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A monthly magazine on ICT and Health

Vol. 2 No.2

February 2007

Rs. 75

www.ehealthonline.org

As ia 20 07

Health to e-Health: The Asian Quest

Sp ec ial

Subscriber’s copy not for sale


6-8 February, 2007 Putrajaya International Convention Centre, Malaysia

Listen to the key decision makers, experts and thought leaders in e-Health, from Asia and beyond ...

Alvin B. Marcelo MD, University of the Philippines

Brenda Zulu Freelance Journalist, Zambia

Dr. Shashi Gogia President, Indian Medical Association, India

Eva Tanner Project Manager, DiploFoundation, Switzerland

Frank Lievens Managing Director of LIEVENS-LANCKMAN BVBA, Belgium

Jibananda Roy Institute for Planning Innovative Research, Appropriate Training and Extension , Kolkata, India

N. Parasuraman M.S. Swaminathan Research Foundation, Chennai, India

Qurat-ul-Ain Salim Khan National University of Sciences and Technology, Rawalpindi, Pakistan

Santulan Chaubey Manager – Information Technology, Institute of Liver and Biliary Sciences, New Delhi, India

Sujay Deb IIT Kharagpur, India

Bruno von Niman ETSI TC Human Factor, Vice Chairman, Lead Expert, Vonniman Consulting, Sweden

Jagjit Singh Bhatia Director, Center for Development of Advanced Computing, Mohali, India

Mandeep Singh Randhawa Project Associate, Center for Development of Advanced Computing, Mohali, India

Sapiah Sulaiman Faculty, Universiti Teknologi Malaysia

Toms K Thomas Consultant, Evangelical Social Action Forum, Kerala, India

Organisers

knowledge for change

Host Organisations

Ministry of Energy, Water and Communications (MEWC) Government of Malaysia

Principal Sponsor

International Government Partners

MCMC

www.e-ASiA.org/ehealthasia.asp


Contents Cover Story

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MIRTS: Malaysia’s Answer to National Health Record Dr. Zaitun A.B. and Dr. M.S. Termanini

Perspective

Health Informatics Health Information 11 Customizing in e-Age Dr. Rakesh Biswas

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Teleconsultation Turns Dynamic Dr. Pushwaz Virk, Dr. David W. Bates

Case Study

15 IT for Development

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Mobile Phone Based Pregnancy Support Jayanthy Maniam, Kanaga Chenapiah, Chin Chee Ken

e-Applications in National Rural Health Mission Toms K. Thomas

Trends

News

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Business

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India Update

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World

February 2007 | www.eHealthonline.org

Face of Health Informatics 37 Changing G. Kalyan Kumar

Project Showcase

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Making Australia e-Health Aware 3


Editorial Guidelines Contributions to eHealth magazine could be in the form of articles, case studies, book reviews, event report and news related to e-Health projects and initiatives, which are of immense value for practitioners, professionals, corporate and academicians. We would like the contributors to follow these guidelines, while submitting their material for publication: • Articles/ case studies should not exceed 2500 words. For book reviews and event reports, the word limit is 800. • An abstract of the article/case study not exceeding 200 words should be submitted along with the article/case study. • All articles/ case studies should provide proper references. Authors should give in writing stating that the work is new and has not been published in any form so far. • Book reviews should include details of the book like the title, name of the author(s), publisher, year of publication, price and number of pages and also have the cover photograph of the book in JPEG/TIFF (resolution 300 dpi). • Book reviews of books on e-Health related themes, published from year 2002 onwards, are preferable. In case of website, provide the URL. • The manuscripts should be typed in a standard printable font (Times New Roman 12 font size, titles in bold) and submitted either through mail or post. • Relevant figures of adequate quality (300 dpi) should be submitted in JPEG/ TIFF format. • A brief bio-data and passport size photograph(s) of the author(s) must be enclosed. • All contributions are subject to approval by the publisher.

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eHealth | February 2007


Editorial Vol. 2, Issue 2

February 2007

An urgent need to improve the state of Asia’s e-Health Though the concept of e-Health is gaining currency across all developed nations of the west, in Asia, the inroads made by the ICT applications in the health sector have not been very exciting. In Asia, e-Health is still conceived as an elitist hype, and this phenomenon has yet to gain critical pace to reach out to its teeming millions. The reasons for this poor reach of e-Health in Asia are not far to seek; the obvious ones are the lack of comprehensive healthcare infrastructure, and the lack of awareness about new technology in most of the Asian countries. However, if the healthcare sector of Asia wants to keep pace with the times, it cannot stay isolated from advances in ICT developments, for only a prudent amalgamation of ICT and health could usher in a healthy tomorrow for the continent. But amidst the clouds, there are some silver linings. Malaysia is a case in the point. Telemedicine and medical informatics as the crucial components of Multimedia Super Corridor project is taking Malaysia by storm, towards the digital age. The focus of MSC-based telemedicine project is to establish a healthcare system, which can leverage advanced information and multimedia technologies to deliver hitherto unattainable healthcare services at the individual, family and community-level. Malaysia can also vie for the distinction of installing the world’s first teleconsultation network. WorldCare (a global player in e-consultation) has put in place a comprehensive teleconsultation network spanning 41 Ministry of Health centers across Malaysia. The 30-month-old project commenced way back in April 2000, when world was yet to wake up to the idea of e-Health. Moreover, under the Ninth Malaysian Plan, US$3.5 billion has already been allocated for telehealth services, health record and health plan sharing, formation of National Health Informatics Centre, expansion of teleconsultation services and implementation of hospital information systems, in the selected hospitals and clinics of Malaysia. Though the facts are encouraging, we need to remember that Asia does not end at Malaysia and the call is for developing countries in South Asia to surge ahead in e-Health initiatives, through systematic and sustained approach in needs assessment, development, deployment and evaluation of e-Health applications. Perhaps there is an intense need to have a viable platform to discuss, disseminate and analyze the potential of e-Health in Asia. In this context, eHealth Asia 2007, being held from 6-8 February 2007 at Putrajaya International Convention Centre(PICC), Putrajaya, Malaysia, is a significant step in addressing this growing concern. The conference aims to share experiences on the utilization, efficiency and impact of e-Health applications and attempts to explore how best to use the best practices within specific Asian countries. I would like to take this opportunity to inform our valued readers that some of the speakers at our eHealth Asia 2007 conference have contributed their articles in this issue, enriching our content. We hope that this event will go a long way in creating a congenial climate for spreading the message of e-Health across Asia.

Ravi Gupta Ravi.Gupta@csdms.in President Dr. M.P. Narayanan Editor-in-Chief Ravi Gupta Assistant Editor Swarnendu Biswas Sr. Sub Editor Prachi Shirur

Designed by Bishwajeet Kumar Singh Om Prakash Thakur

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IT for Development

E-APPLICATIONS IN NATIONAL RURAL HEALTH MISSION ASHA as the conduit to rural poor “The test of our progress is not whether we add more to the abundance of those who have mu ch; it is whether we provide enough for those who have too little.” -Franklin D. Roosevelt, second inaugural address, 1937

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ublic health is one of the important responsibilities of the state. The health of the citizens significantly affects their economic productivity, their livelihood capacity and adversely affects the local economy. Health also impacts access to labour market as it influences the capacity to work. For the poor, a healthy body is an important asset and so ill health does have a greater impact on their livelihood. But sadly public health in many of the third world countries are not given adequate attention and this is amply reflected in the very low allocations given to their public health sector. Providing quality healthcare to the vast majority, living in very remote and rural localities, has become one of the challenges of the governments of developing countries, as majority of the people living in rural areas don’t have the capacity to pay for the healthcare services. It is a fact that healthcare sector has undergone considerable changes with the development of technology. However the rural healthcare system in the developing

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countries is more or less rooted in the same traditional practices. There is a yawning gap in rural and urban healthcare in developing countries. Take the case of India, where infant mortality rate (IMR) in rural areas at 82 per 1000 live births is nearly double the number of 45 for urban areas. While urban middle classes in India today have ready access to best health, the rural population is isolated from these services both because of access and cost. Most of the poor living in rural localities are isolated from the benefits of formal health care (both public and private) and most of them access untrained local ‘private practitioners’ incase of any illness. A formal health centre is only a last alternative as they are mostly located only in the urban localities and present great logistical problem to the poor villagers to commute. In India, poverty is another common barrier to good health. Only 20 countries have a higher IMR than Orissa’s tragic figure of 110 per 1000 births, which shows that the poor localities are most vulnerable to health problems. It can be safely said that India, to a great extent, has failed in bringing equity in healthcare, as it has not been able to effectively address the issue of access. Government though has set up various mechanisms to provide access to the people

Technology connectivity between various public heath tiers and actors can better the health service delivery and improve the health status of the people living in rural areas as such network would improve the capacity of accredited social health activist (ASHA), the local health care provider, as well as the other local healthcare actors like auxiliary nurses and midwives (ANM) and multipurpose health workers (MPHW) Toms K. Thomas Senior Manager (Planning, Research, Monitoring and Evaluation) Evangelical Social Action Forum Mannuthy, Trichur, Kerala, India

eHealth | February 2007


living in rural and remote areas to quality health services, but many of them are not performing as per the requirements of the rural localities. One exception to this depressing healthcare scenario in India is the National Rural Health Mission (NRHM). National Rural Health Mission (NRHM) is an initiative of Central Government in India to integrate various public health services. NRHM has a 10 year target to strengthen the public health system in various Indian states especially the low performing states. Recognizing the importance of health in the process of economic and social development and in improving the quality of life of our citizens, the Government of India has resolved to launch the National Rural Health Mission to carry out necessary architectural alteration in the basic healthcare delivery system. The mission adopts a synergistic approach by relating health to determinants of good health viz. segments of nutrition, sanitation, hygiene and safe drinking water. It also aims at mainstreaming the Indian systems of medicine to make possible healthcare, especially in rural localities. The plan of action includes escalating public expenditure on health, dropping regional discrepancy in health infrastructure, pooling resources, amalgamation of organizational structures, optimization of health manpower, decentralization and district management of health programs, community participation and title of assets, induction of management and financial personnel into district health system, and transforming community health centers into functional hospitals, thereby meeting Indian public health standards in each block of the country. The government has approved the launch of the National Rural Health Mission (2005-12) for providing integrated comprehensive primary healthcare services, with a special focus on the poor and vulnerable sections of the society. Formulation of Indian public health standards is one of the ground-breaking February 2007 | www.eHealthonline.org

steps in NRHM as it attempts to define the quality of public health services and their standards. The mission is to be launched throughout the country with high focus on the 18 states, including 8 empowered action group states (U.P., Bihar, Madhya Pradesh, Orissa, Jharkhand, Uttaranchal, Rajasthan and Chhattisgarh), 8 North-East States (Sikkim, Assam, Arunachal Pradesh, Nagaland, Manipur, Tripura, Meghalaya and Mizoram), and Jammu & Kashmir and Himachal Pradesh. NRHM addresses various public health issues like inadequate financial allocation, lack of trained health personnel in rural localities, emergency medical access and promotion of various other systems of medicines, along with the conventional allopathic system of medicine. The mission aims to undertake architectural correction of the health system to enable it to effectively handle the increased allocation for public health,

the availability of and access to quality healthcare by people, especially for those residing in rural areas, the poor, women and children. The main objectives are; reduction in infant mortality rate (IMR) and maternal mortality ratio (MMR), access to public health services such as women’s health, child’s health, water, sanitation & hygiene, immunization, and nutrition, prevention and control of communicable and non-communicable diseases which includes locally endemic diseases, access to integrated comprehensive primary healthcare, population stabilization, ensuring gender and demographic balance, revitalizing of local health traditions and promotion of best practices in health. The Figure-1 shows the various components of NRHM and suggests the linkages with different healthcare facilities and its functions. However, integration to bring in improvement in quality needs to

The active engagement of technology at various healthcare levels through induction of ICT into NRHM components would improve its outreach as well as quality. The department of IT should take the lead in bringing the technology integration and the ongoing technology initiative should incorporate healthcare components in it. as promised under the National Common Minimum Programme of the United Progress Alliance government. It also aims to bridge the gaps in rural healthcare through increased community ownership, decentralization of the programs to the district level, inter-sectoral convergence and improved primary healthcare. The mission aims to achieve the goal of the National Population Policy and the National Health Policy through improved access to affordable, accountable and reliable primary health services. NRHM also attempts to integrate divergent medical systems, both conventional and alternative, which are practiced in India. The goal of the NRHM is to improve

think of establishing linkages with these different functions and actors. As the local government has been given a crucial role in the implementation as well as monitoring of NRHM activities, the local governments have a great role to play in bringing in quality healthcare in their respective localities.

NRHM Components Public health in India has a bias towards building institutions rather than strengthening the local capacities. Though NRHM is an excellent initiative, having a strong component of local capacity building, it significantly lacks the linkage between various healthcare actors and

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components. It is also important to integrate various technology initiatives in promotion of technology and these initiatives should integrate health component also. Some of the initiatives are; • Knowledge Centre Initiative of the Mission 2007 by Government of India • Common Service Centre initiative of the Ministry of Information Technology and Panchayats • Rural business hubs as an initiative of the Ministry of Rural Development, Government of India. What is needed is to make the technology innovation in human development services more effective is an integration of these various ICT missions under one umbrella to make it more comprehensive both in terms of its content and operations. Succinctly, NRHM is one of the pioneering initiatives to provide quality healthcare access, through bringing in the various public health machineries under one umbrella. The local capacity building has been given central consideration through organising various grassroots training programmes. However the matter of entrance to the quality healthcare remains a concern and the NRHM does

Figure-1: NRHM Components

Though there is technical integration and inclusion of various segments of health care in to the NRHM, there is a gross inadequacy of linkages between various components of NRHM. Establishing these networks would better the efficiency of the rural health service delivery and would impact the quality of rural health care services.

The government has approved the launch of the National Rural Health Mission (2005-12) for providing integrated comprehensive primary healthcare services, with a special focus on the poor and vulnerable sections of the society. Formulation of Indian public health standards is one of the ground-breaking steps in NRHM as it attempts to define the quality of public health services and their standards. not adequately address this particular issue. Though some engagements are made at the local level with the help of Panchayat and ASHA (Accredited Social Health Activist), it is not sufficient to address the issue of bringing in access to quality healthcare.

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Here we attempt to make a dispassionate enquiry into those lacunas, and explore how Information and Communication Technologies (ICT) could be used as a tool to improve the capacities of the local actors; through facilitating the networking with various

rural healthcare actors. Technology connectivity between various public heath tiers and actors can better the health service delivery and improve the health status of the people living in rural areas. Such network would improve the capacity of accredited social health activist (ASHA), the local health care provider, as well as the other local healthcare actors like auxiliary nurses and midwives (ANM) and multipurpose health workers (MPHW). Such network also would give confidence in health service delivery of local actors and make various actors more accountable and functional. Furthermore, a network at the district level between ASHA in various locations as well as establishing of communication network with some of the leading specialists and hospitals could improve the quality of public health services provided by the local healthcare actors like ASHA. The active engagement of technology at various healthcare levels through induction of ICT into NRHM components would improve its outreach as well as quality. The department of IT should take the lead in bringing the technology integration and the ongoing technology initiative should incorporate healthcare eHealth | February 2007


components in it. The following chart shows a representation of technology linkage of the various components of NRHM, and linking of ASHA with various health service providers would help her to provide the best care to the rural poor.

NRHM Components and its Network with ICT The figure-2 below depicts a technology networking between various actors involved in the National Rural Health Mission. ASHA has been shown as the key person in NRHM and the network is instrumental in building her capacity to provide the best possible healthcare to the people living in the rural areas. The various components of this network and its functions are explained below: 1.Telephone network with ASHA and other care providers

ASHA should be connected with a telephone as well as a computer with the rest of the facilities in the public healthcare chain. Telephones are used to transmit health information that facilitates diagnosis of the primary ailments of ill health in case the sickness is not observed as serious. The Verbal Communication System (VCS) is the first step in imparting treatment, where doctor gets only the minimal verbal communication on external symptoms (like temperature, BP, weight, etc.). Doctor could prescribe medicine based on the minimal information provided to him/her. In this case, the medications would be limited to very minimal emergency public health drugs. These drugs could be dispensed from the community pharmacy that is managed by ASHA. ASHA should be authorised to dispense certain emergency drugs that are

Figure-2: PDC and Community Pharmacy are suggested by the author as a means to inprove the operational efficiency of ASHA. February 2007 | www.eHealthonline.org

provided through the PHC. 2.Primary Diagnostic Centre (PDC) Primary diagnostic centre would be a centre that provides further facility for investigation as well as pharmacy service, in case the sickness is being diagnosed with mere external symptoms. Where ASHA has doubt about the cause of the sickness she should refer the patient for further investigation to PDC. This centre would have facility for vital lab investigations apart from the pharmacy service. All PDCs would be supervised by the community doctors and the doctors would directly monitor these centres. The results shall be informed to the doctor by the pharmacist directly and the medicines prescribed are given from the pharmacy at the PDC. What the ASHA does is the follow up of this patient and informs doctor about the progress of the patient. 3. Community Pharmacy Community pharmacy is a crucial component of the healthcare network and this pharmacy is directly controlled by ASHA. She would be authorised to dispense drugs that are given in this pharmacy at the advice of the community doctor. 4. Casualty Ambulance Service This is another important component of the ICT network. A telephone networked ambulance is provided at the PDC level, which would provide transport service to all the clients of ASHA. This would enable ASHA to take the patient to the hospital / the doctor as early as possible, in case of any medical causality. The delivery cases would benefit much through this facility. An appropriate health insurance package also would be worked out to minimise the cost burden of hospitalisation. 5. E-Doctors These doctors are designated doctors for every village. Every ASHA would work under a community doctor who would be available for her to consult at times of any medical casuality. He or she would be available over telephone as well as over net, to provide necessary medical advice to ASHA. He / she would also provide electronic prescriptions and diagnosis

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through PDC. There could be one e-doctor for every 5000 population. The population is limited to 5000 to minimise the number of calls. At the e-doctor level, there would also be an assistant who would receive the calls /download investigation reports and process it before it goes to the doctor. Doctor then would write the prescription and the assistant will sent it to the PDC. Telephone calls from ASHA could also be directly attended by the doctor. 6. e-linkage to various healthcare units Linkage to the primary care facilities like sub-centre, PHC and CHC also is an important element of the use of the ICT solutions for pubic health system. ASHA would be linked through telephone and with the help of village ICT hub (VIH), with these various health services agencies. This could also be used as a means to strengthen the public health information system. The births, deaths and other registrations could be done through ASHA and through these centres, that could be further networked with the Births and Deaths Registrar office. The linkages also could help in following up of patients treated at these various healthcare facilities. The follow-up at the village level could be done through ASHA.

Conclusion The use of Information and Communication Technology (ICT) has lots of potential in improving the overall performance of the public healthcare system. It could transform both quality and access of public health services. The network facilitates appropriate and timely provision of quality treatment at a very minimal cost, along with promoting the best practices in delivering public health services. The rural poor would be greatly benefited as they would be able to access quality health services through ASHA. However, the success of this network will depend on various factors. They are: • The capacity of ASHA to operate ICT kiosks and the willingness of the community to access ICT enabled treatment provided through ASHA. • Acceptance of ASHA in rural locality as there is no patient to doctor contact. • Finding out a person who is acceptable to all villagers. • Willingness of the medical practitioner to provide consultations over phone and to be available for consultations. • The diagnostic capacity of Primary Diagnostic Centres.

• The existing healthcare practices in the rural localities and health seeking behaviour of the poor. • The effect of the local private practitioners and their influence on the local population. • The acceptance of ASHA as a healthcare provider. • The commitment of the local government to promote the work of ASHA • The capacity of the staff at various healthcare centres, starting from the sub-centre, to maintain the linkages as active. In spite of these riders, if planned and executed seriously, such ICT linkages in healthcare would have all the potential to improve the overall performance of the public health delivery mechanism of our country, especially that of the rural areas. To explore more avenues further research is needed on the best and appropriate technology solution that would work better in various local contexts. Such technology solutions would definitely improve the overall performance of NRHM, through making public health interventions more accessible and poor friendly.

The Personal Health Systems 2007 The Personal Health Systems 2007 conference will be held during 12-13 February 2007, in Brussels, Belgium. The conference focuses on the state-of-the-art personal health systems, such as wearable and portable health monitoring systems, and ICT-supported personalised services for extended healthcare, including homecare. The conference is organised by the European Commission and involves cooperation of several Directorates General. Sessions will be held over two days and will attract a cross-scetion of experts and invited speakers from a diverse background including research organisations, medical device industry, healthcare organisations, user groups, and member-state public administrations. The conference attempts to consolidate the results of over ten years of research in the area of personal health systems (including telemedicine and home care) and demonstrate how applications can be expanded at European level to support efforts towards the sustainability of healthcare delivery systems,

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contribute to the i2010 flagship initiative on “caring for people in an ageing society, addressing technologies for wellbeing, independent living and health”, facilitate cross-border health services, reduce disparities between regions related to access and continuity of healthcare, and facilitate the growth and sustainability of eHealth markets. By bringing together healthcare professionals, industrial representatives as well as European, national and regional authorities, the conference aims to stimulate market development and support EU member- states and regions in deploying e-Health systems and services, which will facilitate better care for people in an ageing society. The Personal Health Systems 2007 exhibition will be open to the attendees of the conference.The exhibitors are involved in European research, development, deployment or commercial activities focusing on Personal Health Systems (PHS), services and applications. eHealth | February 2007


Health Informatics

CUSTOMIZING HEALTH INFORMATION IN E-AGE Preserving patient anonymity is still a challenge

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he mind needs constant learning and in medicine, information is exploding at a rate that is challenging all levels of medical learners. For example in the field of health informatics, the technology involved in keeping patient database needs continual reform to keep pace with the demands of the times. Average patient data, which occupies most of our present day information bases, is often unable to satisfy individual patient needs, in an optimal manner. We need an information base that can seamlessly integrate information needs of all categories of certain individual medical learners, with matching solutions offered by other individual medical learners who have already gone through the particular experiences that the other group needs. However, at the very outset the concept of medical learners need to be cleared. In my opinion there is no doctor or patient, but different categories of medical learners. The category I of medical learners comprise of patients and their relatives who are the primary care givers, and category II comprises physicians/health professionals, who are the secondary caregivers. In terms of learning needs, both categories ideally remain life-long medical students. They need to constantly keep learning and updating themselves to keep pace with the February 2007 | www.eHealthonline.org

vast body of medical information connected by a spidery web that keeps evolving and changing rapidly. We also need to have a medical learning database where patients and medical students/health care givers regularly key in their narrative logs into a suitable webinterfacing device. Presently PDAs are the closest fit although in the near future it is expected to improve into something wearable with a more efficient input arrangement than the PDA stylus keyboard. This input would simulate a learning neural network with the input channeled to other individual users (with qualitative narrative analysis software to extract themes suggesting information needs from the individual users e-log input). Following this, the network automatically would match each node’s (individual user’s) information needs through synapses (web based matching, emails) and the output could be reiterated several times via a back propagation algorithm to generate an optimal learning solution output.

Top-down or bottom-up? The present system of medical learning, especially during formal training, is more top- down. Future health professionals are very often simply expected to learn and memorize the structure of their chosen

The present day patient satisfaction with health care seems to be at an all time low. One of the important present day problems with this topdown approach is that from the patients’ perspective, searching the health professional with the appropriate expertise to tackle their particular individual problems becomes like looking for a needle in a haystack. Dr. Rakesh Biswas Associate Professor, Department of Medicine, Melaka-Manipal Medical College Melaka, Malaysia rakesh7biswas@gmail.com

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field of medicine and then apply it for patient care. However, a complete topdown approach in present day health care is increasingly unable to support health care practice as the volume of information keeps growing by leaps and bounds. One response of the present health care structure to this problem has been an ant like division of labor where health care workers specialize in certain areas so that they can focus on a smaller volume/area of accumulated information and thus offer their expertise in their chosen areas. There is an old adage often used to qualify this approach as, “Knowing more and more about less and less until one has known everything about nothing.” Interestingly there isn’t much historical evidence to suggest that this approach is doing wonders to present day health care. On the contrary present day patient satisfaction with health care seems to be at an all time low. One of the important present day problems with this top-down approach is that from the patients’ perspective, searching the health professional with the appropriate expertise to tackle their individual problems becomes like looking for a needle in a haystack. Also it would be much easier for patients if the large task force of health care professionals kept learning more and more about more and more (instead of less and less) and brought back the good old days of the all-knowing family physician (not necessarily all powerful) who could function as a pillar of strength throughout the whole healing process. Only this time the family physician would have an important check in his omniscient streak; in the form of the well-informed patient. In recent times, the top-down compartmentalized structure of medical education and practice has been challenged by the evidence-based healthcare movement (before it got compartmentalized itself into a specialty) and the complexity in healthcare movement. Both groups have recognized the need to disseminate learning on a broader basis that bridges the

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compartmental divide (presently with weak forces) across the specialty structures, in the standard medical model. Bottomsup learning resurged in medical education in a bigger manner with the formalization of problem-based learning in the 1980s, closely followed by the evidence-based healthcare movement in the 1990s. Evidence-based healthcare is a form of problem-based learning applied to daily health care activities with a purported objective of meeting individual patient needs by using the accumulated and growing epidemiological population based average patient outcome data. At present, it fights a gradually losing battle to establish an absolute unchanging structure of

and documented daily in web based archives. Once in the net, there is technically feasible software already existing that can quickly extract themes from these individual process narratives. Once individual users (the patient, medical student, health professionals) information needs are identified using narrative analysis with available qualitative or other softwares, another software/search engine would automatically collect the matching information available on the web from another individual patient/medical student health professional as well as any related top down theory based information content, and post it appropriately to the

The daily narrative data a patient, health care student/professional generates, reflects both their information needs as well as information contribution (learning points) to the medical knowledge base. medical truth that is generalized to all users on the basis of statistically averaged health outcomes from controlled trials.

How e-Health can provide the answer We need a medical learning database that generates narrative informational needs as well as experiences at various levels of medical learning. The underlying theme is that in the daily narrative data a patient, health care student/professional generates and reflects both their information needs as well as information contribution (learning points) to the medical knowledge base. This informational narrative may also address the problem of complex multidimensional needs. Access to life experience information of one patient that finds a match in another patient can itself act as a sort of narrative therapy for that patient. With improvement in technology, these valuable data of daily processes generated by a given individual can be recorded

site/mail of the individual users concerned (with web links) for detailed reading. In this way any individual user feeding inputs into the net can receive automatic feedback that can grow as individual users keep growing and feeding their own daily data. Growing feedback from multiple patients (multidimensional single loop feedback learning) would spur interest and learning in the identified area of need, and can be strengthened by the user returning the feedback with more information/needs to the individuals, who are sending him/her the initial feedback (double loop learning).

Multidimensional Network Learning The multidimensional learning proposed here is similar to a learning neural network not in physical-mathematical terms but in terms of qualitative analogy as you can see an attempt has been made to depict it pictorially in this slide (Fig 1). The individual user (patient, care eHealth | February 2007


giver) input is automatically fed to multiple users (nodes) who may synapse with the initial user and other users (via web based matching, email) and finally the resultant learning output shall return to the initial user (by something qualitatively analogous to a back propagation algorithm for example when knowledge is shared with multiple users it keeps getting altered (which perhaps is a hidden layer process among the nodes) and this process may continue to reiterate till there is an optimal solution to the problem. However, there are several technical problems facing this proposed multidimensional learning method. Firstly, the process is quite time consuming. Recording of daily processes with a PDA at best can be telegraphic information, rather than detailed thought narratives. In the near future however, this may improve with wearable web interfacing devices. Secondly, language will pose a major hindrance, not just in terms of the spoken tongue but even in terms of interpreting symbolic languages like that of mathematics or statistics. They may be undecipherable to the untrained patients. Interpreting information feedback is another problem area to be pondered upon. Once information needs are identified and fed back to the individual user, interpreting and using them would again be a highly individual exercise and although we would have preferred the information to simulate a structured absolute truth, in the complex real world there may be multiple versions of truth that may vary according to individual user’s needs. The evidencebased health care movement at present fights a gradually losing battle to establish an absolute unchanging structure of medical truth that is generalized to all users, on the basis of statistically averaged health outcomes from controlled trials. Critical appraisal is the term for this variety of statistically generalized interpretation but it has demonstrably failed to consistently satisfy the multidimensional needs of the individual patient. There is also a pressing need for a better web interface, to ensure success of this February 2007 | www.eHealthonline.org

multidimensional learning method, which in turn can give a positive technological thrust to the world of health informatics. While individual user/authors write, think, and modify their Elogs, a PDA may be grossly inadequate to sustain such an activity. We need a web interface where pages can be turned and information gleaned from multiple pages at one glance; an essential step in multidimensional learning which the present one dimensional scroll panel in PDAs can hardly provide. Lastly patient privacy shall always remain a thorny issue. Privacy can be seen as a way of blocking the progress of learning. As long as we want to remain private we do not want anyone to learn about us. If patients’ or health professionals want to learn and meet their information needs they have to share their information with a network, which may compromise the privacy element. Even something as personal as a letter is not personal anymore with the advent of email that can be easily forwarded, shared, and not only that, our individual personal letters or E logs (that the present proposal banks on) are being used by search engines to advertise depending on the information needs contained in our letters or E-logs. The future of information age doesn’t seem to have much allowance for privacy, and privacy in future will become a direct antagonist of information,

unless the future ushers in a new era of information withholding technology. All said and done allowances have to be made for preserving patient anonymity with due attention to omit particulars that may make it possible to identify users. Speaking from the viewpoint of a developer or vendor of the solution (arising from this proposal) as the individual user continues keying his/her own logs every day, he or she would need to take the necessary precautions and responsibility to protect his/ her own as well as the privacy of others he mentions in his/her own write ups. How individual medical learners utilize their answered information needs would be the beginning of another process in the pursuit of continued bottom-up development in medical learning, which can positively compliment the present pedagogic top-down approach that dominates the current pattern of medical learning.

References Biswas R, Always a medical student, Student BMJ(UK) vol 11, Feb. 2003, pg 41. http:// www.studentbmj.com/issues/03/02/reviews/ 41.php Smith R, What clinical information do doctors need? BMJ 1996; 313:1062-1068 Hodgkin P, Medicine, postmodernism, and the end of certainty. BMJ Dec 1996; 313:1568-156

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18-20 April 2007 THE INTERNATIONAL EDUCATIONAL AND NETWORKING FORUM FOR eHEALTH, TELEMEDICINE AND HEALTH ICT eHealth and Telemedicine applications worldwide are at a critical growth phase. Med-e-Tel offers unmatched opportunities to meet and network with qualified buyers, specialists, users, researchers, policy makers, and payers/insurers from 50 countries around the world. Med-e-Tel provides visitors with hands-on experience and an opportunity to discover and evaluate new products, systems and technologies and to hear about the latest eHealth/Telemedicine news and trends. Med-e-Tel features an extensive educational and conference program with more than 120 presentations and workshops on topics that matter to your daily business, research and care activities. Topics will include a.o.: - personal and in-home monitoring - use of ICTs in independent living for the ageing and disabled - disease management and medication compliance - maximizing the potential of ehealth in developing countries - funding opportunities for ehealth programs and projects - interoperability and standardization - wireless and broadband applications - satellite communication - and more … Additional events being planned in conjunction with Med-e-Tel 2007, include meetings and workshops by some of the following organizations: - International Society for Telemedicine & eHealth - International Association of Homes and Services for the Ageing / Center for Aging Services Technologies - European Commission & European eHealth Projects - World Health Organization - European Telecommunications Standards Institute - Telemedicine and Advanced Technology Research Center - World Academy of Biomedical Technologies - United Nations Office for Outer Space Affairs - Centre de Recherche Public – Santé

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Case Study

MOBILE PHONE BASED PREGNANCY SUPPORT The most personalized approach to motherhood issues

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eing pregnant can be very challenging for mothers especially if they are expecting for the first time. Many rely on informal information that is passed down from one to another, which may not be accurate as experience from each pregnancy can be different from the other. Matters are made worse when information passed down is concocted with cultural taboo. However in this ICT age, accurate health information pertaining to pregnancy support system can be effectively addressed by the mobile phone technology. Here we present the framework and prototype of mobile phone based pregnancy system, based on the preliminary study conducted among the pregnant mothers and their spouses, in a local private hospital and few maternity clinics. Mobile phone based pregnancy support can position itself as a major breakthrough approach by educating women on pregnancy, monitoring pregnant women and their fetus’ progress, and providing follow up with medical checkups, critical updates and post delivery support through mobile phone. This can reduce the anxiety and stress among pregnant mothers. Women in rural areas can benefit through this system greatly while preparing for February 2007 | www.eHealthonline.org

child birth and post delivery.

The mobile age In 2005, the number of users of mobile phone in the world was 2.2 billion, as compared to 1 billion Internet users (ITU, 2006). This phenomenal growth in mobile phone usage has created the opportunity for localised mobile content development to reach a wider public. With high speed and affordable rate, mobile phone subscribers are now able to get multimedia content such as movie clips and news. Availability of technology such as SmartFit, to reduce the size of the content for mobile display (Access, 2007), allows accurate health information to be easily delivered to even rural areas, where transportation and medical services are limited. There are lots of pregnancy related information widely available in printed form, but usually the information is too general, lengthy and complicated. One of the many easy and fast ways to access information about pregnancy is the Internet. However, the information is generally focused on pregnancy in a western world setting. There are very few available pregnancy resources for population in other parts of the world. Other impediment towards accessing such cyber information is the lack of English language proficiency and computer

Mobile phone based pregnancy support can position itself as a major breakthrough approach by educating women on pregnancy, monitoring pregnant women and their foetus’ progress, and providing follow up with medical checkups, critical updates and post delivery support Jayanthy Maniam

Kanaga Chenapiah

Chin Chee Ken

ICT R&D Centre, School of Computer Technology, Sunway University College

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thanks to the rapid development of the local IT and telecommunication infrastructure as well as the competitiveness of mobile service providers. Though this number is inclusive of those subscribers with multiple phones and 6.3 percent of non Malaysian subscribers, which is a small group, there is no denying the fact that mobile phone has emerged as the most effective, easiest, simplest and popular mode of communicating and delivering of information in Malaysia.

The survey

Figure-1: Mobile phone based pregnancy system support content model

literacy among a vast majority of people. Current trend in healthcare sector is to link patients, physicians and hospitals to provide optimized care to all patients. Greater importance is given to preventive care than curative medicine. This reduces

According to the Malaysian Health Facts, there are 122 government hospitals, 6 special medical institutions, 6 non government hospitals and 222 private hospitals for maternity and nursing. There are only 20,105 doctors in Malaysia with

Smart-Fit Rendering (Access, 2007) is one of the technologies available to adjust the contents and images according to the screen size. This is convenient and avoids unnecessary horizontal or vertical scrolling to see the full content for mobile phone models, which have smaller screen size. cost, improves the quality of treatment and promotes knowledge sharing with physicians. InfoDev (2006), in its framework paper has highlighted that health-based websites has improved knowledge, behaviour and slowed the health decline among the users. Studies conducted in Peru, Egypt and Uganda have showed that the use of ICT has avoided maternal deaths. In South Africa, mobile phones were used to provide timely reminders to patients with tuberculosis (Infodev, 2006).

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the doctor to population ratio being a not so encouraging 1 to 1,300 (MOH 2006). Thus it comes as no wonder that with 25 million population, Malaysia has a fairly high infant mortality rate of 10 in every 1000 births [UNICEF, 2005]. To reduce the infant mortality and morbidity issues, mobile phone based pregnancy support system can be an effective alternative to the Internet in Malaysia. By the third quarter of 2006, there were 21,853,000 cellular phone subscribers in Malaysia (MCMC, 2006),

A survey was conducted as a preliminary fact-finding method, among the pregnant ladies and their spouses, at a local private hospital and two maternity clinics in Petaling Jaya, Malaysia. Fifteen couples volunteered to participate in this survey. The objectives of this survey were to find out the readiness of the pregnant mothers and their spouses to use mobile phone as a tool, to receive support during the pregnancy, and also the types of support expected. A conceptual model for the content development framework and suitable network architecture were drawn to facilitate the personalized pregnancy support. A prototype application for mobile phone was developed and tested, based on the initial findings.

Figure-2: Display of the baby’s development eHealth | February 2007


The survey revealed that all the respondents used mobile phones and were interested in receiving pregnancy related health care information. 17 out of 30 respondents comprised of pregnant mothers, and the spouses used Internet as the source to seek pregnancy related information. The respondents were interested in getting information about medication during pregnancy, information about due date calculator, diet, health, stages of pregnancy, prenatal care, doctor check up reminders, and the nearest maternity clinics or hospital location. A conceptual model is being formulated, based on the preliminary study conducted. The support system is divided into the following six modules as shown in the figure 1. The six modules are: (i) Health Care This module provides general healthcare information to pregnant mothers. This is to help them on what they should or should not do if they have fever, headache, stomach ache, common cold, etc. during the pregnancy period. This is necessary as the pregnant mothers should be careful of the common drugs that they take during pregnancy, which may harm the growing fetus in the womb. In addition, they can key in any illnesses that they have, such as asthma, diabetics, high blood pressure, etc. to allow the system to send information related to these during pregnancy. Drug and disease alerts that are harmful to pregnant ladies, based on their medical profile, can be posted from time to time. (ii) Emergency Care and Alerts Sudden fall or accident can cause emergency situation during pregnancy. Emergency care information such as contact for hospital emergency unit or ambulance service is useful during panic state. The available clinics and hospitals that are located around the user’s place can be traced. System allows the user to key in the numbers of the spouse, close relatives or friends, so that alert with special tone can be sent to them during emergency, with just one click. Health alerts affecting pregnancy from Ministry of Health and World Health Organisation February 2007 | www.eHealthonline.org

through query or website. Illustrative graphics are shown for simple exercise positions during pregnancy. (vi) Post Delivery Support Post delivery support is very important to all mothers as they need to cope with the new born baby and their recovery after the delivery. Caring for the new born can be tiring and frustrating to first time mothers, who are not sure on how to react or what to do when the baby cries.

Prototype of Pregnancy Support System

Figure-3: Due date calendar settings

(WHO), can be sent through this mode to create awareness, and also for preventive care. (iii) Stages of Pregnancy Due date calculator provides the stage of the pregnancy information to the expecting mother and the spouse, at set intervals, selected by the users of this system as shown in figure 3. It tracks the countdown days to the due date and advises the pregnant mother on the progress and changes happening to the child and her self. The stages are shown with graphics of the growing fetus in the womb, as shown in the figure 2. (iv) Pregnancy Calendar and Diary Pregnancy calender and diary is to keep track of the follow up appointments with doctor, reminders, record of weight gain during pregnancy and notes of events. This is also to assist the pregnant mother to take note of any abnormal changes and seek advise on time. In addition, ultrasound images captured through camera phone, music, tones and images related to pregnancy, can be stored if there is enough storage space in the phone. (v) Nutrition and Exercise This is important to mothers who normally have confusing statements from people stating certain food is good and certain others are harmful. General nutrition and hygiene information is provided for healthy pregnancy, and details can be obtained

A prototype of pregnancy support system as in figure 4 was developed for mobile phone, based on the content model discussed above. Prototype was tested on the following mobile phone models: 1. Nokia 6670 and Nokia 7210 mobile phone models run on symbian operating system (OS). The content display was good and details of the graphical content were clear to view. However, the users need to scroll up and down to see full images. 2. Sony Ericsson K750i mobile phone model has smaller screen size that does not allow left to right scrolling. Thus, the images could not be viewed fully. Smart-Fit Rendering (Access, 2007) is one of the technologies available to adjust the contents and images according to the screen size. This is convenient and avoids

Figure-4: Mobile phone based pregnancy support system architecture

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unnecessary horizontal or vertical scrolling to see the full content for mobile phone models, which have smaller screen size. Images which are larger than the screen width are adjusted according to the screen width. Tables larger than the screen are fragmented into small sizes vertically (Access, 2004).

Network Architecture This system is accessed mainly through phone. The mobile application was developed to interact with mobile Internet platform, to send and receive short messages and alerts as shown in the figure 5. Current mobile messaging gateways support Enhanced Messaging Service (EMS), Multimedia Messaging Service (MMS) and Wireless Application Protocol (WAP). A web portal is developed to support the system with updates and provide more content rich information which can be accessed through Internet. Pregnancy is not only challenging to mothers but it is stressful to fathers as well. Mobile phone based pregnancy support can position itself as a personalized approach to educate women on pregnancy, monitor their own and child’s progress, and help them to follow up with medical checkups, critical updates and post delivery support through mobile phone. With the availability of good mobile network infrastructure and mobile phone technologies, a support system that is available anytime and anywhere will help to reduce the stress and anxiety related to pregnancy and its complications. The system will assist the pregnant mother and her spouse to be aware of changes during pregnancy, and facilitate them to take necessary actions to prevent the unforeseen. Women in rural areas can benefit through this system greatly, while preparing for child birth and post delivery. However, this is not the end of the story. Efforts to build on existing prototype and develop personalized content for pregnancy and healthcare in Malaysia will continue.

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References 1. Access (2004). Netfront for series 60: A whole lot of internet on your mobile phone, Access Systems Europe GmbH. 2. Access (2007). Smart-Fit Rendering, Access Co Ltd. http://www.access-lcompany.com/ products/netfrontmobile/contentviewer/ mcv_tips.htm 3. Bental DS, Cawsey A, Jones R (1999). Patient information systems that tailor to the individual. Patient Educ Couns., 36:171–80. 4. Britze T.H. (2005), The Danish National eHealth Portal – increasing quality of treatment and patient life, Technology and Health Care, Vol 13 Issue 5. 5. Cafazzo JA (2000- 2004), A Mobile Phone Based Tele-Monitoring System for Chronic DiseaseManagement. http:// www.ehealthinnovation.org/dh 6. CenterSite, LLC (1995-2007), Everyday Life During Pregnancy. 7. Dodero. G, V.Gianuzzi, E.Coscia, S.Virtuoso (2001). Wireless Networking with a PDA: the Ward-In-Hand project. 8. Giannone. A, La Belle. V, (2005), TELEPET For A Value Added Service Network For PET, Technology and Health Care, Vol 13 Issue 5 9. InfoDev (2006).Improving health, connecting people: the role of ICTs in the health sector of developing countries.

InfoDev, World Bank, 31 May 2006. 10. ITU (2006). Universal Access to Telecommunication Services: Are Current Practises Keeping Pace with Market Trends? International Telecommunication Union http:// www.unctad.org/sections/wcmu/docs/ c1em30po24_en.pdf 11. Kamel Boulos MN (2003), Locationbased health information services: a new paradigm in personalised information delivery. International Journal of Health Geographics. 12. Kelly Zantey (2006), Pregnancy Symptoms & Signs of Pregnancy – A Comprehensive List. http:// www.bellybelly.com.au/articles/pregnancy/ pregnancy-symptom-sign-of-pregnancy. 13. MCMC (2006), “Cellular Phone Subscribers”, Fact and Figures: Statistics and Records, Malaysian Communications and Multimedia Commission (MCMC). Website : http://www.mcmc.gov.my/facts_figures/stats/ index.asp 14. Yvonne Bronner (2000), “Cross-Cultural Issues during Pregnancy and Lactation: Implications for Assessment and Counseling”, Nutrition and Pregnant Adolescent, pg 173-180. 15. Unicef 2005: Info by Country: Malaysia, United Nations International Children’s Emergency Fund. http://www.unicef.org/ infobycountry/malaysia.html 2005.

Figure-5: Mobile phone based pregnancy support system architecture eHealth | February 2007


India's Premier ICT4D event 31July - 02 August, 2007 Pragati Maidan, New Delhi

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A report by Goldman Sachs stated that between 2007 and 2020 India will see a structural increase in potential growth to nearly 8%, four times increase in productivity in industry and services as compared to agriculture, four times increase in GDP per capita, and house ten of the fastest growing cities in the world. This report has identified investment to information technology, openness to trade and greater financial deepening as the key drivers to this accelerating growth. While India has made huge strides and has been a key player in the Information technology revolution, vast digital divide still exists that inhibits a sustained all-inclusive growth for the society. India is bracing itself to catalyse the potential of ICTs in all spheres of development and creating opportunities for private investment and initiatives to supplement its development. In this immense growth environment, there is also a need for strategic planning, knowledge sharing and collaborative vision building between the government and the private sector to leverage the country’s growth potential and steer the country to lead the knowledge revolution. eIndia 2007 is an inclusive, consultative and constructive ICT for Development forum – the largest and only one of its kind in India – promoting and propagating the use of ICT4D through its five seminal conferences. Through its five different but interrelated conferences namely, egovIndia2007, Digital Learning India 2007, Indian Telecentre Forum 2007, eHealth India 2007 and mServe India 2007, the conference will address the issues of digital divide and identify and explore opportunities for Digital India.

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The Ministry of Communications and Information Technology has formulated the National e-Governance Plan which aims to bring all government services to the doorstep of each citizen by making the services citizen centric and ensuring that the right people get the benefits. To further bolster the drive towards efficient and transparent governance, the Right to Information Act was passed in late 2005. While these measures are making a positive impact on the governance practices, there are still issues of access, content, partnerships which need to be addressed for creating the desired environment of trust between the state and her citizens. egov India 2007 aims to consolidate the information available in the domain, giving key stakeholders from India and around the world a chance to showcase the progress and highlight hindrances in this field. The conference will shape the debate around egovernance and build the path towards a constructive knowledge sharing platform and the way forward for the Indian egovernance programme.

India is trying to achieve the ‘Education for All’ goal in one hand and investing in building infrastructure and initiating programmes to build a world class human resource capacity on the other. The National Knowledge Commission has emphasised the need for extensive use of ICTs for research, collaboration and university networking for building ICT skills, sharing education resources and reaching the un-reached in higher education though distance learning. The Indian Government has also recognised that skill building and lifelong education has to begin from school and has increased its investment in school education and technology-enabled learning. Taking a cue from the global trends in education and capacity building, India’s progress to a driver of the knowledge revolution through its human capacity is possible only though sustained efforts by the government, global assistance and collaboration and partnerships with private sector and civil society. Digital Learning India 2007 will take on the existing debates and provide a platform for all stakeholders to deliberate on the issues of enabling and strengthening capacities to achieve the national goals of education.

With the launch of a national programme 100,000 Community Service Centres, the Indian telecentre movement is at a vibrant stage of development, with the key stakeholders representing government, private sector and civil society besides donors being engaged in fulfilling the aspirations of the grassroots community to join the knowledge economy. Technological innovations to improve access have begun to get tested for emerging markets/ emerging people. Civil society is piloting and testing role of upscaled ICTs and telecentres/ public access knowledge centres to fulfil social objectives, provide access to governance and empower the communities, at a scale un-thought of anywhere else in the world. How exactly will we measure the progress, and monitor the impacts? Second year in the series of annual consultations, the Indian Telecentre Forum 2007 will provide the platform to take stock of what has happened. The Forum will shape the way forward for the telecentre movement within India, and for creating an example for the world to learn from.

Telemedicine has been a technological takeaway for the developed countries. Defined as the use of communication networks for the exchange healthcare information to enable clinical care, it is increasingly being viewed as a tool for improving care and enhancing access to healthcare. One of the major ehealth initiative in India was executed by the Indian Space Research Organisation. ISRO took up the initiative of telemedicine in the year 2001 to further expand the application of INSAT to newer areas with the specific aim of bringing in the expert medical facilities to the grassroots level population.Telemedicine helps to connect remote rural hospitals/health centres to super specialty hospitals located in the cities and helps patients in remote and rural areas to avail timely consultations from specialist doctors without the ordeal of travelling.

The Indian telecom sector after liberalisation has shown tremendous growth with its growth rate being one of the highest in the world. The Telecom Regulatory Authority of India has said the total number of telephone subscribers in India had hit 189.9 million, of which 149.5 million are mobile customers.The mobile phones apart from bringing in the aspect of mobility in connectivity have an inherent ease in terms of usage unlike computer-based connectivity, which requires people to be literate and eLiterate at the same time. The immense growth has also meant that the cost-perequipment has also come down drastically. This growth though, has been lopsided and the mobile revolution has been limited to urban areas primarily.The rural areas have remained untouched and in a nation which is plagued by connectivity lapses, mobile technology may well emerge as the key to bridging the digital divide.

eHealth India 2007 will deliberate on such initiatives and many other excellent though scattered efforts in this field and bring it together to form a conduit of critical information.

mServe India 2007 will showcase the immense potential of mobile technology in the implementation of existing and future m-Government, education, agriculture and other applications.

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COVER STORY

MIRTS: Malaysia’s Answer to National Health Record Preventive medicine to get greater primacy

................................................................................................................................................................................................................................................................... Zaitun A. B. and M. S. Termanini

“He who has health has hope; and he who has hope has everything” - Proverb. “When health is absent, wisdom cannot reveal itself, art cannot manifest, strength cannot fight, wealth becomes useless, and intelligence cannot be applied” - Herophilus. “The first wealth is health” -R.W. Emerson.

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ith the advent of Internet technologies, governments across the globe are trying to provide efficient and effective eservice to its citizens. We see the implementation of egovernments with various flagship applications. One of them is health and wellness, which should be the top priority agenda of every government and citizen of the world. In Malaysia, one of these flagship applications of e-governments is e-Health. In order to keep Malaysians healthy and fit, we need information systems that are accessible 24/7, with complete longitudinal health records. One such proposed pragmatic system is the Malaysian Immunization Registry and Tracking System (MIRTS), which can maintain a repository of immunization records of all Malaysians. MIRTS is conceived as a computerized registry of preschool-aged children and their immunization records. The purpose of the registry is to assure that children remain up-to-date with their immunizations and that their vaccination records are available when they are needed - when changing doctors and at the time of daycare/preschool and school entry. More specifically, to allow the Ministry of Health to manage better the immunization data, to generate factual data on the progress of immunization in the country, forecast the eHealth | February 2007

wellness of children in Malaysia, manage the operations better and optimize its cost. The term e-Health covers all forms of electronic healthcare delivered over the Internet, ranging from informational, educational and commercial ‘products’ to direct services offered by professionals, non-professionals, businesses or consumers themselves. It also includes a wide variety of clinical activities that have traditionally characterized telehealth, but delivered through the Internet. Simply stated, e-Health is making healthcare more efficient, while allowing patients and professionals to do the previously impossible. While other industries have captured the value of the Internet early on, the scale and scope of the Malaysian healthcare system perhaps presents the greatest potential in Internet-based applications. Access, cost, quality, and portability have been concerns in the healthcare arena. Evidence suggests that both health consumers and doctors are frustrated with the maze involved in the healthcare delivery. Fortunately, e-Health appears to be helping to resolve many of the challenges confronting the healthcare industry. Looking at the practice of industrialized countries, just in the past few years, the following e-Health services have emerged: 1. Health portals or health information sites, which empower consumers and physicians through customized education and online community experience. 2. Connectivity and communications solutions, which streamline administrative workflow, thereby reducing waste and inefficiencies. 3. e-commerce, including online health insurance and drug prescriptions. As the technology evolves, we could see even greater value-added Internet applications, including sophisticated chronic disease management tools. And as the market matures, a consolidation of all the online services will become likely. We could have a truly ‘Integrated Delivery System,’ with attendant quality, access, and low cost. The Internet could serve as a panacea to all of the complicated challenges confronting healthcare. Technology can never displace the expertise and personal care that only healthcare practitioners can deliver, but we believe that the Internet can go a long way in facilitating communication, and streamlining tedious and

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of the immunization status of their children. Scattered records, created by mobile citizens, non-use of interoperability standards by the hospitals and the absence of tracking system to remind parents compounds the problem.

MIRTS as a Solution

Figure-1 time-consuming administrative work, that often curtails the time of the doctor with patients, and education of both physicians and patients. Here we attempt to discuss how Internet technologies and ICT can be deployed to look after the well being of the citizens and residents of Malaysia as part of the e-health program.

The Problem Statement It is not uncommon to meet citizens who visit the hospitals and clinics only when they are unwell. The general awareness on the efficacy of preventive medicine needs to be reinforced through campaigns, especially in developing countries. Statistics from the UNICEF states the fact that deaths are averted by immunization. The estimated number of deaths averted by immunization in 2003 was more than 2 million, as well as an additional 600,000 hepatitis-B-related deaths, that would otherwise have occurred in the adulthood from liver cirrhosis and cancer. Immunization helps the body to develop protection against a particular disease, so that if at a later stage the body comes into contact with that disease, it will be able to fight it off. A person needs immunization for each disease that he/she wants to develop protection against. Fortunately, childhood immunizations in Malaysia are

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free. If we look at the present challenges facing immunization in Malaysia, we find that there is no systematic nationwide immunization plan, the process of immunization is getting more complex as new vaccines are developed, hospitals have home-grown systems for immunization, hospitals do not regularly share or transfer medical patient records, and physicians have no access to a child’s complete immunization history. Neither do most parents are aware

The solution proposed is in the form of a web-based system named MIRTS, which is conceived as a centralized repository of immunization records of all Malaysians using Standardized Healthcare Level 7 (HL7) interoperability protocol. This centralized repository is capable of simple data aggregation and delivery and saves all records. It also ensures smooth interoperability and facilitates easy integration with other systems. MIRTS will be beneficial to both parents and children. Research has shown that both parents and physicians overestimate the rates at which children are fully immunized. Parents are often unaware of immunization schedule; physicians often overlook 1-2 vaccinations. This is becoming a huge problem with the rapid changes in vaccination recommendations for children. MIRTS can: • Give parents easy access to a permanent record of their children’s shots even if they relocate or their children’s’ doctor retires. • Allows the doctor to find a child’s history

MIRTS is conceived as a computerized registry of preschool-aged children and their immunization records. The purpose of the registry is to assure that children remain up-to-date with their immunizations and that their vaccination records are available when they are needed - when changing doctors and at the time of daycare/preschool and school entry. More specifically, to allow the Ministry of Health to manage better the immunization data, to generate factual data on the progress of immunization in the country, forecast the wellness of children in Malaysia, manage the operations better and optimize its cost.

eHealth | February 2007


in a computerized database • Give parents the official reports about their children’s immunizations for daycare, school or camp. The visible benefits of MIRTS • Better management of immunization records. • Guaranteed privacy and confidentiality • Data Quality • Encouraging hospitals to participate • Extending the model to other areas of healthcare • Easier to integrate with other systems • Electronically determining what immunizations are needed at each encounter • Providing calculations of actual coverage levels and producing immunization status reports for parents during child care visits • Automating the sending of reminder notices to parents • Bringing together fragmented records to produce one complete immunization history. Information in MIRTS will be kept confidential. Only a citizen, his/her doctor, or healthcare workers who can assist him/ her with missed appointments or missed immunizations will have access to MIRTS. The information will not be shared with any other people or any other agency. By calling the Ministry of Health, Malaysia and with proper identification, parents can receive a free copy of their child’s immunization history at any time. Figure 1 and Figure 2 illustrate how all public and private hospitals in Malaysia will be connected to the MIRTS database and be accessible 24/7 through the Internet.

Figure-2

However, the MIRTS project can achieve its desired success only when pediatric practitioner who administers vaccines to children will be required to report to MIRTS. Each month, MIRTS would send a report to each pediatric doctor, asking for immunization histories of children who have turned 7 and 19 months of age. These are two key times when immunization status should be reviewed. Similarly, a 2-year-old clean up report, known as the ‘Goldenrod’ report, would also be sent each year as a last effort to try to bring a 2-year-old population up-to-date with their immunizations. Immunization coverage reports are generated for all Malaysian practices, based on children’s immunization status on their 2nd birthday. Up-to-date coverage is defined as 4 DTaP, 3 polio, 1 MMR on or after the first

Figure-3 : Indexing Immunization Records

eHealth | February 2007

birthday, 3 hepatitis B (with the 3rd dose given after 24 weeks of age), Hib given age appropriately, and Varicella, on or after the first birthday. Sometimes children are up-to-date with their immunizations but were not up-to-date at the time they turned 2 years of age. MIRTS uses this age as a cut-off, as all children should be series complete by the time they turn 2 years of age. Invalid doses are also responsible for its lower rates. The most commonly administered invalid doses of vaccine are: • MMR not given on or after 12 months of age • Hib not on or after 12 months of age • Hep B #3 not given on or after 6 months All too often it is also found that the DTaP #4 and the IPV #3 are not given, suggesting that the older infant is not coming back to the office. MIRTS can provide parents with a more detailed explanation upon request. MIRTS can help pediatric practices to obtain immunization histories for patients who transfer to their practice from any other pediatric facility in the country, and have easy access to the first hepatitis B shot given in the birth hospital. For each pediatric practice the system is able to: 1. Print a list of children who are missing any vaccine at any time 2. Automatically generate recall notices to parents of those children who are behind and reminder notices for upcoming appointments 3. Print out official reports for children with all given immunizations documented

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Figure-4 : Building Longitudinal Immunization Records 4. Determine immunization coverage levels for pediatric practice 5. Order vaccines and report doses administered electronically Building MIRTS Repository The Immunization Registry will follow the HL7 (Health Level 7, 2006) Reference Information Model (RIM), and the HL7 MetaModel Framework. All interfaces with the registry are provided (free) by the HL7 organization, based on XML (XML, 2006). HL7 is also providing net and service oriented architecture documentation to help deploy the registry. The next step comprises of indexing of all the immunization records (seen in figure 3), which is followed by linking all records together and creating the Longitudinal Vaccination Record (seen in the figure 4). The fourth step is adding future records to the Longitudinal Immunization Record (seen in figure 5). New records (chains) will be added to Longitudinal records automatically. A count of the chains will also be stored in the main HL7 registry. Lastly, all current records should be transformed and transferred to HL-7 compliant format and stored in the registry. It is not a surprise that the majority of medical records are paper-centric, or they are stored on a separate computer, or it can be part of the mainframe.

The consolidation process may be tedious, but it must be done. Paper records have to be scanned as image, or retyped. Mainframe records have to be transferred to the new registry through a bridging system, which will convert them to HL-7 format as well. However, the real challenge for the success of this project is to get the commitment of all public and private hospitals and clinics to update immunization data to the repository. An even bigger challenge will be to transfer existing disparate paper based records to MIRTS repository. The proposed system’s benefits, both tangible and intangible, are immense and therefore worth the effort. For a successful implementation of the system, we propose the following holistic approach; • Get sponsorship for the development of the system. The most appropriate will be the Ministry of health. • Carry out an Integration Awareness Campaign amongst hospitals and clinics to convince them and invite participation in this project. • Approach potential technology partners to implement the system • Approach medical schools to encourage contribution from the medical aspect. • Select two hospitals to participate in the project

• Conduct a wellness survey • Build pilot to show benefits • Help Ministry of Health to get hospitals and clinics on the registry. We anticipate that the actual, programming and testing of the system, will not be as time consuming as getting the other human related aspects of the system. These include campaigning, user training and change management. Like any other huge IT projects, this proposal will also require a champion, and the political willpower to be implemented and succeed. Contact Details of the authors Zaitun A. B Department of Information Science, Faculty of Computer Science and Information Technology, University of Malaya, Kuala Lumpur, Malaysia. Email: zab@um.edu.my M. S. Termanini Department of Business Studies, University College of Bahrain Sar, Bahrain. rocky@termanini.com

References

Figure-5 : Updating Longitudinal Records

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Immunization - The Childcare Pages, 2006. Available at http://www.ed-u.com/ immunization.htm, Wysocki, M. “ What is e-Health?” Available at http://www.suite101.com/article.cfm/9670/ 57010, http://www.immregistries.org/pdf/ HIPAA_v2.pdf Health Level 7. Available at http:// www.hl7.org, XML, available at www.xml.org eHealth | February 2007


Business News AdvancedTechno-care with Quality Medcare Medcare Hospital, a new 90,000 sq feet multi-specialty hospital in the heart of New Dubai, will start functioning from mid-February of 2007. Of course, the hospital built with an investment of Rs. 120 crore, will provide advanced medical, surgical, emergency and maternity care services, but what is more news worthy is the fact that this hospital has gone for e-Health in a big way, with wireless Internet facility in all its patient’s rooms. According to Dr. Azad Moopen, the Chairman of the hospital, it will be a paperless hospital with online imaging, investigation processing and prescribing facilities. The hospital has tele-radiology enabled scanning and image transfer systems which will enable the doctors to read scans and X-rays online, even when they are at home or travelling. Not only that, the surgery rooms and conference hall of the Medcare Hospital are equipped with telemedicine facility, which will give the doctors of the hospital to do real time interaction with medical professionals around the world through video conferencing. It can be safely said that this multi-specialty hospital will facilitate to give an added thrust to the e-Health scenario of the Middle-East.

Malaysian hospital to upgrade its clinical information system Integrated Medical Systems (IMS), a company based in the Australian state of Queensland, engaged in healthcare and laboratory software, has entered in to an e-Health deal with Hospital Universitit Kebansaan of Malaysia. The deal entails that IMS will provide their web-based Caring Hospital Enterprise System solution to upgrade the Hospital Universitit Kebansaan’s existing clinical information system. The upgraded system will provide a holistic e-Health solution, allowing February 2007 | www.eHealthonline.org

doctors at the Malaysian hospital to place orders, review patients’ medical history, order tests, examine clinical conditions, and provide medication, all timely, efficiently and through online. The ICT solutions of IMS will relieve the doctors of the administrative rigmaroles and paperwork, and allow him/her to focus their valuable time on the patients. The new solution will plug in directly to the hospital’s existing software to assist in a smooth transition for the hospital staff. However, it is not the first time that the IMS and Hospital Universitit Kebansaan of Malaysia have entered upon a partnership. IMS has previously provided solutions to the hospital to meet advanced technology needs of pathology, laboratory, blood, radiology and imaging departments.

KL Heart Care goes into the ICT mode KL Heart Care, a Kuala Lumpur based state-of-the-art heart and cancer care center having the distinction of being a MSC status company, has recently entered upon RM3milllion partnership with i-Tech Network Solutions. The partnership will see i-Tech Network Solutions providing IT infrastructure solutions and services for KL Heart Care’s latest facilities in Kuala Lumpur. This project is scheduled to take off in the first quarter of 2007. According to Dr. Mohammad Rafiq, the CEO of KL Heart Care, the new facilities at KL Heart Care would provide screening facilities, x-ray facilities and mammography. The super-specialty hospital is expecting to have 50 to 100 users for its latest facilities on a daily basis. Among the users of its latest facilities, foreigners from ASEAN and Middle-East region are also expected. No wonder, KL Heart Care has also assistance from the Malaysian Tourism Ministry’s special fund to promote health tourism. According to Rafiq, KL Heart Care is also exploring the possibility of partnering with a local university for the provision of radiology services. “In this

facility, there would be one or two consulting specialists. The main crux of the services is to have medical notes for web-based health records for easy access,” he said.

Tieto Enator strengthens its Swedish presence TietoEnator, which is the leading healthcare and welfare ICT solution provider in the Nordic region and one of the leading IT services providers in Europe, has entered into a strategic tieup. Recently the conglomerate has acquired the entire share capital in the Swedish healthcare IT provider Provisio AB. The latter specializes in operating room information systems and has made a name for itself with its operation theatre solution named Anaesthesia EPR., which is fully integrated with OT and will be piloted by the University Hospital in Lund, Sweden.The agreement will see TietoEnator broaden its product portfolio and strengthen its position in the Swedish healthcare market. Says Jan B. Andersson, Head of Tieto Enator , Healthcare & Welfare in Sweden, “We expect this market segment to expand in the coming years, both in Sweden and internationally. By this acquisition, TietoEnator will strengthen and broaden its offering for operation room information systems.” Per Wargéus, the Founder of Provisio AB also expressed his happiness over this tieup and said that, “We have now found the perfect partner. I am very confident that together we will be a stronger choice for our customers and employees.”

Agfa HealthCare gives a fillip to Tuscany’s health informatics Agfa HealthCare, a part of the AgfaGevaert Group, has been providing advanced imaging and healthcare IT systems & services for clinical specialties and healthcare facility management

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across the globe. The conglomerate has recently announced that it is launching the second phase of the Tuscan Medical Technology (TMT) hospital digitization project, in which it will install its integrated Radiology Information System (RIS) solution in the hospitals of the central Tuscany region. The first phase of the project, which included the installation of Agfa’s CR solutions, has for a large part been successfully completed. The central Tuscany region comprises five hospital groups, and together, they count more than 1300 general practitioners and some 180 padiatricians who perform more than 1,300,000 examinations per year. The first and second phases of the TMT project which is part of the larger IDIT project (Informatizzazione della Diagnostica di Immagine in Toscana) - are part of a contract of partnership between Agfa HealthCare and Area Vasta Centro; the central health region in Tuscany. The contract with Agfa HealthCare was signed in the second half of January 2006. The TMT project is one of the most important RIS/PACS projects in Europe, with a total tender amount of 45 million euros. In just nine months, more than half of the imaging activities in Tuscany’s Area Vasta Centro region were migrated to a fully digital environment and integrated in the planned RIS/PACS environment. The next phase of the project, in which Agfa HealthCare will install its web-based RIS solution in the twelve hospitals of the region, is now starting.The RIS system, when implemented and fully integrated to the hospitals’ PACS system, will greatly enhance patient and exam workflow and permit authorized users to access information available anywhere and at any time. “With an annual average of over one million examinations, it is vital for the medical staff in the Area Vasta Centro region to go digital. It will allow them to

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increase the operational efficiency substantially. In addition, the installation of Agfa’s RIS will result in a considerable cost reduction for the radiology departments,” said Riccardo Ferraris, Sales Manager, Agfa HealthCare Italy. In the final phase of the project, which is currently planned for July 2008, all twelve hospitals of the Area Vasta Centro region will be linked.

ICW and CISCO bags the NHIF project Bulgaria’s pilot project for national electronic health card has a fairly broad ambit. It includes three 1000 patients, five pharmacies and three general practitioners. The Bulgarian National Health Insurance Fund (NHIF) has assigned the implementation of the pilot project to ICW (InterComponentWare Inc.) and CISCO. InterComponentWare Inc is a leading international player in the field of e-Health with presence across Germany, Bulgaria, Austria, Switzerland and the USA, while CISCO is a global leader in routing and network security solutions. The pilot project for the national electronic health card will take off in a municipality of Bulgaria, and there the participating physicians and patients will identify themselves with their cards during consultation.The system will then automatically establish an online connection to check the current insurance status of the patient and his presence in the patient list of the physician. All these will not only lessen the administrative burden of the physician, but will also prevent the misuse of stolen or lost ecards. Through electronic health cards, the concerned physicians will also be able to issue digitally signed electronic prescriptions to be stored on the card and prescription server, which will eliminate the possibility of misreading an illegible prescription by a given pharmacist, and thereby administering a wrong drug in the process. Moreover,

the electronic prescription will also ensure that only medications that are compatible with a given patient’s other drugs and diseases will be administered.

A feather in the cap for Medify Solutions Limited Medify Solutions Limited has announced that it has been awarded Vodafone certified application status for its MedifyRemote™ application. Here it deserves a mention that Medify Solutions group, which is at the forefront of the technology revolution in patient care with operations across EU, is involved in marketing and delivery of leading edge mobile solutions for the healthcare market. MedifyRemote™ is probably the first application of its type and allows healthcare professionals mobile access to review and update a patient’s medical history records in a single, secure session via a standard Microsoft Windows mobile PDA/phone device. The application offers no interference with the existing device functions, enabling one device to be utilised for telephone, email, calendar, internet access; as well as patient note functions. In order to achieve Vodafone Certified status, MedifyRemote™ underwent technical evaluation by Vodafone UK. As a certified application, Medify Solutions Limited now has access to Vodafone UK’s technical expertise and will be recommended to appropriate customers by Vodafone UK’s account managers. MedifyRemote™ will now be identified by the “Vodafone Certified Application” brand logo. Vodafone UK, which offers a wide range of voice and data communications, has 16.3 million customers. With this, MedifyRemote™ joins a number of other certified application developers in the Vodafone UK applications portfolio, which have developed solutions ranging from telematics and sales solutions to tools, that replicate the functionality or content from the desktop environment on to the mobile device. eHealth | February 2007


Click-start to an e-healthy journey ...

rg e.o n i nl ho t l ea .eh w ww

... by simply logging on to www.ehealthonline.org The pulse on Asia’s e-Health


India Update Madhya Pradesh commences e-healthcare Neonatal care through videoconferencing is finally here. Sagar district in Madhya Pradesh, India has achieved that distinction. In fact, Sagar will be the first district of Madhya Pradesh to have videoconferencing facility in its four community medical obstetric neonatal care centers. The pilot project has already been successfully launched between the Sagar district hospital and Bina’s (a town located in Sagar district) community medical obstetric neonatal care centre. In near future, this video conferencing system will be extended to Khurai, Sahagarh and Devri too. All of these towns are located in the Sagar district. On completion, this project will enable the doctors in Bina, Khurai, Sahagarh and Devri to interact and consult with specialists in the Sagar district hospital, which in turn will be connected with the Apollo Hospital. With the complete establishment of this videoconferencing link, the doctors in these community medical neonatal care centers will not have to refer some of their challenging cases to the Sagar district hospital for want of proper infrastructure and facilities, which causes lots of logistic problem for the patients. Instead of the patient moving to the doctor, the doctor will virtually move to the patient with relevant medical advice. If the project takes off well, poor villagers in Madhya Pradesh will be able to get quality medical care at par with the affluent patients in metros.

e-Health arrives in rural India American Association of Physicians of Indian Origin (APPI) has signed a threeyear memorandum of understanding (MoU) with the Confederation of Indian

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Industries and Indian American Council to give an impetus to the development of the healthcare sector in India, with focus on rural areas. As a result of this partnership, mobile medical units and telemedicine centers will soon be introduced to one hundred Indian villages. CII has committed 100 healthy villages across the states of Bihar, Rajasthan, Haryana, Punjab, Madhya Pradesh and Uttar Pradesh, and corporates like Hero Honda, Bharti Airtel and Infosys would adopt these villages. Hero Honda will take charge of 20 villages, while Bharti Airtel will adopt 10 villages. AAPI aims to promote better hygiene, clean drinking water and clean toilets in these villages in collaboration with the state governments. As part of this initiative, all these hundred villages will have mobile medical units and their primary healthcare centers will have telemedicine facilities. Telemedicine will connect the health centres and district hospitals. The first pilot project will take off in the Patna district of Bihar. According to S. Balasubramanium, President of the American Association of Physicians of Indian Origin, AAPI already has collaboration with the Patna Medical College and NTR Medical College in Andhra Pradesh. Both these academic institutions will help AAPI to execute the project. According to Balasubramanium, AAPI will focus on five major diseases in these villages, which are diabetes, cardiovascular problems, deafness among children, carcinoma cervix and carcinoma prostate. Despite being curable, they result in deaths due to late detection. In this context, telemedicine can solve the problem in a better manner, as poor patients in these villages can get access to world-class medical care through telemedicine, without any untoward delay.

Telemedicine to get a leg up thanks to CII Industry representatives, corporates and diaspora doctors are coming together for the cause of health in India with special focus on rural citizens. The Healthy Village project, part of the Confederation of Indian Industry (CII) plan to forge a linkage with the American Association of Physicians of Indian Origin (AAPI) is ready to take off with an MoU soon. Says Dr Naresh Trehan, chairman, CII’s national committee on healthcare, “The MoU will enable us to bring in a lot of knowledge transfer from AAPI.” With this MoU and activation of telemedicine, many Indian villages can get access to AAPI’s base of doctors to facilitate transfer of knowledge and technology along with the development of emergency medical services. The programme will initially target 100 villages. Work has already started in Patna district of Bihar, and some parts of Rajasthan. Haryana, Punjab and Madhya Pradesh are also high on the list. The AAPI claims a base of over 42,000 physicians. According to Dr Subramaniam Balasubramaniam, “There are five major areas needing urgent attention. Cancer of the cervix, cancer of the prostrate, heart disease, diabetes and deafness in children that are preventable through timely intervention.” Corporates across the country have already pledged support to the CII initiative and offered to adopt villages and make the health drive a self-sufficient movement. Sam Pitroda, chairman, IAC and Knowledge Commission commented: “We want to start telemedicine in the rural areas and we require broadband. At the moment we need to build 100 networks connecting 5,000 nodes in India.” eHealth | February 2007


World News Sindh makes rapid progress in telemedicine Pakistan’s Sindh region will set up telemedicine services all its 23 districts very soon.According to Sindh Governor Dr. Ishrantul Ebad Khan.This will enable people living in remote rural areas of Sindh to access specialist doctors working in Pakistan’s cities.And it seems that Pakistan government is not procrastinating on this issue, which demands urgent addressing. According to the Governor, the telemedicine centers will be opened in the districts of Sindh in the next three months, in which e-consultation system will be introduced. All the taluks would be linked through Internet with hospitals in the big cities of Pakistan. Wherever it would not be possible to establish Internet linkages, the patients would contact the given city specialists within the ambit of this network, through cell phone. In case of emergencies also the patient can contact his nearest telemedicine centre through cell phone and access e-consultancy.

Transmitting medical images, digitally Cuba’s Medical Biophysics Center, located in the city of Santiago, has developed a transmission system of digital medical images, which has already been installed in several hospitals of this island-nation, across 11 provinces. The revolutionary software known as Imagis has the potential to give an added boost to the already fast-developing world of health informatics and telemedicine, as it enables storing, processing, visualizing and transmission by e-mail, the images received in tomographs, ultrasound, magnetic resonance, X rays, angiographs and others. This innovation can facilitate patients’ diagnosis as through this technique, physicians can interact and discuss the cases with each other online, on the February 2007 | www.eHealthonline.org

basis of the images. The medical images at hand can always help the given doctor/s in administering proper medication. The new horizons to its application have been already opened, as positive experiences of generalization of the Imagis system in the health units of Dominican Republic, Ecuador and Venezuela are trickling in.

Getting some teeth in tackling Osteoporosis Osteoporosis or the thinning of bone is a common disease among aged women. Moreover, for a woman of 50, the vulnerability to this disease markedly progresses with the passing of decades. While more than 38 percent of women

the basis of this specific measurement, dentists can easily identify the vulnerability of a given person to this disease. The jaw cortex widths of less than 3mm are a key indicator of osteoporosis, and the researchers used active shape modelling techniques to detect it. Moreover, the method developed by the team of researchers are not only automated and affordable, but is also simple, and can be carried by a dentist next door taking routine X rays. Now the ball is in the court of the X ray equipment manufacturing companies, who have to integrate this innovative software with their products, so that it is available to the dentists, which in turn will allow the dentists to translate this research into pragmatic medical care through dental X rays.

Telehealth reaches where diplomacy can’t Despite the ongoing threat of violence looming over the Middle-East, the doctors and academics from Canada, Jordan, Israel and Palestine are sharing their expertise through telehealth to improve the healthcare of this warravaged region. in the west over 70 are affected by this disease, 70 percent of the western women over 80 are at the risk of osteoporosis, which entails a high risk of bone fractures. Now a three-year long research by a EU funded project has yielded encouraging results, which may lead to the early detection of osteoporosis. Professor Keith Horner and Dr Hugh Devlin of Manchester University coordinated the project in collaboration with the universities of Athens, Leuven,Amsterdam and Malmo, to develop an automated approach to detecting the disease. The researchers have found that the bone-thinning disease of osteoporosis can be detected through dental X rays. The team of researchers has developed a software for measuring the thickness of a part of a patient’s lower jaw, and on

This has been made possible through the joint endeavours of Toronto-based Baycrest Centre for Geriatric Care, Canada International Scientific Exchange Program (CISEPO), the Department of Public Health Sciences at the University of Toronto and the Peter A. Silverman Centre for International Health at Mount Sinai Hospital. They entered a three-year agreement to launch an eHealth learning program with the Middle East in 2006. The result of this agreement is the International Network of Knowledge through Electronic Learning; created to program medical rounds with CISEPO’s Israeli, Jordanian and Palestinian partners, which includes the Edith Wolfson Medical Center, Tel Aviv University, Jordan University of Science and Technology and Al Quds University.

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The telehealth rounds are delivered in real time, where the Canadian and Middle-East doctors link up for videoconference, across vast geographical distances. The topics of discussion for the rounds are generally focused on various geriatric psychiatric conditions that affect such as Alzheimer’s disease, depression and Parkinson’s disease. This is a singular telehealth program, which even manages to bridge the Arab-Israeli divide. Under this programme, Israeli and Palestine doctors are working shoulder to shoulder to create a better world for the unfortunates through telemedicine, proving once again that knowledge and humanity knows no barriers. According to Dr. Arnold Noyek, Director of the Peter A. Silverman Centre and the Chair of CISEPO, this Canadian-driven global eHealth programme is just one of the many initiatives that CISEPO is responsible for. CISEPO, with the support of the Canadian International Development Agency (CIDA), has influenced Jordanian national health policy by making hearing loss screenings at birth a priority factor.

Welcome to Telehealth Ontario The province of Ontario in Canada, has made some significant inroads in public healthcare, through the route of telehealth. Now ill and ailing Ontarians can save or at least reduce the number of visits to hospital, by simply calling Telehealth Ontario for addressing their health concerns. Telehealth Ontario is a free, confidential telephone service that connects a patient to a registered nurse, 24 hours a day, seven days a week. After making a call to Telehealth Ontario, the caller will be asked to describe his/ her symptoms and answer questions to help nurses best assess the seriousness of the problem. Nurses can then help direct callers to the appropriate health care option which may include taking care of oneself

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at home, seeing one’s doctor or going to one’s local emergency department.

US corporates pave the way for e-Prescriptions Human medication errors cause millions of unwarranted sickness and thousands of deaths across the globe. A great part of these human miseries can be avoided if the governments, societies and corporates realize the full potential of IT application in healthcare. One of the remedies to eliminate human error in administering medication is ePrescriptions, as through this technique the possibility of misreading a doctor’s illegible handwritten prescription gets altogether done away with. In this context, the initiative by a cartel of USA corporates is more than praiseworthy. Some of the largest healthcare and technology companies, insurance conglomerates and large pharmacy groups, such as Microsoft, Dell and Wellpoint have recently entered upon a partnership, which entails offering every U.S. doctor free access to electronic prescribing. Now the US physicians will need only a personal computer to transmit their prescriptions to the pharmacy through this web-based interface. The service is appropriately termed as National ePrescribing Patient Safety Initiative. This new initiative is extremely doctor-friendly, requiring minimum technological skills and about 20 minutes of staff training. The service will cost about 100 million USD over the next five years, and a major part of the costs are borne by the corporate sponsors. However, it is not a purely philanthropic initiative, as there is no denying the fact the sponsors stand to gain much through the widespread use of e-Prescribing, which among other things may lead to better healthcare and hence productivity of their employees. The doctors who choose to use this free of cost service will have to access

insurance giant Wellpoint‘s records of 30 million members, and a health-plan maintained database that includes information for 200 million Americans. Here it deserves a mention that Wellpoint has been already offering doctors a 1 percent increase in reimbursement for using e-prescriptions, and an additional 1 percent for using electronic health records, and now this free of cost service will give an added fillip to Wellpoint’s initiative. However, the American Medical Association, the largest group of physicians in the USA is yet to endorse the system, though it supports the promotion of e-Prescriptions.

Big Island gets a big neurological help It seems the entire world, ranging from Tokyo to Honolulu, from Russia to New Zealand, is catching up with e-Health. The Queen’s Medical Center’s Neuroscience Institute in Hawaii, USA is the latest to join the bandwagon. Queen’s Medical Center, located in downtown Honolulu, Hawaii is the largest private hospital in Hawaii, and Hawaii’s only primary stroke care center certified by the Joint Commission on Accreditation of Healthcare Organizations. This leading medical referral center in the Pacific Basin has recently received a federal grant to the tune of 7,27,000 USD to acquire telemedicine facilities, which will enable the Queen’s doctors to offer online medical advice to patients with stroke, brain trauma or other assorted neurological injuries at Hilo Medical Center and Kona Community Hospital. Both these hospitals are located in the Big Island, Hawaii where such expertise in neuroscience was hitherto unavailable. Thanks to telemedicine, now Big Island’s eHealth | February 2007


residents can access quality neurological care without moving away from their cosy little island. Queen’s neurologists will first examine patients in these two above-mentioned Big Island hospitals and only if the need arise, the patients will be advised to fly to Queen’s Medical Center for further treatment. For example a brain surgery may need the patient to be physically present at the Queen’s Medical Center, but the neurological problems which can be sorted through online advise, will not need the patient to fly all the way to Honolulu.

Healthcare and wellness market goes the electronic way According to a report by UK based analysts Wireless Healthcare, which specializes in the application of mobile and wireless technology in the healthcare sector, some consumer electronics companies are exploiting the growing demand for devices and services that help people remain trim, fit and mentally alert. The recently published report ‘eHealth And Consumer Electronics’, produced by Wireless Healthcare, suggests the market for consumer electronics based therapeutic and well-being devices and services will grow by 20 percent per annum and could be worth $4 billion per annum by 2010.Wireless Healthcare highlights developments such as Nintendo’s ‘Brain Age’ software, which helps older people retain their mental agility. Brain Age has helped Nintendo break into the ageing baby boomer market - not a demographic group that usually buys video games. The report also examines the market for devices that reduce blood pressure and February 2007 | www.eHealthonline.org

hypertension by teaching the user to breathe correctly. These products are based on simple ECG technology and are used as part of stress reduction programmes. That’s not all.The exhaustive report also identifies websites that allow users to upload ECG data from devices including exercise monitors - as potential platforms for next generation e-Health services. According to Peter Kruger, Analyst with Wireless Healthcare, “Some of these services are being promoted by healthcare payers who have a vested interest in preventative healthcare. We feel that, in the long term, these services will disrupt the business models of incumbent healthcare providers.” According to Wireless Healthcare, as the exercise device market becomes more competitive, vendors will add healthcare related features to their fitness subscription-based services in an attempt to maintain margins and increase their brand loyalty. The report points to a range of subscription style services that supports both dieting and exercise, and estimates the online well-being market could be worth up to $2 billion per annum by 2010. However, the report warns that services such as mobile phone based online dieting will not maintain growth without support from established players in the diet management sector.

UKPMC: Facilitating biomedical research online The launch of UK PubMed Central online archive is likely to give a great impetus to biomedical research, as thanks to this online archive of peer-reviewed research papers in the medical and life sciences, now more than 500,000 papers on medical research are freely accessible on Internet. This archive can be a great help to the medical fraternity across the globe for

reference and research. The site can serve as a unique online resource reflecting the biomedical research output of the UK. This online archive is based on American PubMed Central database; the free digital archive of biomedical and life sciences journal literature, which is used by the US National Institute for Health. UKPMC is fully searchable and will provide context-sensitive links to other online resources, such as gene and chemical compound databases. Currently all documents in UKPMC are linked to databases hosted by the National Center for Biotechnology Information (NCBI) at the US National Institutes of Health (NIH), but over time, plans are there to provide additional links to resources hosted in the UK and Europe, which are of interest to the UK’s biomedical research community. This archive is being funded by a group of nine research funders, led by Wellcome Trust - an independent charity, funding research to improve human and animal health, and the UK’s largest nongovernmental source of funds for biomedical research. Presently the online database offers 600,000 biomedical digital articles and over the next five years, UK PubMed Central online archive hopes to generate up to £3m of additional funding. UKPMC also provides a manuscript submission system to enable the group of medical researchers, who are funded by the UKPMC Funders Group, to submit articles that have been accepted for publication in a peer-reviewed journal. As of January 2007, this system held details of around 15,000 grants, awarded to over 8000 researchers. The research works of these researchers are freely available at UKPMC, and the system has been developed and put online through a partnership between the British Library, the University of Manchester and the European Bioinformatics Institute.

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Perspective

TELECONSULTATION TURNS DYNAMIC Set to become the fulcrum of healthcare

T

elemedicine has been touted as a significant enabler and facilitator of universal healthcare. As a result, the World Health Organization has committed significant resources to telemedicine for surveillance, monitoring and disease control. While telemedicine has yet to bring a paradigm shift in how healthcare services are being delivered, over the last few years, increasing sophistication in supporting technologies – telecommunications, mobile monitoring devices, artificial intelligence enabled clinical decision making, etc. - has made telemedicine systems much more potent than ever before. And in the near future, telemedicine has a high degree of possibility of becoming a part of everyday life, at least in the developed countries. However, contrary to popular belief telemedicine is not a novel concept. The field of telemedicine is over forty years old. Way back in the 1960’s, NASA started to research about application of telemedicine technologies to communicate with astronauts in space. In 1964, Nebraska Psychiatric Institute established a long distance medical link with Norfolk State Hospital for education and consultations amongst physicians. However, the first documented telemedicine project to provide medical care was setup in 1967 by Dr. Kenneth Bird, between Logan Airport

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in Boston and Massachusetts General Hospital. In this project, he connected MGH to Logan Airport by a microwave link and closed circuit television to provide emergency medical care to travellers and occupational health services to airport staff. The centre was staffed by nurses 24/7 and remote consultation was provided by clinicians based at MGH. This onsiteoffsite framework of remote consultation has not changed much since then.

Why Teleconsultation? Interaction between a physician and a patient is the fundamental tenet of medical practice and it would remain so till evidence based clinical practice systems coupled with powerful artificial intelligence encroaches some part of clinical decision making. As advances continue to be made in the realm of medical research, it is becoming increasingly impossible for a given physician to have a deep insight and expertise in all areas of medical science. Thus, teleconsultation has become essential. Teleconsultation is the use of telecommunication links by physicians to communicate with each other or with the patients. It is an application of telemedicine for evaluation, examination, lab result interpretation, diagnosis, second opinion

The nations with predominantly public healthcare set ups have adopted telemedicine much more successfully than nations with predominantly non-government run healthcare systems.

Dr. Pushwaz Virk Harvard University Health Services, Cambridge, MAv

Dr. David W. Bates Division of General Medicine, Department of Medicine, Brigham and Women’s Hospital; and Partners HealthCare Information Systems, Clinical and Quality Analysis, and Harvard Medical School, Boston, MA.

eHealth | February 2007


or education. The simplest and most common form of teleconsultation is calling up a superior medical practioner or a colleague from different speciality for advice. The other physician could be in the same hospital or at a different location, thousands of miles away. But perhaps the most interesting use of the technology is the interaction of physician with a patient over a telecommunication link, transmitting voice, video, text or a physiological measurement.

Teleconsultation models and new vistas Most of the successful telemedicine programs in the world to date have either been run by government agencies or have been supported by government grants. The nations with predominantly public

The stakeholders with control over teleconsultation projects typically include health systems employing collaborating physicians, government agencies commissioning such systems in the national or statewide initiatives, telemedicine infrastructure companies and insurance companies. The physicians and patients receiving these services usually do not have control over the care delivered to them remotely unless they happened to be employed by a powerful employer. In the usual setup, a government financed and operated telemedicine network provides services to its citizens using physicians who are employees of the government healthcare system. Teleconsultation can occur via email, phone, videoconference or instant messengers. Email communication is

With reference to the example of banking systems, even though technically the solutions for financial data security are very similar to patient data safety, there are important differences.

• • • •

healthcare set ups have adopted telemedicine much more successfully than nations with predominantly nongovernment run healthcare systems. The military is the other example of successful development and deployment of telemedicine systems. The reasons for the low degree of involvement of the private sector in commissioning telemedicine systems is due to unattractive payment or reimbursement models, heterogeneous mix of technology usage in different locations and potential for litigations around missed treatments, and breaches of patient privacy. The lack or rather the acute paucity of proven profit models in telemedicine services has prevented participation by innovative entrepreneurs to establish services and introduce collaborative technologies in telemedicine. February 2007 | www.eHealthonline.org

emerging as the latest platform for consultations among physicians. Some insurance companies in the US have started reimbursing email consults, provided they comply with stipulated guidelines. Furthermore, cellular phones have introduced option of wider mobility for both patients and physicians.

Benefits of Teleconsultation • The most important benefit of teleconsultation is the ability to access medical expertise from any corner of the globe. There are specialized clinical centers, which provide medical services to wilderness enthusiasts, marine industry and oil-field explorers. These services also help to reach pockets of population in far- flung places like remote villages in tropical forests in Asia

or Africa, or cold plains of Arctic in Northern Europe or Canada. Some advanced medical centers like Partners Healthcare System, Mayo Clinic or Johns Hopkins provide expert opinions to physicians from United States and abroad, thereby saving the patients’ cost and harassment of international travel. Teleconsultation technologies can also provide physicians and patients access to treatment modalities that are not available in their home state or country. For example, physicians can have access to information to experts investigating experimental treatments or consult with experts of traditional or complementary medicine. In some chronic care settings, teleconsultations are linked with telemonitoring equipment for patients, requiring high degree of compliance or immediate interventions in case of emergencies. Successful use of teleconsultation has been demonstrated in Providing medical services during disasters Obtaining second opinions by patients or physicians Preliminary work up to schedule a subsequent comprehensive and relevant physician appointment Follow up management of post-surgical interventions or clinical encounters.

Challenges of Teleconsultation However, the setting up of a teleconsultation infrastructure is fraught with challenges. The most important challenge in setting up a teleconsultation system is obtaining sufficient financial commitment. Unless there is a government grant or support from a resourceful organization, it becomes very difficult to setup a sustainable business model for telemedicine services under most payment schemes. Besides, for physician-physician teleconsultation arrangements, it becomes difficult at times to ascertain the correct payment models for remote consultations.

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This becomes especially complex in international consultations. There’s more. In developing countries, the telecommunication network infrastructure is a major bottleneck. The teleconsultation equipment is typically installed in remote areas and it becomes a challenge to maintain this expensive equipment. In case of breakdowns, due to the stretched financial resources, service disruptions sometimes mark the untimely end of these novel ventures. Moreover, so far, most telemedicine services have been targeted either at elderly or inhabitants of remote locations. These segments of users are not very technology-friendly and they are often averse to the introduction of new technologies. Then finally, there is the thorny issue pertaining to information security and patient data privacy. When patient’s health record is put on a publicly accessible network, there is an inherent risk of potential abuse of the information. Though technically this risk is not more than getting someone’s bank account or credit information from the bank’s websites, which is considered sufficiently safe as demonstrated by expanding ecommerce market, but there is a fundamental difference in the nature of access of financial data and patients’ data, which we will discuss below. As the Electronic Medical Records (EMR) deal with sensitive data about patients, their secrecy needs to be protected.

Is the Patient’s Data Secure ? An efficient and effective teleconsultation delivery system should have an integrated EMR system. In theory, it is possible to have a paper based system linked to teleconsultation network, but that would severely limit the benefits. Many physicians at Harvard Medical School receive patient records as scanned attachments in email. These are not only cumbersome to handle but are also error prone. Except in cases of severe infrastructural limitation or temporary teleconsultation arrangements (e.g sites of relief camps, temporary health intervention shelters), an electronic

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medical record system provides the physician flexibility to provide teleconsultation services with complete access to patient information. If EMR systems are linked to teleconsultation, questions arise about patients’ data privacy and security. Many commercially available EMR systems have demonstrated sufficient safeguards to protect patient information. However, this security shell may break when access is granted to healthcare providers over Internet or other wide area networks. The reason is not due to technical limitation but process constraints. With reference to the example of banking systems, even though technically the solutions for financial data security are very similar to patient data safety, there are important differences. In financial services, the consumer is the only person with access to his or her financial

that institutions responsible for each of these activities follow commonly agreed upon protocols. Moreover, there are other unique complications, which can arise in case of teleconsultation. For example, if two specialists are discussing a patient’s case over email, their conversation might change into something different and inadvertently the emails may be forwarded to a person who is not authorized to view the patient’s information. It is for this reason that some hospitals forbid putting patient information on emails and instead provide secure VPNs to their physicians, for accessing patient data offsite. To protect patients’ privacy and at the same time enable smooth exchange of data between those institutions providing patients’ care, and insurance companies, the Health Insurance Portability and Accountability (HIPAA) act was enacted in the United States in 1996. The final deadline for compliance with the security rule was April, 2006. This act made provisions for legal recourse, in case confidential information was made available to unauthorized users. Any attempt for teleconsultation services has to fall under the purview of legal framework to motivate sponsor organizations to undertake sufficient measures to ensure safety of patient information.

Summing up information, while in healthcare, patients’ data is made available to primary care physicians, specialist physicians, insurance companies, insurance affiliates, pharmacies, all of which may be at great distances from each other. The chances of disruptions increase exponentially as the number of data access points increase. It is much more difficult to ensure that all of them have robust, well integrated and secure systems, and all of them follow best practices for data access and security. Security breaches can occur at the time of data capture, data retrieval or data storage. Thus, it is vital to ensure

Succinctly, teleconsultation is an interesting way to supplement hospitals’ clinical resources. It also provides an opportunity to provide medical care in underserved areas. However, for anyone trying to set up teleconsultation services, it is very important to attempt to align the interests of all stakeholders, ensure sustainability and setup systems to safeguard patient information. With increasing telecommunication reach in most parts of the world, ageing population and advancements in medical equipments, teleconsultation is poised to become the fulcrum of healthcare delivery of the future. eHealth | February 2007


Trends

Changing Face of Health Informatics Access to electronic health records is real empowerment

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t is common knowledge that information technology and consumerism are synergistic forces that promote ‘information age healthcare system.’ Consumers use information technology to gain access to information, in order to have better control on their healthcare and the resources thereof. Medical informatics concerns itself with the cognitive, information processing and communication tasks of medical practice, education and research. Till recently, medical informatics was obsessed with developing applications for health professionals, from the point of view of the health professionals, leaving out the perspective of the patients. A decade of development in information systems that trailed physicians and healthcare managers, had a shift in focus in the last couple of years. Now computers drive the pro-consumer slant and telecommunications systems are making the health sector a happening, consumer-friendly place. Greenes and Shortliffe once wrote: “The development of information systems mostly support infrastructure of medicine with a greater focus on physicians and other healthcare professionals in education, decision making, communication, and professional activities. This orientation needs to change in favour of the end users in the coming time”. What is happening now is that prophetic shift. Information technology and consumer health informatics are becoming integral to public health and national healthcare policies. Access to February 2007 | www.eHealthonline.org

Consumer Health Informatics Informing Consumers on Improving Health Care The book ‘Consumer Health Informatics’ explores the multifarious aspects of this fast evolving branch in medical science. Targeted at both medical professionals and students, the book is also a reminder of the broadening scope in consumer health informatics that is already making its impact on the fast changing world of healthcare. The chapter highlights are Consumer Health Informatics, Empowered Consumers, Tailored Health Communication, Design and Evaluation of Consumer Health Information, Information Delivery Methods, Online Learning for Healthcare Consumers and Qualitative Evaluation Practices in Consumer Health Informatics. The book finely ensembles new developments like electronic patient-centered communication that captures consumer health vocabulary, disability informatics, etc. The case studies look at pertinent topics like computer-based information for cancer, national library of medicinal initiatives and importance of web-based patient preferences and utilities. Immensely useful to IT specialists, physicians, healthcare providers, professors and students of medical informatics, the book also takes a look at issues like patient empowerment, frameworks and models for health behaviour change and patient education, patient to patient communication, patient to provider communication, privacy and confidentiality, ethical issues, evaluation methods and lot more. The Editors of this exhaustive literature on medical informatics are Lewis D, Eysenbach G, Kukafka R, Stavri PZ and Jimison H. electronic health records is an act in empowerment of consumers, to track their various needs on health information. Computer-based decision aids and softwares are helping out both patients and professionals to prepare for appropriate interventions. This trend is more palpable in developed countries where the urge to cut healthcare costs is on the higher side. There the volumes of interactive information through Internet and technologies, such as digital television and web television, coincide with the desire of consumers to assume more responsibility

to their health, to ward off pressures of costs on health systems. The renewed emphasis on public healthcare and preventive medicine is adding fuel to it. In the United Kingdom, the introduction of services such as NHS Direct provides advice to patients on both web and phone. Intelligent informatics applications continue to channel floods of health information to consumers and patients for attaining a healthy balance between self-reliance and professional help. - G. Kalyan Kumar

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Project Showcase

MAKING AUSTRALIA E-HEALTH AWARE The Australian NGO Shows the way ...

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he Consumers’ Health Forum of Australia Inc (CHF) is the national voice of Australia for its health consumers. It helps shape Australia’s health system by representing and involving consumers in health policy and program development and reaches nearly 1 million Australians across a wide range of health interests and health system experiences. Established in 1987, it is an independent member-based nongovernment organisation for health consumers. It receives funding from the Australian Government Department of Health and Ageing, and also through membership and specially-funded projects. CHF provides the Australian government and policy makers with a consumer perspective on health issues and balances the view of health care professionals, service providers and industry. CHF has made a major contribution to the understanding of e-health for consumer networks and promoted informed debate on key e-health issues through its 2004-05 and 2005-06 e-Health projects. One of the important projects of CHF in the recent times that the organization has been currently undertaking is the ‘E-health for Consumers Project 2006-08’. A major focus of this project is to involve and encourage health consumers to participate in creating a demand for eHealth initiatives, which will enable them to act as active partners in the matter of their own health. Though the major focus of this project can be described in a sentence-achieving

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‘E-health for Consumers Project 2006-08’ where the major objectives are to be fulfilled in its two-year duration. Besides the above mentioned one, some of the other key project objectives are to empower consumers to lobby healthcare providers, professional health service organisations and statutory bodies for adopting e-Health initiatives that improve consumer outcomes; to inform consumers about eHealth opportunities for themselves through workshops, the CHF website, newsletters, publications and other media opportunities as they arise; liaise with the Australian Government’s Department of Heath and Ageing to inform consumers on a national basis about the e-Health initiatives in their state or region; continuing to support consumer representatives on national e-Health committees, and providing informed consumer representation that is welllinked to health consumer organisations and networks; and maintaining CHF activities that provide consumers with an opportunity to give input on and be kept informed about e-Health developments across Australia. The project is ambitious in its scope and vision and its expected outcomes are also many. Some of them include achieving consumer impact assessments of a sample of e-Health tools and systems; ensuring effective consumer advocacy on Australia’s e-Health committees; and inducing key stakeholders to engage with CHF on effective implementation of e-Health initiatives. Among other expected outcomes, the

project is expected to ensure that the consumer needs and requirements of eHealth tools determine their suitability, and inform about their use with a focus on better health outcomes for consumers. It is also expected to generate increased consumer awareness of the use of electronic medication records and other electronic tools by health care providers, which would strengthen partnerships between health care providers and consumers, and to create improved understanding for consumers, particularly those with a chronic condition, about the use of e-Health tools. The links between CHF, consumer representatives on national e-Health committees, state-based consumer representatives and organisations involved with e-Health committees and initiatives are expected to be maintained or improved. A reference group provides guidance for the project, which includes the development and implementation of consumer consultation strategies on e-Health developments. A Liaison Officer of Australian Government’s Department of Health and Ageing participates as an observer on the Reference Group and facilitates two-way communication between the Department and CHF. The‘E-health for Consumers Project 2006-08 is funded by the Australian Government’s Department of Health and Ageing. For further details visit: http:// www.chf.org.au/projects/PROJ9/ index.asp eHealth | February 2007


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