Ehealth

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Information and Communication Technologies in Health Practice Adoption and Challenges in Latin America and the Caribbean Roberto J. Rodrigues1

Information systems, communications, and collaborative work are critically important to the delivery, accessibility, and quality of healthcare; for the logistical management of health systems; and for the proficient operation of health organizations. Since the early 60’s, incorporation of computer systems into the operation of healthcare services of developed countries led to the progressive automation of libraries; business offices; the management of physical assets, stocks, and patient administrative data; instrumentation and diagnostic equipment; and the implementation of departmental systems, initially in the clinical laboratory and later in many clinical care areas and health organizations. Information and communication technologies (ICT) are the enabling components that support processes carried out by health institutions, care providers, and health programs. The imperative for ICT in the health sector is concrete and essentially driven by the operational requirements of healthcare services and organizations -- of which there are many in terms of national models, institutional formats, and governance -- all functioning in shifting social, economic, and political environments. In the last two decades the health sector has shown: •

Growth of complex and segmented health service markets

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Ubiquity of interactive communications and networks of producers, suppliers, customers, and clients

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Expectations about solutions for telehealth services, second opinion, communities of practice, evidencebased decision support, consumer-oriented information, and health promotion

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Growing importance and need for professional continuing education

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Efficiency in service management, strategic alliance models replacing traditional business organizations based on ownership of physical assets and long-term structures

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Need for rapid responses and forecasting demand

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Demand for customization capable of achieving a “one of a kind” product or service and customer satisfaction

In the past 15 years, advances in ICT and the dissemination of networked data processing and interactive applications created an environment of universal access to information resources and technologies along with the globalization of communications, businesses, and services with both optimistic and alarming implications for the future of health practice. Promising health ICT applications are oriented to professional networking, integration of the clinical care process management, standardization of patient records and provider communications; and the delivery of network-based health information and services, including remote monitoring and direct care. This expanded view of health ICT has been promoted by the ICT industry, professionals, and development agencies as the final stage in bringing online the entire healthcare system.

1

eHealthStrategies, Bethesda MD, USA and Information and Knowledge Management Area (DD/IKM), Pan American Health Organization/Pan American Sanitary Bureau, Regional Office of the World Health Organization, Washington DC, USA

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1. Medical, Social, Economic, and Organizational Issues in the Health Sector In developed as well in developing societies, and in any health sector organizational model, four core performance and outcome challenges are present: increase coverage; provide an ever-expanding range of health services; ensure equitable access to quality services; and reduce or, at least, control costs. 1.1. Healthcare Services in Latin America and the Caribbean The following critical issues have been identified for the health sector of Latin America and the Caribbean, [1]: •

Changing demographics, particularly age structures and the “graying” of the population in mid-income countries, lifestyle, urbanization, and growing industrialization. Aging population groups require greater subsidized medical care and a growing demand for high-cost diagnostic and therapeutic resources.

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Large number of individuals without access to basic healthcare and health information, many living in marginal urban areas with multi-sector shortcomings (housing, sanitation, education) and a healthcare system with chronic deficiencies in terms of infrastructure, distribution, personnel, and services.

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Shifting epidemiological profiles putting an increasing burden on healthcare services and on the society. In high- and middle-income countries, about 40% of the population has been shown to suffer from one or more chronic conditions and in some, chronic conditions account for up to two-thirds of costs.

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The “know-do gap” -- scientific knowledge and significant opportunities do exist to improve health status but still there is a considerable prevalence of preventable diseases and premature deaths, both in absolute and relative terms due to inadequate access to evidence-based knowledge.

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Despite the fact that the health sector is essential to the welfare of the population, to the formation of human capital, and for economic advancement, it has not kept up the pace with the momentum of change experienced in recent years by other productive segments of society.

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Uneven access to basic and specialized health services results in many regions, communities, and social groups being left without access to even the most basic care or, when it exists, there is poor linkage to second and tertiary levels for consultation and management of problems identified at the primary level.

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Disconnected actions in the provision of care, overlapping of responsibilities, and wasteful use of resources leading to quantitative and qualitative deficiencies in the delivery of services.

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In most countries the health sector is underfinanced, there is inefficient or wasteful allocation of scarce resources, and lack of coordination between health subsectors, institutions, academic and research centers, and other social agents and stakeholders.

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Health sector expenditures comprise 6.0% to 17% of the service sector that, in turn, accounts for 50% to 65% of the GDP in almost all countries. The market for health goods and services in the countries of the region represent 9.0% of the global health market, more than Eastern Europe and Central Asia combined and just below that of East Asia and the Pacific. The 1999 average per capita expenditure in health in Latin America and the Caribbean in PPP dollars was US$ 452. Compare this value with US$ 1,868 for the European Union, US$ 2,206 for Canada and US$ 3,978 for the United States [2]. There is a marked variation on the national expenditures among countries, even for countries of comparable income level although healthcare expenditures typically are concentrated to a limited set of health conditions— the “80/20 Rule”.

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Rising costs are mostly driven by technological innovation such as drugs, diagnostic and therapeutic modalities, instrumentation, and digital devices. Although innovation and technological changes in medicine are not new phenomena and picking up speed since the 16th century, what is new, however, is the number of innovations and the momentum by which they are disseminated and incorporated into medical practice and ICT are fast becoming a significant cost component in healthcare organizations.

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Who sets priorities for the deployment and access to technological innovation and who are those that benefit from scientific and technological developments are major issues of social, political, and economic significance and carry a heavy weight in national politics.

1.2. Reforming the Health Sector In many countries, including significant segments of the population of industrialized societies, individuals still do not have access to appropriate care or cannot afford it. Traditional revenue streams that have supported indigent care, public health interventions, medical research, and education are insufficient or are being reduced, prompting the search for new methods to support those essential activities. Health sector reform is a process aimed at introducing substantive changes into the health sector and in the relationships among stakeholders and their roles, with a view to increase equity in benefits, efficiency in management, and effectiveness in satisfying the health needs and expectations of the population. [3, 4, 5, 6]. In market economies, competition, merger of provider organizations, aggressive contracting by payers, and increasing involvement of employer and government purchasers have characterized health system reform processes [7, 8, 9]. Health reform in Latin America and the Caribbean countries has commonalities but different facets, no single model being adopted by all. Each country is moving at a different pace in the implementation of its own particular health system model but the economic and globalization changes of the last years have brought a new urgency to reform processes. Common trend-setters and responses that characterize the objectives of most health sector reform processes occurring in the Region are: [3, 8]: •

The universalization of a high cost-benefit basic package of health services with a set of standardized public health interventions;

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Cost containment and recovery;

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Administrative decentralization and operation of healthcare services;

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Recognition of the role of the private subsector and the intersectorality of health interventions;

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Health models oriented towards primary care and centered on people;

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Focus on quality and accountability; and

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Moving away from the reactive delivery of care to a more proactive management approach of the health status of individuals and population groups.

2. Information and Communication Technologies in the Health Sector In the health sector, ICT is diffusing at a rate consistent with other similar service sectors that require complex, highly networked products. From an outcome, performance, and efficiency driven perspective, information and communication technologies have been important enablers of change, particularly in the conduction of routine

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activities -- this being especially true for complex processes -- addressing three implementation environments [10, 11, 12, 13, 14, 15, 16, 17, 18]: •

Managerial and Educational -- logistics of care provision, health system planning and operation, resource administration, management of biomedical technical and scientific knowledge, and the development of health personnel

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Clinical Care and Public Health -- creation, maintenance, and sharing of personal, community, and population health data by providing remote user access to patient administrative functions such as master registration, scheduling, and the recovery of longitudinal medical record information in chronological, problem, and source-oriented formats including provider contacts, reports, transcribed notes, current medications, diagnostic data, demographics, etc.

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Specialized Health Applications -- support to technical interventions and diagnostic and therapeutic functions such as medical imaging and physiological data acquisition and analysis. Advanced systems provide guideline-based content and patient- and condition-specific reminders, automated diagnosis, population data analytical and management resources, interprovider communication facilities, and auditing tracks.

Health ICT applications have characteristics regularly found in other information- and knowledge-based industries and most ICT solutions applied to the health sector are identical to those used in other social and productive sectors or otherwise share common elements. They (a) provide operational support of technical functions, (b) support knowledge management, (c) are frequently implemented in complex environments, (d) require specialized human and organizational resources, (e) use computer-based technologies and telecommunications, and (f) are dependent on aspects related to fast-changing innovation and market demands and expectations. 2.1. ICT in the Context of Healthcare Technologies The U.S. Congressional Office of Technology Assessment (OTA) defined medical technology as “the drugs, devices, and medical and surgical procedures used in medical care, and the organizational and supportive systems within which such care is provided” [19]. Later on, the term health technology was introduced to broaden that scope also to include disease prevention and health promotion technologies. Health technology is categorized into three classes: •

Diagnostic Technology - such as electrocardiography, electroencephalography, myography, x-ray imaging, fiberoptic endoscopy, computerized tomography, magnetic resonance imaging, ultrasonography, coronary angiography, non-invasive functional organ studies, radionuclide uptake and imaging diagnostic procedures, biochemical, hematological, serological, microbiological, and tissue pathology analytical studies, genetic analysis, etc.

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Therapeutic Technology - including curative and preventive technologies such as pharmaceuticals, laparoscopic and laser surgery techniques, vaccination, radiation by external sources or radionuclides, and the evolving applications of genetic engineering and gene therapy to human disease,

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Information Technology - including manual and computerized data systems, medical records, clinical and administrative documentation, communication resources, fax machines, telephone, e-mail, the internet, handheld computers and portable digital assistants (PDAs), electronic medical records, and “smart cards”.

Diagnostic, therapeutic, and information technologies are most useful when they coexist at a similar level of development and when linked -- a health program that uses advanced diagnostic resources and fails to provide

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the resources needed for an effective therapeutic solution will not improve the health of a target population. The same can be said about ICT solutions promoted and implemented in a healthcare environment that lacks appropriate organizational, physical, and human infrastructure. 2.2. Evolution of ICT Applications in Health Practice As a general rule ICT applications in the health sector evolve by the upgrading of old applications and by the introduction of new solutions and applications to support areas hitherto not provided for and, more rarely, by a total abolition or substitution of an entire area of application. Initially, the predominant ways by which ICT were introduced and applied within the healthcare system related mainly to the operation of administrative, managerial and financial functions. Over the past forty years, applications have evolved by providing a great variety of data-processing resources aiming the improvement of health services management and patient care through the support of clinical and administrative messaging; the operation and administration of resources; logistical management of health sector functions; patient information; health education and promotion; epidemiological surveillance and health status monitoring; clinical decision assistance; knowledge management; image and signal analysis; modeling; and remote consultation and intervention (Figure 1) [18, 20, 21, 22, 23, 24, 25].

00’s OR G A NIZ AT IO N AL R EEST R UC T UR ING (HE A LT H R EF OR M )

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HE A LT HC AR E PAR A D IG M O PER AT IO N A L DET ERM IN A NT S IN F OR M AT IO N T EC H N OL OG Y

Figure 1. Over the Past Four Decades Health Applications of Information Technology Evolved in Response to Changing Operational Determinants [26] From the early administrative and patient management implementations to the organizational restructuring and collaborative work model paradigm of our days, ICT has been deployed in the health sector to provide specific

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solutions to the operational determinants of each health system design model. A characteristic of health sector ICT is that the introduction of a new organizational paradigm does not completely bring previous models to an end but, nearly always, just adds a new dimension to them. This evolutionary perspective is clearly seen in the deployment and functioning of information systems; transactional administrative systems, logistics, resource management, administrative process control, and patient clinical information applications of past and recent technological generations continue to coexist in support of health system operations – and the issue of legacy systems being a lingering problem for early adopters [9, 19, 26, 27, 28, 29, 30, 31, 32, 33]. Particularly since the advent of the Internet public networks a host of opportunities for the health sector have emerged including access to knowledge for personal health decisions and behaviors, new modalities of health care delivery, and operational support to public health and to community-oriented systems. Of special note is the fact that telecommunications made possible widespread access to the largest volume of health knowledge in history -people now can seek support and advice from potentially millions of online peers and professionals worldwide at any time. From the service delivery perspective, there is a growing regionalization of specialty-based medical technologies that consider population distribution, epidemiological profiles, and economies of scale. The global demand for telehealth services is estimated to be of US$1,25 trillion, of which about two-thirds is for direct services and the rest for second opinion, consumer information, continuing education, management and other services [18, 21, 27, 34, 35, 36, 37, 38, 39]. 2.3. ICT and Health Sector Management and Operation The variety of environments, priorities, organization, and operational demands of the healthcare sector require a great diversity of resources and solutions capable of providing support for the challenging and complex interdependent clinical, public health, and managerial decisions and interventions that characterize the everchanging health practice [20, 27, 38, 40, 41]. The health reform processes implemented or being under study in most countries can take advantage of the experience with ICT solutions build for other social, service, and productive sectors of society that share similar determinants of change [42, 43, 44]. Advanced ICT resources have been recognized as appropriate for operational support of a new health and healthcare models [8, 21, 27] focused on individual information, data mining, and concomitant access by multiple users. They also address the new trends in healthcare emphasizing continuous relationship between providers and clients; customization of care; expanding partnering of providers, insurers, and clients; increasing client control of evidence basedhealth decisions; information that is not frozen in paper records kept in separate sites with access limited to their creators but available electronically to all stakeholders; and transparency and cooperation among healthcare providers instead of independent professional roles. Competition, merger of provider organizations, aggressive contracting by payers, and rising involvement of employer and public purchasers have characterized the changing processes occurring in health services management. Those models of care require, beside innovative functions, different responsibilities for users and providers. New roles are expected for providers and the involvement of new professionals, including from nonhealth sector areas, and the local government together with the increased role for local governance (e.g. municipalities and individual health provider organizations) and non-traditional professional categories. 2.4. Matching ICT Applications to Health Sector Requirements Even in developed countries, most public and private healthcare ICT applications evolved in a patchy and inefficient way with limited number of standardized data-related definitions and processes in place, a prerequisite for efficient systems deployment. Besides those shared specifications, information systems must be appropriately designed and implemented in order to support the great diversity of perspectives and operational requirements of regulators, managers, payers, providers, and clients [21, 27]. In order to reap the full benefits of such innovative data processing, communication, and use, it is necessary to have a clear definition of goals;

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effective collaboration among stakeholders; appropriate technology infrastructure, systems integration, and standards; and the implementation of performance metrics. Current developments in the health systems of developed countries that can be successfully supported by ICT are characterized by [7]: •

Economies of speed associated to economies of scale

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Custom-built products and services (“individualization of care”)

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Convenience and “real time” processes (“customer satisfaction”)

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Dealing with the short life cycle and rapid obsolescence of explicit evidence-based knowledge

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Capturing and sharing the tacit knowledge of health professionals

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Modularity and standardization of basic components (“reuse”)

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Convenience and safety becoming more important than price (e.g. kits, one-time use devices)

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Emphasis on more effective use of existing technologies than on the introduction of new solutions

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Evidence-based justification for deployment and utilization of new technologies

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Safety, confidentiality (“data protection”), and regulatory concerns

2.5. From Health ICT to e-Health Rarely mentioned before 1999, the eHealth concept evolved from fields previously known as telehealth and telemedicine to now serve as a general designation to characterize not only networked health applications, but also virtually everything related to computers and medicine overlapping traditional medical informatics and public health combining electronic communications and information technology to transmit, store and retrieve digital data for clinical, educational, and administrative purposes, both at the local site and at distance [45, 46, 47]. The term eHealth was first used by industry leaders and marketing professionals rather than academics. Intel referred to eHealth as "a concerted effort undertaken by leaders in health care and hi-tech industries to fully harness the benefits available through convergence of the Internet and health care." Because the Internet created new opportunities and challenges to the traditional health care information technology industry, the use of a new term to address these issues seemed appropriate. The "new" identified challenges were: (a) the capability of consumers to interact with their systems online (B2C = "business to consumer"); (b) improved possibilities for institution-to-institution transmissions of data (B2B = "business to business"); and (c) new possibilities for peer-to-peer communication among consumers and providers (P2P = "peer to peer") [40, 41, 48]. eHealth development followed a pattern started by other "e-words", such as e-Commerce, e-Business, eFinance, e-Learning, e-Government, e-Solutions, and e-Strategies. An author [48] defined ten areas were the implementation of eHealth solutions should promote significant changes: •

Efficiency - one of the promises of eHealth is to increase efficiency in healthcare, thereby decreasing costs. One possible way of decreasing costs would be by avoiding duplicative or unnecessary diagnostic or therapeutic interventions, through enhanced communication possibilities between health care establishments, and through patient involvement.

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Enhancing quality of care - increased effectiveness and improved quality. eHealth may enhance the quality of healthcare by allowing comparisons between different providers, involving consumers as additional power for quality assurance, reducing errors, and directing patient streams to the best quality providers.

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Evidence based reasoning - eHealth facilitates evidence-based decision making in a sense that their effectiveness and efficiency should not be assumed but proven by rigorous scientific evaluation.

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Empowerment of consumers and patients - by making the knowledge bases of medicine and personal electronic records accessible to consumers over the Internet, opening new avenues for patient-centered medicine, and enabling evidence-based patient choice.

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Encouragement of new relationships - between the patient and health professional, towards a true partnership, where decisions are made in a shared manner.

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Education of health professionals and citizens - through online sources (continuing medical education) and consumers (health education, tailored preventive information for consumers).

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Enabling standardized information exchange and communication - between healthcare facilities, levels of care, and caregivers.

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Extending the scope of healthcare - both a geographical sense as well as in a conceptual sense. eHealth enables consumers to easily obtain health services online from global providers. These services can range from simple advice to more complex interventions or access to products such as pharmaceuticals.

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Ethics - eHealth involves new forms of patient-physician interaction and poses new challenges and threats to ethical issues such as online professional practice, informed consent, privacy and equity issues.

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Equity – aiming at making healthcare more equitable.

Most eHealth solutions build on strategies and experiences in using Internet-based networked technologies to rethink, redesign, and rework how businesses and public services operate. Typically, such developments have been aimed at the improvement of productivity, effectiveness, and efficiency, both internally and in the relationships with clients, customers, suppliers, and partners. The essence of eHealth, as in e-Commerce, is reliable transaction delivery in a fast-changing environment involving people, processes, and a business infrastructure focused on the ill or healthy citizen. Many eCommerce solutions share common elements with the health sector allowing healthcare organizations to migrate to a customer-focused environment and make the transition to a collaborative patient care management strategy. In developed countries, eHealth has rapidly evolved from the delivery of online medical content toward the adaptation of generic solutions to the processing of health-related administrative transactions and logistical support of clinical tasks. Besides the intensive use of advanced information and communication technologies, such applications are grounded on explicit process standardization and economies of scale and oriented to networking, integration of the clinical care process management, and the provision of Web-based health information and patient care, including remote monitoring and healthcare [20, 22, 30, 49, 50, 51, 52, 53]. Frequently, eHealth is equated to telemedicine; however the latter term should be more appropriately applied to the use of ICT for remote clinical consultation, case review, and second opinion. In a broader sense, eHealth characterizes not only a technical development, but also a state-of-mind, a way of thinking, an attitude, and a commitment for networked global thinking, to improve health care locally, regionally, and worldwide by using information and communication technology [48, 54].

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eHealth applications have been deployed in the following areas [7]: • • • • • • • • • • •

Professional Communication among Providers Logistics of Patient Management and Distributed Provision of Care Health System Administrative Transactions Business to Business Transactions Business to Consumer Transactions Biomedical Knowledge Management Electronic Health Record (Computerized Patient Record) Clinical Care (Telemedicine) Health Information Delivery to the Public Distant Education of Health Professionals Consumer to Consumer Exchanges (Chat and Special-Interest Groups)

2.6. Market for ICT Products and Services In many developing countries the market for ICT products and services is limited. The hospital subsector is characterized by small facilities – e.g., in Latin America and Caribbean 60.5 percent of the hospital facilities have 50 or fewer beds (Table 1) – that cannot afford major capital expenses in deploying ICT resources and would be hard-pressed to meet the operational costs to maintain in-house applications.

Number Beds

Hospitals n

Beds %

n

%

1-50 51-100 101-200 201-300 301-400 401-500 501-1000 >1000

10,027 2,615 1,703 544 242 133 186 29

60.5 15.8 10.3 3.3 1.5 0.8 1.1 0.2

219,383 189,559 242,770 133,225 84,811 58,951 126,169 43,097

20.0 17.3 22.1 12.1 7.7 5.4 11.5 3.9

Sub-Total No Data Total

15,479 1,087 16,566

93.4 6.5 100.0

1,097,965

100

Table1. Hospitals in Latin America and the Caribbean by Number of Beds (PAHO HSP/HSO Directory of Latin America and Caribbean Hospitals, 1996-1997) Resources, products, and markets that are highly specialized, closed, and regulated are being swiftly opened to new players in a marketplace that is mostly unregulated and, at the same time, when novel and untried health reform models and ICT are being introduced. These circumstances carry with them a high unpredictability of outcomes. The straightforward transference of the e-Commerce experience and solutions to the health sector is not straightforward since the healthcare environment has characteristics that are quite different from an “ideal” competitive market guided by rational decisions and the balance of availability and demand for goods and services. Such differences include: (a) social goals of the health sector (equity of access and quality of care); (b) restricted number of producers (healthcare providers); (c) self-interest is the main guiding force for providers and consumers (patients); (d) provider makes most of the “buying” decisions (information asymmetry); (e) many barriers to entry; (f) monopoly supported by regulatory and legal instruments; (g) branding is generalized (providers, pharmaceuticals); (h) multiple uncontrolled externalities; and (i) high risk and uncertainty or irreversibility of outcomes. Moreover, in the health sector there is low price elasticity for goods and services.

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Unfounded vendor-driven expectations of how the Internet will revolutionize healthcare have too often overshot their target. Overestimation of results and consequent unfounded expectations is a frequent pitfall. A common error has been to regard technology as the solution for logistical, administrative, and knowledge management problems of healthcare. The lesson to be learned for eHealth is that technology is a tool, which can be justified economically only if organizations deploy it in a real practice environment and closely track how managers and direct care professionals are using it. This requires the stepwise development and implementation of processes and metrics to monitor productivity and impact. 2.7. Presence of an Enabling Organizational and Governance Environment Understanding a country health sector and ICT infrastructure, needs, expectations, and priorities of countries must be followed by the development and implementation of national policies and a regulatory framework for ICT. Policy development is often a long evolutionary process [23, 24, 35, 53, 56, 57, 58, 59, 60]. Those organizational and governance enablers are aimed at the reduction of infrastructure externalities, coordinate the implementation of standards, and facilitation and guidance of organization changes required in the deployment of ICT solutions. The most important decisions relate to finding ways to deal with: •

Policy-related Issues – Inadequacy of policies and norms regarding information technology and, particularly in the case of the public sector, the lack of national strategies for the standardization and cost-effective use of technology and information and failure to integrate the different visions of ICT applications as they relate to health system models. Haphazard development of “islands” of innovation is typically associated with centers of excellence isolated from national, regional, and local approaches. Inconsistency and stability of political support, reflected in funding discontinuity, is a major problem in the Region.

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Standardization Issues - Main problems in this area are data-related involving institutional and organizational standard-setting and their consistent use. Low definition level of contents (deliverables) of health interventions, indetermination of objectives and functionalities desired for applications, and conflicts in defining minimum data sets for operational management and clinical decision-making.

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Organizational Issues - Centered mainly on problems related to the inevitable changes of work patterns and procedures, increased documentation workload for staff and direct healthcare professionals, and issues of retraining, physical data security, and confidentiality of patient-related data. Resistance to change is related to professional hierarchy and clearly demarcated roles -- this major obstacle results in unwillingness of professionals to collaborate in recording and exchanging patient data and there is a general distrust for offsite data storage and access control. Other organizational and managerial aspects involve limited information about impending technologies and low health provider capacity to acquire and deploy ICT and limitations on operating and capital financial resources, market closure, and high tariffs results in low investment in innovation and technology.

Developing countries may require direct assistance in the definition of ICT policies and strategies as part of their comprehensive development strategies as well as with the establishment of the appropriate regulatory environment for competition so that national and foreign private investment can play a role in bringing necessary seed financing through public-private partnerships.

3. Technological Innovation and Acceptance in the Health Sector Science and technology are cultural artifacts and exist in a social environment with defined values. Historical evidence suggests that the prime explanation for the success of advanced industrialized countries lies in their record of innovation and its application involving different dimensions: institutions, technology, trade,

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organization, and application and control of natural resources. In particular, the characteristics of innovation itself -- uncertainty, search, exploration, financial risk, experiment, and discovery -- have so permeated the expansion of trade and the development of natural resources in Western Societies as to make it virtually an additional factor of production [61]. Technology-driven innovation is a multiple-step interactive process requiring attention to constantly changing resources and skills involving a wide range of actors and interests, operating under different intents, incentives, and timelines. Innovative processes, exhibit dead-ends, feedback loops, multi-directional interactions, parallel developmental paths, and unintended consequences. Besides issues of technology effectiveness and appropriateness, questions were raised about the social impact of technological innovation and the many ethical and economic issues related to scientific inquiry and the adoption of innovations. Far-reaching social, cultural, and political impacts result from the introduction of technological innovations in the health sector -- probably the most serious is the focus of medical attention on technology without proper assessment of its effectiveness and its role and impact in the relationship between patient, communities, and the physician. 3.1. Moving Beyond the Health Professional: New Actors and Issues Traditionally, technology developers considered the physician, acting as agents for their patients, as the principal user. In recent years, however, other groups -- hospital administrators, patients, payers, and regulators -- have begun to influence technology-related decisions. Public opinion and perceived benefits, even when unconfirmed, also play an important role in technology diffusion. Unwarranted enthusiasm may result in the sometimes premature diffusion of technologies such as was the case with total-body computed tomography scanning, placing the public at risk of overtesting and overtreatment [62]. Those concerns have been exacerbated by the steady introduction of new technologies and the increasing gap in access to healthcare resources among social groups and countries resulting in [49, 63, 64]: •

Class disparities - technology may create economic disparities both between and within the developed and developing worlds. Those not willing or able to retrain and adapt to new technological opportunities may fall further behind. Moreover, given the market weakness in developing countries, economic incentives often will be insufficient to drive the acquisition of new technology artifacts or skills to serve poorer social groups.

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Reduced privacy - various threats to individual privacy and data security have been created by new technologies. They include diagnostic results databases, increased sensing capability for biochemical markers, DNA testing, and genetic profiles. There is, however, ambivalence about privacy because of the potential benefits derived from availability of population-based information. Unfortunately, since regulation and legislation often lags behind the pace of technology innovation, privacy is generally addressed in reactive rather than proactive fashion and occasions for major breaks in personal data protection are constantly being created.

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Cultural threats - many feel that their national or group culture vitality and possibly even long term existence may be threatened by technology. As the benefits of technology are evident it may be difficult to prevent such changes and technological innovation has been a major driver for the diffusion of a uniform global identity across all social sectors, especially among the young.

3.2. The Anti-technology Prejudice Irrational reaction against science and technological innovation has many causes. In the health sector, opposition to technological advancement and to ICT in particular, is not rare and is generally cloaked in a humanistic, alternative, or political discourse, some critics going to the extreme of questioning the very role of medicine in improving the health of populations [65, 66]. Aligned with more recent postmodern deconstructivism and the emergence of the misdirected logic at the heart of apparently well-meaning but largely flawed

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arguments of “science studies” academics, this view has argued that modern science only reflects dominant social interests and cultural values of Western society. Following this line of thought, postmodern scholars have urged societies to develop their own "alternative science" as a step toward "mental decolonization”. By eroding all distinctions between science and subjectivism, they have unwittingly aided the spread of fallacies and the undermining of evidence-based knowledge [67, 68, 69]. This is reflected in the proliferation of alternative cures and unwarranted claims in the electronic public space of the Web. Notwithstanding those negative positioning, skepticism regarding established intellectual values and uncritical enthusiasm for technology had a positive effect in nurturing the evidence-based movement in health, epitomized by the work of Cochrane, Donabedian, and others and characterized by: concern with broader health issues including prevention and promotion; respect to appropriateness; public involvement in policy making; concern with patient’s satisfaction; commitment to quality assurance; and emphasis on accountability [70, 71, 72]. In fact, the evidence-based movement resulted in profound changes in the diffusion, professional acceptance, and in the methodologies used to assess technologies and medical interventions. 3.3. Development and Adoption of Innovation by the Health Sector A high percentage of new medical technologies have emerged not out of biomedical research, but through transfer of technologies that were developed for other sectors, examples being lasers, ultrasound, magnetic resonance spectroscopy, and that most general-purpose of all technologies, the computer. Indeed, a drawback of a linear model of innovation is that it implies that one can make a neat distinction between research and development (R&D) on the one hand and technology application on the other, without considering the uncertainty inherent to the former. Furthermore, once developed medical technologies often interact with other technologies in unexpected ways resulting in unintended consequences and those interactions frequently cannot be anticipated for the simple reason that complementary technologies may not yet have been invented. These facts underline two critical characteristics of innovation in medicine: new technologies retain a high degree of uncertainty long after their initial adoption and a close interaction between developers, often in industrial laboratories, and users is crucial to the development of new medical technologies. Use of any innovative technology in a clinical setting likewise requires a complete reorganization of how medicine is taught and practiced. This adoption inertia is observed even with technologies where scientific evidence is well established; as an example, George Papanicolau first demonstrated the effectiveness of the Pap smear in the 1920s, but it was not until the 1940s that it was accepted into practice. Health professionals, and particularly physicians, are generally wary of introducing devices that might interfere with their communication with patients and the latter, on the other hand, are suspicious of information technologies that might facilitate the dissemination of personal information to other parties. Because the introduction of a technology may require major changes in professional practice new technologies require considerable effort, expertise, and commitment – not necessarily linked to their inherent complexity; for example, the introduction of electronic fetal monitoring in the 60’s and 70’s required extensive retrofitting of nursing procedures and guidelines to reconcile machine monitoring with midwifery practice as conducted at that time [73]. Other consequences of technological adoption are the required change in medical education and the appearance of the specialist. The dramatic increase in specialists and decline in generalists in the years following World War II was largely due to an explosion of new technology, which required considerable time and study to master and frequent practice to maintain appropriate skills. In the U.S., in 1940 seventy-five percent of direct patient care physicians were general practitioners -- by 1949 that number had dropped to sixty-five percent and in 1975 family physicians accounted for only 13.8% of the physician population [74]. Motivation for providers and hospitals to adopt a new technology is an issue of considerable policy relevance. A study of the adoption of magnetic resonance imaging in the U.S. showed that there are multiple determinants for embracing a new technology: provision of better services, technical and professional preeminence, clinical

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excellence, attraction of new specialists, image building, and revenue generation. Furthermore, insurance and reimbursement insulates providers and patients from the immediate financial consequences of the use of new and expensive technologies [75]. Studies have shown health professionals increasingly using and accepting the Internet paradigm for information and knowledge sharing. Evidence of this phenomenon is the growth of interactive health communication by which individual consumers, patients, caregivers, and professionals access or transmit health information, or to receive or provide guidance and support on a health-related issue through electronic communication technologies to relay knowledge, enable informed decision making, promote healthy behaviors, promote information exchange and promote self-care, or manage demand for health services [76, 77]. A global survey demonstrated that 80% of physicians across eleven North American, European, and Asian countries own a computer and 44% of these physicians have accessed the Internet. The predominant place of Internet access is in the home. Among physicians who have not yet accessed the Internet (56% of physicians in the eleven countries surveyed), two-thirds intend to do so soon. The overall result is that more than 80% of physicians (90% in the US) are online or intend to be online in the near future. Almost all (95%) said they use the Internet to access disease information an average of 14.7 times per month, 88% reported reading medical journals online, and 86% said they use the Internet to obtain drug information. Of the time spent seeking any information on the Internet, experienced user physicians overall report spending a full 50% of that time seeking medical information. A finding, both surprising and indicative of the general trend toward patient empowerment, is that 62% of net-connected physicians reported suggesting to patients that medical information could be obtained online. Almost one-third of physicians reported that patients had brought with them medical or health-related information they had found on the Internet [78]. The modernization of public service is a challenge to existing forms of organization in the public health sector and implies some kind of organizational and personnel change. In fact, technical innovation to a large extent depends on organizational innovation in order to achieve real improvements in efficiency and quality of service. Moreover, the potential of health ICT may fall flat without the active involvement of healthcare professionals and citizens or their representatives in the choice, deployment, and assessment of relevant technologies. For these user groups to participate in a meaningful way in these procedures they have to be empowered and informed about the benefits ICT can bring to healthcare delivery. 3.4. New Technologies Require New Skills People are central in the value-added creation of e-Health products and services and human resource are crucial to success. The introduction of ICT in healthcare disrupts traditional structures and work organization requiring that health professionals keep pace with new technologies. Deployment of ICT in a patient care environment requires that health professionals transcend the strict boundaries of their specialized functions and acquire a new set of skills that may have been unnecessary in the past. These are mainly leadership competencies and systemic thinking -- such as strategic and tactical planning, persuasive communication, negotiating skills, financial decision-making, team building, conflict resolution, and information and knowledge sharing -- as well as some basic ICT-related technical skills [79, 80, 81, 82, 83]. They create an additional burden to the already demanding schedule of health professionals. Education and training are key factors when introducing new methods of work among healthcare providers and in empowering citizens to access health information. The need to equip healthcare professionals with ICT skills has been on the educational agenda of many organizations for the past decade. The current expansion of ICT in the health sector has important implications not only for the support of administrative and functional tasks but also for the actual delivery of healthcare [7, 20, 21, 40, 41, 49, 76, 84, 85].The nurturing of competencies and skills and the introduction of new working methods have become key factors in the successful re-engineering of service suppliers as they transform into agencies providing ICT-enabled services. Changes to strategies,

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structures, and methods of service delivery are dependent upon a creative and innovative workforce. The latter needs to adapt skills, competencies and, above all, mindsets and attitudes to new ways of working that are more responsive to the needs of citizens. Although technical skills are necessary to set up eHealth applications, the delivery of these applications to citizens also requires strong inter-personal and managerial skills since quite often providers are required to manage people over the network. While the technical skills are concerned with the communication technologies used and the clinical processes enabled by those technologies, the interpersonal skills are concerned with relationships between system personnel, providers and patients, and the way in which those relationships are organized. Required skills and competencies can be grouped into the following broad categories [86]: •

Basic computer skills: these include use of computers, web technologies for accessing portals and for using personalized services, together with eHealth applications for delivering telecare services.

•

Organizational and managerial skills: including leadership competencies necessary for the effective development and delivery of services and for dealing with new organizational structures, service delivery models, changes in working methods, job roles, etc.

•

In-depth understanding of the functional capabilities of eHealth technologies and applications: this encompasses the ability to have a thorough understanding of how eHealth applications such as integrated patient management and electronic health records, epidemiological networks, telecare and independent living devices and services, etc., fit into, and are an integral part of, the formal healthcare delivery system.

•

Awareness of legal, ethical, and economic issues surrounding eHealth: this refers to the knowledge and capabilities that need to be acquired in order to manage the relations between the different stakeholders in an eHealth environment, such as identifying their rights and obligations, defining service level agreements, understanding the problems surrounding the security and confidentiality of personal and health data, ways of preventing and dealing with malpractice, etc.

3.5. Command of Technology and Competitiveness among Care Providers Many market segments are becoming increasingly ICT-dependent as part of globalization and the success of developed countries in taking advantage of ICT, particularly the U.S., partly reflects its flexible and competitive markets. Possibly, smaller benefits can be expected in more regulated economies or in the case of implementation environments characterized by rigid labor, trade, and inefficient commodity markets, monopolistic telecommunications sector, and capital exchanges. Areas of concern in electronic marketplaces, particularly in developing countries, are related to the difficulties in regulating offshore business, the dominance of the Internet global communications infrastructure by a few countries, and the growing concentration of power and knowledge in few corporations. As is usually the case with innovation, the agents that first move into the market quickly attain a dominant position, block the entry of new competitors, and capture a large part of potential proceeds. Cross-border challenges are particularly pressing due to the growing number of national, international and non-governmental actors involved in transnational and global concerns. Market capture by strong, organized, and well-funded health provider organizations, some of international nature, is happening at a fast pace and regulatory methods have been advocated to safeguard local competition. Intangible health “e-Solutions” products and services offered by foreign providers, as is the case of investment, insurance, knowledge dissemination, and healthcare applications, present possible challenges to developing and poorly developed countries and has resulted in fears related to flight of capital, tax evasion, employment reduction, capture of the health market, and “cultural colonization”.

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3.6. Standardization The simple automation of current processes and services and putting them on a Web-enabled environment is not feasible without data definition and representation standards. Great amount of work has been done in the creation and promotion of standards [17, 21, 22, 24, 27, 28, 30, 31, 40, 87, 88, 89, 90]. Process and data standards for the healthcare industry promoted by accrediting organizations and involving all constituents – employers, consumers, providers, payers, and regulators – have facilitated the adoption of common procedures and routines. Despite lack of data standards in some areas, there are solutions that allow different organizations and systems to communicate through open access Internet-oriented software languages. A certain amount of standardization also has been driven by regulatory action. In the U.S. the introduction of the Health Insurance Portability and Accountability Act (HIPAA) regulations forced a reluctant health industry to adopt uniform formats for health data exchanges and uniform code sets to identify internal and external health services activities and to be HIPAA-compliant became a requirement of all applications. However, even in developed countries the lack of national standards for unique person identification has slowed implementation of patient-based information systems. An extensive review and reference source on healthcare data standards was published by the Pan American Health Organization [27]. 3.7. Security and Privacy Data security and privacy of personal health data are universal concerns and a high-priority issue in many countries. There is a growing concern regarding the protection of health records against intrusion, unauthorized use, data corruption, intentional or unintentional damage, theft, and fraud. Health data transmitted over national and international networks offer unprecedented opportunities for better patient care and community health interventions by facilitating data exchange among professionals but pose new challenges to confidentiality. The promise of Internet to improve care by timely access to the right information can only be realized through secure connections shared across all platforms. Given the sensitive nature of healthcare information, and the high degree of health professionals dependence on trustworthy records, the issues of reliability (data residing in the electronic health record are accurate and remains accurate), security (owner and users of the electronic health record can control data transmission and storage), and privacy (subject of data can control their use and dissemination) are of particular significance and must be clearly and effectively addressed by health and health-related organizations and professionals groups. Reliability, security, and privacy are accomplished by the implementation of a number of preventive and protective policies, tools, and actions that address the areas of physical protection, data integrity, access to information resources, and protection against unauthorized disclosure of information. A comprehensive review and reference source on personal data protection regulation was published by the Pan American Health Organization [91]. 3.8. Directing and Prioritizing Research and Development The imbalance between developed and developing countries in terms of biomedical research and technology adoption is significant and there is great variation in biomedical research productivity among developing countries. A multiple regression model using research articles publish as indicator and population as the dependent variable and ten social and economic indicators as independent variables reveals that gross national product (GNP) per capita and research and development (R&D) expenditure emerged as significant factors [92]. In developing countries, a review of biomedical research articles published during 1990-2000 normalized to number of publications per million population (PPMP) shows that, in terms of continents, North America had the highest number of biomedical PPMP per year (341.33); this was followed by Australia and Oceania (288.35), Europe (136.88), Asia (12.81), South America and Caribbean region (10.80), and Africa (3.50). In total, 52.7% of the countries showed a positive trend over time: 23.3% in South America, 28.9% in Africa, 40.0% in Australia

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and Oceania, 61.0% in Asia, 84.6% in Europe, and 100% in North America. All the continents except Africa showed a significantly positive trend. The better the economic ranking of a country, the higher will be the number of biomedical PPMP [93, 94]. Science, technology and innovation, used in their broader meaning to include the generation, use and diffusion of all forms of useful knowledge as well as the evolution of associated institutional arrangements, are an important component of the global actions directed to meeting the United Nations Millennium Development Goals (MDGs). A robust science and technology R&D policy cannot exist if it is not underpinned by other welldesigned policies addressing learning, technological development, technology transfer, R&D, and the industrial and commercial aspects of technological product creation and deployment. This is particularly true in areas that involve education, health, the social environment, agricultural and medical biotechnologies, pharmaceuticals, computer networks and telecommunication systems. Given the fact that the worldwide market for information technology, products, and services is currently valued at US$853 billion, and that worldwide investment in telecommunications infrastructure is expected to exceed US$200 billion by 2004, developing countries need to find ways to share this growing trend. Domestic and foreign, public and private investment sources will be involved, ranging from revenue-sharing initiatives and joint ventures to direct investment, transfer schemes, development fund established by a special tax on telecommunications, major private financial institutions, loans from international funding agencies and development banks, and incentive grants.

4. The International Experience with ICT Integration in the Health Sector Dating from the mid-1990s there are well-documented studies that demonstrate that ICT enhance productivity in prominent industries, including wholesale, retail, and services [10, 15, 95]. Similarly, following the introduction of ICT significant productivity improvement has been corroborated in the massive health sector of developed countries with significant positive changes in professional productivity; efficiency of interventions; quality of care; reduction in medical errors; in the expansion of evidence based reasoning; in empowering consumers and patients; as a catalyst in the establishment of new relationships between patients and health professionals; in the education of health personnel and citizens; as an enabler of standardized information exchange and communication; in extending the scope and coverage of healthcare interventions; and in making healthcare more equitable. Most of the experience with health ICT originates from Europe, United States, Canada, and Japan. Among leading digital technologies, Internet-based ICT solutions have brought the greatest impact and they are rapidly changing the way health organizations, providers, care plans, payers, regulators, and consumers, access information, acquire health products and services, deliver care, and communicate with each other [7, 9, 20, 76, 96, 97]. Four out of five European doctors have an internet connection, and a quarter of Europeans use the internet to get information about diseases and health matters. These encouraging figures indicate that ICTsupported health systems and services will develop rapidly. European Community research funding has supported health ICT to the tune of EUR 500 million since the early 1990s, with total investment through cofinancing being around twice that amount. Many of today's success stories are the product of that research. All this has helped to create a new e-Health industry with a turnover of EUR 11 billion. Estimates suggest that by 2010 up to 5% of health budgets will be invested in systems and services. In the European Union, the development of ICT was conducted since the mid-80’s mostly under the aegis of the Advanced Informatics in Medicine (AIM) Initiative [98] a multidisciplinary, multiprofessional partnership dedicated, in association with the health care service, to providing digital based solutions to the problems encountered in modern health care delivery. Establishment of the Initiative was driven by the realization that the healthcare sector was introducing ICT tools without adequate research and coordination – this left the sector

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fragmented and with a great variety of incompatible applications. Managerial and clinical systems were developed from scratch at local or institutional level or bought from vendors without much consideration for the emerging unification of the European healthcare systems. Digital diagnostic and therapeutic equipment was mostly imported from the United States or Japan, the latter taking a leading role particularly in medical imaging. Funded by the European Community, AIM seeks to encourage research and development in areas of telemedicine beyond the scope of any one country, or where the expertise of several countries could usefully come together. AIM is based on a strong academic research infrastructure of experienced scientists and clinicians and close collaboration with the industry for technology transfer -- the Initiative appreciates that to secure maximum advantage from scarce research resources, attention must be paid to the potential commercial exploitation of products and welcomes collaborative arrangements with industry especially those in the healthcare sector. The Initiative is organized in Framework Programs lasting 2 to 4 years, has hundreds of partners and participants and funds selected projects in a great number of application areas ranging from primary care, medical records, coding standards, and decision support systems to instrumentation, multimedia workstations, and security and data protection. The main challenge identified in the European Union 2005 e-Health action plan [99] is to improve health and healthcare through the use of information and communications technologies at a stable or lower cost, and to reduce waiting times and errors. The aim of the action plan is the creation of a "European e-Health Area" and identifies practical steps to achieve this by developing electronic systems for health records, patient identifiers and health cards, and the faster rollout of high speed internet access for health systems to allow the full potential of e-Health to be delivered. The ultimate aim is for e-Health to become the norm among the healthcare profession, patients and the general population by the end of the decade. By end of 2005, each European Union Member State developed a national or regional roadmap for e-Health. The action plan proposed that the Member States agree by the end of 2006 on a common approach to patient identifiers and the definition of interoperability standards for health data messages and electronic health records taking into account best practices, relevant standardization efforts and developments in areas such as the European Health Insurance Card and identity management for European citizens followed by the deployment of health information networks for e-Health based on fixed and wireless broadband and mobile infrastructures and Grid technologies. Considerable investment is required for the development or modernization of systems and services. Consequently, under the action plan, a collaborative approach to supporting and boosting investment in e-Health is being undertaken among Member States. Major efforts are currently underway to establish health information networks. By the end of 2008 the majority of European health organizations should be able to provide online services such as teleconsultation (second medical opinion), e-prescriptions, e-referral, telemonitoring and telecare (remote monitoring of patients in their own homes). It is also expected that the implementation of an electronic health insurance card will be adopted by 2008. Between 2004 and 2010 the European Commission will publish a biennial study on the progress made in implementing e-Health. In the United States and other countries, principal among the factors driving regionalization of care are the economic forces related to the high cost of many new technologies; superiority of outcomes on the basis of the experience and volume of cases or procedures; increased diffusion of information and communication technologies linking providers and support services such as clinical laboratories; public accessibility to health information; and increased public participation in policy and decision making. Studies conducted in the United States have shown that the financial differences in managing patient care in various settings are substantial -US$1,000 to 1,500/day in an acute care facility versus US$48 to 80/day per patient encounter in an ambulatory care setting. Delays in obtaining laboratory test results may cause patients to receive inappropriate or putting off appropriate therapy with associated costs to the health care system due to needless medication, and repeat testing or visits to health care providers, emergency facilities or hospitals. Delayed or lost test results diminish

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patient compliance, lead to errors in diagnosis, and require physicians to use anticipatory treatment while awaiting laboratory results. A large base of physicians, particularly in the US, is using the Internet. Physician usage of the Internet is increasing and almost all physician users are using the Internet for clinical information. Web-based applications are expanding rapidly and major providers, such as the Cleveland Clinic and the Kaiser-Permanente Healthcare system in the U.S., have developed incremental approaches to gathering clinical data, particularly across different organizations and locations. However, a all-or-nothing approach promoted by some Electronic Medical Record (EMR) vendors and integrated delivery systems has met with limited success since a “one-size-fits-all” software model is a hard sell to physicians as replacement to the traditional paper chart, requires a lengthy learning curve, and has a high price tag. At the public health level, it was learned that useful clinical data can be collected incrementally. For example, for heart failure patients, one item of information -- the patient's daily weight -- is a reliable predictor of imminent hospitalization. When a patient gains weight, clinician intervention with medications can often prevent hospitalization. Browser-based technologies are much more adaptable to individual physician practice patterns. In contrast to earlier applications that required physicians to adapt to the structure of the software new Web-based approaches bypass the physician -- for instance, patient education can often be done by "connected" nurses, case managers, or others. In contrast with past approaches, most are offering physicians carrots, rather than sticks, for their involvement. The rigid structures of client/server applications and the EMR are giving way to flexible, browser based, work-flow friendly applications.

5. Health, Poverty, and ICT Poor health is a major contributor to poverty and good health status is one of the means to prevent poverty and necessary to overcome poverty and considered an important element on the international poverty reduction agenda [55, 56, 100]. Approximately 1.2 billion people in the world live in extreme poverty. The vicious cycle of poverty and illness is well known. The poor live in environments without decent shelter, clean water, or adequate sanitation that may cause or contribute to ill-health and, on the other hand, sick individuals have difficulty in keeping jobs. Health and poverty issues are multi-dimensional and markedly differ from country to country, with countries emerging from and affected by social conflicts presenting a particular challenge. At the same time, demand for services, the multiplication of expensive diagnostic tools and treatments have led to ever-growing health costs underlining the urgency of improving healthcare productivity and outcomes; otherwise, realistically, the expansion of coverage and services of a healthcare system to be able to radically change the health status of the population in medium and low income countries will be difficult to achieve since it may threaten the general economic growth by absorbing a significant portion of national budgets. 5.1. The United Nations Millennium Development Goals The informatics industry, academic institutions, and the health private and public subsectors have proposed that ICT present unique prospects for the advancement and broadening of the scope and coverage of public health interventions, particularly among poor and marginalized populations. This role of ICT in improving health actions directed to the poor is captured in the United Nations Millennium Development Goals, especially in its Target 18: “In cooperation with the private sector, make available the benefits of new technologies, especially information and communications” [101, 102]. Furthermore, it is hoped that the strengthening of health systems through ICT will contribute to the movement toward the achievement of fundamental human rights by improving equity, solidarity, quality of life, and quality of care ultimately contributing to the goal of poverty reduction. There is a large body of evidence and experience in the private and public sectors, mostly from developed countries and well-organized health systems, regarding domains and processes where digital technologies are seen as highly effective and desirable as enablers of quality of care, as facilitators of equitable access and a tool

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to support continuity of clinical services sustained by health promotion and maintenance actions involving public and private stakeholders within a region responsible for the collaborative delivery of a continuum of evidencebased health services to individuals and communities joined by networked and informed citizens. Those developed world perspectives, experiences, and strategies are now being proposed as an answer to a great variety of health system management challenges, poorly developed infrastructures, and other specific demands faced by developing countries. Certainly a noble-minded ideal but -- as with the whole question of poverty reduction in general -- how to go about it is still a rather nebulous issue. 5.2. Cautionary Note: A Broader Vision and Scope of Action is Needed Many externalities constraint development efforts. Knowledge-based systems and technologies are embedded in a wide array of national institutions – academic, private, and public – that define the scope and use of ICT and are heavily influenced by political and social priorities issues and by first-movers and their concerns. Producers and countries may thus not be in full control of how they channel technologies, or in which markets they will be able to deploy the technologies once they are developed. Because much present technology is both costly and limited in effectiveness, the greatest challenge in directing development is how to balance external control, freedom to research, inventiveness, and market forces avoiding the reduction of incentives to innovation to such an extent that perpetuates the status quo. The effects of technological innovation are difficult to predict. Besides the intricacies of foreseeing the impact of innovation, interactions, and new applications of old technologies, they have long-term effects and often present unintended consequences for equity, health, and well-being of individuals. Technology transfer is neither costless nor straightforward - the failures of the 60’s and 70’s in technology transfer from industrialized to developing countries highlighted the over-simplistic models on which these visions were based. Moreover, reciprocities exist between poverty and ill-health and other social areas such as basic education, sanitation, and housing. Perhaps too much faith is being placed in ICT, essentially just a supporting or enabling resource, as solution for problems that can only be corrected by significant interventions and investments in health service organization, modalities of health care delivery, infrastructure, reimbursement schemes, and professional and general population education. Without long-term commitment to those interventions and investments on a national scale it would be naive to believe that ICT per se will have a significant impact in the improvement of healthcare. 5.3. A National and International Strategy for Health ICT Joint investment and development involving users, governments, academic and financing institutions and agencies, technical cooperation agencies, and industry interests are seen as necessary. Partnerships with the informatics industry are fundamental and, in the case of general informatics tools, the industry practically drives the solutions. A concerted effort is needed to secure a clearly defined and specified partnership with the informatics industry at the global and national levels aimed at application development at acceptable cost. Investments must be attracted to the telecommunications industry by improving investment conditions, lower duties on telecommunications equipment, and pose no restriction on network design except for technical reasons to allow for new providers [1, 7, 52, 56, 60, 84, 88, 95, 101, 103]. In the international setting, cooperation between developed and less developed countries is essential but special care must be taken to avoid interventionist behavior that ignores user’s real needs, fails to understand host capacities, demands action without allowing sufficient time for conceptual assimilation, neglects cultural constraints, and ignores host's knowledge basis. As in many other areas of international cooperation the danger is to have too much too soon or too little too late. A possible framework for collaborative work should include

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support to international health issues, healthcare reform implementation, application development, education, and economic and technological cooperation. Priority areas for international technical cooperation include: priority assessment, technology evaluation and selection criteria, implementation issues, emerging technologies linking patients and providers, access to knowledge databases, consumer informatics, and the utilization of Internet and Internet-enabled technologies. International aspects of e-Health form a critical and urgent area still to be addressed by the World Trade Organization and regional trade blocks. By demonstrating that social projects, especially healthcare and education, can be advanced through improved information infrastructure international technical cooperation and multilateral agencies must collaborate with national and international authorities and experts to demand that multilateral funding institutions finance large projects in those areas. Consistent to these objectives, international and multilateral agencies should promote and support technical cooperation activities involving the transfer of knowledge, technical support, facilitation of the exchange of experiences between countries, and fostering the use of appropriate technology and knowledge assets. Technology assessment methodologies have been proposed and tested for the economic evaluation and triage and for research prioritization before the funding decision is made. The problem is finding reliable evidence to support decisions and direct evidence that improvements will occur and are sufficient to meet criteria for cost effectiveness is commonly absent. Because information on experiences is limited or non-applicable it is not always possible to carry out pre-project assessment with an acceptable degree of certainty and demonstrating the cost effectiveness of new technologies is especially challenging in the health sector, where the usual paradigm of reliance on well-designed and randomized controlled trial is frequently not feasible [104]. Health organizations in developing countries must be assisted with information about the opportunities as well as the risks of e-Health solutions. Technology evaluation sources and results must be made available and health managers must be closely guided in the difficult process of systems specification, procurement, acquisition, and contracting ICT products and services. The establishment of knowledge repositories in cooperation with the industry, centers for technology evaluation, academic research groups, and centers of excellence is an important step in this direction. 5.4. Developing Organizational and Human Resources: Awareness, Skills, and Leadership Skills are the most expensive and least elastic resource and an obstacle to technological development in developing countries and success in the deployment of institutional e-Health applications depends on the existence of staff with the right mix of skills in all functions and at all levels. The number of technicians, scientists, and portion of the GNP devoted to research and development is a good indicator of those capabilities. The most successful efforts to incorporate information and communication technologies have occurred in countries with strong and efficient government and academic institutions committed to invest in education, scientific and technological development, and public services, in tandem with business sectors ready and willing to invest in research and development. Skilled professionals in a developing country gravitate to regions with adequate facilities and enabling environments and regional variations in innovation levels, technology adoption and diffusion, and institutional mix, all related to the presence of skilled professionals can be significant even inside a single country. Human resources development through awareness programs, education of health staff, continuous training, and career opportunities must be institutionalized from the inception of the developmental effort. Transference of technical expertise and the appropriation of knowledge by health personnel are necessary for the full participation of end-users in the development process and the best insurance for successful implementations. A comprehensive strategy should include:

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•

A structured human resource development program with the goal of increasing awareness of ICT opportunities and capacitating health professionals to assume a leadership role and actively participate in all aspects of systems design and implementation.

•

A training strategy taking into account issues related to the development and the organizational environment in which systems are expected to operate and the specific circumstances of the local health system. Guidelines for training must consider: identify target groups on the basis of functions and training needs; develop training programs to meet identified needs of target groups; and establish a network of training focal points, taking into account the national characteristics, and the specific organization and local health unit workflows and their information requirements.

•

Target groups to be considered are: those who originate, collect and supply data; operational decision makers (direct healthcare professionals and administrators); managers, planners, and policy makers; information systems managers; information technology and computing specialists; data analysts; and statisticians and researchers.

•

Each country will develop its own strategy for initial and continuing training in health information systems, considering the overall development of health information systems and its particular healthcare, educational, research, and market environment.

5.5. Priority Areas for Government Action Development must be conducted in the context a framework linking public, private, and social efforts to speed the development of priority ICT solutions. Technical knowledge, experience, and financial investments needed to establish large and complex information system projects require tapping into resources and expertise that no organization singly retains. Public and private institutions, academic organizations, the industry, and financing agents must find ways to pool their assets through project partnerships and add social value to applications of informatics by providing new employment options, socioeconomic development, educational opportunities, promoting health, and supporting cost-effective health services. Priority interventions with high resolution or mitigation are desirable and feasible – effective diagnostic methods and interventions exist against many widespread health conditions including the limited number of diseases which account for excessive mortality among the poor [105]. The challenge is finding integrated solutions to deliver coverage and access to effective healthcare at the client level backed by cost-effective technological resources that consider the tenets of responsiveness, accountability, and equity with the goal of maximizing population health and reducing access inequalities Speeding up adoption depends, however, on the presence of other factors such as incentives, competition, return on investment, and regulation. Governments must address the establishment of mechanisms to create or secure a market for new and eventually non-profitable technologies thus reducing the risks involved in R&D and improving the chances of a satisfactory return on investment and thus influence new technology development and adoption by the private health subsector. Governments and regulatory bodies have the rationale, the power, and the opportunity to improve competitive conditions by promoting standards, lessening network externalities at the community level, and sharpening the private-market competition among providers to use the best and most efficient solutions. The attainment of this mandate involves participation of a large number of stakeholders, but the coordinating effort will necessarily concentrate on the public sector. Governments must grapple with many transnational and global health ICT issues and address them in a comprehensive and collaborative manner. A major hindrance is that the current health sector organizational structure and national regulatory framework in developing countries are not conducive to problem-oriented, interdisciplinary, rapid-response collaborative technical work, and the

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concomitant implementation of political, regulatory, and managerial tasks required to address multifaceted complex technological problems. Six priority areas are envisioned for government involvement in health ICT development and deployment: (a) promotion of education, training, and national planning capacity in information systems and technology; (b) convening groups for the implementation of standards; (c) providing funding for research and development; (d) ensuring the equitable distribution of resources, particularly to places and people considered by private enterprise to provide low opportunities for profit; (e) protecting rights of privacy, intellectual property, and security; and (f) overcoming the jurisdictional barriers to cooperation, particularly when there are conflicting regulations.

6. International Initiatives Promoting Health ICT in the Americas The Region of the Americas has long recognized the importance of promoting the development of telecommunications and telecommunication-based technologies as a tool for social development [103, 106] and the role of ICT was recognized at the Second Summit of the Americas, held in Santiago, Chile in April 1998 as a solution for strengthening and improving existing national and regional networks of health information and surveillance systems for clinical and managerial decisions. The background for the recommendations emanating from the Summit was prepared by Pan American Health Organization [8] and reflected the consensus of international technical meetings convened by PAHO and by the Inter American Development Bank. The Second Summit of the Americas Plan of Action addressed the need for (a) the development, implementation and evaluation of needs-based health information systems and technology that included telecommunications, (b) support epidemiological surveillance, the operation and management of health services and programs, health education and promotion, telemedicine, computer networks and (c) investment in new health technologies. Concerns about the “digital divide” and the social, economic, and national market impacts of the new technologies and networked global marketplaces have prompted the international community to engage in a variety of initiatives to harness information and communication technologies for development and establishing programs aimed at bridging the “digital divide”. In 1999 the United Nations Economic and Social Council resolved that the high-level segment of its substantive session of 2000 should be devoted to the theme of information technology in the context of a knowledge-based economy development and international cooperation in the twenty-first century. The political will of Latin American and Caribbean countries to expand a knowledge economy was recognized by national leaders has been expressed by leaders during several highlevel meetings. Furthermore, trends in digital convergence occurring between voice and data communication in telecommunications, telecommunications and broadcasting, and telecommunications and consumer electronics reinforce the efforts of countries to expand the knowledge economy. A number of initiatives resulted from the Second and Third Summits, the latter held in Quebec, Canada, in 2001. Of particular importance are the Agenda for Connectivity in the Americas and Plan of Action of Quito [107] coordinated by the Inter-American Telecommunication Commission (CITEL).This initiative was presented at the World Telecommunication Development Conference (WTDC) of the International Telecommunication Union held in Istanbul, Turkey, in March 2002, which adopted Resolution 39 to include, among the high priorities of ITU, the support for initiatives under the Agenda for Connectivity in the Americas. The Resolution 39 recommended mechanisms to help achieve the necessary results for each country and region and promote the exchange of information on the development of global connectivity activities. Subsequently, the Third Regular Meeting of the CITEL Assembly, held in Washington, D.C., in August 2002, adopted Resolution CITEL/RES. 33 (III-02) on implementation of the Agenda for Connectivity in the Americas, which recognized the Agenda and Plan of Action of Quito prepared by CITEL as a significant and positive contribution to ongoing efforts to bridge the digital divide taking place in a number of fora. Aware of the topic high importance, the Plenipotentiary Conference (PP-02) held in Marrakech, Morocco, in September 2002, in Resolution COM 6/10, lent its support

23 ICT in Health (R.J.Rodrigues), Version 2

to the proposal in order to build awareness about the impact of telecommunications on national economic and social development, and its catalytic role in promoting the development, expansion, and operation of telecommunication services and networks, especially in the developing countries of the Region of the Americas. CITEL also established a Group for Connectivity Initiatives Management to interact with the ITU/BDT through the Regional Office of the ITU and with other interested organizations in order to implement projects originating from these initiatives in the following areas: network infrastructure development; eGovernment; eHealth; eEducation; eCommerce; training of human resources; eCulture; access to ICT; minorities; persons with special needs; public protection and disaster relief telecommunications. The countries of the Americas were called upon to formulate a vision of their national agendas in order to improve the capacity for access to knowledge and information -- each country being urged, in defining its national vision, to establish realistic objectives and timeframes. Effective incorporation in this new information and knowledge society will enable the countries of the region to compete on equal terms and to encourage optimization of the use of limited resources. In the health sector, CITEL, the International Telecommunication Union, and the Pan American Health Organization conducted an evaluation of the status of eHealth in the Americas, the incorporation of ICT by the health sector, an overview of pilot experiences, and a review of trends [52]. Similarly, other agencies have implemented observatories and clearinghouses on ICT such as the UNESCO Programa para la Sociedad de la Información en América Latina y El Caribe (INFOLAC), the UN Economic Commission for Latin America and the Caribbean (ECLAC), and the Institute for the Connectivity in the Americas (ICA). More recently, the Fourth Summit of the Americas, held in Mar del Plata, Argentina in 2005 reaffirmed the mandates and commitments of the previous Summits and reiterated the role of the social sectors, health, and technology in the fight against poverty [108]. 6.1. The World Health Organization Mandate for eHealth Since the early 80’s WHO has conducted activities on the use of information technology for health care and medical purposes [35, 84, 109, 110, 111, 112] -- the Regional Office for the Americas (Pan American Health Organization), as attested by its extensive list of publications, was an early promoter of ICT in health [8, 9, 19, 26, 27, 49, 91, 106, 113, 114, 115, 116, 117, 118, 119, 120, 121, 122, 123, 124, 125, 126, 127, 128, 129, 130, 131, 132, 133]. WHO recognizes that the emergence and growth of information and communication technologies, touching many spheres of life, brought opportunities and challenges to all countries and that eHealth – understood to mean the use of information and communication technologies locally and at a distance – presents unique prospects for the development of public health. An international consultation convened by WHO in 1998 [84] prepared input on “telematics” for WHO’s health-for-all policy for the twenty-first century. In the same year, the Pan American Health Organization Resolution WHA51.9 [134] set out lines of action in relation to cross-border advertising, promotion, and sale of medical products through the Internet in line with international efforts on the area. 6.2. Strategic Focus of WHO eHealth Initiative Member States and groups of Members States are drafting their own strategies for eHealth, and other agencies of the United Nations system have drawn up strategies for information and communication technologies in their domains. eHealth was one of the topics discussed at the World Summit on the Information Society held in Geneva in December 2003 [135] and improving the connectivity of healthcare units was recommended. In view of the foregoing, the WHO Secretariat prepared a draft strategy for eHealth to serve as basis for coordinating both eHealth policies internationally and WHO’s activities on eHealth. The strategy sets the general direction for work in the area, together with specific lines of action and ways of providing support to Member States in the use of eHealth for public health purposes, healthcare delivery, capacity building, health education and promotion, and governance. The Fifty-eighth World Health Assembly, held in May 2005, having considered the report on eHealth [136], and noting the potential impact that advances in ICT could have on health-care delivery, public health, research and health-related activities for the benefit of

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both low- and high-income countries and the growing expectations regarding the use of such technologies urged Member States to (Resolution WHA58.28): •

Draw up a long-term strategic plan for developing and implementing eHealth services

•

Develop the infrastructure for information and communication technologies for health as deemed appropriate to promote equitable, affordable, and universal access

•

Built closer collaboration with the private and non-profit sectors

•

Promote services oriented towards communities and vulnerable groups

•

Mobilize multisectoral collaboration for determining evidence-based eHealth standards and norms, evaluate eHealth activities, and share the knowledge of cost-effective models

•

Establish national centers and networks of excellence for best practice, policy coordination, and technical support •

Establish and implement national electronic public-health information systems

The Resolution refers to document WHA51.9 on cross-border advertising, promotion, and sale of medical products through the Internet. The Resolution recommends that eHealth development must respect human rights, ethical issues, and the principles of equity. Differences in culture, education, language, geographical location, physical and mental ability, age, and sex will be considered and implementations must include an appropriate legal framework and infrastructure and encourage public and private partnerships. Recent attention has been given to the central issue of standardized terminologies [87]. One the Resolution’s immediate result was the establishment of a Global Observatory for eHealth. The Observatory's mission being to improve health by providing Member States with strategic information and guidance on effective practices, policies and standards in eHealth [137] by: •

Providing timely and high-quality evidence and information to help national governments and international bodies improve policy, practice, and management of eHealth services

•

Raising awareness and commitment of governments and the private sector to invest in, and advance, eHealth

•

Collecting, analyzing and distilling knowledge which will make a significant contribution to the improvement of health using ICT

•

Publishing annual report, and special guidelines, on key eHealth research topics as a reference for governments and policy makers

•

Build capacity in eHealth research, analysis and reporting in countries

6.3. eHealth and the Pan American Health Organization (PAHO) The Strategic Plan 2003-2007 approved by the Pan American Sanitary Bureau (PASB) [44] focuses on enhancing the Organization’s actions and on the goal of assuming a leadership role in the provision of information and knowledge relevant to health development needs at national, regional and global levels. The Plan’s vision is to ensure that all the peoples of the Americas enjoy optimal health and contribute to the wellbeing of their families and communities. Challenges that the Strategic Plan addresses include, among others,

25 ICT in Health (R.J.Rodrigues), Version 2

the urgent issue of globalization, environmental change, and advances in science and technology. These forces featured significantly in the selection of strategic issues and priorities for technical cooperation for the 20032007 period. Particularly, the Plan recognized that, for the Pan American Health Organization to be able to add value and increase effectiveness and efficiency of the technical cooperation, the cross-organizational managerial, technical, and personnel-related issues should be urgently addressed by actions directed toward the bridging the information divide, maximizing information and communication technology, and harnessing science and technology. From PAHO’s regional perspective, the WHO Resolution WHA58.28 is understood in the context of: (a) PAHO Director agenda regarding the unfinished agenda and new challenges (b) The challenges of multilingualism (c) The recommendations of Mexico Summit for actions related to the immediate need to bridge the “know-do” gap regarding the sharing and application of knowledge (d) The Millennium Development Goals (MDGs) and its Goal 8, Target 18 that addresses the building of a global partnership for development in cooperation with the private sector to make available the benefits of new technologies, especially information and communications (e) The regional effort to expand and improve existing connectivity, in the framework of the resolutions of the Summits of the Americas and the Plan of Action of Quito [107] 6.4. Intersection with PAHO’s Knowledge Management Initiative Public and private organizations and agencies identified Knowledge Management (KM) not merely a latest management fashion, but as signaling the development of a more organic and holistic way of understanding and exploiting the role of knowledge in management and work processes, and as an authentic guide for individuals and organizations in coping with the complex and shifting environment of modern societies [79, 138, 139, 140, 141, 142]. KM is understood as methodologies, processes, and enabling technologies used by managers to allow an organization, company, or institution to create, collect, organize, share and apply the knowledge it possesses. KM directly intersects and shares many of the objectives, methodologies, and technological tools of eHealth. Both consider people, transactions, and added value as the essence – in the case of eHealth, the focus being the customer/client/citizen and the processes related to the delivery of health actions, the operation of health systems, and the support of the managerial and educational needs of health professionals. PAHO’s KM strategy is aligned to the WHO eHealth Resolution WHA58.28 recommendations of: (a) Promoting international, multisectoral collaboration with view to improving compatibility of administrative and technical solutions and ethical guidelines in the health sector (b) Expanding the use of electronic information through the submission of regular reports, documenting and analyzing developments and trends, informing policy and practice in countries, and reporting regularly on use of eHealth worldwide (c) Facilitating the development of model eHealth solutions which, with appropriate modification, could be established in national centers and networks of excellence for eHealth

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(d) Providing technical support to Member States in relation to eHealth products and services by disseminating experiences and best practices, in particular on telemedicine technology, devising assessment methodologies, promoting research and development, and furthering standards through diffusion of guidelines (e) Facilitating the integration of eHealth in health systems and services, including in the deployment of telemedicine infrastructure in countries where medical coverage is inadequate, in the training of health-care professionals, and in capacity building, in order to improve access, quality, and safety of care (f) Promoting mechanisms such as the Health Academy, which promote health awareness and healthy lifestyles through eLearning; (g) Providing support to Member States in promoting the development, application and management of national standards of health information and to collect and collate available information on standards aiming at the establishment of national standardized health information systems in order to facilitate easy and effective exchange of information among Member States (h) Supporting the area of eHealth regional and interregional initiatives or those among groups of countries that speak a common language

7. ICT Integration in the Health Sector of Latin America and the Caribbean The history of health ICT deployment in developing countries of the Region has been less than stellar. Notwithstanding the fact that for the past 25 years, the use of computer and telecommunications in health and healthcare has been a constant item of development agendas, national and international agencies and multilateral institutions the health sector of Latin America and the Caribbean countries approached the concept with changing degrees of enthusiasm with periods of great expectations followed by doldrums where identification of needs and priorities, specification predicaments, technology, costs, and human resources, and lack of political will and continuity of fledgling initiatives many times pose insurmountable barriers to the deployment and effective use of ICT. In the health sector, development and digital divides between industrialized and Latin American and Caribbean countries is wider than the gap observed in other productive and social sectors. In some cases, the changes brought about by the privatization of healthcare did add to the already high degree of structural inequity that prevails in the countries of the Region. The private health sector, insurance companies, group practices, and other stakeholders rapidly understood the importance of information systems for organizational survival, competitiveness, and better service and have been at the forefront of ICT and eHealth developments in the Region. 7.1. Externalities Related to Technology Distribution, Access, and Utilization Access to technology and related resources represent the most acute issues in the dissemination of eHealth applications. In a more limited focus, the “digital divide” encapsulates the dramatic worldwide variation in access to computer-based information technologies, typically measured in terms of teleaccessibility, personal computer ownership, and internet connectivity available to individuals and communities. There are a large number of sources and tools for measuring and monitoring technology distribution, access, and utilization including basic ICT indicators – the International Telecommunication Union and the World Bank being the oldest actors. The UN Regional Commissions and UNCTAD recently conducted a survey on the status of ICT indicators in 179 countries with the objective of assessing the status of ICT indicators in developing countries [143] and the situation for the Region in 2005 was compiled by the Observatory for the Information Society in Latin America

27 ICT in Health (R.J.Rodrigues), Version 2

and the Caribbean using data from different sources and countries, available from public sources such as the Internet, studies, news media and project reports, and others [144]. Digital divides, like social and economic divides, exist within and not just between societies and are integral parts of a much broader and intractable “development divide”. Information technology utilization inequalities found in both industrialized and developing countries are related to level of income and general development, including determining factors such as insufficient telecommunications infrastructure in poor areas, high telecommunications tariffs, and uneven ability to derive economic and social benefits from information-intensive activities. There are today very few technological constraints preventing access to advanced communications and the Internet, even in the most remote village, through solar-powered satellite dish and portable computers. The real problem, especially for the cash-constrained health sector, is financial – the capital cost of deploying the telecommunication infrastructure, particularly fixed lines and fiberoptic cables; processing equipment; recurrent costs of utilization tariffs; maintenance and upgrading; and training and retaining staff. They prevent universalization of access as poor countries cannot afford such expenditures. 7.2. Readiness for ICT Incorporation Countries and communities within countries vary in the ability to incorporate information technology and telecommunications, in particular interactive communications technologies. The readiness of a country or community to adopt technological innovation and applications is a complex concept to measure, because the country may be ready to assimilate some, but not all, technological components and applications. Information and communication technology metrics is an important tool for the implementation of consistent and comparable information about diverse systems, platforms, configurations, and application environments. Indices for measuring ICT diffusion (UNCTAD), opportunity (ITU) and network readiness (Center for International Development, Harvard University) have been developed with the objective of conducting systematic comparison of ICT development of countries. An index is considered to be more reliable than a single indicator in measuring qualitative concepts. This view of a cluster of technologies is consistent with many studies which suggest that individual technologies need to be evaluated in a context that consider technology as a multi-faceted concept and the fact that countries seldom exhibit uniform capabilities across the broad spectrum of ICT [145, 146, 147, 148, 149, 150].The UNCTAD ICT Diffusion Index and has been measured since 1997. The ITU Digital Opportunity index closely matches the UNCTAD ICT Diffusion Index. Recently introduced, the Center for International Development Network Readiness Index (NRI) was created with the objective of measuring the preparedness of countries for the networked world. The NRI has been applied in major international assessment of countries’ capacity to exploit the opportunities offered by ICT mapping the factors that contribute to this capacity. While any attempt to narrow Networked Readiness down to a single measure is admittedly artificial, the research performed in the creation of the NRI has significantly improved the understanding of how different national environments affect the adoption and use of ICT. The Networked Readiness Index marks an important step forward by distinguishing between factors that determine the usability of the Network (the Enabling Factors) and variables that reflect the extent of Network Use. The evidence gathered to date indicates that a high score on Enabling Factors contributes to high levels of Network Use. However, a high score on Enabling Factors also signals a country’s ability to draw upon existing ICT networks. The Index signals broad trends, flags opportunities and deficits, and makes a unique contribution to the understanding of how nations are performing relative to one another with regard to their participation in the Networked World. Other indices have been developed: Composite index of technological capabilities across countries (ArCo), Digital Access Index (DAI), Economist Intelligence Unit (EIU) e-readiness, Index of Knowledge Societies (IKS), Knowledge Economy Index (KEI), Orbicom Digital Divide Index, Technology Achievement Index (TAI), UN PAN E-Readiness Index, and the World Bank ICT Index.

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A critical evaluation of those indices for the Region was recently conducted [151]. Selection of indicators when building indices; subjectivity; data source, coverage, and validity; and their relative weight when calculating indices are points of dispute. Conflicting results – ranking high in one index but low in another – demonstrates how index composition and objectivity vary among indices and suggest that they should be taken with reserve. All indices show that the countries of Latin America and the Caribbean, with few exceptions, rank low in the global context but are in line with the level of economic development of the Region but also that the Region fares well among all developing regions. The Southern Cone presents the highest average score, the worst being the Andean sub-region. Of particular concern are countries that rank below 80 in the UNCTAD ICT Diffusion Index (Dominican Republic, Colombia, Guyana, Venezuela, Belize, Panama, Ecuador, Peru, Cuba, El Salvador, Paraguay, Bolivia, Honduras, Nicaragua, and Haiti. Of concern is also the fact that the evolution of the indices has been essentially flat or even negative in some countries. Notable improvements were observed in Chile, Saint Lucia, Jamaica, Brazil, Mexico, Belize, Peru, and El Salvador – those countries showed improvement of all indices. Chile is the country closest to attain a level comparable to that found in developed regions. 7.3. The Straggling Public Sector Despite the fact that the health sector is key to the welfare of the population and the formation of human capital, the sector has not kept pace with the momentum of change that has been experienced in recent years in other areas of economic, political, and social life, even in developing countries. Opportunities for ICT deployment have not been systematically utilized and there are conflicting or misguided perspectives regarding how to bring technological innovation and integration in an environment of increasing social inequalities and polarization between local and global values and control. Unfortunately, the public health sector has lagged behind despite the increasing diffusion of ICT in public administration and social services. In most countries the public health sector has not applied information and communication technologies resource, methods, and processes for the day-to-day operation and management of health systems as effectively as have other sectors of society and health has been conspicuously underrepresented in national ICT development policies and plans. Although the view that ICT is essential to the operation and management of health systems is generally accepted by public sector decision-makers, most projects are under funded, use obsolete technology, have a restricted vision of requirements and understanding of opportunities, and frequently resort to providers with limited experience and resources. The justification for the cost-effectiveness of ICT uses in health centers, hospitals, ministries, health programs, support programs or the national health care service as a whole, becomes a new challenge every time a deployment is to be assessed, implemented, and sustained in a particular setting. Finally, public projects take long to implement, cost more, and deliver less than planned. 7.4. Some Decision-Makers Have a Misguided Vision of ICT Public health authorities invariably declare the criticality of information for decision making and informed action but repeatedly fail do follow up with the commitment, resources, and sustainability of efforts required for the deployment of industrial-strength applications. Most existing information systems are inadequate to the requirements of the new models of healthcare being deployed in the context of health reform initiatives. Besides the common perception among physicians that health information systems are mostly a source for scientific and technical information, often public health authorities have a view of clinical-administrative information systems that is obsolete and frozen in a “statistical-epidemiological” archetype, designed for the collection of numerical data representing only counts of events and mostly generating only highly aggregated statistical data and time series related to mortality, morbidity, and to service utilization and coverage. Those information systems have very little practical interest to direct care professionals and unit managers and are far behind in providing the

29 ICT in Health (R.J.Rodrigues), Version 2

logistical and longitudinal individual client-based data required to operate and manage the sort of healthcare models being deployed in many countries. Until quite recently, many public health authorities were oblivious to the broad variety of possibilities offered by modern information and communication technologies to manage client-based data, support operations, and mine large databases. Indeed, the health sector has not applied the range of options provided by information and telecommunication technologies as effectively as have other social sectors, and health has been conspicuously underrepresented in national technology development policies and plans. Such concerns have also been raised by traditional national statistics organizations in developed countries. In the last seven years there has been encouraging changes in this scenario. Urged by the global progress towards the Information Society and the promotion of national and regional projects by international and development agencies, many Latin America and the Caribbean public health organizations are actively engaged in adopting ICT but the efforts carried in different countries are still restricted to limited application areas, suffer from continuity breakdowns, and there is very limited intercountry cooperation in the style of the European Union AIM initiative. Significant examples of public sector leadership and commitment are found in the eLAC2007 initiative involving the United Nations, the Economic Commission for Latin America and the Caribbean (ECLAC), the EuropeAid Co-operation Office through the @LIS program, and a number of other national and international technical cooperation and development agencies. As a counterpoint to the passiveness of the public sector, the private providers and managed care groups recognized that a “different” type of information system and data elements are required to run their organizations and survive in a competitive environment driven by increasing consumer demands and expectations and for the delivery of personalized evidence-based services. Besides using ICT resources to boost productive specialization, such as allowing the efficient use of diagnostic services and consultations, the maintenance of integrated records, reduction in the number of specialists, and attaining economies of scale by linking to national and international markets, there are many new areas of application that are rapidly gaining ground and reducing care costs while improving the continuity and quality of care. The lack of involvement of public sector stakeholders in the use of ICT is worrisome. At a time when, in many countries, the ailing, bureaucratic, and inefficient public sector is struggling against poorly regulated privatization of social services, there is a clear danger in that their inaction in adopting ICT solutions may indeed hasten the further reduction and even the demise of public health services incapable of competing with an IT-enabled private sector. 7.5. Incipient Knowledge Brokering Initiatives A disconnect between knowledge and its application is a major challenge in the Region. The organizational and the interpersonal linkages needed to bridge this “know-do gap” are not yet in place, misdirected, or in very early stage [152]. Governance, organization, and delivery of services reward consensus and lessons learned focused on local priorities and common standards of practice which are, many times, far removed from the academic and research environment that provides practically all of the published health technical evidence and research is often perceived by practitioners as opposite to action, not the antidote to ignorance [153]. The urgent need for knowledge brokers, supported by knowledge brokering resources and agencies is clear – most of existing knowledge resources are based on repositories of technical and scientific literature and only recently an effort is being made to implement actionable resources that link researcher to practitioner. Knowledge brokering is a social solution and human interaction is the engine that drives research into practice. This linkage model of connecting research evidence to action goes against the predominant view of evidence informed decision making as a technical exercise with the implicit premise of making compulsory the use of the clinical guidelines or performance indicators. Rather, it characterizes the task of better informing decisions with research as being as much social as technical making clinical guideline translation into practice through social interaction and interpersonal networks. Circulation of knowledge depends on interpersonal networks, and will only diffuse if these social features are taken into account and barriers overcome. This is a lesson learnt long

30 ICT in Health (R.J.Rodrigues), Version 2

ago by the pharmaceutical industry, with its use of local opinion leaders to influence patterns of drug prescribing [154, 155, 156]. In the Region, the Latin American and Caribbean Center for Health Sciences Information (BIREME), a WHO/PAHO Center, is an outstanding example of what a knowledge broker is expected to be. While keeping pace with state-of-the-art scientific information, adopting, adapting and developing technologies, standards, processes, products and services for the countries within this region, BIREME contributes to the continuous strengthening and improvement of national and regional scientific information produced at local, regional and national levels. The most relevant feature of BIREME lies in its networking, where national institutions actively participate based on their political, cultural, social, economic and physical infrastructure and the institution has radically expanded the inclusion of national institutions and communities in producing, operating and using cooperative products and services for scientific and technical information. 7.6. Information on Health ICT Projects and Lessons Learned Information about health ICT projects, methodologies and technical solutions employed, and outcomes is a major problem in the Region. Until quite recently there have been only sporadic attempts to collect such information through limited surveys or case studies [38, 52, 125, 157]. Given the need to measure ICT development, the World Health Organization established a Global Observatory for eHealth and, in the Region of the Americas, the a joint initiative of the United Nations Economic Commission for Latin America and the Caribbean (ECLAC) and the Institute for Connectivity in the Americas (ICA) of the International Development Research Centre of Canada (IDRC) with support from the European Commission @LIS Program crested the Observatory for the Information Society in Latin America and the Caribbean (OSILAC). Data that follows originates from those sources. 7.6.1. The PROTIC Projects Database A major advancement in the collection of project data was the establishment of the PROTIC Projects Database. PROTIC receives support from the Institute for Connectivity for the Americas (ICA) and of the Economic Commission for Latin America (ECLAC) through @LIS. The PROTIC database (www.protic.org) has 1,491 projects recorded (May 2007), of which eighty-eight (88) are in the health sector, representing 5.9% of the database. An analysis of the 88 health projects recorded in the shows: •

Location -- projects were reported in 91 locations, since there were thirteen projects of Regional, four of Subregional, and one of Global nature representing 19.8% (18/91) of projects. Of national projects 56% (51/91) were reported in the following countries: Colombia, Peru, Brazil, Venezuela, Argentina, Bolivia, and Cuba – Colombia being the country with highest number of reported projects (Table 2).

•

Project Focus – the objective of 45.5% (40/88) of the projects is to establish a knowledge repository containing technical and scientific publications, guidelines, best practices, and lessons learned. The next most frequent objective, representing 15.9% of projects, was to provide access to ICT resources including training, needs assessment and evaluation, and development of specialized applications. This is followed by education and prevention applications (13.6%). Only 11.4% (10/88) of projects were focused in the establishment of direct clinical care, epidemiology, or in-practice education in a patient care setting (Table 3).

•

Health Issues Addressed – the Table 4 lists the spectrum of health thematic areas (areas of application) for the 88 projects. Nearly half of the projects (47.7%) are related to access to technical and scientific reference and to clinical care (primary and other levels), family care, immunization, and mental health. Most of the projects have a public health standpoint and aim at supporting and improving health interventions and health education.

31 ICT in Health (R.J.Rodrigues), Version 2

•

Project Drivers – regarding the institutional subsector driving the projects, they were categorized in five classes of institutions: academic; international agency (here understood as national and international funding organizations, agencies, and multilateral institutions except for UN agencies); private (category that includes NGOs, foundations, philanthropic organizations, and companies); public; and UN agencies. Twelve projects have more than one institutional driver. The private sector was found to be the most frequent driver and present in 31.8% (28/88) of projects followed by international agencies and the national public subsector, each driving 23.8% (21/88) of projects. The UN agencies drive 20.4% (18/88) and the academic subsector the remaining 13.6% (12/88) of projects. Only five projects or 5.7% (5/88) were found to be driven by a public-private partnership. As expected, there major variations among different countries regarding the mix of driving institutions (Table 5).

•

Main Funding Source – sources were categorized in six classes, the only difference regarding the categorization for project drivers being the distinction in the category UN Agency that was split into two classes: PAHO and other UN Agencies (Non-PAHO). The public sector was found the most frequent funding source (31.8% of instances) followed by the Pan American Health Organization (29.5%), international agencies and private – each representing 26.1%, academic (9%) and other UN agencies (non-PAHO) funding only 2.2% of projects (Table 5).

Project Location

N

%

Regional Subregional Global

13 4 1

14.3 4.4 1.1

Colombia Peru Brazil Venezuela Argentina Bolivia Cuba Chile Ecuador Mexico Costa Rica Dominican Republic El Salvador Honduras Paraguay Belize Canada Guyana Total

11 9 8 7 6 5 5 3 3 3 2 2 2 2 2 1 1 1 91

12.1 9.9 8.8 7.7 6.6 5.5 5.5 3.3 3.3 3.3 2.2 2.2 2.2 2.2 2.2 1.1 1.1 1.1 100

Table 2. Location of Eighty-eight Health ICT Projects Reported to the PROTIC Database (May 2007). Source: www.protic.org

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Project Focus Access to ITC resources and training, connectivity, infrastructure, deployment and needs assessment, impact evaluation Application and software development and instrumentation Basic research Communication Community of Practice Education, Prevention Evaluation Health service management Knowledge repository Knowledge repository, lessons learned, best practices Management Telemedicine clinical care, epidemiology, education Total

N

%

8

9.1

6 1 5 2 12 1 2 17 23 1 10

6.8 1.1 5.7 2.3 13.6 1.1 2.3 19.3 26.1 1.1 11.4

88

100

Table 3. Main Objective (Project Focus) of Eighty-eight Health ICT Projects Reported to the PROTIC Database (May 2007). Source: www.protic.org

Health Issue Addressed by Projects Access to technical and scientific reference Clinical care (primary and other levels), family care, immunization, mental health Access to ICT and e-Health deployment Environmental health, Water and Solid Waste Health education, promotion Professional education Food safety, Veterinary medicine HIV/AIDS Physiological data Sexual & Reproductive Health Service management, logistics of patient administration Drug abuse Epidemiologic surveillance None indicated Disaster prevention & mitigation Healthy life styles, commercial product promotion Imaging technology Neural physiology Self-help Traditional medicine Violence against women Total

N

%

21 21 6 4 4 4 3 3 3 3 3 2 2 2 1 1 1 1 1 1 1 88

23.9 23.9 6.8 4.5 4.5 4.5 3.4 3.4 3.4 3.4 3.4 2.3 2.3 2.3 1.1 1.1 1.1 1.1 1.1 1.1 1.1 100

Table 4. Health Issues Addressed by Eighty-eight Health ICT Projects Reported to the PROTIC Database (May 2007). Source: www.protic.org

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Total

92

100

1 1 1

12

1 2

1 3

1 1 1 1

1 3

1 4 1

5

2

1

3 1 2 3

2

2

Non-PAHO UN Agency

6 4

Public

1 1

1

1

Private

2 5

2

5 1 1 1 1 1

PAHO

2 3

1

Int Agency

4

5

Academic

1

1 3 3 1

Main Funding Source UN Agency

1.1 14.1 4.3 6.5 1.1 5.4 8.7 1.1 4.3 12.0 2.2 5.4 2.2 3.3 2.2 1.1 2.2 3.3 2.2 9.8 7.6

Public

1 13 4 6 1 5 8 1 4 11 2 5 2 3 2 1 2 3 2 9 7

%

Private

Global Regional Subregional Argentina Belize Bolivia Brazil Canada Chile Colombia Costa Rica Cuba Dominican Republic Ecuador El Salvador Guyana Honduras Mexico Paraguay Peru Venezuela

N

Int Agency

Project Location

Academic

Project Drivers

1

2 2 1 4 1 2 1 1

1 4 1 2

1 2

1 1 5 3

1 1 3 3

21

28

21

1 1 1 1

1

1 1 1 1 18

2 8

23

2 1

3

1 1 1

1 1 2 1 1 1 1

1 1 5 3

26

23

2 1 3 3 1 3 1 1

1

1 2 3 4 28

2

Table 5. Institutional Drivers and Main Funding Source in Eighty-eight Health ICT Projects Reported to the PROTIC Database (May 2007). Source: www.protic.org

Certainly, there are many more projects in operation of being implemented in the Region that are not registered in the PROTIC database. Hearsay and evidence from meetings and contacts with national professionals suggest that registration of projects in the PROTIC database must be promoted. The low coverage, already found in surveys carried in the Region, is a major challenged to be faced if we expect to have a source of project data and experiences capable of providing a comprehensive view of ongoing health ICT activities. 7.6.2. The 2005 WHO Global eHealth Survey Data that follows is a tabulation of responses of sixteen countries -- 44% of countries of the Region of the Americas -- that answered to the WHO Global eHealth Survey 2005 conducted by the Global Observatory for eHealth, Geneva, in July 2005. The survey collected data on eight dimensions: enabling environment, infrastructure, content, cultural and linguistic diversity, capacity, and the existence of national centers and categories of systems and services. The objectives of the WHO Global eHealth Survey 2005 are to (a) describe and analyze country profiles, (b) identify and evaluate measures taken by countries in key action areas, and (c) establish the requirements of

34 ICT in Health (R.J.Rodrigues), Version 2

Member States for tools and services. The Survey responds to issues raised at the Fifty-eighth World Health Assembly, held in May 2005, WHO Report on eHealth (Document A58/21), and the mandates of the Resolution WHA58.28. (a) Enabling Factors: Policies and Strategies The Tables 6 and 7 tabulate the situation for the existence of key national policy or strategy mechanisms for: (a) information; (b) ePolicy or eStrategy; (c) eHealth; (d) adoption of eHealth standards; (e) adoption of hardware; (f) software and content procurement; and (g) health data privacy and security standards, regulations or legislation. The Tables also list the year in which the policy or strategy was approved or implemented. Twelve countries informed that a national information policy or strategy is in place (75%). The policy was implemented in the last three years in five of those countries (41.6 %). The policy or strategy was considered not or slightly effective by three, moderately to very effective in eight (72.7 %) and five countries did not respond. Six countries indicated that the policy or strategy will continue the same in the next two years (37.5 %), six will revise (37.5 %), one will start discussing the issue (BLZ), and two countries are undecided on how to proceed (HON, SUR). Thirteen countries informed that a national ePolicy or eStrategy is in place (81.2%). The policy was implemented in the last three years in seven of those countries (53.8 %). The policy or strategy was considered not or slightly effective by one, moderately to very effective in nine (69.2 %) and three countries did not respond. Six countries indicated that the policy or strategy will continue the same in the next two years (37.5 %), six will revise (37.5 %), one will start discussing the issue (COR, and three countries are undecided on how to proceed (CAN,HON, SUR). Twelve countries informed that a national eHealth Policy or Strategy is in place (75%). The policy was implemented in the last three years in three of those countries (25 %). The policy or strategy was considered not or slightly effective by one, moderately to very effective in nine (75%) and two countries did not respond. Five countries indicated that the policy or strategy will continue the same in the next two years (41.7 %), six will revise (50 %), three will start discussing the issue (COR,PAR,PER), and two countries are undecided on how to proceed (HON, SUR). Twelve countries informed that national eHealth standards are in place (75%). The policy was implemented in the last three years in three of those countries (25 %). The policy or strategy was considered not or slightly effective by one, moderately to very effective in nine (81.2%) and one country did not respond. Twelve countries indicated that the policy or strategy will continue the same in the next two years (100 %). Eight countries informed that a health data privacy and security standards, regulations or legislation is in place (50%). The policy was implemented in the last three years in three of those countries (37.5 %). The policy or strategy was considered moderately to very effective in four (50%) and four countries did not respond. Seven countries indicated that the policy or strategy will continue the same in the next two years (87.5 %), three will start discussing the issue (CHI,DOR,PAN), and four countries are undecided on how to proceed (ARG,HON,PAR,SUR). Eight countries informed that procurement policies for hardware, software, and content are in place (50%).

35 ICT in Health (R.J.Rodrigues), Version 2

Countries

Information policy or strategy Y/N

ARG BAH BLZ BRA CAN CHI COR DOR ELS HON

Y Y N Y Y Y N Y Y N

MEX PAN PAR PER SUR VEN

Y Y Y Y N Y

Year 1997 2003 2000 1998 2004 2004 1998 2001 2004 1997 2003 1978

ePolicy or eStrategy Y/N

Year

Y Y Y Y Y Y N Y Y N

1997 2000 2004 1979 1994 2000

Y Y Y Y N Y

na 2004 2002 2005

2000 1998

2001

eHealth Policy or Strategy Y/N

Year

Y Y Y Y Y Y N Y Y N

1997 2000 2004 1990 1997 2004

Y Y N N N Y

2001 2005

2002 1997

2002

Table 6. Enabling Factors – Policies and Strategies for 16 Countries of the Americas

Countries

eHealth standards adopted Y/N

ARG BAH BLZ BRA CAN CHI COR DOR ELS HON MEX PAN PAR

Y Y Y Y Y Y Y N Y N Y Y N

PER SUR VEN

Y N Y

Year 2000 2002 2005 2002 2001 2005 na 1997 2001 2006 2000 2001

HW,SW,content procurement policy in health sector Y/N N Y N Y Y N N Y Y N Y Y N N N Y

Year 1995 1993 2003

2000 1997 1995 2005

2005

Health data privacy & security standards, regulations or legislation Y/N N Y Y Y Y N N N Y N Y N N Y N Y

Year 2003 2004 1988 1995

1997 2000

2004 na

Table 7. Enabling Factors – Policies and Strategies for 16 Countries of the Americas

36 ICT in Health (R.J.Rodrigues), Version 2

(b) Funding, Partnerships, and International Cooperation The Table 8 lists the situation regarding the areas of: (a) provision of public funding of ICT for programs addressing national health priorities; (b) private funding through grants or private investment for programs addressing national health priorities; and (c) existence of public-private partnerships to foster the use of ICT within the health sector. The Table also lists the year in which the policy or strategy was approved or implemented.

Countries

Public Funding Y/N

ARG BAH BLZ BRA CAN CHI COR DOR ELS HON MEX PAN PAR PER SUR VEN

N Y Y Y Y Y N Y Y Y Y Y N N N Y

Year 1985 1998 1998 1997 2003 2002 1997 1998 2001 2005

2001

Private Funding Y/N N N Y N Y N N N Y N N Y N N Y N

Year

1985 1997

1997

2000

2004

Public-private Partnerships Y/N N Y N Y Y Y N Y Y N Y N N N N Y

Year 1983 na 1998 2005 2004 1998 2000

2001

Table 8. Funding and Public-Private Partnerships for 16 Countries of the Americas

Eleven countries have public funding (68.7 %), four of those (BLZ,CAN,ELS,PAN) informed that they also have private funding (25%) and one (SUR) has only private funding. The expectations are that those arrangements will not change in the next two years. Eight countries indicated that they have public-private partnerships. Of six countries that responded, five (83.3 %) considered public-private partnerships moderately to very effective. (c) Inclusiveness, Equity, Multilingualism, and Cultural Diversity The Table 9 lists the situation regarding the existence of policies in the areas of (a) access inclusiveness and equity and (b) multilingualism and cultural diversity. The Table also lists the year in which the policy or strategy was approved or implemented.

37 ICT in Health (R.J.Rodrigues), Version 2

Country

Inclusiveness and equity

ARG BAH BLZ BRA CAN CHI COR DOR ELS HON MEX

Y/N Y Y Y Y Y Y N N Y N Y

Year 1997 1992 2004 na 1985 2003

PAN PAR PER SUR VEN

Y N N N Y

2005

1999 2000

1980

Multilingualism and cultural diversity Y/N N Y N N Y N N Y N N Y N N Y N Y

Year 1973

2003

2004

2001

2005 2005

Table 9. Access Inclusiveness/Equity and Multilingualism/Cultural Diversity Policies in 16 Countries of the Americas

(d) Market Development and Sustainability The Table 10 displays aggregated data from the WHO Global eHealth Survey related to national ICT in health development plans; policies on affordability of infrastructure; intersectoral and non-governmental cooperation; and perceived actions including effectiveness and challenges. Of the sixteen countries that responded to this survey, only nine have a National ICT in Health Development Plan, which is slightly over 56%. Of these respondents, five or 56% have said they plan to continue their plan in the next two years, while four or 44% plan to revise and continue their plan. Three of the countries (BLZ, CHI, PAN) implemented their National ICT in Health Development Plan during the past three years, and seven (BAH, BLZ, CHI, DOR, MEX, PAN, VEN) implemented their plan in the last five years. This means 33.3% of the countries had plans in place for at least three years. The future for the countries without a National ICT in Health Development Plan is divided. Four of them (Argentina, Costa Rica, Honduras, and Suriname) are undecided about what to do. The other three (Brazil, Paraguay and Peru) have started to implement their plan. Peru specifically noted in their survey response that “ESSALUD has a strategic plan for ICT with a technological calendar.” Over 55% (BAH, CHI, MEX, PAN, VEN) of the countries with a National ICT in Health Development Plan believe they are moderately to very effective, while 11% (CAN) found their plan to be extremely effective. However, about 22% of the respondents (DOR, ELS) said that their plan ranged from not to only slightly effective. Regarding national policies addressed to the issue infrastructure affordability, six countries out of the sixteen respondents or 37.5% (BAH, CAN, CHI, MEX, PAN, VEN) have a Policy on Affordability of Infrastructure. Four or 66% (CHI, MEX, PAN, VEN) have said they plan to continue their policy in the next two years, while two or 33% (BAH, CAN) plan to revise and continue their plan. Three of the countries (CAN, CHI, PAN) had initiated

38 ICT in Health (R.J.Rodrigues), Version 2

their Policy on Affordability of Infrastructure during the past three years, and five (BAH, CAN, CHI, MEX, PAN) had initiated their plan in the last five years. Of the ten without a policy on affordability of infrastructure; Argentina, Costa Rica, Honduras, Peru, and Suriname are undecided about what to do. Brazil, El Salvador, Paraguay and Peru have started to implement their own policy. Despite participating in this section of the survey, Belize did not specify their future plans.

Countries

National ICT in Health Development Plan

ARG BAH BLZ BRA

Y/N No Yes Yes No

CAN CHI COR DOR ELS HON MEX PAN PAR PER SUR VEN

Yes Yes No Yes Yes No Yes Yes No No No Yes

Year 2001 2004 2000 2005 2002 1995 2002 2005

20013

Policy on affordability of infrastructure Y/N No Yes No No Yes Yes No No No No Yes Yes No No No Unknown

Year 2001

2003 2005

2002 2005

Intersectoral and nongovernmental cooperation Y/N No Yes No Yes Yes No No No Yes No Yes Yes Yes Yes No Yes

Year 2001 Unknown 1995

1992 2001 2000 1990 2004 1999

Table 10. National Development Plans and Intersectoral/Non-Governmental Cooperation for 16 Countries of the Americas

One country (PER) initiated their Policy on Affordability of Infrastructure during the past three years, and three (BAH, MEX, PER) had initiated their plan in the last five years. However, five countries (CAN, ELS, PAN, PAR, VEN) had such policies implemented before 2001. Brazil stated they had a policy but did not state what year it was implemented. Three countries (BAH, MEX, VEN), which comprises 50% of the respondents with policies on affordability of infrastructure, believe their plan is moderately to very effective. One country (CAN) found their plan to be extremely effective. However, one country found their plan not or slightly effective (MEX) and one country (CHI) stated the effectiveness of their plan was unknown. Regarding intersectoral and non-governmental cooperation, nine countries out of the sixteen respondents or 56.3% (BAH, CAN, ELS, MEX, PAN, PAR, PER, VEN) indicated to cooperate in the intersectoral and nongovernmental environment. Six or 67% (BAH, ELS, MEX, PAN, PER, VEN) have said they plan to continue their policy of cooperation in the next two years, while two or 22% (CAN, PAR) plan to revise and continue their plan. One country or 11% (BRA) is undecided. Of the seven without a policy on intersectoral and nongovernmental cooperation, two countries (HON, SUR) are undecided about what they will do. Two other countries (ARG, DOR) have started to implement their policies. However, the plans of the remaining three countries (BLZ, CHI, COR) are unknown. Paraguay (PAR) rates the effectiveness of their policy on intersectoral

39 ICT in Health (R.J.Rodrigues), Version 2

and non-governmental cooperation as not or slightly effective. Five countries (BAH, ELS, MEX, PAN, VEN), which comprises 55.6% of the respondents with policies on intersectoral and non-governmental cooperation, believe their policy is moderately to very effective. Canada (CAN) found their policy to be extremely effective. However, the effectiveness of the policy in Peru (PER) was stated as unknown. Out of the sixteen respondents, five countries or 31.3% (ARG, CHI, ELS, MEX, PAN) stated they had implemented other actions. Three countries or 60% (ARG, CHI, PAN) will continue with them in the next two years, while two countries or 40% (CAN, PAR) will revise and continue their present actions. There were two countries or 40% (CHI, PAN) that had started other actions in the last three years. Four of the countries or 80% (ARG, CHI, MEX, PAN) started such actions in the last five years. One country or 20% (ELS) started earlier than 2001. (e) Content – Access to Information and Knowledge Table 11 summarizes the responses of 16 countries in the Region of the Americas on the following topics: access to international electronic journals, access to national electronic journals, national open archive or repository policies, and dissemination of health information to the general public. The Table indicates existence of the access or policy and year it was adopted or started.

Countries

Access to International Electronic Journals

Access to national electronic journals

National Open Archive or Repository Policies

Y/N

Year

Y/N

Year

Y/N

ARG

Yes

2002

Yes

2005

No

No

BAH BLZ BRA CAN CHI COR DOR ELS HON MEX PAN PAR PER SUR VEN

No No Yes Yes No Yes Yes Yes Yes Yes Yes Yes Yes No Yes

No No Yes Yes No No Yes No No Yes No No No No Yes

No No Yes Yes Yes No Yes Yes Yes Yes Yes Yes Yes No Yes

1990 1993 Unknown 2002 1994 2000 2000 1999 2000 2002 2000

No No Yes Yes No Yes No Yes Yes Yes Yes Yes Yes No Yes

1997 1993 Unknown 2002 2000 2000 1999 2000 2002 Unknown

Year

Health information for the general public

1997 1998

2002

2003

2001

Y/N

Year 2002 1999 1997 2002 2000 2002 2000 2001 2005 2004 2002

Table 11. Information and Knowledge Access Status for 16 Countries of the Americas

Access to International Electronic Journals - Of the sixteen countries that responded to this survey, twelve or 75% have access to international electronic journals. Of these respondents, eight (ARG, BRA, COR, DOR, MEX, PAR, PER, VEN) or 67% have said they plan to continue offering this access in the next two years, while four (CAN, ELS, HON, PAN) or 33% plan to revise and continue their current strategy of access. Access to international electronic journals was started in two of the countries (ARG, DOR) during the past three years, and three (ARG, DOR, PER) implemented their access in the last five years. This means 16.7% of the

40 ICT in Health (R.J.Rodrigues), Version 2

countries have had plans in place for at least three years. The remaining four countries who do not have access to international electronic journals (BAH, BLZ, CHI, SUR) have different plans for the next two years. Bahamas (BAH) and Chile (CHI) plan to start having access. Suriname (SUR) stated they are undecided, and Belize (BLZ) did not specify what is likely to happen in the next to years. Over 75% (ARG, CAN, COR, HON, MEX, PAN, PAR, PER, VEN) of the countries with access to international electronic journals believe such access is moderately to very effective, while 16.67% (BRA, ELS) found their plan to be extremely effective. Only the Dominican Republic (DOR) responded that the effectiveness of this access is unknown. Access to national electronic journals - Eleven countries out of the sixteen respondents or 68.75% (ARG, BRA, CAN, COR, ELS, HON, MEX, PAN, PAR, PER, VEN) have access to national electronic journals. Eight countries or 64% (ARG, BRA, COR, HON, MEX, PAR, PER) responded that they plan to continue their policy of access in the next two years, while three or 27% (CAN, ELS, VEN) plan to revise and continue their plan. Panama (PAN) did not specify their plans for the net two years despite participating in the survey. One country (ARG) or just above 9%had initiated their access to national electronic journals during the past three years, and three countries (ARG, ELS, PER) which made up just over 27% had initiated their plan in the last five years. Of the five without access to national electronic journals, three countries (BAH, CHI, DOR) will have started to implement their own access plan in the next two years. Suriname (SUR) stated they are undecided. Despite participating in this section of the survey, Belize (BLZ) did not specify their future plans. Nine countries (ARG, CAN, COR, ELS, HON, MEX, PAN, PAR, PER), which comprises 55.6% of the respondents with access to national electronic journals, believe having access is moderately to very effective. One country (BRA) found access to be extremely effective. However, one country found access was not or slightly effective (VEN) and one country (BRA) stated the effectiveness of access was unknown. National Open Archive or Repository Policies - Most of the countries did not have national open archive or repository policies. In fact, eleven countries out of the sixteen respondents or 68.75% (ARG, BAH, BLZ, CHI, COR, ELS, HON, PAN, PAR, PER, SUR) replied they did not have national open archive or repository policies. In this case, only five (BRA, CAN, DOR, MEX, VEN) or 31.25% said they have such policies. Out of these five in the next two years, three or 60% (BRA, DOR, VEN) plan to continue their policies while the remaining two or 40% (CAN, MEX) plan to revise and continue their policies. One country (PER) initiated their national open archive or repository policies during the past three years, and three (BAH, MEX, PER) had initiated their plan in the last five years. However, five countries (CAN, ELS, PAN, PAR, VEN) had such policies implemented before 2001. Brazil stated they had a policy but did not state what year it was implemented. Of the eleven without national open archive or repository policies, five countries or 45.5% (COR, HON, PAN, PER, SUR) are undecided about what they will do. Five countries or 45.5% (ARG, BAH, CHI, ELS, PAR) plan to have their policies started. Despite participating in this section of the survey, Belize (BLZ) did not specify their future plans. Three countries (CAN, MEX, VEN), which comprises 60% of the respondents with national open archive or repository policies, believe their policy is moderately to very effective. Brazil (BRA) found their policy to be extremely effective. However, the effectiveness of the policy in Dominican Republic (DOR) was stated as unknown. Health information for the general public - Most of the countries did have health information for the general public. In fact, eleven countries out of the sixteen respondents or 68.75% (BRA, CAN, CHI, DOR, ELS, HON, MEX, PAN, PAR, PER, VEN) replied they did have health information for the general public. In this case, only five (ARG, BAH, BLZ, COR, SUR) or 31.25% said they did not have such policies. Out of the eleven countries

41 ICT in Health (R.J.Rodrigues), Version 2

who did have information for the general public, in the next two years, seven or 64% (CHI, DOR, MEX, PAN, PAR, PER, VEN) will continue their policies while the remaining four or 36% (BRA, CAN, ELS, HON) plan to revise and continue their policies. Two countries (PAN, PAR) initiated their health information for the general public policies during the past three years, and seven (BAH, CHI, ELS, MEX, PAN, PAR, PER) had initiated their plan in the last five years. Three countries (BRA, CAN, DOR, HON) had such policies implemented before 2001. Venezuela (VEN) stated they had a policy but did not state what year it was implemented. Of the eleven without health information for the general public policies, two countries or 40% (ARG, SUR) are undecided about what they will do. Two countries or 40% (BAH, COR) plan to have their policies started. Despite participating in this section of the survey, Belize (BLZ) did not specify their future plans. Seven countries (BRA, CHI, ELS, MEX, PAN, PER, VEN), which comprises 63.6% of the respondents with health information for the general public policies, believe their policy is moderately to very effective. Canada (CAN) found their policy to be extremely effective, while Honduras (HON) and Paraguay (PAR) considered their policy to be only slightly effective. However, the effectiveness of the policy in Bahamas (BAH) was stated as unknown. (f) Country Perceptions of Most Important Challenges and Most Effective Actions Tables 12 and 13, respectively, summarize the actions found to be most effective and the most important challenges to be overcome regarding access to information and knowledge. MOST EFFECTIVE ACTIONS ARG

BRA

CAN

To date the most effective action has been the digital library, which provides access to the complete texts of science reviews for all national universities and research institutes. The Scielo Program ("Reach for the Sky with Science") is also yielding positive results in Argentina, including online open access to the country's leading health reviews. However, having only started this year, it is still in its nascent phase. • The Virtual health Library project (BVS): promotion of inter-institutional partnerships for the production of health information; • Scielo (electronic journals portal): comprehensive and open scientific content; • Capes portal: makes international journals available free of charge to all Brazil's teaching institutions; • Health portal: (Ministry of Health). For approximately 10 years, Canada has successfully worked with its citizens, including voluntary and community groups, to identify and post electronic health information that is relevant to the public and reflects the various literacy levels. This has been particularly important for those citizens whose first language is not English or French. Through the multi level approaches and partnerships awareness building exercises, access to authoritative and appropriate eHealth information has risen substantially within the last six years. Partnerships with community groups, seniors centers, and the various educational institutions ranging from public schools to Universities training future health practitioners have ensured that consumer education focuses on being aware that the health-related information a consumer accesses is accurate as opposed to being commercially motivated, and that it has been reviewed by appropriate experts. In 1999, approximately 5,000 nonfederal government resources were identified, made accessible through federally funded sites, and accessed by approximately 200,000 visitors. In 2005, this collection had risen to more than 19,000 nonfederal current and authoritative resources with over 1 million unique visitors per year. The Canadian Women’s Health Network (CWHN) facilitates national networking of women’s health organizations in Canada. The purpose of the Network is to communicate the research findings of the Centers of Excellence for Women’s Health and other initiatives by means of a monthly e-bulletin on women’s health issues each month. CWHN’s extensive database serves as a virtual clearinghouse with a website of 2,000 pages, used by about 1

42 ICT in Health (R.J.Rodrigues), Version 2

COR

DOR

ELS

HON MEX

PAN PAR PER VEN

million visitors monthly. Besides information in English and French, some postings include up to 40 other languages. 1. The most effective action has been development of the Scielo Costa Rica project and the production of electronic versions of national reviews not included in that project. This has been so effective because users are able to access full text without the needing to go to the information units and with no time limit. 2. Development of web sites of health-sector institutions, such as CCSS, the Ministry of Health, the Institute of Statistics and Censuses, the Central American Centre for Population, the Costa Rican Cancer Institute, and the Social Security Virtual Health Library. Development of the national virtual health library (BVS), which is the fruit of efforts by 19 institutions in the health and health and environment sectors. Thanks to this library, information produced in these areas in the country is available and accessible in electronic format. Most effective action El Salvador is developing and improving information systems to facilitate and encourage their use, although this is essentially being done on a sector-by sector basis. Reasons why this is effective As these concerns a number of sectors in the country, it has been effective mainly because it has raised the profile of the topic and because financial resources have become available. The strengthening of a number of sectors in this field is tangible proof of the importance and usefulness of information and communication technology. In addition, this is the starting point for nationwide dissemination of ICT. The creation of the Virtual Health Library of Honduras, sustainability, cooperative work of various institutions, national initiative, not institutional, institutional commitment. Upgrading information technology and telecommunications in order to improve the health services provided to the population, and in particular to marginalized and vulnerable groups. The eHealth portal was developed, the first portal for the general public to be developed by the health sector in Mexico. This focused the sector's attention on the topic. Since the launch of this portal, the following initiatives have got under way. 1. An institutional page: "Advice on health care and prevention from ISSSTE" 2. A section entitled "How can we look after our health?" on the page of the national public health institute. 3. Creation the IMSS journal "Here's to your health" Technological strengthening of the web of the Ministry of Health and the insertion within the organization Integration of the network of the Virtual Health Libraries with the opportunity to utilize technological methodologies to register and access different data bases. Issuance of the Law of "Governmental Transparency" (Law 27806/2002) The development and sustainability of networks like the VHL (Virtual Health Library) and SciELO (Scientific Electronic Library Online), which enable equitable and free access to health information.

Table12. Most Effective Actions and Important Actions Identified by 16 Countries that Responded to the WHO Global eHealth Survey MOST SIGNIFICANT CHALLENGES ARG

BEL BRA

The most significant challenge is funding, given that the cost of access to international science reviews is very high for our country. In this regard, purchasing joint subscriptions for the entire scientific community via the digital library has yielded positive results, although it has not solved the problem entirely. It has not been considered a priority. • Lack of high-quality connectivity; • Shortage of computers in universities and research institutes; • High cost of subscriptions to journals; • Resistance to the computer culture; • Computer illiteracy

43 ICT in Health (R.J.Rodrigues), Version 2 CAN

COR

DOR

ELS

HON

MEX PAN PAR PER

VEN

Having built a myriad of websites and resources (by federal, provincial/territorial governments, voluntary groups, public health associations) that provide electronic health content to citizens over the last ten years, Canada’s challenge now is to find a way to ‘harmonize’ all the information now available on- line. This information is currently offered through multiple levels of government as well as non-government organizations including professional associations, volunteer organizations, private and corporate enterprises etc., but few use the same platform or infrastructure. The challenge therefore lies in ensuring that users can access the information, regardless of the level of technology they have available to them, and in finding ways to ensure that the information is ‘seamless’ and easy to use. Projects working toward ‘harmonization’ of various federal government-sponsored websites are underway, and will continue. 2. The many languages in use in Canada other than French and English pose an ongoing challenge. As noted above, some provinces with large non-English speaking populations (e.g. Ontario, British Columbia) have been working diligently to meet this challenge. Most government sites highlight health materials developed in other languages as options. 3. Canada’s diversity is not limited to language – differing cultural and religious beliefs are also a factor. Since information on health choices for all groups in Canadian society must be presented on government-sponsored websites, this may include information about health care procedures and practices (e.g. birth control) with which some groups in Canada may disagree, no matter how factually accurate the information presented. Website managers deal with these issues in the same way as they handle other questions from the public. 1. The main challenge is that many health workers lack access to the Internet. 2. The lack of high-speed communications media and the cost of equipment. We have addressed this via projects to improve communications facilities through the Costa Rican Electricity Institute. The main challenge has been the difficulty in ensuring regular collection of information in electronic format because of the absence of an appropriate national policy. Nevertheless, BVS and BVSA are tools which may be used to improve this situation. Main challenge. Some sectors in El Salvador are somewhat reluctant to share information because there are still shortcomings in data analysis. Few sectors have access to or the resources required by this type of system. The shortage of infrastructure and connectivity. It has been confronted with alternative information products: CDROMs for communities without access to the Internet, increased awareness of the decision makers to equip the documentation centers and libraries with ICT. The lack of professionals in the area of information management. Lack of sufficient Internet access. Providing the population with shared access, for example via Internet kiosks Development of content intended for the population Resistance to change Lack of human resources training Expensive equipment, high Internet service costs, slowness of the servers in the country and lack of training of the human resources. a) There is no culture of systematic diffusion of technical information on health that is politically sensible, like the publication of indicators for the fulfillment of health goals b) Only 7% of the homes have access to computers and it is estimated that in 2005, only 1% of the homes have access to the Internet. The limited budget for this in national universities, the inexistence of consortia for acquiring journals and the per capita income of Venezuela make it impossible to access the Health InterNetwork Access to Research Initiative (HINARI).

Table 13. Most Important Challenges Identified by 16 Countries that Responded to the WHO Global eHealth Survey

44 ICT in Health (R.J.Rodrigues), Version 2

(g) Cultural and Linguistic Diversity Table 14 provides an overview of the creation and dissemination of electronic health content in local languages, which recognizes and promotes cultural diversity. Cultural diversity is an essential factor in promoting cultural identity and linguistic diversity in an information society. More specifically, the table lists the existence of – (a) multilingual projects; (b) translation and cultural adaptation; and (c) other actions, as well as the year in which the policy or strategy was approved or implemented.

Countries

Multilingual projects adopted Y/N

ARG BAH BLZ BRA CAN CHI COR DOR ELS HON MEX PAN PAR PER SUR VEN

N N N N Y N N N N N Y N N N N Y

Year

2004

2000

2004

Translation and cultural adaptation implemented Y/N N N N Y Y N N N N N Y N N N N Y

Year

1985 1997

2003

na

Other Actions taken Y/N N N N N Y N N N N N N N N N N N

Year

2001

Table 14. Cultural and linguistic diversity, and cultural identity Strategies for 16 Countries of the Americas Three countries informed that they have introduced special projects to promote the development and use of new electronic health content in multiple languages -- multilingual projects (18.75%). These projects were adopted in the last three years in two of the three countries (66.67 %) and in the last 5 years in the remaining country (33.33%). The multilingual projects were considered not or slightly effective by one country (33.33%) and moderately to very effective in the remaining two countries (66.67 %). One country indicated that the multilingual project implementation process will continue the same in the next two years (33.33 %), while two countries (66.67 %) will revise it and continue. Of the thirteen countries that have not yet adopted and implemented multilingual projects, ten are undecided on how to proceed (ARG, BAH, BRA, CHI, ELS, HON, PAN, PAR, PER, and SUR), one will start to implement them (DOR) and two have not replied (BLZ, COR). Four countries informed that they support the translation and cultural adaptation (localization) of existing highquality content which has been created either locally or abroad --translation and cultural adaptation (25%). The translation and cultural adaptation policy was implemented in the last three years in one of these countries (25%) and in the last five years in two other countries (50%). The date of implementation in the fourth country (VEN) is unknown. The translation and cultural adaptation policy was considered not or slightly effective by one country, moderately to very effective by two (50%) and extremely effective by one country. One country indicated that the policy will continue the same in the next two years (25%) and three responding countries will revise it and continue (75 %). Of the twelve countries without a translation and cultural adaptation policy, nine

45 ICT in Health (R.J.Rodrigues), Version 2

countries are undecided on how to proceed (ARG, BAH, CHI, ELS, HON, PAN, PAR, PER, and SUR), one has started to implement (COR), one will continue the same (DOM) and one has not replied (BLZ). One country (CAN) informed that it is taking Other Actions on Cultural and Linguistic Diversity and Cultural Identity (6.25%). These actions were implemented within the last 5 years and are considered moderately to very effective. CAN indicated that it will revise these actions and continue. The remaining fifteen countries that provided answers to the previous sections of this chapter on Cultural and Linguistic Diversity and Cultural Identity did not identify any Other Actions they are taking with respect to Cultural and Linguistic Diversity and Cultural Identity. (h) Human Resources and Skills Table 15 lists the situation for the existence of key national policy or strategy mechanisms (a) undergraduate or post training graduate training on ICT, (b) continuing education on ICT, and (c) eLearning in health sciences. In addition, it highlights the year in which the policy or strategy was approved or implemented. Seven countries informed that a policy on undergraduate or post graduate training on ICT is in place (43.75%). The policy was implemented in the last three years in two of those countries (28.57 %). The policy or strategy was considered not or slightly effective by two, moderately to very effective by three (42.86 %) and two countries did not respond. Five countries (ARG, PAN, PER, SUR, VEN) indicated that the policy or strategy will continue the same in the next two years (71.43 %); two countries (BRA, CAN) will revise and continue (28.57 %). Of the nine countries without policy on affordability of undergraduate or post graduate training on ICT, four countries are undecided on how to proceed (CHI, ELS, HON, PAR), two countries have started to implement (BAH, MEX) and one has not replied (BLZ).

Countries

Undergraduate or post graduate training on ICT Y/N

ARG BAH BLZ BRA CAN CHI COR DOR ELS HON MEX PAN PAR PER

Y N N Y Y N Y N N N Y Y N Y

SUR VEN

Y Y

Year 2005

Continuing education on ICT Y/N

2002

Y Y N Y Y N N N Y N Y N N N

1983 na

N Y

1983 1997 na

1996 2004

Year 2005 1980 1986 1997

1990 2001

na

eLearning in health sciences Y/N Y N N Y Y Y Y Y Y Y Y N N N N Y

Year 2001

1996 1997 2003 na 2002 2000 2004 2001

2005

Table 15. Human Resources Knowledge and Skills Policies and Strategies for 16 Countries of the Americas

46 ICT in Health (R.J.Rodrigues), Version 2

Seven countries informed that a policy on continuing education on ICT is in place (46.67%). The policy was implemented in the last three years in one of those countries (14.29 %). The policy or strategy was considered not or slightly effective by one, moderately to very effective by five (83.33 %). Three countries (ARG, BAH, VEN) indicated that the policy or strategy will continue the same in the next two years (42.86 %) and four countries (BRA, CAN, ELS, MEX) will revise and continue (57.14 %). Of the eight countries without a policy on affordability of continuing education on ICT, four countries are undecided on how to proceed (CHI, HON, PAR, and SUR), two countries have started to implement (COR, PAN) and one country has not replied (BLZ). Nine countries informed that a policy on e-learning in health sciences is in place (56.25%). The policy was implemented in the last three years in three of those countries (33.33 %). The policy or strategy was considered not or slightly effective by none of the countries, moderately to very effective by nine (90%) and one country did not respond. Six countries (ARG, BRA, DOR, HON, MEX, VEN) indicated that the policy or strategy on elearning in health sciences will continue the same in the next two years (66.67 %) and three countries (CAN, CHI, ELS) will revise and continue (33.33 %). Of the seven countries without policy on affordability of e-learning in health sciences, two countries are undecided on how to proceed (PER, SUR), three countries have started to implement (BAH, PAN, PAR) and one country has not replied (BLZ).

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