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A great deal of additional information on the European union is available on the Internet. It can be accessed through the Europa server http://europa. eu/.JRC83502 EUR 26601 EN ISBN 978-92-79-37793-8 (pdf) ISSN 1831-9424 (online) doi:
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and Training (E&t) systems to keep pace with the digital economy and society. In order to modernise E&t systems, true ICT-enabled learning innovations (ICT-ELI) are needed that improve significantly upon the status quo
There is still a need to narrow digital divides and policy should: Ensure that all learners have equal and ubiquitous ICT access, in and out of school;
Data collection and content analysis covered a wide range of materials such as journals and conference papers;
portals, websites, blogs and wikis; promotional literature; video clips; and slideshow presentations. In parallel, a number of consultation rounds with key educational stakeholders (policy-and decisionmakers, teachers, researchers, IT developers etc.
and an online survey with 74 etwinning teachers who took part in a webinar was organized by the etwinning Creative Classrooms Group. 7 Findings from the workshops
and one in Hong kong, in January 2013) offering valuable insights and evidence on effective policies 7 http://groups. etwinning. net/web/creative-classroom/welcome 10 and implementation
Developing the final set of recommendations Following the aforementioned procedure, a set of qualitative data was developed including case reports, workshop findings and conclusions, interview summaries, open items of online
and analyse the qualitative data to develop a set of policy recommendations for sustaining and scaling up educational innovations at local, regional, national,
and reporting implicit and explicit patterns (themes) within the data (Braun & Clarke, 2006). ) In the present study, thematic analysis was used to transcribe qualitative data;
generate initial codes; search for themes (i e. recommendations; review themes; and refine and merge themes.
Next, an internal procedure was undertaken by the SCALE CCR research team to conduct a clustering and further reduction of the recommendations.
was developed in 1ka tool for online surveys. 9 1ka is an open source online survey application,
10 the Future of Learning Linkedin Group; 11 the etwinning Creative Classrooms Group; 12 the 10 http://groups. etwinning. net/web/creative-classroom/welcome 13 European Civil Society Platform on Lifelong Learning;
13 the European Forum on Learning Futures and Innovation; 14 the European Forum of Technical and Vocational education and Training;
16 and the SCALE CCR website. 17 Survey analytics showed that most of participants entered the survey through a direct link from the around 250 personal invitations sent by email.
A small subset of the participants came from other dissemination channels such as Linkedin, SCALE CCR webpage and etwinning Creative Classrooms Group.
which stabilised after the Organisation and leadership area with 120 respondents. 11 http://www. linkedin. com/groups/Future-Learning-2266966/about 12 http://openeducationeuropa. eu/en
/blogs/join-jrc-ipts-line-consultation-policy-recommendationsmainstreaming-ict-enabled-innovation-le 13 http://www. eucis-lll. eu/news/public-consultations
/q=story/european-forum-learning-futures-and-innovation 15 http://www. efvet. org/index. php?
which lie at the core of ICT-ELI, require content and curricula that are customised open,
in order to facilitate the innovative teaching and learning practices that lie at the core of ICT-ELI.
in order to reform assessment practices (e g. cloudbased e-portfolios that follow a web 2. 0/social media model).
The data analysis of the online consultation (Table 5) also confirms the importance of the School Staff Professional Development for mainstreaming ICT-ELI as the statements in this area were evaluated the highest compared to other areas (see more in Section 3. 8). Policy
"Innovative pedagogical practices made possible by the use of ICT lie at the core of learning innovations
with networked learning as the online component and a limited number of offline meetings, all of
and incentivise teachers to share their innovative practices with peers and other stakeholders through online and/or offline networks (71.1%).
Helping teachers to acquire much greater proficiency in data handling and methods such as learning analytics
or go to a licensed library to download) or (b) because they do not know that this research exists
Supporting policy actions for open research and dissemination of data (e g. open access publications, open data repositories, data protection strategies etc.
%Last but not least, policy should support the application of various research methods (e g. teacherled research, control groups, experimental research, longitudinal studies, social networks analysis, learning analytics, big data research, etc.
Supporting the application of various research methods (e g. teacher-led research, control groups, experimental research, longitudinal studies, social networks analysis, learning analytics, big data research, etc.
Supporting policies and initiatives for open research and free dissemination of data (e g. open data, open access publications etc.
taking into account intellectual property, security and data protection issues. 131 58.0 25. Supporting research on the perspectives of various actors and stakeholders such as policy-makers, school leaders, teachers, learners, parents, IT providers, educational content providers etc. 129 58.0 26.
Policies are needed that help learning organisations to promote networking with other organisations and stakeholders across sites and also within the same organisation,
Making sure that technological innovation (e g. 1 to 1 computing) in formal education settings is part of a wider transformation agenda
Setting evaluation, communication and feedback mechanisms (e g. platforms for collecting big and/or rich data and learning analytics) right from the start of different pilots or initiatives. 121 57,0 47.
Recent research reveals that increased and wide-ranging connectedness lies at the core of ICT-ELI with significant scale and/or impact (Kampylis, Law, et al.
Supporting data portability and interoperability between online professional networks, making it easier for teachers to participate in a number of them (e g. without having to duplicate data.
"Policy/decision-makers give their highest recommendation to developing data portability and interoperability between online professional networks, making it easier for teachers to participate in number of them. 27 3. 7 Area 7:
Policy should increase efforts and investment in infrastructure developments (e g. broadband, cloud computing, creative learning spaces etc.)
%Such ICT access requires not only appropriate ICT infrastructure (e g. cloud computing), but also the effective support structures (e g. helpdesk services) needed to implement smoothly all the necessary learning technologies.
In conclusion, policy should increase efforts and investment in infrastructure developments (e g. broadband, cloud computing, creative learning spaces etc.)
Increasing efforts and investment in ICT infrastructure (e g. broadband, cloud computing) of appropriate performance and interoperability (any device, anywhere, any system, any time) to support effective implementation and evolution of innovation for learning. 120
Policy should increase efforts and investment in infrastructure developments (e g. broadband, cloud computing, creative learning spaces etc.)
) Key Data on Learning and Innovation through ICT at School in Europe 2011. Retrieved 15 december 2013, from Education, Audiovisual and Culture Executive agency http://eacea. ec. europa. eu/education/eurydice%20/documents/key data series/129en. pdf Griffin, P.,Mcgaw, B,
from Centre for Strategic Education http://www. innovationunit. org/sites/default/files/Only%20connect%20-%20a%20new%20paradigm%20for%20learning%20innovation%20in%20the%2021st
and the data you provide will be anonymous and confidential. If you have any questions or concerns, please do not hesitate to contact us.
in order to reform assessment practices (e g. cloudbased e-portfolios that follow a web 2. 0/social media model).
Helping teachers to acquire much greater proficiency in data handling and methods such as learning analytics
1 2 3 4 5 6 7 Supporting policies and initiatives for open research and free dissemination of data (e g. open data, open access publications etc.
taking into account intellectual property, security and data protection issues. Encouraging research on the implementation process of ICT-ELI, focusing on the possible learning gains.
Supporting the application of various research methods (e g. teacher-led research, control groups, experimental research, longitudinal studies, social networks analysis, learning analytics, big data research, etc.
Making sure that technological innovation (e g. 1 to 1 computing) in formal education settings is part of a wider transformation agenda
communication and feedback mechanisms (e g. platforms for collecting big and/or rich data and learning analytics) right from the start of different pilots or initiatives.
Supporting data portability and interoperability between online professional networks making it easier for teachers to participate in a number of them (e g. without having to duplicate data.
Developing long-term sustainability and scalability strategies for cross-border professional networks, such as etwinning, for disseminating pedagogical innovation.
1 2 3 4 5 6 7 Increasing efforts and investment in ICT infrastructure (e g. broadband, cloud computing) of appropriate performance and interoperability (any device, anywhere, any system, any time
please enter your email address (e g. john@email. com). 42 Annex 2 Workshop participants Participants in the expert workshop'Scaling up ICT-enabled innovation for learning:
in order to reform assessment practices (e g. cloud-based e-portfolios that follow a web 2. 0/social media model).
7 2. 2 4. 4 8. 1 14.7 27.2 42.6 69.9 Helping teachers to acquire much greater proficiency in data handling and methods such as learning analytics,
experimental research, longitudinal studies, social networks analysis, learning analytics, big data research, etc. to the study of complex'ecosystems'of ICTELI..
8 3. 9 3. 9 10.1 22.5 34.1 24.8 58.9 Supporting policies and initiatives for open research and free dissemination of data (e g. open data
taking into account intellectual property, security and data protection issues..8 4. 6 3. 8 11.5 21.4 22.9 35.1 58.0 Supporting research on the perspectives of various actors and stakeholders such as policy-makers, school leaders, teachers
and orchestrate ICT-ELI. 1. 6 1. 6 1. 6 9. 0 13.9 42.6 29.5 72.1 Making sure that technological innovation (e g. 1 to 1 computing
data and learning analytics) right from the start of different pilots or initiatives..8 1. 7 6. 6 16.5 17.4 26.4 30.6 57.0 Encouraging collaboration and communication channels between supranational agencies (i e.
7. 6 10.1 16.0 26.9 34.5 61.3 Supporting data portability and interoperability between online professional networks
making it easier for teachers to participate in a number of them (e g. without having to duplicate data..
, broadband, cloud computing) of appropriate performance and interoperability (any device, anywhere, any system, any time) to support effective implementation and evolution of innovation for learning..
in order to reform assessment practices (e g. cloud-based e-portfolios that follow a web 2. 0/social media model).
Helping teachers to acquire much greater proficiency in data handling and methods such as learning analytics,
) Helping teachers to acquire much greater proficiency in data handling and methods such as learning analytics,
. 6 25 5. 59 17 (1. 47)( 0. 87)( 1. 41)( 1. 54) Making sure that technological innovation (e g. 1 to 1 computing) in formal education
communication and feedback mechanisms (e g. platforms for collecting big and/or rich data and learning analytics) right from the start of different pilots or initiatives. 5. 55 53 5. 59
. 38) 26 5. 75 (1. 22) 24 5. 18 (1. 59) 17 Supporting data portability and interoperability between online professional networks, making it easier
, without having to duplicate data. 5. 62 (1. 58) 53 5. 35 (1. 35) 26 5. 92 (1. 21) 24 5. 18 (1. 59) 17
, broadband, cloud computing) of appropriate performance and interoperability (any device, anywhere, any system, any time) to support effective implementation and evolution of innovation for learning. 5. 98 (1. 38) 53 5
WHO Library Cataloguing-in-Publication Data Management of patient information: trends and challenges in Member States:
. Data collection. I. WHO Global Observatory for ehealth. ISBN 978 92 4 150464 5 (NLM classification:
fax:++41 22 791 4857; e-mail: bookorders@who. int). Requests for permission to reproduce or translate WHO publications
5 9 A note on terminology 11 information systems in the literature 13 2. 1 Maturity and adoption models...
18 2. 5 Interoperability of patient data...18 2. 6 Conclusions drawn from the literature...
24 Individual patient data 24 Aggregate patient data 27 2 3. 4 Regional/District offices...
30 Individual patient data 30 Aggregate patient data 33 3. 5 National level...36 Individual patient information 36 Aggregate patient data 39 3. 6 mhealth and patient information...
42 3. 7 International standards for ehealth...42 International guidelines documents 43 Metadata standards 44 Messaging standards 45 Medical record standards 46 Vocabulary standards 46 3. 8 National
and health systems 49 Standards to identify patients 49 Individual patient data standards 49 Vocabulary standards 49 Messaging standards 50 Survey metadata standards
Data Collector 68 Preparation to launch the survey 69 Survey 70 Limitations 70 Data processing 71 Response rate 72 Response rate by WHO region 73 Response rate by World bank
Patient information systems, for example, have the ability to track individual health problems and treatment over time, giving insight into optimal diagnosis and treatment of the individual as well as improving the delivery of services.
Analysis of data in patient information systems can lead to new insight and understanding of health and disease
It examines the adoption and use of patient information systems in Member States and reviews data standards and legal protection for patient data.
and globally showed that electronic information systems are being adopted increasingly within health settings; while this is seen primarily in higher-income countries, emerging economies such as Brazil, China and India,
While some low-income countries have been able to attract technical and financial resources to install patient information systems at some sites,
patient information systems designed for high-income country health systems may not be appropriate in low-income countries In particular,
internationally-harmonized clinical models and concepts are needed for data interoperability and standardized international case-reporting,
Of course, these issues are only relevant to electronic patient information systems. While use of such systems is increasing
many Member States still rely on paper-based systems for health data collection. The survey data analysed by WHO region showed that all regions have a high use of paper-based systems, particularly the African Region and Southeast asia Region.
Countries within the Regions of The americas, Eastern Mediterranean, and the Western Pacific reported a higher use of electronic transmission of health records than computer use to collect health data.
This may be due to the use of fax or scanned image technology where the communication is electronic
The use of electronic systems is aggregated higher for (summary) data than individual patient data. This could be
because there is an institutional need for the aggregate data at management levels which in turn stimulates the creation of an electronic system.
There may be a perception that individual patient data in electronic format may not be of as much value for administration,
particularly given the difficulty of implementing patient information systems in general. However, the value of individual patient data for improved patient care is very much a case of‘connect the dots':
'given that many patients receive services from separate facilities and care providers, some form of electronic record system could compile these data
and make them accessible to other health care professionals, leading, for example, to early detection of an influenza outbreak.
Executive summary 7 Electronic health systems must be built in a way to facilitate the exchange of data;
Standards must be applied to the data and the systems themselves to allow for and facilitate the exchange of data between various sources.
The adoption of standards is progressing well across most Member States including standards for ehealth architecture, data, interoperability, vocabulary, and messaging.
These are important foundation blocks for the implementation of patient information systems because they facilitate clear communication.
In addition, most countries have taken steps to establish legal frameworks for the protection of patient data.
The report concludes with an overview of steps Member States can take to facilitate the implementation of patient information systems.
These include adoption of open source standards-based software platforms and data exchange standards to make efficient use of existing resources.
In addition, there needs to be clear legislation governing patient privacy and protecting the security of health information for records in electronic format.
Finally, the development of well-trained health informatics professionals should be a priority. Introduction 9 As part of its ongoing objective to the improvement of health through information and communication technology (ICT), the Global Observatory for ehealth (GOE) of the World health organization (WHO) conducted an extensive ehealth survey in 2009
While a significant amount of health data comes from the community and environmental observations a great amount of valuable detailed health data originates from patients in their encounters with health professionals.
In addition, surveys and surveillance activities collect more data from and about individuals. The key to effective patient information systems is to retain the link between the individual
and the data collected over time and to make those data available to multiple health care providers when needed.
Following this‘data trail'that charts the health of an individual is both valuable and important:
these data can be aggregated to provide data trails for communities, regions, and countries, upon which public health policy is shaped.
This includes resource management, monitoring and evaluation, disease surveillance, and operational research (as shown in the flow diagram below).
Many health information systems do not in fact retain data in the form of an individual patient record.
Instead the data are aggregated into summary totals which obscure the individual patient link, making it difficult to follow patients over time.
One of the reasons for this is that systems that collect, manage, and display individual patient data can be difficult to implement particularly in low-resource settings,
where health budgets are strained already. 1 Introduction Introduction 10 Most health systems collect at least some individual patient data during clinical face-to-face encounters.
Keeping these data personalized rather than anonymous is facilitated by using electronic systems which can more easily store,
access, analyse, and share data. While the conventional way to collect such data are on paper forms
and register books, increasingly, face-to-face encounters are being captured electronically. This trend will continue as improvements are made in computer hardware, software,
and telecommunication infrastructure and as countries develop the skills necessary to implement electronic data storage and transmission systems.
This report charts this progress the evolution from paper-based to electronic records. Data from patients Data linked to individual patients EMR/EHR/PHR Hospital IS (For use by
or for an individual and also research) Aggregated data (For use in planning, management and research) Part of the ehealth series based on the second global ehealth survey, this report is aimed at professionals in health care policy, planning,
and management to help them understand the role of individual patient information systems, the current state of their deployment,
and the issues in their implementation and use. A literature review of electronic patient information is followed by detailed analysis of the survey results.
The survey covers individual and aggregate patient information at the local, regional, and national levels.
The promising area of mobile health patient information is covered also. The foundation area of adoption of standards including existing international standards as well as national efforts to use these standards
which to develop a framework for action to improve the effective use of patient information systems.
The EMR can also support the collection of data for uses other than clinical care such as billing, quality management, outcome reporting,
Furthermore, an EMR may contain clinical applications that can act on the data contained within its repository, for example, a clinical decision support system (CDSS), a computerized provider order entry system (CPOE), a controlled medical vocabulary,
if they are able to exchange data using standardized data transmission formats (1). The electronic health record (EHR) is a longitudinal electronic record of patient health information generated by one or more encounters in any care delivery setting.
Included in this information are patient demographics progress notes, problems, medications, vital signs, past medical history, immunizations, laboratory data,
and assisting with chronic disease management via an interactive, common data set of electronic health information and ehealth tools.
and is subject to various legal limitations (3). Patient information systems in the literature 13 2 Electronic patient information systems have the potential to improve health by giving health professionals improved information about their patients.
The literature review covers health information systems with an emphasis on the management of patient information and will help contextualize the survey results.
or describe the current level of information technology adoption in the health sector. These are useful benchmarks
when looking at patient information systems. Capability Maturity Model The Capability Maturity Model (CMM)( 4) was defined originally for software development by Carnegie mellon University
and is useful for assessing health information systems. Five levels are defined along the model's continuum.
Predictability effectiveness, and control of an organization's software processes are believed to improve as the organization moves up these five levels.
Patient information systems in the literature Patient information systems in the literature 14 Level 1. Initial (chaotic, ad hoc, individual heroics) the starting point for use of a new process.
Level 2. Repeatable the process is able to be used repeatedly, with roughly repeatable outcomes. Level 3. Defined the process is defined/confirmed as a standard business process Level 4. Managed the process is managed according to the metrics described in level 3, that is
data collection and analysis. Level 5. Optimized process management includes deliberate process optimization/improvement. Enterprise Architecture An alternative method is the Enterprise Architecture (EA) approach. 1 An early description of this methodology was described by Spewak
architecture vision, business architecture, information system architecture, technology architecture, opportunities and solutions, migration planning, implementation governance,
This continuous cycle is the key to successful information system improvement in this process. Australian National ehealth Interoperability Maturity Model Individual health information must follow the patient as s/he receive services from various providers.
This requires data interoperability which is the key to effective use of health information. The Australian National ehealth Transition Authority has defined an Interoperability Maturity Model (6) that identifies increasing capability for data interoperability.
Interoperability Maturity Model levels Initial: There is an early awareness of ehealth interoperability requirements and characteristics and perhaps some initial ehealth interoperability solutions adopted,
shared understanding of data services or internal processes as well as initial governance established to ensure repetition of earlier successes. Defined:
An organization has defined a set of guidelines for the adoption of ehealth standards for data, services and processes,
facilitating a shared understanding across technical and semantic issues. 1 See for more information, http://enterprise-architecture. info/and http://www5. opengroup. org/togaf Patient information systems in the literature 15 Measured:
Major ancillary clinical systems feed data to a clinical document repository (CDR) that provides physicians access to results.
and national standards. 2 www. himss. org 3 http://www. cdc gov/nhsn/CDA ESURVEILLANCE. html Patient information systems in the literature 16 2. 2
ICT in developing countries Developing countries usually collect district level aggregate health data to plan
After they have established district level health data collection, these countries may move to more complex data systems including patient information systems,
which rely on ICT infrastructure. ICTS can help developing countries make better use of limited resources to improve health by providing better use of information.
The Gates Foundation sponsored a comprehensive analysis on the state of health information systems in developing countries that was published in 2009 (10.
The first three focus on the development of the district health information system from manual (level 1) through optimized (level 2) and electronic reporting (level 3). Level 4 incorporates operational health ICT systems
automatic data capture and access to information. Their top level is integrated a fully national health information system,
which includes data from all public and private sources. Results showed that most of the 19 countries selected only collected district level information
6 of which were at level 1 (manual; 7 had started to integrate level 2 (optimized) or level 3 (electronic reporting).
the state of telecommunications reform and availability of affordable ICT access; presence of data standards and regulatory frameworks;
mechanisms to develop the capacity of health workers; and options to ensure the continuity and sustainability of the effort.
and why to foster support. infodev has created also a continuously updated database to function as an ongoing resource for stakeholders. 4
what works and how many of these lessons apply equally to developed countries. 4 http://www. asksource. info/res library/ict infodev. htm Patient information systems in the literature 17 2. 3 Benefits of electronic
Benefits included increase in immunization rates, improved data collection, increased staff productivity, increased visitor satisfaction with services, improved communication, quality of care, access
to data, reduced medical errors, and more efficient use of staff time. Some of the disadvantages noted were:
time-consuming data entry, slow access of data and decreased quality of patient-doctor interaction.
In recent papers, Mckay, Douglas and colleagues (17,18) document their experience implementing clinical workstations at the point of care in Malawi.
They designed and built an innovative hardware and software system using touch screen clinical workstations which collected individual patient information,
analysed the data and presented information on national protocols. They demonstrated that the system could efficiently
and accurately guide low-skilled health care workers through the diagnosis and treatment of patients following national protocols.
and presented clinical data that supplemented clinical decision-making. In addition, the data were aggregated and used at the national level for policymaking and analysis. In 2010,
a total of 650 000 patients were registered with 50 000 receiving care for human immunodeficiency virus (HIV. The systems were used for patient registration, HIV care, paediatric patient management, radiology, pharmaceutical and laboratory work.
They used free open-source software for the project which enabled them to enlist the support of a large community.
and supported by private enterprise and also in the form of free open source software systems which are supported by non-profitmaking organizations and private enterprises.
Open source systems have advantages of local sustainable community development and support and lower cost by building on a proven software foundation (19.
Patient information systems in the literature 18 Studies have shown improvements in health information technologies increasing adherence to guideline
Another area of demonstrated improvement is increased in the coverage of preventive care services such as influenza vaccination,
and outcomes and use this to introduce changes. 2. 4 mhealth The use of mobile technologies for data collection about individuals
and interoperability. 2. 5 Interoperability of patient data The purpose of collecting and storing patient information is to make it available for decision-making at a point of care or for analysis and action for management and policy.
It is essential that their individual patient information be available at all points of care and all sites for analysis. In order for this to work,
there must be standards for representing the data and for communication. Distributed health data networks have been proposed to improve the ability to collect
and analyse data across institutions leading to improved effectiveness, safety, and quality of care (26).
In the health field, there are several common nomenclatures that have been developed and are maintained by various organizations.
6 5 http://www. ihtsdo. org/snomed-ct 6 http://www. who. int/classifications/ichi/Patient information systems in the literature 19 2. 6
and communication technology in health care due to its potential for improving the efficiency of health care delivery and quality of care, particularly through interoperable data standards.
improved access to timely data by care providers and for access by multiple users (not geographically bound)
Several core aspects of ehealth implementation are crucial. The first is need the to ensure that data are exchangeable.
Interoperable data standards are fundamental requirements that are overlooked frequently, with the result that many sites are unable to share data thus limiting the flow of information.
Interoperability depends on agreed standards enforced across all applications. Second attention must be paid to data quality
since this will impact the quality of decisions. Finally, health ICT systems require skilled personnel for their development and maintenance.
Therefore training (e g. computer literacy, program usage) and human resources development are critical components within systems, and must be addressed.
Analysis of survey results 21 3 3. 1 Survey methodology Results of the second global survey on ehealth are presented within the context of three classifications:
Most countries have developed fairly well systems for capturing aggregate health data from clinics for use in disease surveillance and health status. However,
which means that computer software designed for this purpose must reflect its complexity. Capturing and using individual patient information electronically also requires installation of computer equipment at or close to the point of care.
In addition to the cost of the computer hardware and software, EMR/EHR systems require substantial resources including electricity, a controlled environment, training, maintenance and support.
The survey contained a module on the management of patient information at the local, regional/district,
a simplified maturity model with three methods of data collection (levels of technological implementation) was used in the survey.
and data are transferred from paper for analysis or use. Computerized data: Data are entered into a computer (often from paper) from where they can be analysed
and retrieved. Computerized data and electronic communication: This most advanced level combines the use of computerized data with the ability to electronically transmit it to multiple users in multiple locations.
Format use Survey respondents were asked to estimate the use of a format on a five point scale starting at none indicating no use to very high meaning over 75%.
%Details of the measurement scale are found below. None no use Low below 25%Medium 25 to 50%High 50 to 75%Very High above 75%These categories are sufficiently broad to offer a measure of accuracy
while providing meaningful quantitative results from which conclusions can be drawn. All countries have a broad range
and mix of adoption of technology: countries with low overall adoption still often have pockets of higher adoption;
Tables 1 and 2 provide summary data of the trends identified in the transition from paper to digital records.
Analysis of survey results 23 Table 1. Use of paper and electronic formats for individual patient data, by health system level and income group National Regional
Table 2. Use of paper and electronic formats for aggregate patient data, by health system level and income group National Regional/District 0%20%40
and community health sites and primary health care centres. These are the first points of care
and encounters with patients and the‘front line'of the health information system. It is not only the source of patient data
but also the location where the information can be put to immediate use to guide the diagnosis
Individual patient data Individual patient information is collected and tagged with a patient identifier and can later be retrieved by that identifier.
Figure 1. Individual patient data collected in local health care facilities, globally Figure 1 shows the global responses to the question about individual patient data.
high or medium adoption) with much lower levels of data collected in electronic format (45%reporting very high,
Key findings Most patient data are collected still on paper. Countries in higher income groups have higher adoption of EMR/EHR systems.
Adoption of patient information systems is linked to country resources. 0%20%40%60%80%100%Very high High Medium Low None No answer Paper Electronic Electronic transmission
Percent of countries Data format Analysis of survey results 25 Figure 2. Individual patient data collected in local health care facilities,
income Lower-middle income Low income None No answer Paper Electronic Electronic transmission Data format 0%20%40%60%80%100%High income
Upper-middle income Lower-middle income Low income None No answer Paper Electronic Electronic transmission Data format 0%20%40%60%80%100
Data format Lower-middle income Low income 0%20%40%60%80%100%High income Upper-middle income Lower-middle income
Low income None No answer Paper Electronic Electronic transmission Data format 0%20%40%60%80%100%High income Upper-middle income Lower
-middle income Low income None No answer Paper Electronic Electronic transmission Data formats Data format There appears to be a direct relationship between country income and the adoption of electronic patient information systems and communication
of data. Figure 2 shows that high-income countries report medium to very high use of electronic information systems in over 50%in these categories for electronic communication of health data.
In contrast, only a small percentage (4%)of low-income countries report medium adoption of electronic patient information systems and communication of health data and none report higher levels
of adoption. These patterns of adoption can be explained primarily by the fact that high-income countries have the clear advantage of greater available resources
and access to trained professionals to implement electronic patient information systems at the local level. Analysis of survey results 26 Figure 3. Individual patient data collected in local health care facilities
by WHO region African Region Eastern Mediterranean Region 0%20%40%60%80%100%High income Upper-middle income Lower-middle income
Low income None No answer Paper Electronic Electronic transmission Data format 0%20%40%60%80%100%High income Upper-middle income Lower
-middle income Low income None No answer Paper Electronic Electronic transmission Data format European Region Regions of The americas Percent of countries 0%20%40%60
%80%100%High income Upper-middle income Lower-middle income Low income None No answer Paper Electronic Electronic transmission Data format 0%20
%40%60%80%100%Very high High Medium Low None No answer Paper Electronic Electronic transmission 0%Data format 20%40%60%80%100
transmission Data format Southeast asia Region Western Pacific Region 0%20%40%60%80%100%High income Upper-middle income Lower-middle
income Low income None No answer Paper Electronic Electronic transmission Data format 0%20%40%60%80%100%High income Upper-middle income
Lower-middle income Low income None No answer Paper Electronic Electronic transmission Data formats Data format When the same data are analysed by WHO region (Figure 3),
and the Western Pacific Region show a higher adoption rate of electronic transmission of data than actual collection of patient information in electronic format.
It could also be the case that data are transferred offline using compact discs (CDS) or cassette tapes between data centres from the health care centre to the districts or central agency.
Analysis of survey results 27 Aggregate patient data The data collected from individuals can be aggregated to give counts of various diseases
health status, diagnoses, and treatments. In basic health information systems, data may be aggregated directly at the time
and point of care using tally sheets or totalled from registers. If there is an electronic system in place to collect such information,
aggregation can be done automatically by a computer counting the incidents of interest over a given time period this might provide early evidence of emerging
Figure 4. Aggregate patient data collected in local health care facilities, globally Figure 4 shows there is still a large proportion of countries worldwide using paper to record health data.
Results show that use of electronic formats for aggregate patient data is higher than for individual patient data
except at local levels where it appears many facilities are collecting and using their aggregate data on paper.
While this may be feasible for local use, paper-based reporting at higher levels of the health system is more cumbersome (labour-intensive) and prone to error.
Key findings Use of electronic formats is aggregated higher for data than individual data. There is a relationship between country income and the use of electronic formats.
High Medium Low None No answer Paper Electronic Electronic transmission Percent of countries Data format Analysis of survey results 28 Figure 5. Aggregate patient data collected in local health care facilities,
Electronic transmission Percent of countries Data format 0%20%40%60%80%100%Very high High Medium Low None No answer Paper Electronic Electronic transmission
transmission Percent of countries Data format 0%20%40%60%80%100%Very high High Medium Low None no answer Paper Electronic Electronic transmission Data formats
Data format 0%20%40%60%80%100%Very high High Medium Low None No answer Paper Electronic Electronic transmission Data format Analysis of survey results
data collected in local health care facilities by WHO region It is interesting that countries of the Southeast asia
this may be explained by countries using digital communication formats such as fax to send paper-based reports. African Region Eastern Mediterranean Region 0%20%40%60%80%100%Very high High Medium Low None No answer Paper Electronic Electronic transmission
Data format 0%20%40%60%80%100%High income Upper-middle income Lower-middle income Low income None No answer Paper Electronic
Upper-middle income Lower-middle income Low income None No answer Paper Electronic Electronic transmission Data format 0%20%40%60%80%100
%Very high High Medium Low None No answer Paper Electronic Electronic transmission 0%Data format 20%40%60%80%100%Very high High Medium
Low None No answer Paper Electronic Electronic transmission Data format Southeast asia Region Western Pacific Region 0%20%40%60%80%100%Very high High Medium Low None No answer Paper Electronic Electronic transmission Data format 0%20%40
%60%80%100%Very high High Medium Low None No answer Paper Electronic Electronic transmission Data formats Data format Analysis of survey results 30 3. 4
Regional/District offices Regional or district offices are a crucial management link for most health care systems these are the offices
and representative data from local facilities is crucial to this work. Regional or district offices are involved often in immediate short-term operational planning for the facilities
Individual patient data Figure 7. Individual patient data collected in regional offices, globally Figure 7 shows that most responding countries reported that they continue to use paper-based methods of collecting patient information at the regional level with 38%and 26%reporting very high and high use
Percent of countries Data format Analysis of survey results 31 Figure 8. Individual patient data collected in regional offices,
Low None No answer Paper Electronic Electronic transmission Data format 0%20%40%60%80%100%High income Upper-middle income Lower-middle income
Low income None No answer Paper Electronic Electronic transmission Data format 0%20%40%60%80%100%Very high High Medium Low None No answer Paper
Electronic Electronic transmission Data format Lower-middle income Low income 0%20%40%60%80%100%High income Upper-middle income Lower-middle income Low income
None No answer Paper Electronic Electronic transmission Data format 0%20%40%60%80%100%High income Upper-middle income Lower-middle income
Low income None No answer Paper Electronic Electronic transmission Data formats Data format Responses by World bank income group are shown in Figure 8. The trend is similar to that found at the local level:
mostly paper-based data recording. Low and lower-middle income countries report both very high
While upper-middle income countries report similar levels of the use of paper as the two lower-income country groups, countries in this group have made greater strides towards digitization:
Analysis of survey results 32 Figure 9. Individual patient data collected in regional offices, by WHO region Approximately 70%of responding countries from the African Region reported very high use of paperbased systems followed by the Western Pacific (46%)and Eastern Mediterranean (43%)Regions (Figure 9). The pattern of using paper
Data format 0%20%40%60%80%100%Very high High Medium Low None No answer Paper Electronic Electronic transmission Data format European Region Regions
of The americas Percent of countries 0%20%40%60%80%100%Very high High Medium Low None No answer Paper Electronic Electronic transmission Data format 0
%20%40%60%80%100%Very high High Medium Low None No answer Paper Electronic Electronic transmission 0%Data format 20%40%60%80
%100%Very high High Medium Low None No answer Paper Electronic Electronic transmission Data format Southeast asia Region Western Pacific Region 0%20%40
Low None No answer Paper Electronic Electronic transmission Data format 0%20%40%60%80%100%Very high High Medium Low None No answer Paper Electronic
Electronic transmission Data formats Data format Analysis of survey results 33 Aggregate patient data Aggregate patient data provide the core data on which regions
Aggregate patient data collected in regional offices, globally Globally, there is still a high use of paper-based systems accounting for 31%of responding countries ranking its deployment level as very high.
There is also generally low deployment of electronic patient data and electronic communication systems with these systems showing none or low deployment (approximately 37%and 48%,respectively;
of countries Data format Analysis of survey results 34 Figure 11. Aggregate patient data collected in regional offices,
by World bank income group The deployment trend of paper-based systems compared to electronic formats across all World bank income groups is clear:
It is interesting to note that there is at least a low to medium level of deployment of aggregate electronic patient information and communication systems in lower-income countries.
which are usually set up to facilitate the collection of aggregate data. High-income countries have a more diverse system for delivering care including an active private sector where it is more difficult to collect data.
High income Upper-middle income Percent of countries 0%20%40%60%80%100%Very high High Medium Low None No answer Paper Electronic
Electronic transmission Percent of countries Data format 0%20%40%60%80%100%Very high High Medium Low None No answer Paper Electronic Electronic transmission
Percent of countries Data format 0%20%40%60%80%100%Very high High Medium Low None No answer Paper Electronic Electronic transmission Data format Lower
of countries Data format 0%20%40%60%80%100%Very high High Medium Low None No answer Paper Electronic Electronic transmission Percent of countries Data formats
Data format Analysis of survey results 35 Figure 12. Aggregate patient data collected in regional offices
by WHO region Countries of THE WHO African, Eastern Mediterranean, and Western Pacific Regions show a high level of paper use and low use of electronic systems (Figure 12).
The European Region's high deployment of both paper-based and electronic patient information systems is at 25%and 22%,respectively.
but overall noting of data is low. Thus, it appears that where data are recorded, they are being transmitted electronically roughly half the time.
Again the data show that the European Region and Region of The americas are advanced more in the transition to digital formats,
and that the African Region is likely to have the most significant challenges digitizing their records in the future.
Data format 0%20%40%60%80%100%Very high High Medium Low None No answer Paper Electronic Electronic transmission Data format European Region Regions
of The americas Percent of countries 0%20%40%60%80%100%Very high High Medium Low None No answer Paper Electronic Electronic transmission Data format 0
%20%40%60%80%100%Very high High Medium Low None No answer Paper Electronic Electronic transmission 0%Data format 20%40%60%80
%100%Very high High Medium Low None No answer Paper Electronic Electronic transmission Data format Southeast asia Region Western Pacific Region 0%20%40%60
None No answer Paper Electronic Electronic transmission Data format 0%20%40%60%80%100%Very high High Medium Low None No answer Paper Electronic Electronic
transmission Data formats Data format Analysis of survey results 36 3. 5 National level At the national level,
individual patient data are most useful for operational research, planning, and policy. Longitudinal records of the history of individual patients can be useful in tracking the course of diseases and responses to treatment,
Individual patient data collected at the national level, globally Globally, the use of paper-based systems remains high for the collection of individual patient information with half of the participating countries ranking their use as either high or very high (Figure 13).
Key findings The use of paper-based systems continues to be high for individual patient data at the national level.
Countries in the high and upper-middle income groups tend to have higher adoption of electronic patient information systems. 0%20%40%60%80%100%Very high High
Medium Low None No answer Paper Electronic Electronic transmission Percent of countries Data format Analysis of survey results 37 The trend seen globally is the same
which is likely to indicate that some countries do not use electronic patient information systems for individual patients at the national level.
Individual patient data collected at the national level, by World bank income group High income Upper-middle income Percent of countries 0%20%40%60%80%100%Very high High Medium
Low None No answer Paper Electronic Electronic transmission Percent of countries Data format 0%20%40%60%80%100%Very high High Medium Low None No answer Paper
Electronic Electronic transmission Percent of countries Data format 0%20%40%60%80%100%Very high High Medium Low None No answer Paper Electronic Electronic
transmission Data format Lower-middle income Low income 0%20%40%60%80%100%Very high High Medium Low None No answer Paper Electronic
Electronic transmission Data format 0%20%40%60%80%100%Very high High Medium Low None No answer Paper Electronic Electronic
transmission Data formats Data format Analysis of survey results 38 Figure 15. Individual patient data collected at the national level,
by WHO region THE WHO regional differences are similar to the trends seen at the health facilities and regional/district levels.
Data format 0%20%40%60%80%100%Very high High Medium Low None No answer Paper Electronic Electronic transmission Data format European Region Regions
of The americas Percent of countries 0%20%40%60%80%100%Very high High Medium Low None No answer Paper Electronic Electronic transmission Data format 0
%20%40%60%80%100%Very high High Medium Low None No answer Paper Electronic Electronic transmission 0%Data format 20%40%60%80
%100%Very high High Medium Low None No answer Paper Electronic Electronic transmission Data format Southeast asia Region Western Pacific Region 0%20%40%60
None No answer Paper Electronic Electronic transmission Data format 0%20%40%60%80%100%Very high High Medium Low None No answer Paper Electronic Electronic
transmission Data formats Data format Analysis of survey results 39 Aggregate patient data Aggregate patient data is useful at the national level for planning, policy formulation, programme
Aggregate patient data collected at the national level, globally Figure 16 shows that one third of countries reported high to very high use of electronic records and electronic transmission of data, respectively, at the global level.
which indicates that use of electronic systems for data collection and dissemination is growing. Key findings Globally
approximately one third of responding countries collect aggregate data in electronic formats and one third transmit it electronically at the national level indicating fairly widespread adoption of electronic systems.
High-income countries have moved clearly to electronic formats with a majority reporting high to very high use of electronic data collection and transmission at the national level.
and Eastern Mediterranean Regions show a higher use of electronic communication modalities than electronic data collection.
of countries Data format Analysis of survey results 40 Figure 17. Aggregate patient data collected at the national level,
by World bank income group The trend of increased deployment of electronic systems seen globally does not appear to apply to low-income countries, however:
Electronic transmission Percent of countries Data format 0%20%40%60%80%100%Very high High Medium Low None No answer Paper Electronic Electronic transmission
Percent of countries Data format 0%20%40%60%80%100%Very high High Medium Low None No answer Paper Electronic Electronic transmission Data format Lower
-middle income Low income 0%20%40%60%80%100%Very high High Medium Low None No answer Paper Electronic Electronic transmission Data format
0%20%40%60%80%100%Very high High Medium Low None No answer Paper Electronic Electronic transmission Data formats Data format Analysis of survey results
The European Region reported the lowest level of deployment of paper-based systems and reported extensive use of electronic systems for data storage and transmission.
Aggregate patient data collected at the national level by WHO region African Region Eastern Mediterranean Region 0%20%40%60%80%100%Very high High Medium Low None No answer Paper Electronic Electronic
transmission Data format 0%20%40%60%80%100%Very high High Medium Low None No answer Paper Electronic Electronic transmission Data format European Region
Regions of The americas Percent of countries 0%20%40%60%80%100%Very high High Medium Low None No answer Paper Electronic Electronic transmission Data format
0%20%40%60%80%100%Very high High Medium Low None No answer Paper Electronic Electronic transmission 0%Data format 20%40%60
%80%100%Very high High Medium Low None No answer Paper Electronic Electronic transmission Data format Southeast asia Region Western Pacific Region 0%20%40
High Medium Low None No answer Paper Electronic Electronic transmission Data format 0%20%40%60%80%100%Very high High Medium Low None No answer Paper
Electronic Electronic transmission Data formats Data format 42 3. 6 mhealth and patient information The second global survey on ehealth also covered the use of mobile technologies for health.
It defined mhealth as an emerging term for medical and public health practice supported by mobile devices, such as mobile phones, patient monitoring devices, personal digital assistants (PDAS),
and other wireless devices. mhealth applications include the use of mobile devices in collecting community and clinical health data,
Electronic information systems rely on standards; in order to share and aggregate data, countries utilizing such systems need to collect data using standard definitions and formats.
In order to exchange health data systems must include syntax and semantic content that is clear and unambiguous to both sender and receiver.
Messaging standards describe protocols to communicate data. Medical record standards specify the structure, content, and organization of individual patient medical records.
which countries can use in developing indicators for their health information systems. Eighteen per cent of the responding countries report using this toolkit to strengthen their health systems. 0 20 40 60 80 100 Other IXF DCMI DDI SDMX CEN/ISO GFATM
Metadata standards Countries tend to be advanced fairly in the planning for information systems before they see the need for
Unfortunately the importance of metadata is understood usually only after a country becomes involved with planning and information systems.
Further complicating use of metadata standards is the lack of communication that is often in evidence between the professionals who develop digital information systems
Dublin Core Metadata Initiative (DCMI) The Dublin Core Metadata Initiative7 is engaged an organization in the development of interoperable metadata standards, architecture, and modelling.
and environment of data. The purpose of defining metadata is to improve interoperability of data through standardization,
that is, giving the collector and receiver of information as much information as possible on the context of the data so that the receiver will attach the same meaning to the data as the original collector.
Only 5%of countries responding to the survey use the DCMI model methodology. This low uptake could represent a lack of knowledge of the standard or difficulty in implementation.
The Data Documentation Initiative (DDI) The Data Documentation Initiative8 is a metadata specification for the social sciences to promote data interoperability and integration
using Extensible Markup language (XML) to express the data. It takes a life-cycle approach to data;
from collection, analysis, publication, and management, data can be reprocessed at later stages of their life-cycle.
This creates an iterative, circular process with respect to data usage. Only 5%of responding countries report using this standard for their data.
Its low level of adoption could be that the standard is not well known or is considered not appropriate for use in the health sector.
Statistical Data and Metadata exchange (SDMX) SDMX is an initiative for standards for statistical data and metadata exchange.
The SDMX sponsoring institutions are the Bank for International Settlements, the European central bank Eurostat (the 7 http://www. dublincore. org 8 http://www. ddialliance. org 45 statistical office of the European union), the International monetary fund (IMF), the Organisation for Economic Co
because of their utility and interoperability they have found use for health data with the adoption of the Statistical Data and Metadata Exchange Health Domain9 (SDMX-HD).
These standards are useful for exchanging health data and the metadata describing health data. Nine per cent of responding countries use the SDMX standards.
Metadata standards have a much lower rate of adoption. This could be due to difficulty of implementation or perhaps due to the lack of awareness by,
Messaging standards Overall, messaging standards have been adopted widely because of their clear utility in communicating health data.
This is due to the fact that the HL7 standard is built into most commercial health information software and therefore widely recognized.
It was adopted by UNAIDS for use by the Country Response Information System (CRIS) software (32.
XMLBASED data exchange. 9 http://www. sdmx-hd. org 46 Thirty-four countries report using a version of CRIS;
they seek to build synergies, through data exchange, with other data management tools between sectors.
Survey respondents may not have realized that the CRIS software uses IXF and therefore underreported IXF use.
ISO TC 215 and CEN/TC 251 ISO's Technical Committee (TC) 215 on health informatics works on health information and communications technology to facilitate interoperability of health data.
data structure, data interchange, semantic content, security, pharmacy and medicines business, devices, business requirements for electronic health records,
A number of workgroups, each dealing with a specific aspect of the data have been formed under TC 251.
and device communication as well as privacy and security issues related to patient data. Fifteen per cent of the responding countries use this standard.
and modifications of the ICD to provide better coverage of clinical conditions, health care procedures, and morbidity.
The SNOMED CT is a collection of medical terms covering most areas of clinical information that is systematically organized to be processed by computer.
and retrieve clinical data across care boundaries and sites, and consists of over a million medical concepts.
and a patient care data set. LOINC is preferred the code set for HL7 laboratory test names in transactions.
category of health data for use in-country. National standards are usually based on the international standards discussed in the previous section,
and effort but has the benefits of improved information flow and better use of health data with better health outcomes as a result.
Often the guideline documents will specify the use of national data sets or identifiers in order to improve the compatibility of health data.
Fifty-eight per cent of the responding countries use guidelines documents for national health data standards. 0 10 20 30 40 50 60 Other Survey
metadata Messaging Vocabularies Indiv patient data Patient identiers Indicators Guidelines Percent of countries National standards 49 Standards for indicators used to monitor health
and health systems Most countries will have a national set of indicators which are used to monitor health status and health system performance.
Usually these have a legacy of data and usage that means that they may not fully adhere to international standards.
since there is a risk of losing compatibility with historical data. However, if the definitions in the standards are not clear,
When dealing with individual patient data it is important to identify specific information so that the patient can be referenced uniquely and reliably.
Most systems will define a unique identifier that is local to the software application. Clinics and hospitals often have an identifier that is used throughout a system to transfer information such as clinical observations, laboratory and radiology results, and orders.
Individual patient data standards Thirty-eight per cent of responding countries have standards for individual patient data.
This can be anything from a small data set of demographic and basic clinical information to a complete longitudinal electronic medical record with full professional, laboratory, radiology and ancillary service input.
Most commonly, countries have defined some set of individual patient data that is useful for continuity of care, monitoring and evaluation,
or aggregate data for planning or research. Examples of international individual patient data standards are the Continuity of Care Record (CCR)( 33) and the Continuity of Care Document (CCD)( 34;
the latter is based on the Clinical Document Architecture (CDA) in use in the USA. The CCR was developed to facilitate transfer of the essential health record of an individual patient from one care provider to another through the use of a standard format and vocabulary.
Countries might find it useful to define their own vocabulary for a data set that is used within the country such as national health indicators, routine facility reporting,
Messages can be used to retrieve historical data as well as current data. A health message includes health data that is expressed in a standard vocabulary.
It may also include metadata about the definitions or environment of the data. The message itself is in a precisely defined format
so that it can be received by a computer program which will understand its meaning. HL7 is the most commonly used health message standard.
Health software applications often use a proprietary or ad hoc messaging format that must be customized to be understood by both sender and receiver.
These formats are usually only useful in a local context. The more messages that are sent
Survey metadata standards Surveys are a valuable method of collecting health data. They usually identify a specific topic
or collect data using standards which allows comparison with other surveys. In order to compare survey data,
it is necessary to have a standard set of metadata about the survey so that the complete context of the data,
as well as the health data set definitions, are specified. Only a relatively small percentage (19%)of responding countries have adopted standards for survey metadata.
However, it is anticipated that uptake will increase as more countries realize the value of defining standards for survey metadata (e g. reaping the benefits of having standard reference data about time and location.
3. 9 Legal framework and adoption By its nature health information is sensitive, particularly when it comes to individual health information.
it is assumed that the legal framework governing health information would apply. 3. 10 Summary of key findings Most patient data are still being collected on paper in spite of the high costs, limited usefulness,
Use of electronic formats is aggregated higher for data than individual data. This can be due to the relative difficulty of implementing electronic formats for individual patient data
which require more complex software and training. High-income countries have transitioned to the point where there is today a higher use of electronic formats than paper records for patient data.
Only a limited number of countries report widespread use of electronic formats coupled with electronic communications,
the most advanced scenario polled. These are high-income countries which have advanced ICT infrastructure as well as a highly educated workforce.
which could be indicative of adoption of interoperable systems to communicate electronic data. The increasingly widespread availability of mobile telephone communications technology is an important asset
many countries collect aggregate health data in electronic formats at the national level indicating fairly widespread adoption of electronic systems for reporting at this level.
Many countries have adopted standards for data interoperability and have national plans for implementation. Often these are based on international standards developed by international organizations such as UNAIDS,
and benchmarking of data. The survey illuminates active exploration and adoption of electronic tools for management of patient information.
and legal foundations for solid future growth of electronic records and their electronic transmission. 53 The survey results and supporting literature make a compelling case for the broad adoption of patient information systems
They show that countries in the higher-income groups are more likely to be advanced further in the digitization of patient information than those in the lower-income groups.
as the process of digitization of records is highly dependent on, and linked to, the availability of human and ICT resources to
national health system priorities and institutional will also play key roles in the successful implementation of patient information systems,
for WHO including specific reference to patient information systems, interoperability, and privacy of patient information and security (36).
and implementation of ehealth services including patient information systems. It calls on governments to form national ehealth bodies to provide guidance in policy and strategy, data security, legal and ethical issues, interoperability, cultural and linguistic issues,
The body should include a division responsible for the governance of ehealth data interoperability standards and patient data privacy and security.
and request input from WHO offices to assist with the more detailed elements of strategy development and ehealth services planning including advice on patient information systems.
and the International Telecommunication Union (ITU) have developed jointly a comprehensive resource on ehealth strategy and planning.
Among the components covered related to the management of patient information are data privacy, security, and interoperability.
It is essential that Member States adopt data interoperability standards for the recording and communication of health information.
and receiver of data have the same definition and understanding of them. Without this understanding, health data communication is not reliable.
WHO and its partners maintain a repository of indicator metadata to promote harmonization and management of indicators (37) for summary data.
Individual patient clinical data can be standardized using the standards already covered in this publication WHO further recognizes the important need for the development of patient health data privacy and security standards.
Individual patient data must be protected from unauthorized disclosure. This requires the development and adoption of national regulations governing the collection, storage,
and use of patient health data. 11 http://www. who. int/ehealth 55 The collection of individual patient information permits the establishment of a longitudinal medical record which is invaluable for improving care
Electronic health information systems have been shown to be effective at improving the quality and efficiency of health services.
The use of free open-source software to develop sustainable health informatics capacity may leverage the investment in developing such systems.
Free open source software is particularly a boon to countries with financial constraints. The survey demonstrates that the greatest barrier to adoption of patient information systems is the lack of resources.
Human resources for implementation and training are the greatest cost of patient information systems. Free open-source software enables the development of sustainable local human resources for the implementation and maintenance of health information systems by drawing on a community of developers and users
all of whom share advances. Each project can benefit from the efforts of the community and,
in turn, contribute to the community. This can lessen the demand for expensive external resources and enable the development of sustainable health information systems.
Further, it can leverage the investment in trained human resources for maximum benefit. A major and well recognized obstacle to the adoption of patient information systems, particularly in developing countries, is the lack of skilled health informatics professionals.
By encouraging the development of a cadre of trained professionals, Member States will facilitate the adoption of health information systems.
In time these professionals can provide a sustainable bridge to improved use of health information and most importantly, better health. 57 1. Electronic medical records.
The Office of the National Coordinator for Health Information technology, United states Department for Health and human services (http://healthit. hhs. gov/portal/server. pt/community/electronic medical records/1219/home/15591
Enterprise Architecture planning-developing a blueprint for data applications and technology. Hoboken, NJ, John Wiley and Sons, 1993.6.
Health information systems in developing countries: a landscape analysis. Vital Wave Consulting, 2009 (www. minsa. gob. pe/ogei/conferenciaops/Recursos/43. pdf, accessed 2 july 2012). 11.
Touchscreen clinical workstations at the point of care: guiding protocols and managing data in Malawi.
Baobab Health unpublished observations, 2008.18. Douglas GP et al. Using touchscreen electronic medical record systems to support
and monitor national scale up of antiretroviral therapy in Malawi. PLOS Medicine, 2010,7 (8: e1000319. 19.
Weerawarana S, Weeratunga J. Open source in developing countries. Swedish International Development Cooperation Agency, 2004,(http://www. eldis. org/fulltext/opensource. pdf, accessed 1 june 2012). 20.
Inpatient computer-based standing orders vs physician reminders to increase influenza and pneumococcal vaccination rates: a randomized trial.
Distributed health data networks: a practical and preferred approach to multiinstitutional evaluations of comparative effectiveness, safety,
Data exchange with the country response information system and UN AGENCY software. A step by step guide. Geneva, UNAIDS, 2006 (http://data. unaids. org/pub/Basedocument/2007/cris de web final en. pdf, accessed 28 march 2012). 33.
Continuity of care record. Version 2. 1b. American Society for Testing and Materials/Massachusetts Medical Society/Health Information management and Systems Society, 2012.
Geneva, World health organization, 2011 (http://www. who. int/gho/indicator registry/en/,accessed 28 march 2012). 61 Bandwidth A measure of the amount of data that can be transmitted per unit of time.
which allows physicians to enter orders for diagnostic and therapeutic actions directly into a computer for execution.
Data Data refer to raw, unedited observations. Glossary 62 Data dictionary A specialized type of database containing metadata,
which is managed by a data dictionary system. This centralized repository of information describes the characteristics of data used to design, monitor,
document, protect, and control data in information systems and databases; it can also refer to an application of data dictionary systems.
Data management A set of procedures to collect, store, analyse, and distribute data. Once data are collected,
a sound management approach is essential. Firstly, a metadata dictionary is necessary to accurately describe the data elements.
Next, effective data storage procedures require a well-designed logical structure to permit data retrieval and analysis. Data analysis and presentation include calculating indicators
and preparing tables and graphs. Finally, the data should be made available to all those who can use
and act upon them. ehealth ehealth refers to the use of information and communications technology for health.
GNI Gross National income is the total value of all that is produced within a country plus the net income from trade with other countries.
Health information system A health information system includes the people, processes and technology to collect, communicate, manage, analyse,
and present information for decision-making. It represents sources of population based data like census, vital events registration, surveys,
as well as facility based data like individual health records, health service records, and resource management records.
A health information system may be referred to as a health management information system or health management information system and is also likely to comprise any number of subsystems.
Information Information is data which has been processed and organized into a meaningful output which can be used for decision-making or understanding concepts.
Information and communication technology (ICT) Includes the computers software, data-capture devices, wireless communication devices, and local and wide area networks that move information,
and the people that are required to design, implement, and support these systems. 63 Interoperability The ability of health information systems to exchange data in a semantically meaningful way,
whether at the aggregate or patient level. mhealth Mobile ehealth or mhealth encompasses the use of mobile telecommunication
and multimedia technologies as they are integrated within increasingly mobile and wireless health care delivery systems. Open standards Standards for information exchange that are freely available without restriction,
e g. open source software (also referred to as free and open-source software). The user has the freedom to:
run the program for any purpose (freedom 0; study how the program works and adapt it (freedom 1;
redistribute (adapted) copies to others (freedom 2; and improve the program and release those improvements to the public,
for the benefit of the whole community (freedom 3). Note that access to the source code is a precondition for all of these freedoms.
Metadata Metadata is the information which describes data. Metadata is used to describe the definition, structure,
and administration of data whereby the communication and use of those data are improved. 65 Purpose The World health organization's ehealth resolution WHA 58.28 was adopted in 2005 and focused on strengthening health systems in countries through the use of ehealth (1);
building public-private partnerships in ICT development and deployment for health; supporting capacity building for the application of ehealth in Member States;
and the development and adoption of standards. Success in these areas is predicated on a fifth strategic direction:
monitoring, documenting and analysing trends and developments in ehealth and publishing the results to promote better understanding.
The aim was to provide governments with data that could be used as benchmarks for their own development as well as a way to compare their own progress with that of other Member States.
The thematic design of the survey has provided the GOE with a rich source of data that is being used to create a series of eight publications The Global Observatory for ehealth Series due for publication during 2010 and 2011.
Each publication in the series is targeted primarily to ministries of health, ministries of information technology, ministries of telecommunications, academics, researchers, ehealth professionals,
as well as processing the data and analysing the results. Survey instrument The instrument focused on issues relating to processes and outcomes in key ehealth areas.
action concerning online child safety, Internet pharmacies, health information on the Internet, and spam; and governance and organization of ehealth in countries. 67 Table A1 shows the seven themes of the survey.
Theme Action mhealth Identify the diverse ways mobile devices are being used for health around the world and the effectiveness of these approaches.
Consider whether mhealth can overcome the digital divide. Telemedicine Identify and review the most frequently used telemedicine approaches across the globe as well as emerging and innovative solutions.
Legal and ethical frameworks for ehealth Review the trends in the introduction of legislation to protect personally identifiable data
and health-related data in digital format as well as the right to access and control one's own record.
Review government action to provide for child safety on the Internet. ehealth policies a systematic review Identify the uptake of ehealth policies across the globe
and effectiveness of elearning for the health sciences for students and health professionals. ehealth country profiles Presentation of all participating Member States ehealth data aggregated by country to act as ready reference of the state
One of the constraints identified in the first survey was on the management of data
and its availability for compilation and analysis. In order to facilitate data collection and management, Data Collector (Datacol) 12 was used to make the survey instrument available online
and therefore streamlining the collection and processing of data. A set of questions was developed and circulated in the first quarter of 2009 for comments to selected partners in all regions through virtual teleconferences.
The range of partners included those from government, WHO regional and country offices collaborating centres and professional associations.
Over 50 experts worldwide were involved in the process. Collaborative efforts extended to other WHO programmes as well as international organizations,
such as the International Telecommunications Union (ITU) and Organisation for Economic Co-Operation and Development (OECD). An online forum to discuss the survey instrument
instructions and data entry procedures were translated into all WHO official languages plus Portuguese. Data Collector Data Collector, Datacol, is based a web tool that simplifies online form creation for data collection
and management and is designed, developed and supported by WHO. The collected data are stored in a SQL database maintained by WHO database administrators,
and can be exported as a Microsoft excel file for further analysis using other statistical software. This is the first time that Datacol has been used as the primary method of implementing an online survey of over 40 pages of text and questions.
Significant preparation and testing was required to ensure that the system was robust and able to accommodate the data entry process from around the world,
as well as the volume of data entered and stored online. The various language versions of the survey instrument and supporting documentation were entered into Datacol by language.
In addition, individual country login names and passwords were assigned to ensure that only one entry was submitted per country rather than multiple entries.
Country coordinators were responsible for completing the forms after obtaining agreement from the expert informant group. 12 Web-based tool for online creation of forms in surveys developed by WHO. 13 http://www
and were followed by a series of teleconferences. One significant outcome during the survey implementation was the development of strong and productive working relationships with regional counterparts
or designee) Identification of expert informants National consensus meeting to complete survey Submission of one national survey per country GOE data processing and analysis Publication of ehealth series
While survey responses were checked for consistency and accuracy, it was not possible to verify the responses for every question.
when responding. 71 Data processing On receipt of the completed questionnaires, all non-English responses were translated into English.
Data were exported from Datacol in Microsoft excel format and the data analysis was performed using R statistical programming language. 14 Data were analysed by thematic section.
For closed-ended questions percentages were computed for each possible response to obtain the global level results.
In addition, the data were aggregated and analysed by WHO region and World bank income group to see trends by region and by income level.
External health and technology indicators, such as mobile phone penetration, were introduced into the analysis for comparison purposes where relevant.
or act on GOE data. World bank income group Clear economic definition based on GNI per capita. Consistent application of criteria across all countries.
Responding Member States Reponding Member State Data not available Not applicable Responding WHO Member States The boundaries
Data Source: World health organization Map Production: Public health Information and Geographic Information systems (GIS) World health organization 73 Response rate by WHO region Administratively WHO is made up of six geographical regions,
which are quite heterogeneous: Member States differ with respect to size, economy, and health care challenges. Nevertheless, it is still important to present high-level ehealth analyses at the regional level as this reflects the organizational structure and operational framework of WHO.
Geneva, International Telecommunications Union, 2009 (http://www. itu. int/ITU-D/ict/publications/idi/2009/index. html, accessed 17 may 2011). 15
http://data. worldbank. org/about/country-classifications. World bank income group High income Upper-middle income Lower-middle income Low income Total no. countries 49 44 53 43 No. of responding countries
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