1 Recommendation

Is it time to think about xHealth instead of mHealth, eHealth etc. ?

By Jorn Klungsoyr | 07 Jun, 2013


The past few years the borders between mobile phones, pads, tablets, laptops, convertibles, smart phones, ereaders, desktops +++ has been blurred, and it is now a continuum where devices no longer can be properly categorized.

For a long time mHealth has been a hyped field and viewed as the big solver of almost every problem in the health domain.

Mobile specific solutions have popped up in all kinds of domains, contexts and vertical domains, it is just like the influx of NGO causing chaos.

The focus on mobile has in many cases led to new silos and interoperability, standardization and vendor or hardware lock-in.

I think we are now at a stage where we no longer should view mHealth as a specific domain - it should no longer be about the devices, but that services can work across the continuum of devices - the users should manage to do their work with what is available - not what is supported by some solution for some purpose.

With today's continuum of devices and services, I believe we should talk about xHealth instead of the myriads of specialized fields including mHealth, eHealth, +++.

xHealth can possibly be defined as devices and services for patients and health service providers and implementations of interoperable standards used with the aim of improving health of a given population (globally, nationally etc. or individually).

Hope to have a lively discussion on whether changing focus to e.g. xHealth could help us all focus on the importance on the services and not on the actual devices used to provide support for those services.

What do you think about the idea of xHealth as a merged concept of mHealth and eHealth (plus other variants of _Health) ?

Have a great weekend!



Alvin Marcelo, MD Replied at 6:17 AM, 7 Jun 2013

I have to agree with Jorn. But rather than use 'x' as a placeholder for 'e' or 'm', I would say it represents 'eXchange'.

In the Philippines, the texting capital of the world, there is no dearth of pilots in mHealth and eHealth. But they remain pilots or die a silent death because they could not get into 'mainstream'. That's simply because there is no 'mainstream' to connect to. There is no xHealth or a health information exchange.

If there was a consciousness about xHealth, this would inform the eHealths and mHealths how to connect to the 'mainstream' and work together. The xHealth will define the transactions as contracts and constrain the e- and m-apps to comply and establish meaningful relationships with each other.

+1 then for xHealth (if x is for exchange). Unless prior art is demonstrated, I'll give credit to Jorn...

A/Prof. Terry HANNAN Moderator Replied at 7:33 AM, 7 Jun 2013

Jorn, it is wonderful to read such wise words. I believe your arguments fit the EMR/EHR/etc concepts. They fit us into a 'fixed' mind set (let alone a technological one). So xHealth is even better than eHealth. It MUST include the direct "information management AT the patient care interface and usable across the total xHealth domain. Terry Hannan

Rajib Sengupta Replied at 2:23 AM, 8 Jun 2013

I completely agree with the interoperability issue. But I don't think creating another acronym is going to solve that much. Please also consider that a huge number of health applications exists outside the Patient level eHealth/mHealth solutions, such as Aggregate Health Data, Medical Education, Supply Chain, Infrastructure, Environmental Services, Human Resource for Health etc. Infact, in US they already have the HIE (health information exchange) acronym created for interoperability purpose. I will strongly discourage in creating another acronym unless it can objectively solve the interoperability issue, which I don't see how an acronym is going to solve or bring the focus back.Most of the vendors / organizations working in mHealth, eHealth, EMR, EHR etc tries to make their product interoperable (there are always few who will want to remain siloed). I think we have enough focus in interoperability , but it being not an easy issue to solve, I don't think we will see a silver bullet soon. In this topic, I will actually try to bring in a related but little separate issue - it is regarding the absence of unstructured data, specifically the unstructured communication between Patient, Patient's well-wisher, Patient's relative, and all the different doctors who are working with him/her. This communication shows that the medical professions at the end is not a financial transaction but an human transaction between multiple individuals who are concerned for each other. It is the fundamental of empathy based medical treatment which is lacking in the cut and dry, objective/goal oriented based medical treatment. I am not suggesting it is either or but a good combination is required. And may I dare say that, the current eHealth, mHealth etc solutions somehow pushed this objective based process by emphasizing on structured data . We don't have these in the existing EMRs nor in the standards also. Can we include communications between care-seeker and care-providers in the eHealth and mHealth (and xHealth) solutions, make it part of the interoperability and may be implicitly we will be able to bring some empathy back in the goal oriented medical service.

A/Prof. Terry HANNAN Moderator Replied at 2:52 AM, 8 Jun 2013

Rajib, I am in total agreement re the acronym problem. How many definitions of the EHR do we have? I poorly described my thoughts on how we have to keep thinking at ways to solve the patient care clinical information management problems. We all need to build on what we know HAS worked in the past -our informatics history- and is often overlooked.
See IJMI vol 54 1999-complete issue
The solutions lie in solving the problem you describe, "This communication shows that the medical professions at the end is not a financial transaction but an human transaction between multiple individuals who are concerned for each other". Your statement reminds me of a statement from Warner Slack. "Medicine is not a business. Our business is clinical medicine".
These discussions are stimulating and informative.

Najeeb Al-Shorbaji Replied at 4:47 AM, 8 Jun 2013

This is very interesting discussion and excellent topic to raise. I agree that we should focus on the real and core issue at stake which is healthcare. We should concern ourselves with "health" and leave the discussion about the e or m or tele or the x or digital or the any other prefix one can think of as this distracts the attention. Adding a new prefix to this chaos will not help. The World Health Assembly Resolution of 2005 http://extranet.who.int/iris/bitstream/10665/20378/1/WHA58_28-en.pdf described eHealth as the use of information and communication technology for health. This very simple and inclusive description says it all. The different components, which are purely infrastructure, are required to move health data, information and knowledge as a basis for health care delivery. The World Health Assembly resolution on eHealth of last week http://apps.who.int/gb/ebwha/pdf_files/WHA66/A66_R24-en.pdf made exactly the point for what Rejib says about interoperability. Through these resolutions both the health community and the ICT community have the mandate and responsibility to work together to make ICT for health work for people: reduce cost, improve efficiency and improve equity to access to healthcare. Of course there are ethical, legal, economic, and technical implications in addition to the impact on the medical practice itself. We should not forget that many of the eHealth projects never made it to scale because they were never able to be part of change management in healthcare. They focused on technology, the e or the m or the tele, and did not pay enough attention to health. The e is broader than the m, the m is narrower than the e. A mobile health application requires a data base and a server and a telecommunication infrastructure be it GSM, broadband, WFI or satellite to carry data. Why would a healthcare professional care about this infrastructure? Should care about the patient, the data and what you do with these. With mobile health in particular, it seems to me that we all have been converted to "sales and marketing agents" for mobile companies as many of us forgot that the mobile is only a carrier of data. Remember that data is like water and telecom infrastructure is like pipes. Do you care if the pipe/container is made of steel or other material, whether it is 0.5" or 2": diameter as long as the water is delivered at quality, quantity, cost-effective and timeliness manner to every single individual? One day we will see all health infrastructure managed through "e" which will make it meaningless to add to the ""e or m or anything else" to the "health". Kind regards. Najeeb Al-Shorbaji

Rajib Sengupta Replied at 6:22 AM, 8 Jun 2013

Najeeb, Thanks a lot for the great link. Terry , I will look up that volume.
I hope that I haven't hurt anyone's feeling. The earlier reply was a little haste. But as Terry and Najeeb mentioned, all of us (starting from the physicians to the patient) who have a stake in Healthcare should look at ICT as just an aid (but a very important aid) to solve the Healthcare problems globally which includes interoperability issue - but it is a subproblem of bigger issues.. It needs to be defined in the context of the Healthcare problem that we are trying to solve .. I gave one example above - where bringing empathy in medical treatment is the goal where interoperability problem is different compared to the interoperability issue that we face when we discuss of continuity of care. I am recently faced with a completely different interoperability problem when I am are trying to integrate varied emergency healthcare service providers Facilities (here is the project that I am currently executing in India - http://www.missionarogya.org/p/kmes.html where we want to publish real time update of CCU beds by specialty , blood availability and ambulance availability so that golden hour is reduced) - The interoperability problem is completely different in this context .. Please don't think that I am trying to trivialize ICTs (e or m or whatever it is ) role in Healthcare - I just want to make sure that it is discussed in the right context of the Healthcare problems - I truly believe ICT can help significantly in all the HealthCare challenges.. My experience (several years in US and few years in India) now convinced me that though economically, socially and culturally all the countries are different but the Healthcare problems are very universal - and ICT being an universal tool can be really important in providing help to solve these universal problems ..

Rakesh Biswas MD Replied at 10:32 AM, 8 Jun 2013

Thanks Rajib, Najeeb, Terry and others for this interesting discussion.

My two cents:

Medicine is a collaborative effort in problem solving between individual
patients and
their health professionals. This collaboration also involves others who are
directly or indirectly
related to the patient and health professional (for example, the patient’s
relatives, the practice staff
and the physicians’ institutions etc) who provide the necessary support to
the two primary collaborators. There is an emergent necessity to direct the
development of health information systems such that they serve as important
vehicles between patient and health professional users in communicating and
sharing information other than their role in automated alerts and
responses.As Rajib emphasized, ICT is likely to have a dominant role in
helping maintain 'healthcare informational continuity' of the kind that
allows stakeholders to know about available services (Rajib's KMES project)
as well as to let both health professional and patient users to make an
empathic sense of their entire patient journeys. More here:

Alain Labrique, PhD, MHS, MS Replied at 7:18 PM, 8 Jun 2013


Integrated solutions and current research
Evidence emerging from Bangladesh, Pakistan, and Nepal, suggests that integrated packages of community and facility-based services, across the continuum of care from pre-pregnancy through the postpartum period, can produce significant reductions in stillbirths (16%), neonatal (24%) and perinatal (20%) mortality as well as maternal morbidity (25%). These substantial accomplishments are attributable to both improvements in service delivery as well gains in the effective coverage of interventions of known efficacy (e.g. vaccines, essential newborn care, etc.) These are achieved not by new vertical programs, but through strategies that focus on the quality and coverage of what we know works. It is thisintegrated approach that is now needed in mHealth- not dwelling on the technology as the center of attention, but on the health system constraints being addressed with the technology, as part of system strengthening across the board. mHealth innovations do not, as has often been said, work in a vacuum and the upstream and downstream components of the health system must be bolstered as mHealth solutions are implemented.
What we are learning
In our current research, we are developing formal mHealth systems which leverage lessons learned from families and frontline health workers using mHealth in its ‘natural state’. These mHealth strategies focus on a) improving frontline health worker efficiency through simple work planning and scheduling tools, b) improving system accountability and service equity by identifying and acting on identified lapses in antenatal or postnatal care, and most excitingly, c) to allow families in crisis to notify and receive timely care where and when it is most needed. Among the key lessons we have learned over the course of our research efforts is the importance of engaging the end users from the beginning. Ensuring that the systems we develop mimic the natural workflow of health workers is important, given that many workers have been following these processes for decades in their community service. We strive to be technologically unobtrusive, focusing on the work being done and the human interactions being enabled. Simplicity is important, but often difficult to preserve, resisting the temptation of adding unnecessary digital bells and whistles.
Engaging a broad ecosystem of stakeholders is critical from the outset of mHealth research, given that the adoption and sustainability of these innovations lies in meaningful ownership of the research findings. The value proposition of mHealth investments may not be obvious to all who need to support it for scale-up — robust, rigorous research is necessary to provide evidence to stakeholders and to overcome mSkepticism and policy inertia. Monitoring and evaluation of programmatic mHealth should not be a sideline activity or afterthought, but needs to be a core pillar of how we move this emergent field forward and be taken seriously by the mainstream global health community. Doing this is neither easy nor inexpensive. Measuring gains in efficiency, coverage, quality of care and reach are the low-hanging fruit in constructing the value proposition for mHealth strategies in global heath.
When mHealth becomes just Health
Many lament the slow pace at which formal mHealth innovations are mainstreamed, blaming a dearth of robust evidence and hesitant policy makers. Still, the pace of evidence is accelerating, and a possible future is not difficult to imagine:
Where women and families will have ready access to information; families will be empowered to question, challenge, and even avoid dangerous socio-cultural norms – from harmful birthing practices to introducing foods other than breast milk early in life;
Where health systems will be accountable and able to count events. Where we move away from estimating maternal deaths to counting them as individual lives lost;
Where critical time delays before, during and after childbirth will be compressed, shortening the time to recognize a crisis, respond and receive appropriate care;
Where “social health networks” will be harnessed to expand the community of care and response to need, even in remote, rural and resource-limited settings, and finally;
Where innovations in optimizing demand- and supply-side incentives, linked to real-time performance and accountability, will be focal points of mHealth success.
In the not-too-distant future, one imagines the most effective mHealth solutions being those that are so seamlessly integrated into global maternal and child health programs that they cease to be thought of as “mHealth”, but simply as the “way programs are implemented”. One might say the success of mHealth lies in its disappearance – shifting the question from whether to go ‘mobile’ to which mobile approach to take.

William Philbrick Replied at 7:50 PM, 8 Jun 2013

Bravo, Alain! This is GREAT....it's time to measure the impact of integrated responses vs. siloed approaches.** I did not know about this evidence....but it's wonderful. When I was at CARE we developed and Essential Package for ECD in HIV contexts....basically an integrated holistic approach toward early childhood development in HIV contexts that spanned technical areas. They are attempting to measure the impact of this approach....but I don't think they are using a very rigorous methodology. In the HIV world, we also spoke frequently of the "wrap-around" and multi-sectoral approaches to achieving greater impact on HIV (and improving the well-being of children affected by and infected with HIV. But again....identifying the evidence for these approaches is another story...I think the RCT they are doing in Bihar is (partly) looking at measuring the impact of integrated interventions.

This is why the use of mobile gets me excited....I think it can be a valuable tool to facilitate integrated interventions. A perfect example is using the alrgorithms and checklists to use IMCI.

Anyway....seeing this got me very excited....fantastic posting!

Thank you.

** Ironically, I just got home from the gym where I ran into a friend from the CDC....and we were discussing how the response in global HIV has evolved from a "siloed" approach to an integrated approach. He remarked that the word "silo" is probably a very US centric term, wondering whether people in Africa....or even Europe know what silos are (like we have on farms in Iowa). He noted that when he was getting is MPH, they used the term vertical and horizontal programming. Interesting point.

This is one of the reasons

A/Prof. Terry HANNAN Moderator Replied at 9:18 PM, 8 Jun 2013

Alain, not only have I found your written words very interesting but the SKOLL world forum video is a very good knowledge base. The video (the bit I have watched so far) elicits both a sense of hope and realism. Despite the “seductions” of mobile technologies and their epidemic spread it is the end user “adaptation” and the ultimate “evaluation” of them that matters.
While watching the first part of the video it reminded me of a quote we used in the early days of the eHealth project in Kenya. “We sat in the dirt, physically and metaphorically with the end users for 18 months to meet their needs”. Terry Hannan

A/Prof. Terry HANNAN Moderator Replied at 3:18 AM, 9 Jun 2013

I have been thinking about these discussions over a relaxing weekend and thought what other systems need "interoperability" and maybe health could learn from them. Of course aviation came immediately to mind. Here is an article - satirical humour - from the National Journal on this topic. It compares aviation and health interoperability in the most delightful manner.
Wouldn't it be a big positive for the aviation industry to come and demonstrate its core interoperability's and then have HIT specialities fit that into health care information management of PATIENTS, CLINICIANS, ALLIED HEALTH, RESEARCH, ETC.
Maybe then our ehealth systems would fly.
Terry Hannan

Najeeb Al-Shorbaji Replied at 4:19 AM, 9 Jun 2013

Well said Dr Labrique. The success of e, m, x, is by their disappearance. They go and health stays. The question is how we can make this happen? Kind regards. Najeeb Al-Shorbaji

NGENZI Joseph Lune Replied at 4:52 AM, 9 Jun 2013

When I see how international business is conducted and regulated, complex
aviation system is being done, money transfer business worldwide is being
conducted I wonder when national and international health care services
will look like in terms of patients record interoperability, remote
telemedicine application will done and well regulated using xhealth

As example it is easy to transfer funds from Rural Africa to India via

Ivy de-Souza Replied at 11:39 AM, 9 Jun 2013

l support the interoperability issue but also think that introducing another acronym will to some extent will delay processes. Until now, most people especially in some parts of Africa have not yet explore mhealth, ehealth, etc. applications. Some healthcare practitioners are still struggling to understand the concept and a lot more are reluctant to change. l think if efforts are concentrated on the use of available ehealth applications we would advance in solving most of the healthcare problems in Africa and the world at large.

Ron Ribitzky, M.D. Replied at 1:05 PM, 9 Jun 2013

Very thoughtful and strategic consideration Ivy. Well stated!

These important points you brought up are consistent with my experience and observations in Africa and around the world.

Andrew Kanter, MD MPH Replied at 1:17 PM, 9 Jun 2013

I am pretty sure it was Karl Brown of the Rockefeller Foundation who first coined the term Uhealth on the way to just Health as Alain has mentioned. At a spring meeting of the American Medical Informatics Association, Karl said that the focus on m in mHealth was misplaced, that these tools were part of integrated systems and that we needed to move to uHealth (ubiquitous health) first, and the the U would drop away entirely as it was just assumed that this was the way Health was supposed to be in the first place…

I agree…


Ivy de-Souza Replied at 7:04 PM, 9 Jun 2013

Thank you Prof. Ron. The issues are clear. Observing the trend of this discussion, interoperability seems to be a leading solution. I will like to ask how then can interoperability be intensified or effective. l have observed duplication of ehealth initiatives, concentrated applications at one points especially cities whiles other places mostly the rural communities lacking.
The challenge still remain how efforts could be combined and see to it that available applications are exhausted while encouraging fair distribution(s). l propose we trade ideas on how interoperability can be successful among various health systems and countries and this way, we could be making a head way and perhaps make the ehealth systems fly as Prof Terry said.

Rajib Sengupta Replied at 3:33 AM, 10 Jun 2013

Thanks for all the thoughtful posts. The idea of Terry is terrific. Can we elaborate/discuss a little bit on Terry's idea? It will be great if we can identify the shortcomings of the current interoperability issues and new ways of handling it. As I think through it Terry is absolutely right - Aviation industry is much ore real time and global and still they talk with each other very efficiently. Back in 80's/90's they were very isolated , much more compared to the current Healthcare industry. By 2000 they are fully integrated. How they achieved such integration within 10 years? What do you guys think? Let us look at other industries , such as Banking and Stock Market. Though, I agree Healthcare is not as simple as financial transaction , may be their is some learning in all these other industries. Another example where unstructured data moves around the world is Newspaper industry - Reuters etc send their news/images pretty much in real time . Can we learn from them?

A/Prof. Terry HANNAN Moderator Replied at 3:40 AM, 10 Jun 2013

Rajib, thank you for the compliments. I for one will try and gather some thoughts on this and post them in the next day or so. Terry

Rakesh Biswas MD Replied at 11:17 AM, 10 Jun 2013

Rajib, If we could have a learning ecosystem where IT students intern with
us in our hospitals to understand our day to day health professional
workflow and document and share not just the workflow but the regular
hurdles, we can achieve to a great extent the integration currently seen in
Banking, Airlines etc.

I am keen to float such an elective program in or institute where IT
students can shadow our unit doctors to understand the workflow and develop
a grounded approach to integrating it utilizing the ArogyaUDHC website
http://care.udhc.co.in to transparently document all our day to day
workflow and processing.

As you mentioned earlier it is not just an issue of health systems
interoperability but a complex issue of human interaction (which appears
currently dysfunctional to a large extent). I am sure this approach has
been tried before and continues to be tried but it is possible that fresh
perspectives from different areas of the globe can offer better chances of

Usman Raza Moderator Emeritus Replied at 1:50 PM, 10 Jun 2013

This video was posted on LinkedIn sometime back and talks about the "Open
mHealth" concept which attempts to address the interoperability issue we
are discussing: http://youtu.be/tKuqLyl0Nis

That we are yet far from achieving a satisfactory level of
interoperability, probably means that the health care transaction is much
complex, with too many variables involved in either direction, many of
which we are still getting our heads around. Jorn's idea is thoughtful
indeed. I would suggest looking at it more as a concept than simply a fancy

The eXchange (in x-Health) to me represents the *seamless flow of health
related information* (which would facilitate the actual delivery of care).
Looking at it this way, *interoperability* would be a core requirement for
an efficient health system. Although the quality of *interface* with
consumer and provider would also affect the experience in a very
significant manner.

Neil Pakenham-Walsh Replied at 2:10 AM, 11 Jun 2013

Dear Rakesh and all,

What you are saying is important. Technologists
and IT professionals can be more effective if
they immerse themselves in a progressive
understanding of the everyday needs and
priorities of end-users, and discuss different IT
options with users before starting to develop new
IT solutions, programs and apps. I have a sense
that many IT professionals are indeed already
doing this: they are moving gradually from being
primarily technology-driven to being primarily needs-driven.

In order to help expedite this transition, IT
professionals need to spend at least as much time
- on an everyday basis - communicating with
end-users (citizens, health professionals,
researchers, policymakers...) as they do
communicating with fellow IT professionals. For
those IT professionals who are seeking better to
understand healthcare information and learning
needs of citizens and health professionals in
low- and middle-income countries, I would like to invite you to join HIFA2015.

HIFA2015 (Healthcare Information For All by 2015)
is a global social movement and email discussion
forum working for a future where people are no
longer dying for lack of basic healthcare
knowledge. We are 6000-plus professionals from
more than 2000 organisations in 167 countries,
working to explore how to improve the
availability of healthcare knowledge in low- and
middle-income countries. We are supported by more
than 170 leading health and development
organisations. We also run groups in French and
Portuguese, in collaboration with WHO.

For further information, and to join, please go to: www.hifa2015.org

With thanks,

Dr Neil Pakenham-Walsh MB,BS, DCH, DRCOG
Coordinator, HIFA2015 and CHILD2015
Co-director, Global Healthcare Information Network
Corner House (John Kibble Room)
Charlbury, Oxfordshire OX7 3PN, UK
Tel: +44 (0)1608 811899
Email: <mailto:>
HIFA2015: http://www.hifa2015.org
Skype: neilpw1
Follow us on Twitter: twitter.com/hifa2015

Join HIFA2015, CHILD2015, HIFA-Portuguese,
HIFA-EVIPNet-French, HIFA-Zambia: www.hifa2015.org

"Healthcare Information For All by 2015: By 2015,
every person worldwide will have access to an informed healthcare provider"

With thanks to our 2013 Financial Supporting
Organisations: British Medical Association (main
funder), Anadach Group, BioMed Central, Council
of International Neonatal Nurses, Global HELP,
Health Sciences Online, NextGenU.org, CABI,
Chartered Society of Physiotherapy, Global Health
Media Project, Global HELP, Haiti Nursing
Foundation, Instituto de Cooperación Social
INTEGRARE, International Child Health Group
(Royal College of Paediatrics and Child Health),
International Confederation of Midwives, Joanna
Briggs Institute, Network for Information and
Digital Access, Partnerships in Health
Information, Public Library of Science, Royal
College of Nursing, UnitedHealth Chronic Disease Initiative.

At 16:20 10/06/2013, you wrote:

NGENZI Joseph Lune Replied at 2:36 AM, 11 Jun 2013

In the article with the title about Successful developing a telemedicine
system ( Peter M Yellowlees, 2005) highlight 10 reasons why physicians fail
to accept new information system :

1. Too much change (‘change toxicity’)

2. Failure to begin with an adequate physician base of support

3. Lack of a user-friendly interface

4. Concern regarding the information collected

5. Failure to collect the most important information

6. Physician technophobia

7. Excluding physician involvement from the financial analysis

8. Failure to include marketing to physicians in the implementation plan

9. Inadequate training of physicians to use the system

10. Lack of strong, centralized information systems leadership respected by

11. Lack of control by the organization over physician practices

Anyway there is a reason why Healthcare system is not as much as advanced
as far the use of information communication technology in their daily

Thank you

A/Prof. Terry HANNAN Moderator Replied at 6:23 AM, 11 Jun 2013

Joseph, Peter's paper is a good standard to read. Yet it was written > 8 years ago so why have we not progressed? It worries me that many discussions reamin circular with little progress. Here is data from the Regenstrief system in 2012 after ~ 30 years.
Technology is NOT the problem. Regenstrief Institute: April 2012:
18 hospitals
>32 million physician orders entered by CPOE
Data base of 6 million patients
900 million on-line coded results
20 million reports-diagnostic studies, procedure results, operative notes and discharge summaries
65 million radiology images
CLINICAL DECISION SUPPORT- BLINK TIMES-iterative interrogation of the comprhensive datadase.
Also another good references are 2000-To Err Is Human Building a Safer Health System. INSTITUTE OF MEDICINE.
2005 -Leape, L.L. and D.M. Berwick, Five years after To Err Is Human: what have we learned? JAMA.
2011- Health Information Technology Institute Of Medicine, Health IT and Patient Safety Building Safer Systems for Better Care, The National Academies Press: Washington D.C.
2011-Jha, A.K. and D.C. Classen, Getting moving on patient safety--harnessing electronic data for safer care. N Engl J Med.

Om G Replied at 7:52 PM, 11 Jun 2013

I feel that any situation remaining inefficient in the face of obvious opportunities to realize gains, must be in conflict with some aspect of human nature.
Systemically, health care benefits the individual practitioner (shaman, MD, or facility) who inspires confidence over competing solutions (home remedy, collective opinion, doing nothing).
Practitioners have no problem discussing a case in the abstract, yet feel reluctant to hand over 'their' patient or expose 'their' decisions to scrutiny.
Aviation enjoys interoperability as a result of a worldwide culture inherent to the practice. Yet functional details are guarded jealously. An airfoil or hydraulic fitting could be of benefit to all, but private advances are the bread and butter of manufacturers.
Profit motive reinforces separation, fear of being evaluated cements it. Standards based treatment with profit motive tends to punish the more thorough providers and ultimately people suffer.
Patient first makes sense, but medical practitioners ought to be taking a more active role in designing the systems and criteria as well as shaping expectations.

"A/Prof. Terry HANNAN via GHDonline" <> wrote:

A/Prof. Terry HANNAN Moderator Replied at 4:04 AM, 12 Jun 2013

I am stepping out on a limb here with strong promppting by Rajib Sengupta. It is an attempt to be "collaborative" - linking IT with clinicians and whomever elese wants to join in. The attached document is a possible"call to arms" over interoperability and a desire to see it work for the betterment of patients. Rajibhas read the atatched document in advance as I did not want to think I was writing dribble. Terry

Attached resource:

Rajib Sengupta Replied at 4:23 PM, 12 Jun 2013

We have some great exchanges going around. So a big thanks to John to start this topic. Few important points that have emerged are completely in line with my thought process.
First and foremost, we need to realize that Healthcare problems are multitude in nature and each of them require different type of solutions in which ICT is surely one of the most important tool, but it needs to be build in context. We should concentrate on solving the Healthcare problems and ICT should be treated as an aiding tool to solve that Healthcare problem. As rightly mentioned by Neil, when I ( a technology entrepreneur) started to delve into LMIC Healthcare ICT solutions, I realized that, building these systems in my US office is not going anywhere - I need to be with the end users (Physician, CHWs, Quacks and finally with the people) in these countries (currently, I am in West Bengal, India where I have enough connections to experience this life changing event). And this decision turned out to be a great decision- in-line with what is mentioned by Rakesh and Neil.
Now coming back to the “Interoperability” part - it has a bigger context to me which requires multi-domain integration with a seamless workflow providing the best Healthcare possible to all (uHealth concept as mentioned by Andy and Karl Brown of RF) - Obviously information interoperability is a key part of it. While building any ICT solution to help a specific Healthcare problem this information interoperability needs to be considered. But as mentioned above, it all depends on the Healthcare problem that we are trying to solve. I think, one of the biggest issues with interoperability is we try to come up with that silver bullet. Taking example from other industry, such as finance and supply chain (my earlier life, before healthcare), which is pretty complex like Healthcare, these industries didn’t tried to address interoperability with a single bullet – it has different interoperability solution for different problems. I guess in any industry (including Aviation), that is the case. Let us take one of the primary Healthcare problem Continuity of Care (PHR record) which is probably the most researched interoperability issue in Healthcare (and several of the posts above are concentrated on that area) - do we have any simplistic solution for this? It seems HL7 and myriad of codings are really not the most simplest solution, as I have asked multiple EMR/eHealth/mHealth vendors who deals with individual records why they don't have this right-out-of-the-box and most of them told me, it is so difficult to implement (obviously not in a public forum but over dinner while chit-chatting). Can we learn from other industries, such as the document provided by Terry?

Beatriz de Faria Leao Replied at 5:20 PM, 12 Jun 2013

Wonderful discussion! Fully agree with Alan. We have similar results in Brazil using this integrated approach - with focus in the patient and primary care.
Interoperability is the key issue but there is no silver bullet. Semantic interoperability demands models to represent health information and terminologies. At ISO TC 215 ( 100 standards published - http://www.iso.org/iso/home/store/catalogue_tc/catalogue_tc_browse.htm?commid...) and the difficult part is which standard to select for each specific use case. IHE (www.ihe.net) is doing an excellent job on that. By defining the scenarios and interactions and the implementation guides ANY programmer can write the code. We are having this experience now in Brasil in two different states using the IHE Lab Profile to integrate Lab requests and results to the integrated primary care system running in two cities São Paulo (2.3 million lab exams /month) and Belo Horizonte ( 200 thousand exams a month). However, to accomplish the desired seamless interoperability one has to consider an ehealth architecture behind the scenes to orchestrate all the pieces and events. I invite you to read the ISO TC 215 Health informatics -- Capacity-based eHealth architecture roadmap -- Part 1: Overview of national eHealth initiatives (http://www.iso.org/iso/home/search.htm?qt=14639&sort=rel&type=simple&publishe...). This is a two part document. Part 1 presents national eHealth initiatives from Australia, Brasil, Canada, Kenya and India. Base on these experiences it became clear the need to consider and propose an eHealth architecture model that takes into consideration a maturity model. Part 2 - Health informatics — Capacity-based eHealth architecture roadmap — Part 2: Architectural components and maturity model, describes the business requirements of the different components of this architecture according to maturity levels low, medium and high.
At the last plenary meeting of ISO TC 215 last April in Mexico, a resolution was passed asking ISO TC 215 to make these two documents freely available - "based on the rationale that these reports are potentially important resources for countries, especially Low and Middle Income Countries (LMIC), in the implementation of their national eHealth policies. The content will guide readers to increased use of ISO/TC 215 standards. "

We have not yet heard back from ISO Secretariat. We expect this can raise the discussion on how to increase the access and adoption of standards to support countries in their national eHealth initiatives.
Again, great discussion!!

Beatriz de Faria Leao
ISO TC 215 WG1 Framework, Architecture and Models Vice-Convener

BEATRICE MURAGURI Replied at 3:06 AM, 13 Jun 2013

Dear All,

When analyzing a Health Information System critically, which areas can I mainly focus on?Am I to compare what the guidelines e.g. HIS policy and Strategic plan says with what is happening?I request the group to help me understand this issue which am struggling with.

A/Prof. Terry HANNAN Moderator Replied at 3:23 AM, 13 Jun 2013

Beatrice, maybe you could think about it like this.
We need to understand what we are doing-information management and knowledge access in a timely and complete manner AT THE PATIENT CARE INTERFACE.
The "systems" to do this must have Standardisation, Interoperability, Scalability (to handle thousands and millions of patients and observations) AND MOST IMPORTANTLY involve "Clinicians" (that includes patients as clinicians-read Larry Weed) who are the most important users and creators of the data.
The rest of the functionalities of health care we measure e.g. resource utilisation, quality, costs and outcomes, are BYPRODUCTS OF THIS CARE PROCESS.
By definition any effective system requires INCREMENTAL IMPLEMENTATION because WE CHANGE PEOPLE with these technologies.
This is why Open Source systems are relevant as they allow the end user to have systems that can be designed to facilitate data capture that supports clinical decision making.
By having the "data" we can measure what we do.
I hope this makes sense.

Alvin Marcelo, MD Replied at 7:11 PM, 13 Jun 2013

Dear Beatriz,

Thank you for this. Would it be possible to get a draft copy of the ISO/TR

Beatriz de Faria Leao Replied at 9:32 AM, 14 Jun 2013

Hi Alvin,
As you know, once the standard is published the only way to get it is through the ISO website. http://www.iso.org/iso/iso_technical_committee?commid=54960 on this link.
However, you could have access to all ISO documents through the NMB (national member body) that is part of ISO TC 215. http://www.iso.org/iso/home/store/catalogue_tc/catalogue_detail.htm?csnumber=...

The NMB and its links are here:

There are "P" members (Participating) that have the obligation to vote in every ballot and "O" (observers) members that do not have the obligation to vote.

For Philippines the link is:

Bureau of Product Standards
Department of Trade and Industry
3rd Floor Trade and Industry Building
361 Sen. Gil J. Puyat Avenue
PH-Metro Manila 1200

Tel: +63 2 751 31 26
Fax: +63 2 751 47 35
Web: www.bps.dti.gov.ph

I also want to take this opportunity to invite all interested in standards to be part of the IMIA Standards WG. We will have a meeting of this group during MEDINFO in Copenhagen on August 22-26 (http://www.medinfo2013.dk). I'd like to have as many members as possible in this group so that we could through IMIA endorse ISO TC 215 pledge to open up a list of ISO standards to promote its adoption specially in LMIC.

If possible I'd like to know who would be willing to participate in the IMIA Standards WG.

Pamela Marks Replied at 11:04 AM, 14 Jun 2013

I'm currently taking an mHealth course through mhealth Alliance and Tech Change and the focus is more on how technology can affect health outcomes. I think as a result of pilotitis the focus is now on using mhealth intervetions that can be developed at scaled, appropriate for the context, and sustainable.

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