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<h2 class="hd hd-2 unit-title">Introduction</h2>
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<h4>Introduction</h4>
<p>There are several well-known bottlenecks in the typical healthcare care process, such as delay in acting on symptoms, delayed or wrong diagnosis, non-compliance with treatment regimens, loss of patients to follow up, and incomplete self-management. Additional bottlenecks are introduced by inefficiencies of the health system itself – supply chain management, human resources ill-adapted in number and skills to population’s health needs, poor information management, and fragmented care with weak links between primary, secondary and tertiary care.</p>
<p>Resource-limited settings suffer the most from these bottlenecks, leading to poor health outcomes, such as those defined by the Millennium Development Goals (MDG). For example, the regional MDG report of Asia-Pacific for 2011-2012 assesses country performance in 8 indicators directly related to the healthcare goals. Of these 8 indicators, India is 'slow' on 5, 'regressing' on 1, 'on track' on 1, and 'early achiever' on 1. This situation is representative of several low- and middle-income countries (LMICs) the world over.</p>
<p>New alternatives have to be sought to strengthen health systems and make care processes more efficient. Information and communications technologies (ICTs) - a term that encompasses technology such as telecommunications, personal computers, mobile phones, sensing systems - may offer part of the solution. With the ever expanding reach of these technologies, they are increasingly providing important roles in areas such as agriculture and commerce, politics and governance, and of course healthcare.</p>
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<h2 class="hd hd-2 unit-title">Defining eHealth, Global Health Informatics, and mHealth</h2>
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<h4>Defining eHealth, Global Health Informatics and mHealth</h4>
<p>We are still learning the full potential of ICT's impact on the health of individuals and health systems in global health. The field remains in its infancy and definitions and terms also remain in flux with little agreement around terminology. Various terms to define the field have risen, from Electronic Data Processing (EDP) in Health, to terms such as Medical Informatics, Health Informatics, eHealth, mHealth, and ICT-for-Health. Some terms have taken distinct definitions, while some, such as EDP in Health, are now rarely used. Sub-categories and related terms with similar names such as clinical informatics and biomedical informatics cloud the nomenclature even more.</p>
<p>Two of the most common ICT terms in healthcare today are Health Informatics and eHealth. The difference between these terms is intensely debated amongst professionals in the field, particularly around which term is a parent to the other. Our goal is to help innovators to develop tools that will impact and improve health, rather than get caught up in the nomenclature debate. For simplicity we will often use the terms eHealth, Health Informatics, and Digital Health interchangeably throughout this course.</p>
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<h4>eHealth</h4>
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<p>Generally, eHealth is considered the umbrella term encompassing the various uses of ICT in healthcare. To highlight the controversy, the following are frequent overlapping descriptions of eHealth:</p>
<ul>
<li>"The use, in the health sector, of digital data - transmitted, stored and retrieved electronically - in support of health care, both at the local site and at a distance."</li>
<li>"The cost-effective and secure use of information and communication technology or ICT in support of health and health-related fields, including health-care services, health surveillance, health literature, and health education, knowledge and research".</li>
<li>The World Health Organization (WHO) defines eHealth as "the use of ICT for health"</li>
<li>The European Commission refers to eHealth as "ICT tools and services that can improve prevention, diagnosis, treatment, monitoring and management"</li>
<li>Scott and Varghese describe eHealth as a collection of various implementations within two inter-related domains: telehealth and health informatics. Under each domain are examples such as telemedicine, electronic health records, decision support systems, etc.</li>
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<p><span style="font-size: 16px; color: #1a1a1a; font-weight: bold; font-style: normal; font-variant-ligatures: normal; font-variant-caps: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap; background-color: transparent;">Global Health Informatics</span><span style="font-size: 16px; color: #1a1a1a; font-weight: 400; font-style: normal; font-variant-ligatures: normal; font-variant-caps: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap; background-color: transparent;">:</span></p>
<p><span style="font-size: 16px; color: #1a1a1a; font-weight: 400; font-style: normal; font-variant-ligatures: normal; font-variant-caps: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap; background-color: transparent;">“The informatics discipline focused on empowering people to use appropriate technology to provide <strong>information-based solutions</strong> with a global perspective that support health care for all.” </span></p>
<p><span style="font-size: 16px; color: #1a1a1a; font-weight: bold; font-style: normal; font-variant-ligatures: normal; font-variant-caps: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap; background-color: transparent;">mHealth</span><span style="font-size: 16px; color: #1a1a1a; font-weight: 400; font-style: normal; font-variant-ligatures: normal; font-variant-caps: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap; background-color: transparent;">:</span></p>
<p><span style="font-size: 16px; color: #000000; font-weight: 400; font-style: normal; font-variant-ligatures: normal; font-variant-caps: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap; background-color: transparent;">Similarly to eHealth, the definition of mHealth has undergone an evolution over the past decade, but we will define it as “</span><span style="font-size: 16px; color: #2f2924; font-weight: 400; font-style: normal; font-variant-ligatures: normal; font-variant-caps: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap; background-color: transparent;">the</span><span style="font-size: 16px; color: #000000; font-weight: 400; font-style: normal; font-variant-ligatures: normal; font-variant-caps: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap; background-color: transparent;"> </span><span style="font-size: 16px; color: #2f2924; font-weight: 400; font-style: normal; font-variant-ligatures: normal; font-variant-caps: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap; background-color: transparent;">subset</span><span style="font-size: 16px; color: #000000; font-weight: 400; font-style: normal; font-variant-ligatures: normal; font-variant-caps: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap; background-color: transparent;"> </span><span style="font-size: 16px; color: #2f2924; font-weight: 400; font-style: normal; font-variant-ligatures: normal; font-variant-caps: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap; background-color: transparent;">of</span><span style="font-size: 16px; color: #000000; font-weight: 400; font-style: normal; font-variant-ligatures: normal; font-variant-caps: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap; background-color: transparent;"> </span><span style="font-size: 16px; color: #2f2924; font-weight: 400; font-style: normal; font-variant-ligatures: normal; font-variant-caps: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap; background-color: transparent;">eHealth</span><span style="font-size: 16px; color: #000000; font-weight: 400; font-style: normal; font-variant-ligatures: normal; font-variant-caps: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap; background-color: transparent;"> </span><span style="font-size: 16px; color: #2f2924; font-weight: 400; font-style: normal; font-variant-ligatures: normal; font-variant-caps: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap; background-color: transparent;">that</span><span style="font-size: 16px; color: #000000; font-weight: 400; font-style: normal; font-variant-ligatures: normal; font-variant-caps: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap; background-color: transparent;"> </span><span style="font-size: 16px; color: #2f2924; font-weight: 400; font-style: normal; font-variant-ligatures: normal; font-variant-caps: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap; background-color: transparent;">includes</span><span style="font-size: 16px; color: #000000; font-weight: 400; font-style: normal; font-variant-ligatures: normal; font-variant-caps: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap; background-color: transparent;"> </span><strong><span style="font-size: 16px; color: #2f2924; font-style: normal; font-variant-ligatures: normal; font-variant-caps: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap; background-color: transparent;">mobile</span><span style="font-size: 16px; color: #000000; font-style: normal; font-variant-ligatures: normal; font-variant-caps: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap; background-color: transparent;"> </span></strong><span style="font-size: 16px; color: #2f2924; font-weight: 400; font-style: normal; font-variant-ligatures: normal; font-variant-caps: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap; background-color: transparent;">phones,</span><span style="font-size: 16px; color: #000000; font-weight: 400; font-style: normal; font-variant-ligatures: normal; font-variant-caps: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap; background-color: transparent;"> </span><span style="font-size: 16px; color: #2f2924; font-weight: 400; font-style: normal; font-variant-ligatures: normal; font-variant-caps: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap; background-color: transparent;">other</span><span style="font-size: 16px; color: #000000; font-weight: 400; font-style: normal; font-variant-ligatures: normal; font-variant-caps: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap; background-color: transparent;"> </span><span style="font-size: 16px; color: #2f2924; font-weight: 400; font-style: normal; font-variant-ligatures: normal; font-variant-caps: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap; background-color: transparent;">mobile</span><span style="font-size: 16px; color: #000000; font-weight: 400; font-style: normal; font-variant-ligatures: normal; font-variant-caps: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap; background-color: transparent;"> </span><span style="font-size: 16px; color: #2f2924; font-weight: 400; font-style: normal; font-variant-ligatures: normal; font-variant-caps: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap; background-color: transparent;">devices,</span><span style="font-size: 16px; color: #000000; font-weight: 400; font-style: normal; font-variant-ligatures: normal; font-variant-caps: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap; background-color: transparent;"> </span><span style="font-size: 16px; color: #2f2924; font-weight: 400; font-style: normal; font-variant-ligatures: normal; font-variant-caps: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap; background-color: transparent;">and</span><span style="font-size: 16px; color: #000000; font-weight: 400; font-style: normal; font-variant-ligatures: normal; font-variant-caps: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap; background-color: transparent;"> </span><span style="font-size: 16px; color: #2f2924; font-weight: 400; font-style: normal; font-variant-ligatures: normal; font-variant-caps: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap; background-color: transparent;">services</span><span style="font-size: 16px; color: #000000; font-weight: 400; font-style: normal; font-variant-ligatures: normal; font-variant-caps: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap; background-color: transparent;"> </span><span style="font-size: 16px; color: #2f2924; font-weight: 400; font-style: normal; font-variant-ligatures: normal; font-variant-caps: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap; background-color: transparent;">delivered</span><span style="font-size: 16px; color: #000000; font-weight: 400; font-style: normal; font-variant-ligatures: normal; font-variant-caps: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap; background-color: transparent;"> </span><span style="font-size: 16px; color: #2f2924; font-weight: 400; font-style: normal; font-variant-ligatures: normal; font-variant-caps: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap; background-color: transparent;">via</span><span style="font-size: 16px; color: #000000; font-weight: 400; font-style: normal; font-variant-ligatures: normal; font-variant-caps: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap; background-color: transparent;"> </span><span style="font-size: 16px; color: #2f2924; font-weight: 400; font-style: normal; font-variant-ligatures: normal; font-variant-caps: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap; background-color: transparent;">telecommunications</span><span style="font-size: 16px; color: #000000; font-weight: 400; font-style: normal; font-variant-ligatures: normal; font-variant-caps: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap; background-color: transparent;"> </span><span style="font-size: 16px; color: #2f2924; font-weight: 400; font-style: normal; font-variant-ligatures: normal; font-variant-caps: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap; background-color: transparent;">networks,</span><span style="font-size: 16px; color: #000000; font-weight: 400; font-style: normal; font-variant-ligatures: normal; font-variant-caps: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap; background-color: transparent;"> </span><span style="font-size: 16px; color: #2f2924; font-weight: 400; font-style: normal; font-variant-ligatures: normal; font-variant-caps: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap; background-color: transparent;">the</span><span style="font-size: 16px; color: #000000; font-weight: 400; font-style: normal; font-variant-ligatures: normal; font-variant-caps: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap; background-color: transparent;"> </span><span style="font-size: 16px; color: #2f2924; font-weight: 400; font-style: normal; font-variant-ligatures: normal; font-variant-caps: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap; background-color: transparent;">software,</span><span style="font-size: 16px; color: #000000; font-weight: 400; font-style: normal; font-variant-ligatures: normal; font-variant-caps: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap; background-color: transparent;"> </span><span style="font-size: 16px; color: #2f2924; font-weight: 400; font-style: normal; font-variant-ligatures: normal; font-variant-caps: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap; background-color: transparent;">platforms,</span><span style="font-size: 16px; color: #000000; font-weight: 400; font-style: normal; font-variant-ligatures: normal; font-variant-caps: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap; background-color: transparent;"> </span><span style="font-size: 16px; color: #2f2924; font-weight: 400; font-style: normal; font-variant-ligatures: normal; font-variant-caps: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap; background-color: transparent;">devices,</span><span style="font-size: 16px; color: #000000; font-weight: 400; font-style: normal; font-variant-ligatures: normal; font-variant-caps: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap; background-color: transparent;"> </span><span style="font-size: 16px; color: #2f2924; font-weight: 400; font-style: normal; font-variant-ligatures: normal; font-variant-caps: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap; background-color: transparent;">and</span><span style="font-size: 16px; color: #000000; font-weight: 400; font-style: normal; font-variant-ligatures: normal; font-variant-caps: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap; background-color: transparent;"> </span><span style="font-size: 16px; color: #2f2924; font-weight: 400; font-style: normal; font-variant-ligatures: normal; font-variant-caps: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap; background-color: transparent;">infrastructure</span><span style="font-size: 16px; color: #000000; font-weight: 400; font-style: normal; font-variant-ligatures: normal; font-variant-caps: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap; background-color: transparent;"> </span><span style="font-size: 16px; color: #2f2924; font-weight: 400; font-style: normal; font-variant-ligatures: normal; font-variant-caps: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap; background-color: transparent;">that</span><span style="font-size: 16px; color: #000000; font-weight: 400; font-style: normal; font-variant-ligatures: normal; font-variant-caps: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap; background-color: transparent;"> </span><span style="font-size: 16px; color: #2f2924; font-weight: 400; font-style: normal; font-variant-ligatures: normal; font-variant-caps: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap; background-color: transparent;">are</span><span style="font-size: 16px; color: #000000; font-weight: 400; font-style: normal; font-variant-ligatures: normal; font-variant-caps: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap; background-color: transparent;"> </span><span style="font-size: 16px; color: #2f2924; font-weight: 400; font-style: normal; font-variant-ligatures: normal; font-variant-caps: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap; background-color: transparent;">used</span><span style="font-size: 16px; color: #000000; font-weight: 400; font-style: normal; font-variant-ligatures: normal; font-variant-caps: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap; background-color: transparent;"> </span><span style="font-size: 16px; color: #2f2924; font-weight: 400; font-style: normal; font-variant-ligatures: normal; font-variant-caps: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap; background-color: transparent;">by</span><span style="font-size: 16px; color: #000000; font-weight: 400; font-style: normal; font-variant-ligatures: normal; font-variant-caps: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap; background-color: transparent;"> </span><span style="font-size: 16px; color: #2f2924; font-weight: 400; font-style: normal; font-variant-ligatures: normal; font-variant-caps: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap; background-color: transparent;">the</span><span style="font-size: 16px; color: #000000; font-weight: 400; font-style: normal; font-variant-ligatures: normal; font-variant-caps: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap; background-color: transparent;"> </span><span style="font-size: 16px; color: #2f2924; font-weight: 400; font-style: normal; font-variant-ligatures: normal; font-variant-caps: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap; background-color: transparent;">mobile.”</span><span style="font-size: 9.6px; color: #000000; font-weight: 400; font-style: normal; font-variant-ligatures: normal; font-variant-caps: normal; text-decoration: none; vertical-align: super; white-space: pre-wrap; background-color: transparent;"> </span></p>
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Unit Exercise
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<legend id="586131fb0afe4bf6a1397dfdd0dd7944_2_1-legend" class="response-fieldset-legend field-group-hd">Which of the following are examples of eHealth?</legend>
<p class="question-description" id="description_586131fb0afe4bf6a1397dfdd0dd7944_1_1"> Select all that apply:</p>
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<input type="checkbox" name="input_586131fb0afe4bf6a1397dfdd0dd7944_2_1[]" id="input_586131fb0afe4bf6a1397dfdd0dd7944_2_1_choice_0" class="field-input input-checkbox" value="choice_0"/><label id="586131fb0afe4bf6a1397dfdd0dd7944_2_1-choice_0-label" for="input_586131fb0afe4bf6a1397dfdd0dd7944_2_1_choice_0" class="response-label field-label label-inline" aria-describedby="status_586131fb0afe4bf6a1397dfdd0dd7944_2_1 description_586131fb0afe4bf6a1397dfdd0dd7944_1_1"> Improving electronic health record systems to include physician decision support
</label>
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<input type="checkbox" name="input_586131fb0afe4bf6a1397dfdd0dd7944_2_1[]" id="input_586131fb0afe4bf6a1397dfdd0dd7944_2_1_choice_1" class="field-input input-checkbox" value="choice_1"/><label id="586131fb0afe4bf6a1397dfdd0dd7944_2_1-choice_1-label" for="input_586131fb0afe4bf6a1397dfdd0dd7944_2_1_choice_1" class="response-label field-label label-inline" aria-describedby="status_586131fb0afe4bf6a1397dfdd0dd7944_2_1 description_586131fb0afe4bf6a1397dfdd0dd7944_1_1"> Development of low cost surgical instruments for use in developing nations
</label>
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<input type="checkbox" name="input_586131fb0afe4bf6a1397dfdd0dd7944_2_1[]" id="input_586131fb0afe4bf6a1397dfdd0dd7944_2_1_choice_2" class="field-input input-checkbox" value="choice_2"/><label id="586131fb0afe4bf6a1397dfdd0dd7944_2_1-choice_2-label" for="input_586131fb0afe4bf6a1397dfdd0dd7944_2_1_choice_2" class="response-label field-label label-inline" aria-describedby="status_586131fb0afe4bf6a1397dfdd0dd7944_2_1 description_586131fb0afe4bf6a1397dfdd0dd7944_1_1"> Development of a telemedicine system for neurology consultations
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<input type="checkbox" name="input_586131fb0afe4bf6a1397dfdd0dd7944_2_1[]" id="input_586131fb0afe4bf6a1397dfdd0dd7944_2_1_choice_3" class="field-input input-checkbox" value="choice_3"/><label id="586131fb0afe4bf6a1397dfdd0dd7944_2_1-choice_3-label" for="input_586131fb0afe4bf6a1397dfdd0dd7944_2_1_choice_3" class="response-label field-label label-inline" aria-describedby="status_586131fb0afe4bf6a1397dfdd0dd7944_2_1 description_586131fb0afe4bf6a1397dfdd0dd7944_1_1"> Analysis of several years of digital ICU data to answer specific research questions
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<input type="checkbox" name="input_586131fb0afe4bf6a1397dfdd0dd7944_2_1[]" id="input_586131fb0afe4bf6a1397dfdd0dd7944_2_1_choice_4" class="field-input input-checkbox" value="choice_4"/><label id="586131fb0afe4bf6a1397dfdd0dd7944_2_1-choice_4-label" for="input_586131fb0afe4bf6a1397dfdd0dd7944_2_1_choice_4" class="response-label field-label label-inline" aria-describedby="status_586131fb0afe4bf6a1397dfdd0dd7944_2_1 description_586131fb0afe4bf6a1397dfdd0dd7944_1_1"> Creation of a text message reminder system to encourage parents to vaccinate their children.
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<h2 class="hd hd-2 unit-title">What is the Current Status of eHealth?</h2>
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<h4>What is the current status of eHealth?</h4>
<p>This past decade has seen a very high number of health programs with integrated ICT elements. These ‘tech-enabled’ programs are to be found in both the public and private health sectors. The WHO’s 2009 Global Observatory on eHealth (GOe) survey, in which WHO member countries self-assessed ICT integration in their health systems, reported that 83% of the 112 responding countries had at least one mHealth program running. A 2013 eHealth survey by the GOe, which surveyed eHealth in the 75 countries of the Commission on Information and Accountability (CoIA) in maternal and child health, identifies a “quiet revolution” at work in the use of ICT tools to collect data on health indicators, as well as the use of health services by these target populations, and to assess quality of these services. This picture is completed by a positive sign from the Centre for Health Market Innovation (CHMI) 2012 survey of eHealth in the private sector, which found that 27% of the 650+ programs surveyed had ‘expressly’ integrated ICT elements to help achieve their goals. </p>
<p>Several recent efforts have sought to make sense of the rising corpus of eHealth initiatives, for example by classifying impact in closing health performance gaps. A recent classification places mHealth within the context of universal health coverage, which is seen as the third global health transition after the demographic and epidemiological transitions. The work is itself built on a 1978 cascading model that illustrates how health systems lose performance because of bottlenecks at successive levels, each dependent on the previous layer.</p>
<p>The authors adapt the model to illustrate where eHealth investments can have the greatest impact towards the achievement of universal health coverage. The components of the health system into which eHealth ought to be integrated are grouped into categories of accountability, supply, demand, quality and cost. Suites of eHealth strategies could contribute to efforts in strengthening any given category. This superposition of mHealth strategies on layers of health systems is shown in the following figure.</p>
<p><img src="/assets/courseware/v1/1cbe2753548fdbce222848810210c50b/asset-v1:MITx+HST.936x+1T2019+type@asset+block/Screen_Shot_2016-07-05_at_10.55.22_AM.png" /></p>
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<h4>Application Examples</h4>
<p>A lack of harmonization of innovations across different layers of the health system is often cited as a reason for limited interest from government entities and ultimately the failure of many eHealth initiatives. The following examples illustrate how eHealth is currently impacting global health communities:</p>
<p>Personal health applications:</p>
<ul>
<li>Decision-making for diagnosis: such as decisions support systems for clinicians, point of care diagnostics, call centers and tele-consultations.</li>
<li>Patient reminders: appointments, adherence, etc</li>
<li>Emergency medical response to persons</li>
<li>Self-management devices</li>
</ul>
<p>Public health or institutional applications:</p>
<ul>
<li>Data gathering: routine surveillance, disease outbreaks, etc</li>
<li>Supply chain management</li>
<li>Financing: payments, insurance, etc</li>
<li>Training and support to healthcare professionals</li>
<li>Accountability</li>
</ul>
<p>Interaction between individual and public health:</p>
<ul>
<ul>
<li>Awareness, information and promotion to population</li>
<li>Electronic medical records</li>
</ul>
</ul>
<p>The healthcare area where eHealth is commonly used is disease surveillance, whereas an area that has been slower to adopt eHealth is diagnostic and clinical decision support.</p>
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Unit Exercise
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<legend id="7e4d8fd5fcc24a87b0f1d07964b720bc_2_1-legend" class="response-fieldset-legend field-group-hd">What mHealth strategy might be employed to address the issue of "continuous coverage"?</legend>
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<input type="radio" name="input_7e4d8fd5fcc24a87b0f1d07964b720bc_2_1" id="input_7e4d8fd5fcc24a87b0f1d07964b720bc_2_1_choice_0" class="field-input input-radio" value="choice_0"/><label id="7e4d8fd5fcc24a87b0f1d07964b720bc_2_1-choice_0-label" for="input_7e4d8fd5fcc24a87b0f1d07964b720bc_2_1_choice_0" class="response-label field-label label-inline" aria-describedby="status_7e4d8fd5fcc24a87b0f1d07964b720bc_2_1"> Mobile financial transactions
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<input type="radio" name="input_7e4d8fd5fcc24a87b0f1d07964b720bc_2_1" id="input_7e4d8fd5fcc24a87b0f1d07964b720bc_2_1_choice_1" class="field-input input-radio" value="choice_1"/><label id="7e4d8fd5fcc24a87b0f1d07964b720bc_2_1-choice_1-label" for="input_7e4d8fd5fcc24a87b0f1d07964b720bc_2_1_choice_1" class="response-label field-label label-inline" aria-describedby="status_7e4d8fd5fcc24a87b0f1d07964b720bc_2_1"> Behavior change communications
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<input type="radio" name="input_7e4d8fd5fcc24a87b0f1d07964b720bc_2_1" id="input_7e4d8fd5fcc24a87b0f1d07964b720bc_2_1_choice_2" class="field-input input-radio" value="choice_2"/><label id="7e4d8fd5fcc24a87b0f1d07964b720bc_2_1-choice_2-label" for="input_7e4d8fd5fcc24a87b0f1d07964b720bc_2_1_choice_2" class="response-label field-label label-inline" aria-describedby="status_7e4d8fd5fcc24a87b0f1d07964b720bc_2_1"> Development of persistent electronic health records, provider-to-provider communication, and work planning and reminders
</label>
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<input type="radio" name="input_7e4d8fd5fcc24a87b0f1d07964b720bc_2_1" id="input_7e4d8fd5fcc24a87b0f1d07964b720bc_2_1_choice_3" class="field-input input-radio" value="choice_3"/><label id="7e4d8fd5fcc24a87b0f1d07964b720bc_2_1-choice_3-label" for="input_7e4d8fd5fcc24a87b0f1d07964b720bc_2_1_choice_3" class="response-label field-label label-inline" aria-describedby="status_7e4d8fd5fcc24a87b0f1d07964b720bc_2_1"> Supply management
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<input type="radio" name="input_7e4d8fd5fcc24a87b0f1d07964b720bc_2_1" id="input_7e4d8fd5fcc24a87b0f1d07964b720bc_2_1_choice_4" class="field-input input-radio" value="choice_4"/><label id="7e4d8fd5fcc24a87b0f1d07964b720bc_2_1-choice_4-label" for="input_7e4d8fd5fcc24a87b0f1d07964b720bc_2_1_choice_4" class="response-label field-label label-inline" aria-describedby="status_7e4d8fd5fcc24a87b0f1d07964b720bc_2_1"> Counterfeit prevention
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<h2 class="hd hd-2 unit-title">What Challenges Does eHealth Face?</h2>
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<p>Andrea Beratarrechea MD, MSc<br /> Institute of Clinical Effectiveness and Health Policy<br /> Buenos Aires, Argentina</p>
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<h3 class="hd hd-2">Challenges facing eHealth</h3>
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<h4>Challenge: Interoperability</h4>
<p>The past two decades have seen an eruption of eHealth initiatives. As a discipline, eHealth is considered to be at a ‘tipping point’ between a multitude of small-scale pilots and scaled and long-term integration into health practice. The reality is that most eHealth initiatives fail to reach scale or create desired impacts. Some fear we are being plagued by ‘pilotitis’ with many small initiatives sprouting up without any real coordination or ability for many of these pilots to scale. This passage is riddled with several challenges that prevent most eHealth initiatives from scaling <i>up</i> in numbers, scaling <i>out</i> across different settings, scaling <i>in</i> across different groups in a setting, and scaling <i>across</i> different disease areas. </p>
<p>One important challenge is interoperability. eHealth has to co-exist and cooperate with off-line legacy systems (such as the mandatory paper-based reporting and health surveillance). Moreover, technical interoperability is needed with existing eHealth landscape in the given setting. The example of Kenya is telling: before the government decided to impose interoperability as a pre-condition to new initiatives, the eHealth landscape had become an ‘incompatible patchwork of solutions’. </p>
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<h4>Challenge: Evidence Base and Security</h4>
<p>A second challenge is a lack of evidence on the impact of eHealth on health system performance and on individual health. The lack of formal evaluations of most eHealth initiatives prevent the formation of a solid evidence base which is essential to gather interest (and investment) from the multiple stakeholders that are invariably needed for any eHealth initiative to scale. The 2009 GOe survey on eHealth found that only 7% of the countries with mHealth initiatives actually evaluated their impact.</p>
<p>Evaluation is certainly very difficult, for several reasons. eHealth is often used in conjunction with other health initiatives, and it becomes difficult to ascertain the contribution of the eHealth element alone to any improvements in healthcare outcomes. Moreover, initiatives that seek to impact behavioral change may require long periods of time before the expected benefits are realized. Further, evaluation is a challenge because technology evolves rapidly and often outpaces the speed of our evaluation methods. For example, it may take months or years to rigorously evaluate a new system that uses a new technology but by the end of the evaluation period the technology is obsolete.</p>
<p>Environment is also important in terms of effectiveness of a technology. A technology could be successful in one environment and then in a different environment with different users and a workflow it could miserably fail. Given there exists a history of failed technology initiatives that have caused serious financial harm to many health systems, it is essential to conduct such evaluations, and indeed to build them into the initial design of the solution itself. Further lectures discuss the evaluation of health information systems in more detail.</p>
<p>The third major challenge is concern about the privacy and security of data, which are inherent to any system storing and exchanging digital data and exacerbated because of the critically private nature of health data. The confidentiality of data is even more necessary in highly stigmatized diseases such as HIV, and in cases where the exchange of information takes place over commercial mobile networks and the storage takes place on off-site cloud platforms (which is increasingly the case).</p>
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<h4>Challenge: Infrastructure & Data</h4>
<p>Other challenges arise from the physical infrastructure available in the particular setting, such as the availability of power supply and connectivity, as well as physical devices like servers. User-centric design is also a major challenge, as an oft-overlooked concern is the acceptability of the solution by the destined users. Literacy and language barriers could significantly limit the technology options available for the design, and insufficient user training and perceived ‘ownership’ of the solution by the user could lead to rejection of the solution altogether. Finally, challenges are presented by the ever increasing volume and complexity of data available at the individual and population level. While the data offers huge potential in terms of health intelligence, the expertise and technology needed to process the data are specialized, highly sought after, and not easily accessible.</p>
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<h2 class="hd hd-2 unit-title">Examples of Technologies Used in eHealth</h2>
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<h4>Technology Architectures</h4>
<p>One simplified overview of the landscape suggests that many eHealth solutions present a similar architecture, comprising of three primary elements: </p>
<p>•<span class="Apple-tab-span" style="white-space: pre;"> </span><strong>Front-end:</strong> The primary user device and the user interface (website, or app)</p>
<p>•<span class="Apple-tab-span" style="white-space: pre;"> </span><strong>Back-end: </strong>The underlying ICT infrastructure (server hardware and databases)</p>
<p>•<span class="Apple-tab-span" style="white-space: pre;"> </span><strong>Controller:</strong> Interfaces the front and back ends and decides on the information to be exchanged between the two</p>
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<h4>Example Technologies</h4>
<p>In lower middle income countries with minimal resources, mobile devices may be more accessible and reliable than computers, and individuals may be more practiced in their use. As a result, the mobile phone is often the front-end device of choice for eHealth initiatives. The increasing feature-per-cost and feature-per-size is likely to further aid the use of mobile devices (be they basic phones, feature phones, smart phones, or tablets) in eHealth. The rise of the tablets with mobile broadband connectivity make them an interesting option as future eHealth user interfaces.<span style="font-size: 1em;"> </span></p>
<p>SMS is often considered the best ‘common-denominator’ service for eHealth. It is available in all mobile devices, featured in all generations of mobile standards, used by the largest majority of mobile users, and is the most cost-effective communications means in many settings. The added advantages of asynchronous communication and notification of delivery make SMS a good choice in non-real-time situations, despite its limitation in terms of message size limitations and lack of guaranteed delivery. <span style="font-size: 1em;"> </span>Accordingly, most eHealth solutions today are either designed for SMS or also integrate SMS as one of the data-delivery tools.</p>
<p>At the back end, it is increasingly popular to make use of "cloud computing“ services, which offer scalability and powerful computing resources. Using cloud services may relieve developers of the need for heavy infrastructural investments and offer assurances of data back-up in case of problems on site. The main perceived challenge to cloud computing, especially in the sensitive area of health, is the concern of data security (both while storage and communication). That said, some recent large-scale eHealth programs in resource-limited settings integrate cloud back-ends, such as GxAlert for diagnostics and surveillance of tuberculosis in Nigeria. Connectivity may also be an issue, which is by no means guaranteed in most low income settings.</p>
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<p>Eric Winkler</p>
<p>Lead Engineer, MIT Sana</p>
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<h3 class="hd hd-2">Sana Platform as an example of mHealth Architecture</h3>
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<h4>Open Source Software</h4>
<p>Open-source development is also gaining ground for the end-to-end design of eHealth solutions, as is evidenced by the enormous spread of platforms like RapidSMS (used in the excellent Project Mwana for diagnosis and follow-up of infant HIV in Zambia. Magpi (formerly Episurveyor) and the OpenRosa consortium’s CommCare are telling examples of open-source solutions for mobile data collection, aggregation, analysis and reporting. OpenMRS (open-source medical record system) was initially developed for HIV and TB, but is also used for cardiac diseases and primary care and many other clinical areas. Being open-source, it can be adapted at several levels, from form creation to addition of software modules and modification of the core code. OpenMRS is reportedly used at large scales in over 25 countries, and many eHealth initiatives (including GxAlert mentioned above) interface with OpenMRS. </p>
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<h3 class="hd hd-2">Open Source Technology</h3>
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