Per projections based on Cisco VNI data, average global bandwidth demand per household in 2020 (the target data for achieving the DAE€ s objectives for
ultra-fast broadband) is less than 2 Mbps The evolution over time of consumer bandwidth demand during the busy hour
Cisco VNI 2011 data, 1 WIK calculations Ultra-fast broadband access is useful, but in light of realistic consumer demand it is not
to the quality of currently available data. A study that has been conducted on behalf of the European commission will hopefully provide clarity
there has been little customer demand for upstream data bandwidth. The biggest single impediment is that such a shift would conflict with analogue FM radio
Data Over Cable Service Interface Specification (version 2/3; see Section 5. 2 DSL Digital Subscriber Line;
GB Gigabyte GDP Gross domestic product GHZ Gigahertz GPON Gigabit Passive Optical Network; in a GPON system the
bandwidth is shared by all users connected to a given splitter; see Section 4. 1. 1
communication of high-speed data Mbps Mega bit per second (one million bits per second MDF Main distribution frame
TB Terabyte (1 Terabyte=1000 Gigabytes VDSL/VDSL2 Very High Speed Digital Subscriber Line (version 2;
data, average global bandwidth demand per household in the busy hour in 2020 is less than 2 Mbps
8 Cisco analysts compile data from multiple sources in order to estimate current and future Internet traffic by region, by application, and fixed versus
(which is 1 Terabyte, or 1 TB) per month 9 Cisco VNI (2012), op cit 10 Cisco VNI (2012), op cit
File sharing Web/Data Internet Video 29%CAGR 2011-2016 Petabytes per Month 22 %23 %54
%18 Rethinking the Digital Agenda for Europe (DAE Table 1: Internet households by average traffic per month
Translating the above Cisco data into Mbps demand, during the average hour and during the busy hour, we have depicted the results in Table 2. Data networks are generally
designed to carry near-peak traffic; thus, traffic during the busy hour12 is a good measure
because there is no upper bound to the offered load in an IP data network. See J. S. Marcus (1999:
Cisco VNI 2011 data, 14 WIK calculations Estimation of the mean aggregate bandwidth demand during the busy hour from the data
is straightforward, and is shown in Figure 3. The 2010-2015 figures are based directly on Cisco data,
while the 2016-2020 figures are an extrapolation reflecting an exponential regression of the 2010-2015 data.
The fit of the regression is very good 14 Ibid 20 Rethinking the Digital Agenda for Europe (DAE
Cisco VNI 2011 data, 15 WIK calculations What is particularly striking is that the mean global bandwidth demand per household
In a sophisticated study drawing on data from more than 6, 000 New zealand businesses Grimes et al.
as to the quality of currently available data. A study that has been conducted on behalf of the European commission will hopefully provide clarity
36 In a Gigabit Passive Optical Network (GPON), the typical bandwidth is up to 2. 5 Gbps downstream and up to 1, 25
simultaneously carrying voice, data and video services. In a nutshell, the key elements of a cable network are39 one or more master headend (s)( together with a Network
Cable networks can offer Gigabit bitrates for IP traffic. The customers within a given cable cluster,
data transmission, and also in efficiency in terms of bits per Hertz. Typical realistically achievable speeds are less than those that are theoretically achievable,
ADSL coverage, for many years. 46 These data have been reflected in a range of Commission studies,
46 See IDATE (2011), Broadband Coverage in Europe, Final Report, 2011 Survey Data as of 31 december 2010,2011
reflecting detailed geographic data on the locations of streets, buildings, and business and residential customers.
demand for upstream data bandwidth. The biggest single impediment is that such a shift would conflict with analogue FM radio
These headends are data centres requiring a power supply, and security arrangements. They are typically connected via a fibre transport ring (regional backbone.
current state of the art for Europe as regards delivery of data, voice, and video over a cable television system. 63 It is the cable technology platform that competes most directly
Due to the inherent characteristics of an HFC cable network, whatever data capacity is available is shared by all connected customers.
the data capacity can meet realistic customer requirements under quite a wide range of assumptions. First, one must bear in mind that the capacity required to support
linear video is separate from the capacity used to support data (as is also the case with
It is important to bear in mind that all modern data networks are shared in some degree Networks differ in where the sharing takes place.
With digital transmission, cable television can now carry hundreds of channels, in comparison with analogue-only cable systems that
It is worth noting once again that Cisco VNI data strongly suggest that average data consumption per household during the busy hour will be less than 2 Mbps, even in
the Cisco VNI 2011 analysis finds that Internet data traffic is become less symmetric over time, not more,
the data are plotted together 16.2 10.3 11.7 10.0 8. 8 6. 9 26.8 20.2 16.2
I want every European to have 30 Megabit coverage by 2020: and that†s where next generation wireless networks will play a very important
least half of Europeans to have ultra-fast access at over 100 Megabits by 2020:
a cross-sectional analysis of U s. data, in: Issues in Economic policy no. 6, The Brookings Institute, July
Countries, OECD Digital economy Papers, No. 197, OECD Publishing. http://dx. doi org/10.1787/5k9bcwkg3hwf-en
IDATE, Broadband Coverage in Europe, Final Report, 2011 Survey Data as of 31 december 2010,2011, at http://ec. europa. eu/information society/digital-agenda/scoreboard/docs/pillar
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
Data collection and content analysis covered a wide range of materials such as journals and conference
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
Helping teachers to acquire much greater proficiency in data handling and methods such as learning analytics,
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
learning analytics, big data research, etc. to study in depth the complex'ecosystems'of ICT-ELI 61.8
learning analytics, big data research, etc. to the study of complex'ecosystems'of ICT-ELI 131 61.8
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
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 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
Key Data on Learning and Innovation through ICT at School in Europe 2011 Retrieved 15 december 2013, from Education, Audiovisual and Culture Executive agency
approximately 20 minutes and the data you provide will be anonymous and confidential. If you have any questions
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
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
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
proficiency in data handling and methods such as learning analytics, which would allow them to monitor and personalize learning processes
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
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
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
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
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
WHO Library Cataloguing-in-Publication Data Management of patient information: trends and challenges in Member States:
care. 4. Confidentiality. 5. Data collection. I. WHO Global Observatory for ehealth ISBN 978 92 4 150464 5 (NLM classification:
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
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
needed for data interoperability and standardized international case-reporting, which could mitigate discrepancies between systems.
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
However, the value of individual patient data for improved patient care is very much a case of †connect the dotsâ€:
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
protection of patient data The report concludes with an overview of steps Member States can take to facilitate the implementation
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
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
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
is, data collection and analysis •Level 5. Optimized †process management includes deliberate process optimization
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
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,
operational health ICT systems such as EMR, pharmacy, laboratory, automatic data capture and access to information.
data from all public and private sources Results showed that most of the 19 countries selected only collected district level information, 6
presence of data standards and regulatory frameworks; mechanisms to develop the capacity of health workers;
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
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
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
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
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.
data from clinics for use in disease surveillance and health status. However, it is more difficult to capture
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
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
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
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
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
Figure 3. Individual patient data collected in local health care facilities, by WHO region African Region Eastern Mediterranean Region
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
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
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.
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
Data format A nalysis of survey results 37 The trend seen globally is the same when viewed by World bank income group.
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
collecting community and clinical health data, delivery of health care information to practitioners, researchers, and patients, real-time monitoring of patient vital signs
and aggregate data, countries utilizing such systems need to collect data using standard definitions and
•Messaging standards describe protocols to communicate data •Medical record standards specify the structure, content,
communication that is often in evidence between the professionals who develop digital information systems and those who develop the standards,
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
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
-based data exchange 9 http://www. sdmx-hd. org 46 Thirty-four countries report using a version of CRIS;
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.
communications technology to facilitate interoperability of health data TC 215 consists of eight working groups dealing with various aspects of electronic health records.
data structure, data interchange, semantic content, security, pharmacy and medicines business devices, business requirements for electronic health records,
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.
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
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
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
electronic formats than paper records for patient data  Only a limited number of countries report widespread use of electronic formats coupled
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
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
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.
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
Enterprise Architecture planning-developing a blueprint for data applications and technology. Hoboken, NJ, John Wiley and Sons, 1993
managing data in Malawi. Baobab Health unpublished observations, 2008 18. Douglas GP et al. Using touchscreen electronic medical record systems to support
Distributed health data networks: a practical and preferred approach to multi -institutional 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
A measure of the amount of data that can be transmitted per unit of time Computerized physician order entry (CPOE
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
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
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
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.
personally identifiable data and health-related data in digital format as well as the right to access
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
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
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
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
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
15 http://data. worldbank. org/about/country-classifications World bank income group High income Upper-middle
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
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