Fax:++34 954488300 http://ipts. jrc. ec. europa. eu http://www. jrc. ec. europa. eu
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: 10.2788/52088 Luxembourg: Publications Office of the European union, 2014 Â European union, 2014 Reproduction is authorised provided the source is acknowledged
http://is. jrc. ec. europa. eu/pages/EAP/SCALECCR. html Yves Punie Project Leader ICT for Learning and Skills
Education 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
still a need to narrow digital divides and policy should x Ensure that all learners have equal and ubiquitous ICT access, in and out of school
3 http://is. jrc. ec. europa. eu/pages/EAP/SCALECCR. html 4 In the context of SCALE CCR study,
Data collection and content analysis covered a wide range of materials such as journals and conference
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 decision
-makers, teachers, researchers, IT developers etc. were conducted to provide firsthand experiences of learning innovations and inputs from real settings for the development of policy
part in a webinar was organized by the etwinning Creative Classrooms Group. 7 Findings from the
7 http://groups. etwinning. net/web/creative-classroom/welcome 10 and implementation strategies of effective ICT-ELI with significant scale and/or impact at system
Following the aforementioned procedure, a set of qualitative data was developed including case reports, workshop findings and conclusions, interview summaries, open items of online surveys etc
and analyse the qualitative data to develop a set of policy recommendations for sustaining and scaling up educational innovations at local
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.
clustering and further reduction of the recommendations. As the framework for clustering the recommendations in key areas of policy actions, the CCR multidimensional concept was used
for online surveys. 9 1ka is an open source online survey application, developed by researchers at
Department of Social Informatics and methodology at the Faculty of social science, University of Ljubljana, Slovenia The majority of the questionnaire items (see Annex 1) were measured for relevance on a seven
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;
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. No reminders were sent,
11 http://www. linkedin. com/groups/Future-Learning-2266966/about 12 http://openeducationeuropa. eu/en/blogs/join-jrc-ipts-line-consultation-policy-recommendations
-mainstreaming-ict-enabled-innovation-le 13 http://www. eucis-lll. eu/news/public-consultations/ipts-online-consultation-up-scaling-creative-classrooms
15 http://www. efvet. org/index. php? option=com content&task=view&id=451&itemid=226 16 http://ec. europa. eu/education/lifelong learning-policy/doc/exchange/ict en. pdf
17 http://is. jrc. ec. europa. eu/pages/EAP/SCALECCR. html 14 3. Recommendations for policy action
Putting ICT-ELI into practice on a large scale, involving large and diverse groups of learners
which lie at the core of ICT-ELI require content and curricula that are customised open,
order to facilitate the innovative teaching and learning practices that lie at the core of ICT-ELI.
"Open educational resources, the content of which can be adapted by users according to their needs have great potential to stimulate innovative teaching and learning practices (European commission
-based e-portfolios that follow a web 2. 0/social media model. 142 62.7 Relevance according to four groups of participants
The data analysis of the online consultation (Table 5) also confirms the importance of the School Staff Professional
"Innovative pedagogical practices made possible by the use of ICT lie at the core of learning
of offline meetings, all of which are directed towards fostering collaboration and network building rather than content delivery) is key to this...
and other stakeholders through online and/or offline networks (71.1%).%)Establishing and participating in teacher networks
Helping teachers to acquire much greater proficiency in data handling and methods such as learning analytics,
pay or go to a licensed library to download) or (b) because they do not know that this research
Supporting policy actions for open research and dissemination of data (e g. open access publications, open data repositories, data protection strategies etc.
are needed also at local regional, national and EU levels (58 %Last but not least, policy should support 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.
to study in depth the complex'ecosystems'of ICT-ELI 61.8 %22 Table 6: Research policy recommendations
control groups, experimental research, longitudinal studies, social networks analysis learning analytics, big data research, etc. to the study of complex'ecosystems'of ICT-ELI
131 61.8 23. Promoting research on the ICT-ELI that happens at micro-level and could be scaled-up. 129 58.9
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.
networking with other organisations and stakeholders across sites and also within the same organisation, in order to encourage the emergence and scaling up of learning innovations.
Making sure that technological innovation (e g. 1 to 1 computing) in formal education settings is part of a wider transformation agenda
collecting big and/or rich data and learning analytics) right from the start of different
wide-ranging connectedness lies at the core of ICT-ELI with significant scale and/or impact
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 120 60.8 56. Supporting the development of bigger teacher professional networks (networks of
"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
boundaries of the learning across time and space whereas user-centred and flexible physical spaces
investment in infrastructure developments (e g. broadband, cloud computing, creative learning spaces etc. to support effective implementation and progressive mainstreaming of ICT-ELI
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
the physical spaces in which learning takes place (e g. user-centred premises and furniture) and
e g. broadband, cloud computing, creative learning spaces etc. to support effective implementation and progressive mainstreaming of ICT-ELI
computing) of appropriate performance and interoperability (any device, anywhere, any system, any time) to support effective implementation and evolution of innovation for
broadband, cloud computing, creative learning spaces etc. to support effective implementation and progressive mainstreaming of ICT-ELI
http://ec. europa. eu/eu2020/pdf/COMPLET%20en%20barroso%20%20%20007%20 -%20europe%202020%20-%20en%20version. pdf
European commission. 2012). ) Rethinking Education: Investing in skills for better socioeconomic outcomes COM (2012) 669 final.
Training http://ec. europa. eu/education/news/rethinking/com669 en. pdf European commission. 2013a). ) Opening up Education:
http://ec. europa. eu/education/news/doc/openingcom en. pdf European commission. 2013b). ) Supporting teacher competence development for better learning
http://ec. europa. eu/education/school-education/doc/teachercomp en. pdf European commission. 2013c). ) Survey of Schools:
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,
http://www. innovationunit. org/sites/default/files/Only%20connect%20 -%20a%20new%20paradigm%20for%20learning%20innovation%20in%20the%2021st%2
0century. pdf 34 Kampylis, P.,Bocconi, S, . & Punie, Y. 2012). Towards a mapping framework of ICT-enabled
http://www. oecd. org/dataoecd/17/51/43023606. pdf OECD. 2013. Innovative Learning Environments, Educational research and Innovation.
-results-volume-I. pdf Redecker, C. 2013. The Use of ICT for the Assessment of Key Competences.
http://is. jrc. ec. europa. eu/pages/EAP/SCALECCR. html The survey includes a number of policy recommendations for further developing and
approximately 20 minutes and the data you provide will be anonymous and confidential. If you have any questions
-based e-portfolios that follow a web 2. 0/social media model Encouraging a shift of ownership of assessment from teachers to learners by giving
Helping teachers to acquire much greater proficiency in data handling and methods such as learning analytics,
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. to the study of complex'ecosystems'of ICT-ELI 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 Supporting research on (physical and mental health, security and legal issues related
Making sure that technological innovation (e g. 1 to 1 computing) in formal education settings is part of a wider transformation agenda
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
computing) of appropriate performance and interoperability (any device anywhere, any system, any time) to support effective implementation and
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:
that follow a web 2. 0/social media model 1. 4 3. 5 3. 5 6. 3 22.5 31.0 31.7 62.7
proficiency in data handling and methods such as learning analytics, which would allow them to monitor and personalize learning processes
longitudinal studies, social networks analysis learning analytics, big data research, etc. to the study of complex'ecosystems'of ICT
-ELI 8. 8 4. 6 8. 4 23.7 29.8 32.1 61.8 Promoting research on the ICT-ELI that
research and free dissemination of data (e g open data, open access publications etc 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 learners, parents, IT providers, educational content providers etc
computing) in formal education settings is part of a wider transformation agenda which includes pedagogical and organisational innovation
rich 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
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 8 3. 3 6. 7 12.5 15.8 26.7 34.2 60.8
, broadband, cloud computing) of appropriate performance and interoperability (any device, anywhere any system, any time) to support effective
that follow a web 2. 0/social media model 5. 58 1. 49) 66 5. 83
proficiency in data handling and methods such as learning analytics, which would allow them to monitor and personalize learning processes
proficiency in data handling and methods such as learning analytics, which would allow them to monitor and personalize learning processes
e g. 1 to 1 computing) in formal education settings is part of a wider transformation agenda which includes pedagogical and
collecting big and/or rich data and learning analytics) right from the start of different
Supporting data portability and interoperability between online professional networks, making it easier for teachers to participate in a number of
, without having to duplicate data 5. 62 1. 58) 53 5. 35 1. 35) 26
, broadband, cloud computing) of appropriate performance and interoperability (any device, anywhere any system, any time) to support effective
ISBN 978-92-79-37793-8 (pdf doi: 10.2788/52088 Abstract Technologies for learning are considered as key enablers of educational innovation.
ISBN 978-92-79-37793-8 (pdf
Based on the findings of the second global survey on ehealth Global Observatory for ehealth series-Volume 6
WHO Library Cataloguing-in-Publication Data Management of patient information: trends and challenges in Member States:
1. Medical records systems, Computerized. 2. Medical informatics-standards. 3. Delivery of health care. 4. Confidentiality. 5. Data collection.
I. WHO Global Observatory for ehealth ISBN 978 92 4 150464 5 (NLM classification: W 26.5
fax:++41 22 791 4857; e-mail: bookorders@who. int Requests for permission to reproduce or translate WHO publications †whether for sale or for noncommercial
/licensing/copyright form/en/index. html The designations employed and the presentation of the material in this publication do not imply the
2 Patient information systems in the literature 13 2 1 Maturity and adoption models 13 Capability Maturity Model 13
2 5 Interoperability of patient data 18 2 6 Conclusions drawn from the literature 19
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 adoption of standards 48 Guidelines documents 48 Standards for indicators used to monitor health and health systems 49
Individual patient data standards 49 Vocabulary standards 49 Messaging standards 50 Survey metadata standards 50
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 income group 74
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
Analysis of data in patient information systems can lead to new insight and understanding of health and disease, both chronic and acute
systems in Member States and reviews data standards and legal protection for patient data. The survey
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, for instance, are also
to install patient information systems at some sites, these require significant investments for their successful implementation.
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, which could mitigate discrepancies between systems.
Committee on health informatics ISO TC 215, or example, has developed an ehealth architecture that incorporates levels of maturity into the components of a health system to address these differences in
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,
records than computer use to collect health data. This may be due to the use of fax
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
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 dotsâ€:
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
Electronic health systems must be built in a way to facilitate the exchange of data; disparate systems using separate disease definitions,
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
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 In tr od uc ti on 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.
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, and public health
Furthermore, an EMR may contain clinical applications that can act on the data contained within its
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
laboratory data, and radiology reports. The EHR automates and streamlines the clinician†s workflow. It
an interactive, common data set of electronic health information and ehealth tools. The PHR is owned
Electronic patient information systems have the potential to improve health by giving health professionals improved information about their patients.
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 Pa tie nt in fo rm at io n
is, data collection and analysis •Level 5. Optimized †process management includes deliberate process optimization
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
This requires data interoperability which is the key to effective use of health information. The Australian
increasing capability for data interoperability Interoperability Maturity Model levels •Initial: There is an early awareness of ehealth interoperability requirements and characteristics
adoption of specific ehealth standards while gaining an early, shared understanding of data services or internal processes as well as initial governance established to ensure repetition of
for data, services and processes, according to the lessons learnt from previous maturity levels Communication standards for interaction with internal and external partners are established
Major ancillary clinical systems feed data to a clinical document repository (CDR) that provides physicians access to results
3 http://www. cdc. gov/nhsn/CDA ESURVEILLANCE. html Pa tie nt in fo rm at
Developing countries usually collect district level aggregate health data to plan and manage their health
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
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 such as EMR, pharmacy, laboratory, 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 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
Second, involve users in the design by demonstrating benefit. It is always useful to develop
done and why to foster support. infodev has created also a continuously updated database to function as
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 THE WHO Western Pacific Region published the Medical records Manual:
A Guide for Developing Countries which provides extensive information on the characteristics of medical records and related policies and
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. The system captured and presented clinical data that supplemented clinical decision-making.
In addition, the data were aggregated and used at the national level for policy -making 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.
enterprise and also in the form of free open source software systems which are supported by nonprofit -making 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
Improvements in quality have been demonstrated by increased adherence to guideline-based care enhanced surveillance and monitoring,
Studies have shown improvements in health information technologies increasing adherence to guideline or protocol-based care (21) and clinical decision support (22.
The use of mobile technologies for data collection about individuals and interactive information services are a part of a growing area of ehealth called mhealth.
2 5 Interoperability of patient data The purpose of collecting and storing patient information is to make it available for decision-making at
sites for analysis. In order for this to work, there must be standards for representing the data and for
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
particularly through interoperable data standards The beginning of such standardization is electronic patient records (EMRS and EHRS.
access to timely data by care providers and for access by multiple users (not geographically bound) and
EHRS have the ability to use multimedia including images, sound, and video to provide comprehensive
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 frequently overlooked, 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
A nalysis 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
data from clinics for use in disease surveillance and health status. However, it is more difficult to capture
complex 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
with a much finer level of detail, a simplified maturity model with three methods of data collection (levels
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 â€oenoneâ€
indicating no use to â€oevery high†meaning over 75%.%Details of the measurement scale are found below
data of the trends identified in the transition from paper to digital records A nalysis of survey results
Table 1. Use of paper and electronic formats for individual patient data, by health system
Table 2. Use of paper and electronic formats for aggregate patient data, by health system
and community health sites and primary health care centres. These are the first points of care
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 and care of patients to improve health
Individual patient data Individual patient information is collected and tagged with a patient identifier and can later be retrieved
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.
Each bar in Figure 1 represents one of the three modes of collecting and disseminating patient information:
reporting very high, high or medium adoption) with much lower levels of data collected in electronic
 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
Data format A nalysis of survey results 25 Figure 2. Individual patient data collected in local health care facilities, by World bank income group
High income Upper-middle income Pe rc en t o f c ou nt ri
Data format 0 %20 %40 %60 %80 %100 %High income Upper-middle income Lower-middle income
Data format 0 %20 %40 %60 %80 %100 %Very high High Medium Low None No answer
Data format Lower-middle income Low income 0 %20 %40 %60 %80 %100 %High income Upper-middle income
Data format 0 %20 %40 %60 %80 %100 %High income Upper-middle income Lower-middle income
Data formatdata formats 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 â€oemedium†to â€oevery 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 â€oemedium†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
A na ly si s of s ur ve y re su lts 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
Data format 0 %20 %40 %60 %80 %100 %High income Upper-middle income Lower-middle income
Data formateuropean Region Regions of The americas Pe rc en t o f c ou nt
Data format 0 %20 %40 %60 %80 %100 %Very high High Medium Low None No answer
Data format0 %20 %40 %60 %80 %100 %Very high High Medium Low None No answer
Data format Southeast asia Region Western Pacific Region 0 %20 %40 %60 %80 %100 %High income Upper-middle income
Data format 0 %20 %40 %60 %80 %100 %High income Upper-middle income Lower-middle income
Data formatdata formats When the same data are analysed by WHO region (Figure 3), it can be seen that all regions have high
paper use, with the African Region and the Southeast asia Region reporting the highest levels. It is
Region show a higher adoption rate of electronic transmission of data than actual collection of patient
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 A nalysis 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 (or
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-income countries have transitioned to the point where there is a greater use of electronic
Data format A na ly si s of s ur ve y re su lts 28
Figure 5. Aggregate patient data collected in local health care facilities, by World bank income group When countries are grouped by World bank income group, the high-and upper-middle income groups
Data format 0 %20 %40 %60 %80 %100 %Very high High Medium Low None No answer
Data formatlower-middle income Low income 0 %20 %40 %60 %80 %100 %Very high High
Data format 0 %20 %40 %60 %80 %100 %Very high High Medium Low None no answer
Data formatdata formats 0 %20 %40 %60 %80 %100 %Very high High Medium Low None
Data format A nalysis of survey results 29 Figure 6. Aggregate patient data collected in local health care facilities, by WHO region
It is interesting that countries of the Southeast asia and Western Pacific Regions have made greater use of electronic communications than actual electronic collection formats (see Figure 6). As already
noted, this may be explained by countries using digital communication formats such as fax to send paper-based reports
Data format 0 %20 %40 %60 %80 %100 %High income Upper-middle income Lower-middle income
Data formateuropean Region Regions of The americas Pe rc en t o f c ou nt
Data format 0 %20 %40 %60 %80 %100 %Very high High Medium Low None No answer
Data format0 %20 %40 %60 %80 %100 %Very high High Medium Low None No answer
Data format Southeast asia Region Western Pacific Region 0 %20 %40 %60 %80 %100 %Very high High
Data format 0 %20 %40 %60 %80 %100 %Very high High Medium Low None No answer
Data formatdata formats A na ly si s of s ur ve y re su
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
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 â€oevery high†and â€oehigh†use
Data format A nalysis of survey results 31 Figure 8. Individual patient data collected in regional offices, by World bank income group
High income Upper-middle income Pe rc en t o f c ou nt ri
Data format 0 %20 %40 %60 %80 %100 %High income Upper-middle income Lower-middle income
Data format 0 %20 %40 %60 %80 %100 %Very high High Medium Low None No answer
Data format Lower-middle income Low income 0 %20 %40 %60 %80 %100 %High income Upper-middle income
Data format 0 %20 %40 %60 %80 %100 %High income Upper-middle income Lower-middle income
Data formatdata formats Responses by World bank income group are shown in Figure 8. The trend is similar to that found at the
mostly paper-based data recording. Low and lower-middle income countries report both â€oevery high†and â€oehigh†use of paper-based systems accounting for just under 80%of responding countries
country groups, countries in this group have made greater strides towards digitization: approximately 38%reported a high level of electronic records and their transmission
Figure 9. Individual patient data collected in regional offices, by WHO region Approximately 70%of responding countries from the African Region reported â€oevery high†use of paper
Data format 0 %20 %40 %60 %80 %100 %Very high High Medium Low None No answer
Data formateuropean Region Regions of The americas Pe rc en t o f c ou nt
Data format 0 %20 %40 %60 %80 %100 %Very high High Medium Low None No answer
Data format0 %20 %40 %60 %80 %100 %Very high High Medium Low None No answer
Data format Southeast asia Region Western Pacific Region 0 %20 %40 %60 %80 %100 %Very high High
Data format 0 %20 %40 %60 %80 %100 %Very high High Medium Low None No answer
Data formatdata formats A nalysis of survey results 33 Aggregate patient data Aggregate patient data provide the core data on which regions
or districts depend to properly perform their critical management functions, which includes allocating human resources and materials and
supplies for the operation of local facilities. Monitoring and evaluation activities are integral to that management.
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
data and electronic communication systems with these systems showing â€oenone†or â€oelow†deployment approximately 37%and 48%,respectively;
Data format A na ly si s of s ur ve y re su lts 34
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
electronic patient information and communication systems in lower-income countries. This could be due to the national health systems used in many low-income countries,
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
Data format 0 %20 %40 %60 %80 %100 %Very high High Medium Low None No answer
Data format 0 %20 %40 %60 %80 %100 %Very high High Medium Low None No answer
Data format Lower-middle income Low income 0 %20 %40 %60 %80 %100 %Very high High
Data format 0 %20 %40 %60 %80 %100 %Very high High Medium Low None No answer
Data formatdata formats A nalysis 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 â€oehigh†level of paper use and â€oelow†use of electronic systems (Figure 12.
of both paper-based and electronic patient information systems is at 25%and 22%,respectively. The
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
Data format 0 %20 %40 %60 %80 %100 %Very high High Medium Low None No answer
Data format European Region Regions of The americas Pe rc en t o f c ou nt
Data format 0 %20 %40 %60 %80 %100 %Very high High Medium Low None No answer
Data format0 %20 %40 %60 %80 %100 %Very high High Medium Low None No answer
Data format Southeast asia Region Western Pacific Region 0 %20 %40 %60 %80 %100 %Very high High
Data format 0 %20 %40 %60 %80 %100 %Very high High Medium Low None No answer
Data formatdata formats A na ly si s of s ur ve y re su
At the national level, individual patient data are most useful for operational research, planning, and
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
 The use of paper-based systems continues to be high for individual patient data at the national
electronic patient information systems 0 %20 %40 %60 %80 %100 %Very high High Medium Low None
Data format A nalysis of survey results 37 The trend seen globally is the same when viewed by World bank income group.
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
Data format 0 %20 %40 %60 %80 %100 %Very high High Medium Low None No answer
Data format 0 %20 %40 %60 %80 %100 %Very high High Medium Low None No answer
Data format Lower-middle income Low income 0 %20 %40 %60 %80 %100 %Very high High
Data format 0 %20 %40 %60 %80 %100 %Very high High Medium Low None No answer
Data formatdata formats A na ly si s of s ur ve y re su
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
Data format 0 %20 %40 %60 %80 %100 %Very high High Medium Low None No answer
Data formateuropean Region Regions of The americas Pe rc en t o f c ou nt
Data format 0 %20 %40 %60 %80 %100 %Very high High Medium Low None No answer
Data format0 %20 %40 %60 %80 %100 %Very high High Medium Low None No answer
Data format Southeast asia Region Western Pacific Region 0 %20 %40 %60 %80 %100 %Very high High
Data format 0 %20 %40 %60 %80 %100 %Very high High Medium Low None No answer
Data formatdata formats A nalysis of survey results 39 Aggregate patient data Aggregate patient data is useful at the national level for planning, policy formulation, programme
management, monitoring and evaluation, and disease surveillance. By understanding disease status trends, patterns and response to interventions,
resources can be allocated better Figure 16. Aggregate patient data collected at the national level, globally
Figure 16 shows that one third of countries reported â€oehigh†to â€oevery high†use of electronic records and
electronic transmission of data, respectively, at the global level. This is contrasted with 42%of countries
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
â€oehigh†to â€oevery high†use of electronic data collection and transmission at the national level
higher use of electronic communication modalities than electronic data collection. This could be due to widespread use of mobile telephone communications technology
Data format A na ly si s of s ur ve y re su lts 40
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
Data format 0 %20 %40 %60 %80 %100 %Very high High Medium Low None No answer
Data format 0 %20 %40 %60 %80 %100 %Very high High Medium Low None No answer
Data format Lower-middle income Low income 0 %20 %40 %60 %80 %100 %Very high High
Data format 0 %20 %40 %60 %80 %100 %Very high High Medium Low None No answer
Data formatdata formats A nalysis of survey results 41 Figure 18 shows the results by WHO region.
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
Data format 0 %20 %40 %60 %80 %100 %Very high High Medium Low None No answer
Data format European Region Regions of The americas Pe rc en t o f c ou nt
Data format 0 %20 %40 %60 %80 %100 %Very high High Medium Low None No answer
Data format0 %20 %40 %60 %80 %100 %Very high High Medium Low None No answer
Data format Southeast asia Region Western Pacific Region 0 %20 %40 %60 %80 %100 %Very high High
Data format 0 %20 %40 %60 %80 %100 %Very high High Medium Low None No answer
Data formatdata formats 42 3. 6 mhealth and patient information The second global survey on ehealth also covered the use of mobile technologies for health
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, delivery of health care information to
practitioners, researchers, and patients, real-time monitoring of patient vital signs and direct provision of care
The results show that most countries are conducting at least one mhealth initiative, indicating that they
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,
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
Countries tend to be advanced fairly in the planning for information systems before they see the need for
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 and those who develop the standards, which can hinder interoperability. Examples of metadata standards are discussed below
Dublin Core Metadata Initiative (DCMI The Dublin Core Metadata Initiative7 is engaged an organization in the development of interoperable
metadata standards, architecture, and modelling. Metadata is information that describes the source characteristics, 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-operation and Development (OECD), the United nations (Statistics Division), and the World bank. Although these standards were developed originally for the financial industry, 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. The World health organization maintains an Indicator and Metadata Registry (IMR)( 31.
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, and training of, users in the systems controlling metadata standards Messaging standards Overall, messaging standards have been adopted widely because of their clear utility in communicating
health data. Examples are discussed below Health Level Seven (HL7 HL7 is a framework of related messaging standards for the exchange and retrieval of electronic
software and therefore widely recognized Indicator Exchange Format (IXF The IXF is a reporting format that was developed for purposes of HIV/AIDS monitoring and evaluation.
was adopted by UNAIDS for use by the Country Response Information system (CRIS) software (32 It was a precursor to the SDMX-HD format,
-based data exchange 9 http://www. sdmx-hd. org 46 Thirty-four countries report using a version of CRIS;
Most users of the program are low or lower-middle income countries; they seek to build synergies, through data exchange, with other data management tools between sectors
Only a very small percentage of responding countries (2%)report having adopted IXF. Survey respondents
may not have realized that the CRIS software uses IXF and therefore underreported IXF use Medical record standards
ISO€ s Technical Committee (TC) 215 on health informatics works on health information and communications technology to facilitate interoperability of health data
TC 215 consists of eight working groups dealing with various aspects of electronic health records. These
data structure, data interchange, semantic content, security, pharmacy and medicines business devices, business requirements for electronic health records,
The Comitã Europã en de Normalisation (CEN) TC 251 on health informatics works on standardization
each dealing with a specific aspect of the data, have been formed under TC 251. These include information
security issues related to patient data Fifteen per cent of the responding countries use this standard.
systematically organized to be processed by computer. It provides a terminology that is optimized to index, store,
and retrieve clinical data across care boundaries and sites, and consists of over a million medical concepts.
care data set LOINC is preferred the code set for HL7 laboratory test names in transactions.
National leadership is important in defining standards for each category of health data for use in-country
use of health data with better health outcomes as a result The survey investigated a group of common types of standards that might be adopted at the national
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 identiï¿ers Indicators Guidelines Percent of countries N at io na l s ta
legacy of data and usage that means that they may not fully adhere to international standards.
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
local to the software application. Clinics and hospitals often have an identifier that is used throughout a
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
a data set that is used within the country such as national health indicators, routine facility reporting, or
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
Surveys are a valuable method of collecting health data. They usually identify a specific topic and a
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
 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.
of adoption of interoperable systems to communicate electronic data. The increasingly widespread availability of mobile telephone communications technology is an important asset
 Globally, 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
benchmarking of data  The survey illuminates active exploration and adoption of electronic tools for management
information systems in developed and developing countries. The survey results provide a clear picture of the current state of adoption across WHO regions and by World bank income groups.
that countries in the higher-income groups are more likely to be advanced further in the digitization
digitization of records is highly dependent on, and linked to, the availability of human and ICT resources
in the successful implementation of patient information systems, which contributes to improved patient health, more efficient health care systems,
ehealth strategy for WHO including specific reference to patient information systems, interoperability and privacy of patient information and security (36
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
responsible for the governance of ehealth data interoperability standards and patient data privacy and security Member States rely on this resolution to provide high-level guidance for ehealth planning.
Many also find that they need further information and request input from WHO offices to assist with the more
information systems It is worth noting that WHO 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.
This unique resource, the National ehealth Strategy Toolkit, will be published in 2012 and will be made available to all
It is essential that Member States adopt data interoperability standards for the recording and communication of health information.
receiver of data have the same definition and understanding of them. Without this understanding, health
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 of the individual as well as enhancing administrative, planning, and research functions.
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, accessed 29 march 2012 2. Electronic health records. Healthcare Information and Management Systems
http://www. himss. org/asp/topics ehr. asp, accessed 29 march 2012 3. Personal health records. Definition and position statement.
Systems, 2007 (http://www. himss. org/content/files/phrdefinition071707. pdf, accessed 29 march 2012 4. Capability Maturity Model Integration.
Enterprise Architecture planning-developing a blueprint for data applications and technology. Hoboken, NJ, John Wiley and Sons, 1993
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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. Chetley A. Improving health, connecting people: the role of ICTS in the health sector of developing
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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. Pagliari C, Detmer D, Singleton P. Potential of electronic personal health records. British Medical Journal
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 multi -institutional evaluations of comparative effectiveness, safety,
2001 (http://www. who. int/classifications/icf/en/index. html, accessed 28 march 2012 29. Monitoring and evaluation toolkit.
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. Concept paper, accessed 1 june 2012 34. Continuity of care document.
/pressreleases/20070212. pdf, accessed 28 march 2012 35. Legal frameworks for ehealth. Geneva, World health organization, 2012 36.
http://apps. who. int/gb/ebwha/pdf files/WHA58/WHA58 28-en. pdf, accessed 1 june 2012 37.
A measure of the amount of data that can be transmitted per unit of time Computerized physician order entry (CPOE
into a computer for execution CCD The Continuity of Care Document is a HL7 CDA compliant implementation of the CCR
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. In direct response to the ehealth resolution, the Global Observatory for ehealth (GOE) was established to monitor
and analyse the evolution of ehealth in countries and to support national planning through the provision
of strategic information The GOE€ s first objective was to undertake a global survey on ehealth to determine a series of benchmarks
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
rich source of data that is being used to create a series of eight publications †The Global Observatory for
technology, ministries of telecommunications, academics, researchers, ehealth professionals nongovernmental organizations involved in ehealth, donors, and private sector partners
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;
Identify the diverse ways mobile devices are being used for health around the world and the effectiveness of these approaches
personally identifiable data and health-related data in digital format as well as the right to access
Internet ehealth policies †a systematic review Identify the uptake of ehealth policies across the globe and analyse
Presentation of all participating Member States ehealth data aggregated by country to act as ready reference of the state of
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
such as the International Telecommunications Union ITU) and Organisation for Economic Co-Operation and Development (OECD). An online forum to discuss
In order encourage countries to respond, the survey questions, 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.
12 Web-based tool for online creation of forms in surveys developed by WHO 13 http://www. triplehelixinstitute. org
teleconferences One significant outcome during the survey implementation was the development of strong and productive
GOE data processing and analysis Publication of ehealth series 70 Survey The survey was launched on 15 june 2009,
Data processing On receipt of the completed questionnaires, all non-English responses were translated into English Survey responses were checked for consistency and other errors,
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
Preliminary analysis based on aggregation by ICT Development Index showed similar results as for World bank income group (2). This is due to the high correlation between ICT Development Index and
as mobile phone penetration, were introduced into the analysis for comparison purposes where relevant Results from the current survey were compared to those from the previous survey wherever possible
interpret or act on GOE data World bank income group Clear economic definition based on GNI per capita Consistent application of
Data not available Not applicable Responding WHO Member States The boundaries and names shown and the designations used on this map do not imply the expression of any opinion whatsoever
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,
World health organization, 2005 (http://apps. who. int/gb/ebwha/pdf files/WHA58/WHA58 28-en. pdf accessed 18 may 2011
Telecommunications Union, 2009 (http://www. itu. int/ITU-D/ict/publications/idi/2009/index. html
15 http://data. worldbank. org/about/country-classifications World bank income group High income Upper-middle
Patient information systems in the literature 2. 1 Maturity and adoption models Capability Maturity Model Enterprise Architecture
2. 5 Interoperability of patient data 2. 6 Conclusions drawn from the literature Analysis of survey results
Individual patient data Aggregate patient data 3. 4 Regional/District offices Individual patient data Aggregate patient data
3. 5 National level Individual patient information Aggregate patient data 3. 6 mhealth and patient information
3. 7 International standards for ehealth International guidelines documents Metadata standards Messaging standards Medical record standards
Vocabulary standards 3. 8 National adoption of standards Guidelines documents Standards for indicators used to monitor health and health systems
Standards to identify patients Individual patient data standards Vocabulary standards Messaging standards Survey metadata standards
3. 9 Legal framework and adoption 3. 10 Summary of key findings Conclusions 4. 1 Policy and strategy
Data Collector Preparation to launch the survey Survey Limitations Data processing Response rate Response rate by WHO region
Response rate by World bank income group References
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