

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Primary Data Source
Rumor Registries
Data Collection
Courtesy: US. CDC
Primary Data Source
Vertical Program Data
Data Collection
Courtesy: US. CDC

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Primary Data Source
Malaria Registries

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Surveillance
Forms
Specimen Collection and Shipment

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47 | WCIT 2014 - Guadalajara, Mexico - | September 30, 2014 Slide 47
Patient File Recordkeeping

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Data Aggregation
Data Analysis and Reporting

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Information Management
Examples of complexity of data flow
within disease‐specific

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HIV/AIDS Data Flow
Active Pneumonia Surveillance

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28
National Public
Health Data Flow

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29
IDSR Data Flow
Courtesy: Voxiva Inc., 2008.
Justifying the Need for
Appropriate Use of Standards in Health Data
Examples

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Need for Data Consistency
Paper‐based System
Electronic System
Need for
Standards
Need for Data Consistency
Example below illustrates lack of use of Standardized Vocabularies
Question: Cause of Death; Answer: (free text)
Sample Extract of an analysis from over 10,000 electronic records

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A mixture of Techniques in
Public Health Data Collection
and the
Need for Harmonization of Approaches
Scannable Data Forms

9/30/2014
32

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33
Electronic Data Collection Methods
Surv
eilla
nce
Logb
ook
Rapid Data Collection
Efforts
Data Transfer
Surveillance
Tool
Data
Collection

9/30/2014
34
Electronic Medical Records

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35
Mobile Computing Devices

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36
Sense of Urgency
for establishing Interoperable
Health Information Systems using
Health Data Standards
Sense of Urgency
• eHealth and HIS are essential for rapid
detection and containment of infectious
diseases, respond to health emergencies, and
delivery of healthcare to population at all levels
• Fragmented eHealth systems pose threat to
health care delivery
• Multiple sectors within countries depend on
accurate and timely health information for
decision making
eHealth ‐ Effective use of ICT to provide and support health service delivery

9/30/2014
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HIS Sub Systems
700
700
30%
20%
30%
600
Monitoring
500
Policy
600
10%
20%
10%
Data
Warehouse
Evaluation
Research
400
300
200
100
25% 50% 75% 100% 125% 150% 175% 200%
500
400
300
200
100
0
25% 50% 75% 100% 125% 150% 175% 200%
0%
0%
-10%
-10%
-20%
-20%
-30%
B02 E02 E04 E15 H01 H02 H03 H04 H10 J03
-30%
-40%
B02 E02 E04 E15 H01 H02 H03 H04 H10 J03
Census Vital Event
Registry Surveys
Health
Events
& Risks
Health
Service
Records
Resource
Tracking
Resources
Processes
Information
Services
0
Patients
Status 143 221 412 574 325 172 68 145
Patients
Status 143 221 412 574 325 172 68 145
-40%
Variance 10% 4% -20% -21% 30% 8% 10% -17% -28% -13
Variance 10% 4% -20% -21% 30% 8% 10% -17% -28% -13%
Statistical
Systems
Financial
Systems
General State of Health Information Systems
Indicator‐based Records Individual/Patient Records
Lack of
Reliable &
Timely Data
Exchange
Registries
Diagnostics/Images Records

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38
eHealth
eHealth Innovation Areas ‐ Examples
o Electronic Medical
Records
o Mobile Health
o Decision Support Systems
o Electronic Health Records
o Personal Health Records
o Telemedicine (telehealth)
o Electronic Medication
Services
o Health Knowledge
o Chronic Disease
Management Services
o Patient, and Clinical
management Systems,
o Distance Learning for
health Professionals
Resources
o Mobile Health
(eLearning)
o Health Information Systems

9/30/2014
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Example of a
Commonly Adopted Standard
International Standards Road Traffic Lights
Joint ISO/CIE
Standard
ISO 6508:1999
CIE S006.1/F‐1998
CIE S006/G‐1998
Example of a Widely
Accepted Standard

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40
Standardization Process
Simplified Standardization Process
Standards
Development
Standards
Maintenance
Standards
Adoption
Standards
Development
Organizations (SDOs)
Standards Setting
Organizations (SMOs)
Designated Standards
Maintenance
Organizations (DSMOs)
National Authorities
(Implementation,
Policy, Governance)
Identify Need and
Develop Standards
Review and Update
Standards
Implementation of
Standards

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41
Sample List of Standards
• ICD‐ International Classification of Diseases
• SNOMED ‐ Systemized Nomenclature of Medicine
• DICOM‐ Digital Imaging and Communications in
Medicine
• HL‐7 ‐ Health Level Seven
• LOINC‐ Logical Observation Identifier Names and Codes
• ISO ‐ International Organization for Standardization
(TC 215 – Health Informatics)
Generalized Categories of Standards

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42
Generalized Categories of Standards
• Health Data Standards
(Primary area of World Health Organization)
o Data Standards, Information Content Standards,
Information Exchange Standards, Entity/Person
Identifiers Standards, Privacy and Security Standards
• Information Technology Standards
(Primary area of International Telecommunications Union)
o Telecommunication, Machine to Machine
Communications, and other Technical Standards
related to ICT
Source: Public Health Data Standards Consortium; http://www.phdsc.org/; Accessed: June 3, 2012
Standards Relevant to Health Data

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43
Standards Relevant to Health Data
• Data Standards
• Information Content Standards
• Information Exchange Standards
• Entity/Person Identifiers Standards
• Privacy and Security Standards
• (Functional Standards; Business Requirements)
Source: Public Health Data Standards Consortium; http://www.phdsc.org/; Accessed: June 3, 2012
Data
Standards
• Disease Classification
• Drugs Classification
• Laboratory Data Standards
•• Digital Images
• Medicinal Products,
Pharmaceutical Doses,
Units, Common
Terminology Services
gy
Examples only
(non exhaustive list)

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44
Data
Standards
• Clinical Procedure
Terminology
• Pharmacy Terminology
•• Nursing/HRH Terminology
• Payer Terminology
• Financial/Business
Transactions Terminology
Examples only
Information
Content
Standards
• Healthcare Content
• Pubic Health Card
• Medical Device
Communication
Examples only

9/30/2014
45
Information
Exchange
Standards
• Digital Images
• Pharmacy Business
Transactions
• Country‐specific Mandated
• Financial/Business
Examples only
Entity/Person
Identifier
Standards
• Patient Identifier
• Provider Identifier
• Employer Identification
Number
• Country Identifier
• Health (Insurance) Card
Issuer Identifier
Examples only

9/30/2014
46
Privacy and
Security
Standards
• Anonymization and
Pseudonymization
Standards
• Security Standards
• Confidentiality Standards
• Patient Consent Standards
• Data Audit Trails
Examples only
Example of standards adoption

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47
Example of Standards for Digital Images
“facilitate the interchange of information
between digital imaging computer systems in
medical environments”
Source: http://medical.nema.org/standard.html; Accessed August 6, 2012
Ultrasound Device Digital Interface

9/30/2014
48
WHA Resolution 66.24
eHealth Standardization and Interoperability
Recognized the value of
adoption of standards for
interoperability
and Health on the Internet
2013: Adoption of resolution on
eHealth Standardization and
Interoperability by 66th World
Health Assembly

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49
National efforts in eHealth

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50
National eHealth Strategy
Self Assessment Dimensions
• National e‐health strategy
• ICT Infrastructure
• Services for information sharing
• Standards for interoperability
• Governance and coordination mechanism
• Policies and legislation in place and enforced
eHealth
Standardization and Interoperability
efforts at WHO

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51
Standardization & Interoperability
– Established the WHO Forum on eHealth
Standardization and Interoperability,
December 2012; now adopted as an annual
Forum.
– Adoption of resolution on eHealth
Standardization and Interoperability by the
66th World Health Assembly (WHA66.24)
– Finalization of Minimum Data Set for Health
Workface Registry

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52
Forum‐2012

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53
Forum‐2014
Rapidly changing global health landscape
and the avenue of possibilities for
informaticians
f

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54
Example 1
Health Informatics Practice
Geospatial Science, and National Planning and
Global Health Security
Global Health Facilities Locator
DATA MANAGEMENT
Country Ministries of CHealthONCEPT
+ WHO Validation Community Managed Data
Country/Regional
Space Agency

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55
DATA DISPLAY
• Source: OpenStreetMap.org (data license: OpenStreetMap is open data, licensed under the Creative Commons Attribution‐ShareAlike 2.0 licence (CC BY‐SA);
Special Recognition: Dr. Markus Neteler and his team, Fondazione E. Mach, Italy
DATA VISUALIZATION
• Source: OpenStreetMap.org (data license: OpenStreetMap is open data, licensed under the Creative Commons Attribution‐ShareAlike 2.0 licence (CC BY‐SA);
Special Recognition: Dr. Markus Neteler and his team, Fondazione E. Mach, Italy

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56
Example of Global Mapping of Health Facilities.
Source: Neteler, 2012
Potential Space Technology Applications
to Global Health Facilities Locator
• Linking GPS Location, remote sensing imagery, thermal maps,
weather th data, d t GIS shape h fil files, to t all llH Health lthF Facilities
iliti
• Developing advance visualization tool for tele‐epidemiology,
telehealth, and health emergency response
• Linking Health Workforce (Human Resources) and Health
Commodities data
• Link information on Public Safety and other Public Health and
Emergency Management entities

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57
Example 2
Health Informatics Practice
and Mobile Computing Platforms
Mobile Computing in Healthcare
Examples
o Electronic Health Records
o Personal Health Records
o Decision Support Systems
o Distance Learning for
h lthP f i l
o Telemedicine (telehealth)
o Electronic Medication
Services
o Public Health Surveys and
Surveillance
health Professionals
(eLearning)
o Chronic Disease
Management Services

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58
Mobile Computing Devices
Antenatal and Neonatal Care
improve access
to quality
antenatal and
neonatal care in
Ghana;
Grameen
Foundation’s
MOTECH project
Source: http://www.grameenfoundation.org/what‐we‐do/health/maternal‐and‐infant‐health

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59
Eye care
Source: http://www.1ohww.org/mhealth‐trends‐pairing‐needs‐challenges‐one‐healthcare‐worldwide/
.
Dental care
Source: WHO, 2011. mHealth: new horizons for health through mobile technologies: second global survey on eHealth.

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60
Environmental Sampling
Source: CDC, 2007
Emergency Response
China, Sichuan Province
Source: US CDC, 2005

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61
mHealth for NCDs Toolkit
Source, WHO, 2013.
mHealth initiatives
*
Source: WHO, 2011. mHealth: new horizons for health through mobile technologies: second global survey on eHealth.
* WHO Member States (193 members during 2011)

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62
Harmonization and Interoperability
of Data and Systems
Interoperability and Standards

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63
Framework, Architecture, and Standards
Example eHealth
Architecture: ISO TR 14639
A need for systematic approach to HIS design, implementation, and management
Measuring HIS Progress Over Time
Figure depicting Countries at Various Levels of HIS Maturity
2
3
0
1

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64
Health Informatics and
the Science of Public Health
Need for common conversation among
SMEs and Informaticians
Public Health
Science
+
Informatics
Domain
Public Health
= Informatics
Adoption of best practices from both domains

9/30/2014
65
Public Health Informatician Senior Public Health Informatician
1. Supports development of strategic direction for public health informatics within
the enterprise
1. Leads creation of strategic direction for public health informatics
2. Participates in development of knowledge management tools for the enterprise 2. Leads knowledge management for the enterprise
3. Utilizes standards 3. Assures utilization of standards
4. Assures that knowledge, information and data needs of project or program users
and stakeholders are met
4. Assures that knowledge, information and data needs of users and
stakeholders are met
5. Supports information system development, procurement, and implementation
that meet Public Health program needs
5. Assures that information system development, procurement, and
implementation meet Public Health program needs
6a. Manages Information Technology operations related to project or program (for
public health agencies with internal IT operations)
6a. Assures effective management of Information Technology operations (for
public health agencies with internal IT operations)
6b. Monitors Information Technology operations managed by external
organizations
6b Assures adequacy of Information Technology Operations managed by
external organizations
7. Communicates with cross‐disciplinary leaders and team members 7. Communicates with elected officials, policy makers, agency staff and the
public
8. Evaluates information systems and applications 8. Assures evaluation of information systems and applications
9. Participates in applied public health informatics research 9. Conducts applied public health informatics research
10. Contributes to the development of public health information systems that are
interoperable with other relevant information systems
10. Assures that public health information systems are interoperable with
other relevant information systems
11. Supports use of informatics to integrate clinical health, environmental risk, and 11. Uses informatics to integrate clinical health, environmental risk, and
population health population health
12. Implements solutions that assure confidentiality, security, and integrity, while
maximizing availability of information for public health
12. Develops solutions that assure confidentiality, security, and integrity,
while maximizing availability of information for public health
13. Conducts education and training in public health informatics 13. Contributes to progress in the field of public health informatics
Slide Courtesy: Denise Koo, Herman Tolentino. CDC, 2008.
Approach to strengthening
aligning efforts and role of multi‐sectors

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66
Dependencies of Health Information Systems
HIS Data Use
for Better Health
Outcomes
Stakeholder
HIS
Need for
Multi‐sectoral
Engagement
HIS Policy and
Planning
Information &
C iti
Governance
Health
Domain
Experts
HIS
Alignment
Communication
Technology
Human
Resources
for HIS
Financing
Multi‐sectoral Engagement
Examples of Partners within HIS Landscape
• Ministry of Health
• Ministry of Finance
• Ministry of Education
• Ministry of Labor
• Ministry of ICT/Telecommunications
• Ministry of Infrastructure
P i t H lthS t
Coordination
is essential
to owning and
sustaining
Health
Information
Systems
tN ti l d
• Private Health Sector
• Donors and Implementing Partners
at National and
Sub‐national Levels

9/30/2014
67
Alignment of
HIS Stakeholders and Strategies
Alignment of Stakeholders
Health Information Activities
Better
Health
Outcomes
(stakeholder’s positions vary depending on the model)
Value Chain of Solutions
driven by Public Private Partnerships

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68
Alignment of Strategies
Health Information Activities
Better
Health
Outcomes
(stakeholder’s positions vary depending on the model)
Value Chain of Solutions
driven by Public Private Partnerships
Health Information System Alignments
Health Health
Science
Appropriate
Informatics
Approach
Impact
Reliable Data
to Results
Human
Capacity
Sustainable
Approach

9/30/2014
69
Key Messages
Key Messages
• Reliable Health Information Systems are essential for
better healthcare delivery and better health
outcome
• Functional Health Information Systems depends on
harmonized and interoperable data elements
between and within systems through adoption of
Health Data Standards and IT Standards
• Strengthening Health Information Systems depends
on national ti l ownership, hi multisectoral lti t l engagement,
t
appropriate use of ICT, and adequate human
capacity

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

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