The fractured face of e-health

The potential of e-health has been discussed globally since the 1990s, and has been claimed by some as the most important revolution in healthcare since the advent of modern medicine. But approaches to implementation have differed greatly.

At the ICT and business conference, CeBIT (Asia Pacific's largest), held at the end of May in Sydney, Australia, Finn Klamer from Denmark stood in front of a small, but packed, conference room as an expert in open health services, and other exploitation of the IT possibilities in health care services.

Klamer described his work with Sundhed.dk, the Danish centralised health care data network, to which 98% of primary care medical practitioners, all hospital physicians, and all pharmacists have access. This national e-health portal, launched in 2005, provides a single access point to healthcare services for citizens and health professionals.

While demonstrating how to interact with the portal, he pulled up an example: his wife’s health record.

It appeared with a warning (in Danish): ‘You haven’t entered this patient’s record before, are you sure you want to view their records?’ Klamer chose to proceed, and, with a chuckle, told the audience of how his wife would now be receiving a text message to alert her to the fact that a new practitioner had accessed her records.

The Danish e-health system has long been viewed as the shining example of e-health systems around the world. Using a digital signature, Danes can log on to a personal web space through Sundhed.dkto book appointments with medical practitioners, renew prescriptions, review medication records, and communicate with healthcare authorities. It works in conjunction with MedCom, a cooperative venture between authorities, organizations and private firms, which develops and ensures the quality assurance of electronic communication and information in the healthcare sector.

“Denmark is at the leading edge of eHealth uptake in Europe,” John Dalli,
European Commissioner for Health and Consumer Policy, said at the e-health Week event, held in early May in Copenhagen. “I believe other Member States have much to gain from taking inspiration from the Danish e-health model, rather than re-inventing the wheel.”

In the UK, for example, the National Health Service started gradually implementing electronic medical records in 2004, but its progress has been hampered by lengthy debate over what constitutes e-health, the degree of centralization and who would be responsible for it. And a May 2011 report by the British National Audit Office found that monies spent in Britain on e-health and associated reform did not represent value for money.

The necessary steps to make a working e-health system

The Danish population has several characteristics that make their e-health system work: it is a small country, with a population of about five million people, who are relatively IT-savvy. Trust in the federal government in Denmark is high. And, most of all, the country unknowingly laid the groundwork for electronic health records in 1977, when they put in place centralized record keeping, which doctors had to use in order to be reimbursed for their work.

As e-health innovations start up, this success has not been mirrored in other countries.

“One of the biggest challenges is scalability: while pilot projects have generally been successful, when taken to scale, they resulted in costly and inefficient programs due to the proliferation of discrete and independent systems. Success in the future will depend on achieving much more interoperability and cooperation than is today the case, between all the major stakeholders,” said Hamadoun Touré, secretary-general of the International Telecommunications Union, in the May 2012 Bulletin from the World Health Organization, which focused on e-health.

Another speaker at CeBIT was Gaur Sunder, the principle technology officer at The Centre for Development of Advanced Computing (C-DAC) in India, whose group makes telemedicine software in India.

In June 2012, Sunder’s group will deploy new software in two hospitals in India. The software, which is based on open source software such as Java and MySQL, isn’t designed as an electronic health care record – they decided having one standard for all of India was not a feasible idea - but it’s designed to later integrate with an electronic health care record. “It’s a highly scalable, highly reliable system,” Sunder said.

When deciding how to implement health care records, Sunder said, one decision that had to be made was what to do if someone created an electronic record for someone who already had a record.

“Don’t get stressed about possible duplicates,” Sunder said. “It’s more important to get everyone into the system.”

One of the biggest problems facing India’s e-health, he said, is getting healthcare providers and patients to use it. While the Danish government provided and paid for technical support for healthcare providers as it rolled out its e-health systems, this will not be the case in India.

“The government often has to foot the bill. And, in India, there are two problems: one, the bill would be huge, and two, India doesn’t have much money,” Sunder said. “Technology is easy – it’s just an enabler. The biggest problem is the willingness of medical organizations and the individual.”

What about m-health instead?

The next few years are crucial for e-health initiatives. If they fail to succeed, perhaps the next step in innovation will come from m-health (health services provided via mobile phones). In parts of Africa, where costs and access to infrastructure are prohibitive for e-health, innovative m-health products are already appearing.

In Zambia, healthcare services have been trialing text message services for infant HIV-blood-test results, cutting the time to get the results from 44.2 to 26.7 days. And the new, low-cost smartphone app LifeLens can be used to diagnose malaria, processing a picture taken by mobile phone of a blood sample used to detect parasites.

Mobile penetration globally is about 87%, and in Africa it is close to 50%, and this could make mobile phones potentially a powerful tool for healthcare.