Ehealth In Latin America: Challenges & Opportunities

E-HEALTH IN LATIN AMERICA AND THE CARIBBEAN: CHALLENGES AND OPPORTUNITIES Roberto J. Rodrigues eHealthStrategies.com, Bethesda, MD and The Institute for Technical Cooperation in Health Inc. (INTECH), Potomac MD

Adjunct Professor, Science, Technology, and International Affairs Program E. Walsh School of Foreign Service, Georgetown University, Washington, D.C.

8th International Congress in Nursing Informatics June 22-25, 2003 Rio de Janeiro, Brazil

E-HEALTH PERSPECTIVES IN LATIN AMERICA AND THE CARIBBEAN

!

DRIVING FORCES AND BARRIERS

!

HEALTH SECTOR CHARACTERISTICS

!

ICT INFRASTRUCTURE AND MARKET

!

IMPLEMENTATION ISSUES

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E-HEALTH PERSPECTIVES IN LATIN AMERICA AND THE CARIBBEAN

!

DRIVING FORCES AND BARRIERS

!

HEALTH SECTOR CHARACTERISTICS

!

ICT INFRASTRUCTURE AND MARKET

!

IMPLEMENTATION ISSUES

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HEALTH SECTOR TREND-SETTERS IN LAC (1) SATISFACTION, QUALITY, AND EFFICIENCY n

DISSATISFACTION WITH HEALTHCARE SYSTEM (CHOICE, ACCESS, QUALITY, CONTINUITY, LONG-TERM PROVIDER RELATIONSHIP)

n

INCREASING DEMAND (DEMOCRATIZATION PROCESSES)

n

ANTICIPATION OF NEEDS, DEMAND FOR CUSTOMER SERVICE, “MADE TO MEASURE” CARE, AND CONVENIENCE

n

EFFICIENCY OF ADMINISTRATIVE PROCESSES (ELIGIBILITY,CLAIMS, REIMBURSEMENT, PROCUREMENT AND SUPPLY MANAGEMENT)

n

LOGISTICS OF HEALTHCARE / COOPERATION IS A PRIORITY (DYNAMIC SCHEDULING, DATA COMMUNICATION)

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HEALTH SECTOR TREND-SETTERS IN LAC (2) INCREASING DATA REQUIREMENTS OF HEALTH PRACTICE

n

NEED FOR DETAILED DATA AND INFORMATION (DISTRIBUTED MULTIDISCIPLINARY PRACTICE, IMPROVED DOCUMENTATION, ERROR REDUCTION, ACCOUNTABILITY, AND TRANSPARENCY)

n

RETRIEVAL OF STRUCTURED AND UNSTRUCTURED HEALTH DATA

n

ACCESS TO BIOMEDICAL KNOWLEDGE (REFERENCE, PROTOCOLS OF CARE, REGISTRIES, KNOWLEDGE BASES, EVIDENCE-BASED PRACTICE, CONSUMER PARTICIPATION)

n

INTERNET-BASED APPLICATIONS (INFORMATION DISSEMINATION, DISTANT EDUCATION, EHR, REMOTE CARE)

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HEALTH SECTOR TREND-SETTERS IN LAC (3) COST RECOVERY AND CONTAINMENT n

HEALTH IS ONE OF THE LARGEST SECTORS OF THE ECONOMY

n

LIMITED NUMBER OF CONDITIONS ACCOUNT FOR MOST HEALTHCARE EXPENDITURES

n

IN HIGH INCOME AND MIDDLE INCOME COUNTRIES 40% OF THE POPULATION HAVE ONE OR MORE CHRONIC CONDITIONS

n

CHRONIC CONDITIONS ACCOUNT FOR MORE THAN 2/3 OF HEALTH CARE EXPENDITURES

n

HEALTH PROBLEMS ARE MAJOR IMPEDIMENT TO SOCIAL AND ECONOMIC DEVELOPMENT

n

URGENCY TO CONTAIN HEALTHCARE COSTS eHealthStrategies.com

THE GLOBAL MARKET FOR HEALTH GOODS AND SERVICES (1)

1990-1998 South Asia 5% 1990-1998 Eastern Europe & Central Asia 6%

1990-1998 Middle East & North Africa 2%

1990-1998 Sub-Saharan Africa 1%

1990-1998 East Asia & Pacific 10%

1998 United States 44%

1996-2000 Latin America & Caribbean 9% 1996-2000 European Union 20%

2000 Canada 3%

Source: Casas, JA Trade in Health Services in the Americas: Trends and Opportunities, PAHO/WHO, 2001 eHealthStrategies.com

THE GLOBAL MARKET FOR HEALTH GOODS AND SERVICES (2) Total Health Expenditure x GDP Per Capita (191 Countries)

Source: Casas, JA Trade in Health Services in the Americas: Trends and Opportunities, PAHO/WHO, 2001 eHealthStrategies.com

THE GLOBAL MARKET FOR HEALTH GOODS AND SERVICES (3) HEALTH EXPENDITURES PER CAPITA 1998-2000; in 1999 International US dollars (Purchase Power Parity) 4,500

3,978

4,000

3,500

US Dollars (PPP)

3,000

2,500

2,206

WORLD 1,868

2,000

1,500

1,000

500

346

452 324 144

216 91

48

-

World

U.S.

Canada

European LA & East Asia E Europe Union Caribbean & Pacific & C Asia

South Middle East Sub-Saharan Asia & N Africa Africa

Source: Casas, JA Trade in Health Services in the Americas: Trends and Opportunities, PAHO/WHO, 2001 eHealthStrategies.com

THE CHANGING PRACTICE ENVIRONMENT

Current Approach n n n n n n n n n n n

Care based on visits Professional autonomy Professionals control care Provider “owns” records Decision based on experience Safety is individual issue Privacy is individual issue No transparency of operations The system reacts to needs Cost not controlled Independent providers

New Model n n n n n n n n n n n

Continuous relationships Customized patient care Patient is source of control Information flows freely Evidence-based decisions Safety is a system property Privacy is a system property Transparency is necessary Needs are anticipated Control costs Cooperation is required

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THE “CONNECTED CONSUMER”

! WELLNESS AND MEDICAL INFORMATION !

SHOPPING FOR PROVIDERS AND SERVICES

! RISK ASSESSMENT TESTING ! BUYING PHARMACEUTICALS AND HEALTH PRODUCTS ! COMMUNICATION WITH SPECIAL INTEREST GROUPS ! E-MAILING TO PROVIDERS AND INSURERS

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TECHNOLOGY BARRIERS (1) INFORMATION TECHNOLOGY INFRASTRUCTURE

!

TECHNICAL RESOURCES AND WEB DEMOGRAPHICS

!

DATA AND COMMUNICATION STANDARDS

!

TECHNOLOGICAL INNOVATION X ACTUAL USE GAP

!

OPEN x PROPRIETARY ARCHITECTURE

!

COST-BENEFIT JUSTIFICATION

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THE DEVELOPMENT / ANALOG / DIGITAL DIVIDES BY INCOME Percentage of World Total 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Population

Low

Television

Telephone

Lower Middle

GDP

Upper Middle

Internet

High

Source: Digital Opportunities Taskforce (DOT Force), 2000 eHealthStrategies.com

Ownership of Personal Computers in 155 Countries Categorized by Level of Income (Data from: International Telecommunication Union, World Telecom Indicators 2002)

Number of Personal Computers x 100 Persons (Log Scale)

100

m = 31.30 10 m = 10.08 HIGH INCOME m = 3.64 1 UPPER MIDDLE INCOME m = 0.68

LOWER MIDDLE INCOME

0.1

LOW INCOME m = Arithmetic Mean 0.01

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THE RESEARCH & DEVELOPMENT DIVIDE BY REGION

SELECTED TECHNOLOGY INPUTS BY REGION (1992-1997) Region

OECD Eastern Europe & FSR East Asia Latin America & Caribbean Middle East Sub-Saharan Africa South Asia

Source: Rodríguez F and Wilson E

R&D as % of GDP 1.8 0.9 0.8 0.5 0.4 0.2 0.8

Technicians 6 per 10 pop 1,326.1 577.2 235.8 205.4 177.8 76.1 59.5

Scientists 6 per 10 pop

GPD per capita

2,649.1 1,841.3 1,026.0 656.6 521.0 324.3 161.0

20,113.5 4,027.4 6,270.6 5,635.8 8,941.5 1,971.5 1,764.3

( InfoDev , World Bank 2000 ) modified

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NATIONAL INVESTMENT CAPACITY IS A MAJOR PROBLEM

Expenditure on Information and Communication Technologies in Selected Countries ICT Expenditure Per Capita in US$ (2000)

ICT Expenditure as % of GDP (2000)

ICT Expenditure Per Capita in US$ (2000)

ICT Expenditure as % of GDP (2000)

Argentina

317

4.1

Hungary

431

8.7

Australia

1,992

9.7

Italy

1,068

5.7

Austria

1,697

7.2

Japan

3,118

8.3

Belgium

1,769

8.0

Mexico

189

3.2

289

8.4

Norway

2,445

6.9

1,911

8.4

Russia

63

3.7

Chile

360

7.8

Singapore

2,104

9.7

China

46

5.4

Spain

731

5.1

Colombia

228

12.0

Sweden

2,674

10.4

Finland

1,835

7.8

United Kingdom

2,187

9.1

France

1,916

8.7

United States

2,296

8.1

Germany

1,798

7.9

Venezuela

196

3.9

Country

Brazil Canada

Country

Source: World Bank, 2002 World Development Report

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GLOBAL INTERNET USERS Millions of Users

350

28%

300 250

21%

Penetration

200 15%

150 9%

100

1.6%

6%

50

4% 0.1%

0

1% 0.3%

0.5%

0.1%

1995

1996

1997

1998

1999

2000

Developed

30

47

77

124

180

232

Developing

3

7

13

25

51

83

Source: International Telecommunication Union, 2000 eHealthStrategies.com

GLOBAL INTERNET USERS (APRIL 2001) TOTAL NUMBER OF USERS 427,213,610

47.95%

0.78%

North America South America Central America Europe Asia

4.56%

Oceania Africa

4.12% 18.58% 0.38% 23.63% Source: www.netsizer.com eHealthStrategies.com

NETWORKED READINESS INDEX (75 Countries) Access & Infrastructure) / Policy & Business Environment / Learning & Opportunities / Economy)

6.5 IN THE TOP THIRD IN THE TOP THIRD

6

FIN

• 14 in Western Europe (best in Scandinavia) • 14 in Western Europe (best in Scandinavia) • 7 in Asia and Oceania (led by Singapore) • 7 in Asia and Oceania (led by Singapore) • 2 in North America (U.S. and Canada) • 2 in North America (U.S. and Canada) • 1 in Middle East (Israel) • 1 in Middle East (Israel)

5.5

NET GBR

USA

SWE

SGP AUT

GER

5 4.5 4

IN THE MID THIRD IN THE MID THIRD

FRA

• 10 in L America/Caribbean (led by Argentina) • 10 in L America/Caribbean (led by Argentina) • 6 in Western Europe (led by Portugal) • 6 in Western Europe (led by Portugal) • 4 in Eastern Europe (led by Slovenia)) • 4 in Eastern Europe (led by Slovenia)) • 1 in Asia (Malaysia) • 1 in Asia (Malaysia) • 1 in Africa (South Africa) • 1 in Africa (South Africa)

CAN

JPN

SPA CHI

ARG

BRA

POL IND BUL PAN TUR COL SAR URU MEX IN THE BOTTOM THIRD JOR IN THE BOTTOM THIRD PER VEN • 1O in Latin America (led by Peru) ELS • 1O in Latin America (led by Peru) JAM • 7 in Asia (led by India)

EGY PAR CHN

3.5

BOL

3

NIC HON

2.5 2

VIE

BAN

GUA ECU

RUS

• 7 in Asia (led by India) • 4 in Eastern Europe (led by Bulgaria) • 4 in Eastern Europe (led by Bulgaria) • 3 in Sub-Saharan Africa • 3 in Sub-Saharan Africa • 1 in the Middle East (Egypt) • 1 in the Middle East (Egypt)

NIG Source: The Global Information Technology Report 2001-2002 (Modified to shown only selected countries) World Economic Forum and Harvard University Center for International Development eHealthStrategies.com

TELEPHONE LINES DENSITY AND INTERNET USAGE

Source: The Global Information Technology Report 2001-2002 World Economic Forum and Harvard University Center for International Development * Fixed and mobile subscriptions ** Based on individual user who access the Internet at least once a month

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TELEPHONE LINES DENSITY AND INTERNET USAGE

Source: The Global Information Technology Report 2001-2002 World Economic Forum and Harvard University Center for International Development * Fixed and mobile subscriptions ** Based on individual user who access the Internet at least once a month

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TECHNOLOGY BARRIERS (2)

INFORMATION TECHNOLOGY DEPLOYMENT

!

INTEGRATION IN THE WORK ENVIRONMENT

!

PROJECT MANAGEMENT AND EDUCATION / TRAINING OF HEALTH PROFESSIONALS

!

ACCESS TO RELIABLE APPLICATIONS PRODUCTS AND SERVICES (INTEGRATION, CUSTOMER SUPPORT, TRAINING)

!

VENDOR DEPENDENCY

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Technology Exports, Royalties, and Licenses Payments for the Year 2000 for Selected Countries. (Source: World Bank, 2002 Development Indicators) C o u n tr ie s

A rg e n tin a B o livia B ra z il C h ile C o lo m b ia C o s ta R ic a D o m in ic a n R e p u b lic Ecuador E l S a lva d o r H o n d u ra s J a m a ic a M e xic o Panam a P e ru U ru g u a y W o rld L o w a n d M i d d l e In c o m e E a s t A s ia & P a c ific E u ro p e a n d C e n tra l A s ia L a tin A m e ric a & C a rib b e a n M id d le E a s t & N o rth A fric a S o u th A s ia S u b -S a h a ra n A fric a H i g h In c o m e E u ro p e a n C o m m u n ity U n ite d S ta te s Japan

H ig h T e c h n o lo g y R o y a ltie s a n d R o y a ltie s a n d E x p o r ts a s % o f L ic e n s e s L ic e n s e s A ll M a n u fa c tu r e d In c o m e in P a y m e n ts in P r o d u c ts M illio n s o f U S $ M illio n s o f U S $ E x p o r te d

9 19 3 7

6 6 2 0 22 0 3 2

16 25 10 16 1 3 8 22 16 34 28

13 2 126 102 4 1

2 0 6 43 0

1 ,8 7 3 784 313 501 106 87 82 7 0 ,3 2 1 1 1 ,0 1 9 3 8 ,0 3 0 1 0 ,2 2 7

R o y a ltie s a n d L ic e n s e s B a la n c e in M illio n s o f US$

G ro s s N a tio n a l In c o m e in B illio n s U S $

R o y a ltie s a n d L ic e n s e s B a la n c e a s % of G N I

458 5 1 ,4 1 5 44 71 31 30 62 20 10 41 407 30 57 11

-4 4 5 -3 -1 ,2 8 9 58 -6 7 -3 0 -3 0 -6 2 -1 8 -1 0 -3 5 -3 6 4 -3 0 -5 7 -1 1

2 7 6 .2 8 .2 6 1 0 .1 6 9 .8 8 5 .3 1 4 .5 1 7 .8 1 5 .3 1 2 .6 5 .5 6 .9 497 9 .3 5 3 .4 20

-0 .1 6 -0 .0 4 -0 .2 1 0 .0 8 -0 .0 8 -0 .2 1 -0 .1 7 -0 .4 1 -0 .1 4 -0 .1 8 -0 .5 1 -0 .0 7 -0 .3 2 -0 .1 1 -0 .0 6

1 1 ,0 6 4 5 ,4 0 9 1 ,7 5 3 2 ,6 6 6 614 338 283 6 2 ,9 8 8 2 3 ,4 2 2 1 6 ,1 0 0 1 1 ,0 0 7

-9 ,1 9 1 -4 ,6 2 5 -1 ,4 4 0 -2 ,1 6 5 -5 0 8 -2 5 1 -2 0 1 7 ,3 3 3 -1 2 ,4 0 3 2 1 ,9 3 0 -7 8 0 eHealthStrategies.com

HEALTH SECTOR BARRIERS (1) NEED RECOGNITION ! DISSEMINATION STILL LIMITED = HEALTH SECTOR LAGS BEHIND OTHER SECTORS ! MANY PUBLIC HEALTH ORGANIZATIONS ARE NOT TAKING ADVANTAGE OF ICT OPPORTUNITIES !ROLE IN COMPETITIVENESS AND ORGANIZATIONAL SURVIVAL IN THE NEW HEALTHCARE ENVIRONMENT ! MOST EXISTING INFORMATION SYSTEMS ARE INADEQUATE TO THE NEW MODELS OF HEALTHCARE = “STATISTICALEPIDEMIOLOGICAL PARADIGM”

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HEALTH SECTOR BARRIERS (2) REQUIREMENTS SPECIFICATION !

LOW DEFINITION LEVEL OF CONTENTS (DELIVERABLES) OF HEALTH INTERVENTIONS

!

DETERMINATION OF OBJECTIVES AND FUNCTIONALITIES (COMPLEXITY AND VARIETY OF TECHNICAL CONTENTS)

!

CONFLICTS IN DEFINING MINIMUM DATA SETS FOR OPERATIONAL MANAGEMENT AND CLINICAL DECISION-MAKING

!

HEALTHCARE ORGANIZATIONS AND PROVIDERS TEND TO SEE THEIR OWN DATA AS THE ONLY GOOD AND VALID DATA

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HEALTH SECTOR BARRIERS (3)

ORGANIZATIONAL AND POLICY-RELATED

!

INFRASTRUCTURE, INVESTMENT SUSTAINABILITY, AND DEPLOYMENT CAPABILITY

!

DISTRUST OF HEALTH PROFESSIONALS IN OFF-SITE DATA STORAGE AND ACCESS CONTROL

!

NATIONAL POLICIES AND STRATEGIES FOR THE STANDARDIZATION AND COST-EFFECTIVE USE OF TECHNOLOGY AND INFORMATION

!

CONSISTENCY AND CONTINUITY OF POLITICAL SUPPORT

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AREAS OF KNOWLEDGE MANAGEMENT APPLICATIONS

Collaborative Professional Work Intranet Content Management Intellectual Asset Management Customer Relationship Management Competitive Analysis and Intelligence Research and Development Call Center Support Proposal Development Corporate Portals Corporate Operations Electronic Commerce

Current

Case Management

Planned

Function-Centered Desktops Other Litigation Support Medical Records Management

0

10

20

30

40

50

60

70

80

PERCENT Source: U.S. Market, The Delphi Group, 2000 eHealthStrategies.com

90

U.S. PHYSICIANS USE OF COMPUTERS (2000)

Billing Scheduling Patient Reminders Managed Care Apps Patient Records Treatment Alerts Referrals Telemedicine Prescriptions

0

20

40

60

80

100

PERCENT Source: Pricewaterhouse Coopers Modern Physician 2000

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SOURCES OF INFORMATION ABOUT NEW HEALTH WEB SITES HOW THE PUBLIC LEARNS ABOUT HEALTH INFORMATION IN THE WEB Health Professional

0.5

Billboards

1.2

Radio

6.3 10.2

Media Story

17.4

Newsprint

19.1

TV

26.5

Web Banners

32.9

Friends/Family

40.3

Internet Search

45.7

Web Links

61.3

E-mail 0

20

40

60

80 %

U.S. Survey by Gómez Advisors, Inc. , 2000 eHealthStrategies.com

E-HEALTH PERSPECTIVES IN LATIN AMERICA AND THE CARIBBEAN

!

DRIVING FORCES AND BARRIERS

!

HEALTH SECTOR CHARACTERISTICS

!

ICT INFRASTRUCTURE AND MARKET

!

IMPLEMENTATION ISSUES

eHealthStrategies.com

HEALTH SECTOR IN LATIN AMERICA & THE CARIBBEAN

! WESTERN BIOMEDICAL / SOCIAL SECURITY MODELS ! 80% URBANIZATION / LARGE URBAN AREAS ! BURDEN OF DISEASE: COMMUNICABLE DISEASES, MATERNAL AND PERINATAL CONDITIONS, LIFE-STYLE (HIV/TOBACCO/ALCOHOL), CHRONIC-DEGENERATIVE AND CARDIOVASCULAR DISEASES, RESPIRATORY CONDITIONS, INJURIES ! INADEQUATE INFRASTRUCTURE, FACILITY AND SERVICES DISTRIBUTION, POOR ACCESS, AND LOW QUALITY ! LOW INVESTMENT AND INCREASING COSTS ARE A MAJOR IMPEDIMENTS TO THE DEVELOPMENT OF THE HEALTH SECTOR ! HEALTH SECTOR REFORM

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DISTRIBUTION OF GROSS DOMESTIC PRODUCT BY SECTOR, 1999 80 70 Percentage of GDP

60 50 40 30 20 10

Sector

0

ARG

BOL

BRA

CAN

CHI

COL

COR

DOR

ECU

ELS

GUA

HAI

HON

J AM

MEX

NIC

P AN

P AR

P ER

TRT

US A

URU

VEN

Agric ult ure

6

16

9

3

8

14

14

11

12

11

23

30

18

8

5

26

8

26

8

2

2

9

5

Ind/ Ma nufc

22

17

23

18

16

12

17

16

22

22

13

7

18

15

19

14

9

16

24

8

18

19

12

Ind/ Non-Ma nufc

11

13

6

15

17

13

5

19

11

6

6

13

12

18

8

7

9

6

14

32

8

10

12

S e rvic e s

61

54

62

64

59

61

64

54

55

61

58

50

52

59

68

53

74

52

54

58

72

62

71

Source: World Bank, World Development Indicators 1999 eHealthStrategies.com

HEALTH CONTRIBUTION TO THE SERVICES SECTOR %

HEALTH SERVICES AS PERCENTAGE OF THE SERVICE SECTOR

25 NIC

23 20 USA

18

ARG CAN

HON

COL

URU

15 13 10 8

PER

ELS BOL

COR BRA

HAI

CHI

JAM DOR ECU

GUA

PAN MEX

PAR TRT VEN

5 3 0 Source: World Bank, World Development Indicators 1999 eHealthStrategies.com

THE LATIN AMERICAN & CARIBBEAN MARKET Latin America & Caribbean, 1998-2000: National Health Expenditures Per Capita in US$ (Countries Grouped by Income Levels)

US$ 800

700

HIGHEST INCOME 600

MID INCOME 500

LOWEST INCOME 400 300

200

BAH

ARG

NEN

BAR

ANG

URU

MEX

TRT

CHI

BRA

COR

VEN

PAN

BLZ

SVG

PER

COL

PAR

JAM

ECU

ELS

DOR

GUT

CUB

BOL

GUY

HON

NIC

0

HAI

100

Source: Casas, JA Trade in Health Services in the Americas: Trends and Opportunities, PAHO/WHO, 2001 eHealthStrategies.com

THE LATIN AMERICAN & CARIBBEAN MARKET PUBLIC AND PRIVATE COMPOSITION OF HEALTH EXPENDITURES (1998-2000)

Private Insurance 18%

Central Government 23%

Local Governments 8% Direct Out-of-Pocket Expenditure 37% Social Security 14%

Source: Casas, JA Trade in Health Services in the Americas: Trends and Opportunities, PAHO/WHO, 2001 eHealthStrategies.com

HOSPITAL MARKET Hospital Size in Latin America and the Caribbean by Number of Beds (Source: PAHO Directory of Latin America and Caribbean Hospitals, 1996-1997) Hospitals Number of Beds

Beds Available

Number

Percent

Number

Percent

1-50

10,027

60.5

219,383

20.0

51-100

2,615

15.8

189,559

17.3

101-200

1,703

10.3

242,770

22.1

201-300

544

3.3

133,225

12.1

301-400

242

1.5

84,811

7.7

401-500

133

0.8

58,951

5.4

501-1000

186

1.1

126,169

11.5

>1000

29

0.2

43,097

3.9

Sub-Total

5,479

93.4

No Data

1,087

6.5

Total

16,566

100.0

1,097,965

100.0

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HOSPITAL MARKET Legal Ownership of 16,566 Hospitals and Computerized Information Systems in Latin America and the Caribbean, period 1995-1997 (Source: PAHO Directory of Latin American and Caribbean Hospitals Database) HOSPITAL GROUPS OWNERSHIP CLASS

ALL FACILITIES

NO COMPUTERS Percent

Number

Percent

Number

6,498

39.22

876

Private Philanthropic

Public Non-Social Security Public Social Security

Military Total

WITH COMPUTERS Percent Number

In Class

In Group

5,099

78.47

44.98

1,399

21.52

26.74

5.29

438

50.00

3.86

438

50.00

8.37

7,783

46.98

4,924

63.26

43.43

2,859

36.73

54.66

1,284

7.75

779

60.66

6.87

505

39.33

9.65

125

0.75

96

76.80

0.84

29

23.20

0.55

16,566

100.0

11,336

---

100.00

---

100.00

5,230

In Class

In Group

31.6% HAVE COMPUTERS, OF THOSE ABOUT 54.6% ARE PRIVATE

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E-HEALTH PERSPECTIVES IN LATIN AMERICA AND THE CARIBBEAN

!

DRIVING FORCES AND BARRIERS

!

HEALTH SECTOR CHARACTERISTICS

!

ICT INFRASTRUCTURE AND MARKET

!

IMPLEMENTATION ISSUES

eHealthStrategies.com

HEALTH INFORMATION TECHNOLOGY DEVELOPMENT INDICATORS

LIMITATIONS OF INFORMATION TECHNOLOGY METRICS

!

LACK OF STANDARDIZED DEFINITIONS FOR IT COMPONENTS

!

DATA ON IT RARELY COLLECTED ON A SYSTEMATIC BASIS

!

ABSENCE OF COST DATA

!

INFORMATRION ON HOW IT IS BEING ACTUALLY USED

!

LACK OF EVALUATION OF POSITIVE AND NEGATIVE IMPACTS

!

RAPIDLY CHANGING TECHNOLOGY

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THE INCOME BARRIER (1) PERCENT OF U.S. HOUSEHOLDS WITH COMPUTER BY LEVEL OF INCOME (1998) 90 90 80 80 70 70 60 60 50 50 40 40 30 30 20 20 10 10 00

U.S. U.S. Rural Rural Urban Urban

Under Under 5,0005,000- 10,00010,000- 15,00015,000- 20,00020,000- 25,00025,000- 35,00035,000- 50,00050,000- 75,000 75,000 5,000 ++ 5,000 9,999 9,999 14,999 14,999 19,999 19,999 24,999 24,999 34,999 34,999 49,999 49,999 74,999 74,999

U.S. U.S. Rural Rural

15.9 15.9 11.9 11.9

12.3 12.3 8.1 8.1

15.9 15.9 13.8 13.8

21.2 21.2 22.1 22.1

25.7 25.7 24.7 24.7

35.8 35.8 34.0 34.0

50.2 50.2 51.0 51.0

66.3 66.3 64.2 64.2

79.9 79.9 76.5 76.5

Urban Urban

16.9 16.9

13.6 13.6

16.6 16.6

20.8 20.8

26.1 26.1

36.5 36.5

50.0 50.0

67.1 67.1

80.8 80.8

Source: U.S. National Telecommunication and Information Agency, DOC, 1999 eHealthStrategies.com

THE INCOME BARRIER (2)

SELECTED COUNTRIES - GNP PER CAPITA BY POPULATION QUINTILES (1999)

BRA

CAN

CHI

COL DOR ECU GUA HON MEX

NIC PAR URU

USA

VEN

Hi Q 14,105 37,661 14,629 7,563 5,404 3,307 5,013 2,265 13,021 1,298 5,079 14,539 70,190 9,938 4th Q 4,046 22,041 4,341 2,285 2,073 1,417 1,480 769 4,296 470 1,522 6,472 33,885 3,968 3rd Q 2,211 16,483 2,614 1,378 1,318 945 835 457 2,640 296 871 4,455 23,598 2,545 2nd Q 1,216 12,362 1,583 820 835 625 462 277 1,611 188 480 3,010 15,883 1,572 Lo Q 553 7,187 839 373 433 359 167 133 805 99 187 1,626 7,866 692

Source: Data from the World Bank Development Report, 2000 eHealthStrategies.com

THE INCOME BARRIER (3) SELECTED COUNTRIES - GNP PER CAPITA BY POPULATION QUINTILES (1999) 25,000 22,500 20,000 17,500 15,000 12,500 10,000 7,500 5,000 2,500

N

R

R

U

N

PA

PA

PE

UR

VE

N IC

X ME

M JA

N HO

A GU

I

S EL

HA

U EC

R DO

R CO

L CO

I CH

A BR

L BO

AR

G

0

Hi 10% 5th Quintile (Hi 20%) 4th Quintile 3rd Quintile 2nd Quintile 1st Quintile (Low 20%)

Source: Data from the World Bank Development Report, 2000 eHealthStrategies.com

THE INCOME BARRIER (3) BRAZIL - CELLULAR TELEPHONY AND COMPUTERS USE BY SOCIAL CLASS PERCENT 60 50

CLASS

51 40 40.8

A/B C D/E

30 30.2 20

24.1 17.9

10

11

8.5

2

3.8

0 CELLULAR

MICROCOMPUTER

INTERNET

Source: Ministry of Health, Brazil (1999) eHealthStrategies.com

THE EDUCATIONAL BARRIER PERCENT OF U.S. HOUSEHOLDS WITH COMPUTER BY LEVEL OF EDUCATION (1998) 80 70 60 50

U.S. Rural Urban

40 30 20 10 0

Elementary

Some High School

High School or Equiv

Some Collegue

B.A. or more

U.S.

7.9

15.7

31.2

49.3

68.7

Rural

6.3

17.2

33.2

51.7

69.7

Urban

8.7

15.0

30.3

48.6

68.5

Source: U.S. National Telecommunication and Information Agency, DOC, 1999 eHealthStrategies.com

THE GENERATION GAP BRAZIL - CELLULAR TELEPHONY AND COMPUTERS USE BY AGE GROUP PERCENT 30

AGE GROUP

25 20

14-19 20-35 36-45 46 +

15 10 5 0 CELLULAR

MICROCOMPUTER

INTERNET

Source: Ministry of Health, Brazil (1999) eHealthStrategies.com

SKN

Source: International Telecommunication Union, 2000

* BVI

ANG

HAI

NIC

CUB

HON

GUA

PAR

BOL

PER

GUY

ELS

ECU

DOR

VEN

MEX

BEL

BRA

COL

PAN

SUR

JAM

SVG

ARG

COR

TRT

CHI

DOM

SLU

URU

FGU

GRE

PUR

ARU

NAT

BAH

BAR

MAR

GDL

CAY

*

No Data

eHealthStrategies.com

TUC

MON

10

20

30

40

50

60

70

80

90

PERCENT

ANT

CAN

USA

UVI

BER

0

TELECOM INFRASTRUCTURE

WIRED (FIXED) TELEPHONE LINES X 100 PERSONS (1998)

00 ANG ANG ANT ANT ARG ARG ARU ARU BAH BAH BAR BAR BEL BEL BER BER BOL BOL BRA BRA BVI BVI CAN CAN CAY CAY CHI CHI COL COL COR COR CUB CUB DOM DOM DOR DOR ECU ECU ELS ELS FGUY FGUY GRE GRE GDL GDL GUA GUA GUY GUY HAI HAI HON HON JAM JAM MAR MAR MEX MEX MON MON NAT NAT NIC NIC PAN PAN PAR PAR PER PER PUR PUR SKN SKN SLU SLU SVG SVG SUR SUR TRT TRT TUC TUC USA USA URU URU UVI UVI VEN VEN

COST OF WIRED CONNECTION

ANNUAL RESIDENTIAL SUBSCRIPTION AS PERCENTAGE OF GNP x CAPITA (1997)

PERCENT

20 20

18 18

16 16

14 14

12 12

10 10

88

66

44

22

Source: International Telecommunication Union and PAHO Basic Indicators

eHealthStrategies.com

INTERNET USE - PHYSICIANS IN BRAZIL (1) SAMPLE SIZE: 42,744 PHYSICIANS * 60 50

58 User

40

Non User

%

42

30 20 10 0 Group 1999 SURVEY (In 1996 there were 205,828 physicians)

eHealthStrategies.com

INTERNET USE - PHYSICIANS IN BRAZIL (2) SAMPLE SIZE: 24,603 PHYSICIANS LOCATION FROM WHERE INTERNET IS ACCESSED 90 80 85

70

Home University Office Hospital

60 50

%

40 30 20 10

10

0 Site of Access 1999 SURVEY (In 1996 there were 205,828 physicians) eHealthStrategies.com

USA

Source: International Telecommunication Union, 2000

* CUB

CAY

BVI

BER

ARU

ANT

ANG

NIC

BOL

HON

GUA

PAR

ELS

PER

ECU

GUY

COL

PAN

BRA

COR

JAM

VEN

ARG

MEX

TRT

CHI

BAR

DOM

SVG

URU

BAH

MAR

*

No Data

eHealthStrategies.com

TUC

SUR

PUR

NAT

MON

HAI

DOR

5

10

15

20

25

30

35

40

45

50

PERCENT

GRE

FGU

BEL

SKN

SLU

GDL

UVI

CAN

0

DIGITAL INFRASTRUCTURE (1)

PERSONAL COMPUTERS X 100 PERSONS (1998)

DIGITAL INFRASTRUCTURE (2) INTERNET CONNECTIVITY X 100 PERSONS (1999)

eHealthStrategies.com

TUC

NAT

MON

BVI

*

CAY

ARU

HAI

ANG

ECU

CUB

DOR

HON

GUY

NIC

PAR

BOL

GDL

MAR

ELS

GUA

FGU

SLU

TRT

*

No Data

COL

PER

VEN

SUR

SVG

PAN

Source: International Telecommunication Union, 2000

BAR

JAM

GRE

BRA

ARG

PUR

MEX

DOM

COR

CHI

BAH

BEL

ANT

SKN

UVI

URU

BER

CAN

USA

0.0

0.1

1.0

10.0

100.0

PERCENT (LOG SCALE)

INTERNET USERS IN LATIN AMERICA & CARIBBEAN (2000) IN MILLIONS TOTAL POPULATION CONNECTED 17,135,000

0.300 0.400

0.150

0.520

0.400

BRA MEX

0.600

ARG CHI COL

0.625

PER

9.840 0.900

VEN URU COR OTHER

2.500

Source: NUA Internet Surveys eHealthStrategies.com

INTERNET HOSTS IN SOUTH, CENTRAL AMERICA & CARIBBEAN TOTAL NUMBER OF HOSTS 1,825,760 (APRIL 2001)

1.49%

43.58% Brasil

2.23%

Mexico Argentina

2.95%

Chile Colombia Uruguay

3.18%

Venezuela Other

5.45% 14.69%

26.43%

Source: www.netsizer.com eHealthStrategies.com

INTERNET USE - LANGUAGE NUMBER OF NATIVE SPEAKERS ONLINE (MARCH 2001)

Portuguese 2.5%

Russian 2.3%

Dutch 2.1%

Other 6.2%

Italian 3.1% English 47.5%

French 3.7% Korean 4.4% Spanish 4.5% German 6.1% Japanese 8.6%

Chinese 9.0%

Source: Global Reach, Internet Statistics eHealthStrategies.com

NETWORK ACCESS SPEED Connectivity Speed in Selected Countries of Latin America (Source: Harte-Hanks CI Technology Database, 2001)

Countries

Organizations with Access > 56 Kbps

Mexico

42%

Peru

39%

Chile

37%

Brazil

33%

Argentina

31%

Colombia

31%

Venezuela

27%

Ecuador

22%

Regional Average

35%

eHealthStrategies.com

DEVELOPED COUNTRIES / BROADBAND PENETRATION

eHealthStrategies.com

E-MARKET IN LATIN AMERICA

SHARE OF REGIONAL e-MARKET

PERCENTAGE OF e-COMMERCE SPENDING

Mexico 6% Other 10% Venezuela 5%

Other 6%

Brazil 40%

Colombia 5% Chile 6%

Brazil 88% Argentina 12%

Mexico 22%

Source: www.xplane.com, 2000

eHealthStrategies.com

E-MARKET IN LATIN AMERICA MILLIONS OF US DOLLARS, LOG SCALE

Other Peru Chile Colombia Venezuela Argentina Mexico Brazil 10,000

1,000

100

Brazil

Mexico

Argentina Venezuela

2005

4,256

1,542

1,094

1999

121

25

15

10

1

Colombia

Chile

Peru

Other

348

336

312

164

277

7

7

4

5

8

Source: www.xplane.com, 2000

eHealthStrategies.com

THE FUTURE OF THE TELECOM INFRASTRUCTURE LATIN AMERICAN AND CARIBBEAN TELECOMMUNICATIONS MARKET Millions Mobile Subscribers

70

Main Lines

69

60 50

54

50

40 30 25.3

20 10

7

12.7

0 1995

1997

2000

Source: International Telecommunication Union, Jan 2000 eHealthStrategies.com

THE FUTURE OF THE TELECOM INFRASTRUCTURE TELEPHONY INSTALLATION - BRAZIL Privatization of Telecommunication Markets have Resulted in Expansion of Infrastructure In Brazil, in a Period of Four Years the Telephony Density Increased from 13.6 Fixed and 4.5 Mobile Lines per 100 People to 28.5 and 26.2 Respectively

Millions of Lines 50 45 40

Fixed Lines Mobile

35 30 25 20 15 10 5 0 1998

1999

2000

2001

2003*

Source: ANATEL, 2000 eHealthStrategies.com

BRAZIL - MAGNETIC/BAR CODE/SMART CARD USE

No Card Credit Card Store Card Health Plan Card Bank Card 0

10

20

30

40

50

PERCENT OF POPULATION

Source: Ministry of Health, Brazil (1999) eHealthStrategies.com

E-HEALTH PERSPECTIVES IN LATIN AMERICA AND THE CARIBBEAN

!

DRIVING FORCES AND BARRIERS

!

HEALTH SECTOR CHARACTERISTICS

!

ICT INFRASTRUCTURE AND MARKET

!

IMPLEMENTATION ISSUES

eHealthStrategies.com

EXPERIENCES IN LATIN AMERICA & THE CARIBBEAN

!

MANY UNCOORDINATED PRIVATE AND PUBLIC SECTOR INITIATIVES

!

MAJOR PUBLIC SECTOR PROJECTS (ARGENTINA, BRAZIL, CHILE, COSTA RICA, CUBA, MEXICO, PERU)

!

POORLY ALIGNED TO INSTITUTIONAL GOALS, IMPROVEMENT OF HEALTH AND EXPECTATIONS OF PROVIDERS, CLIENTS, PAYERS, AND REGULATORS

!

SUMMIT OF THE AMERICAS 1996 AND 2000, FLORIANÓPOLIS (2000), BRASÍLIA (2000), RIO GROUP/EUROPEAN UNION (2001)

eHealthStrategies.com

STAKEHOLDERS HAVE DIFFERENT PERSPECTIVES AND MOTIVATIONS

Need Recognition

Constrained by statistical / epidemiology paradigm

Need Recognition 5 4

Vision of Required Applications

Highly aggregated data of mortality, morbidity, and utilization

3

Involvement/Commitment

Vision of Applications Required

2 1

Context of Utilization

Lagging behind all other sectors

Expectations

Uninformed regarding ICT opportunities

Expectations

Involvement and Commitment

Lack of continuity and sustainability Staff not engaged

Context of Utilization

Government Health Authorities

eHealthStrategies.com

STAKEHOLDERS HAVE DIFFERENT PERSPECTIVES AND MOTIVATIONS

Need Recognition

Focus on personal health needs and beliefs

Need Recognition 5 4

Vision of Required Applications

Poor recognition of interactions and limited recognition of managerial applications

3

Involvement/Commitment

2

Vision of Applications Required

1

Context of Utilization

Expectations

Big picture lacking

Excessive expectations

Expectations

Involvement and Commitment

Economic, cultural and educational barriers

Context of Utilization

General Public

eHealthStrategies.com

STAKEHOLDERS HAVE DIFFERENT PERSPECTIVES AND MOTIVATIONS

Need Recognition

Focus on specialized clinical applications or utilization niches

Need Recognition 5 4

Vision of Required Applications

Poor recognition of interactions and limited recognition of managerial applications

3

Involvement/Commitment

Vision of Applications Required

2 1

Context of Utilization

Expectations

Involvement and Commitment

Big picture lacking

Skeptical and uninformed regarding ICT opportunities

Passive and poorly engaged

Expectations

Context of Utilization

Healthcare Professionals

eHealthStrategies.com

STAKEHOLDERS HAVE DIFFERENT PERSPECTIVES AND MOTIVATIONS

Need Recognition

Clear and balanced perspective

Need Recognition 5 4

Vision of Required Applications

Excellent recognition or requirements

3

Involvement/Commitment Context of Utilization

Understand the complexity of needs

Expectations

Most vocal and optimistic

1

Expectations Involvement and Commitment

Vision of Applications Required

2

Context of Utilization

Drivers for adoption

Health ICT Experts

eHealthStrategies.com

STAKEHOLDERS HAVE DIFFERENT PERSPECTIVES AND MOTIVATIONS

Need Recognition

Feel restricted due to lack of broad understandin g of needs

Need Recognition 5

Vision of Required Applications

Commercial interest directs promotion of own products and services

4 3

Involvement/Commitment Context of Utilization

Expectations

Underestimat e complexity of health products

1

Pessimistic regarding progress in next 5-10 years

Expectations

Involvement and Commitment

Vision of Applications Required

2

Do not see health market as providing return on investment

Context of Utilization

Health ICT Suppliers

eHealthStrategies.com

STAKEHOLDERS HAVE DIFFERENT PERSPECTIVES AND MOTIVATIONS

Need Recognition

Vision of Required Applications

Context of Utilization

Expectations

Involvement and Commitment

Fail to distinguish between clerical, administrative , and clinical processes Perceive applications as commodities supporting standardized processes

Need Recognition 5 4 3

Involvement/Commitment

Poor understanding on how health systems operate Optimistic as result of eCommerce and other sectors adoption of ICT

Drivers for adoption

Vision of Applications Required

2 1

Expectations

Context of Utilization

Generic ICT Suppliers

eHealthStrategies.com

IMPLEMENTATION IN LATIN AMERICA & CARIBBEAN (1)

! RELIABILITY OF SERVICE DEPENDENT ON QUALITY OF NETWORK AND INFORMATION TECHNOLOGY INFRASTRUCTURE

! ELECTRONIC TRANSACTIONS REQUIRE SUBSTANTIAL AMOUNT OF DETAILED OPERATIONAL INFORMATION BEFORE AN "E-ARCHITECTURE" CAN BE EFFECTIVELY IMPLEMENTED

! TECHNOLOGICAL BEGINNING-TO-END SOLUTION, LINKING DIFFERENT PLATFORMS, LEGACY AND PROPRIETARY SYSTEMS INVOLVING PROVIDER, INSURER, PAYER, PATIENT AND EMPLOYER DATA

! ORGANIZATIONS AND PROVIDERS WITH COMPUTERIZED INFORMATION SYSTEMS IN PLACE, MUST FIGURE OUT HOW TO LINK INTO THE NEW APPLICATIONS, INCORPORATE ITS LEGACY SYSTEMS, OR START ANEW

eHealthStrategies.com

IMPLEMENTATION IN LATIN AMERICA & CARIBBEAN (2)

! INFRASTRUCTURE AND “PREPAREDNESS”: ANALOG/DIGITAL DIVIDES ARE CONSEQUENCE OF INEQUITIES THAT MUST BE BRIDGED

! INCENTIVE THROUGH REGULATION ! MECHANISMS AND PROCESSES FOR CONSENSUS AND ACTION WITH HIGH-LEVEL POLITICAL SUPPORT

! LEADERSHIP AND CONTINUITY AND SUSTAINABILITY OF INVESTMENT ! BEST PRACTICES, AVOIDANCE OF REDUNDANCIES AND AVOIDANCE OF DOWNSIDE ASPECTS OF POWER CONCENTRATION

! RETURN ON INVESTMENT THAT JUSTIFIES CAPITAL INVESTMENT AND OPERATIONAL COSTS

eHealthStrategies.com

IMPLEMENTATION IN LATIN AMERICA & CARIBBEAN (3)

! GROWING MARKET WITH GREAT POTENTIAL BUT IDENTIFICATION OF OPPORTUNITIES AND MARKET DEVELOPMENT MAY BE A LONG AND DIFFICULT PROCESS

! E-HEALTH DEVELOPMENT NEEDS INTEGRATION OF TECHNOLOGY, GEOGRAPHY, CULTURE, LANGUAGE, AND….HEALTHCARE SYSTEMS

! NO SINGLE “COOKBOOK” OR “TRANSLATED” SOLUTION ! COST-EFFECTIVE AND COUNTRY-DIFFERENTIATED SOLUTIONS ! PROACTIVE ROLE OF THE INTERNATIONAL COMMUNITY G-8 Digital Opportunity Task Force (Okinawa Charter) U.N. Health InterNetwork Initiative World Bank InfoDev U.N. Economic and Social Council (ECOSOC) U.N. ICT Taskforce

eHealthStrategies.com

INFORMATION INFORMATION AND AND COMMUNICATION COMMUNICATION TECHNOLOGIES TECHNOLOGIES HEALTH HEALTH SERVICES SERVICES PLANNING PLANNING AND AND MANAGEMENT MANAGEMENT CLINICAL CLINICAL CARE CARE SYSTEMS SYSTEMS EMERGENCY EMERGENCY AND AND CRITICAL CRITICAL CARE CARE SERVICES SERVICES MEDICAL MEDICAL TECHNOLOGY TECHNOLOGY CLINICAL CLINICAL AND AND ADMINISTRATIVE ADMINISTRATIVE DOCUMENTATION DOCUMENTATION PROJECT PROJECT MANAGEMENT MANAGEMENT RESEARCH RESEARCH DESIGN DESIGN

Web: http://www.ehealthstrategies.com

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