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A HIMSS em 2003 constitui uma comissão para elaborar um quadro de definições básicas para o conceito de e-Health e de todos os vetores que o compôem. Abaixo temos um resumo dele, mas que expôe com clareza acadêmica o conceito e a amplitude das TICs na Saúde.

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HIMSS - Healthcare Information and Management Systems Society

E-Health SIG White Paper - E-Health Defined

 

Executive Summary

E-health is defined as the application of Internet and other related technologies in the healthcare industry to improve the access, efficiency, effectiveness, and quality of clinical and business processes utilized by healthcare organizations, practitioners, patients, and consumers in an effort to improve the health status of patients. [23] 

 
E-Health includes many dimensions:

- Delivery of key information to healthcare partners

- Provision of health information delivery services

- Facilitation of interaction between providers and patients

- Facilitation of the integration of healthcare industry-related business processes

- Both local and remote access to healthcare information

- Support for employers and employees, payers and providers

 

Within this framework, the overarching goal is to improve the health status of patients.

Introduction

Many people today are using Internet technologies to communicate with others to gather information, research and/or purchase goods and services. One of the most important areas where these activities are occurring is related to healthcare. According to an April 2002Harris Poll, of the 137 million Americans who surf the Internet, more than 60 percent use the resource for health advice. In addition 90% of adults would like to be able to communicate with their physicians on line. Between 1998 and 2002, the number of adults who have looked for health information has climbed from 54 million to 110 million. [15]

The attempt to define E-Health in this format is two fold. First, we wish to demonstrate that E-Health is a realistic and viable concept and advise the healthcare industry at large that E-Health has arrived and will continue to evolve driven by technology and the need of consumers (patients) for health care information and services. Despite the rapid flare-up and demise of the dot.com industry at the end of the 20th century, E-Health is not a flash in the pan. It will not and should not go away. The continuous development of new and innovative techniques and the consumers’ (patients’) increased desire for access to healthcare information and services will drive this market. Second, we hope to engage both healthcare and technology leaders to continue to challenge and grow the definition of E-Health with the progress of new technologies and increased patient demand.

Background

The explosive growth of the world wide Internet over the last 10 years has exceeded the expectations and imagination of technology industry. [20] The expansion of computer and telecommunications technology across all economic sectors was fueled by the ease of communication, transactions and information gathering through this new medium [20]. Consumers were intrigued by the ability to gather information from a variety of sources and to make purchases quickly using a variety of shopping tools. Entry into this new world to establish a web site could be achieved by acquiring a domain name and a webpage, at a nominal cost. From chat groups to individual web pages, the sharing of health information also grew rapidly, and often without quality controls. [29] 

During this same period, investment in the technical infrastructure for healthcare was increased to meet the new challenges of managed care and financial pressures. Clinicians who had used computers in their academic training demanded the same ease of access to on-line reference materials. As new tools, such as radiology Picture Archive Communications Systems (PACS), laboratory and electronic medical record systems were introduced, physicians expected to have current information available at their fingertips wherever they were – at home, in the office, at the hospital. 

During the 1980’s electronic commerce, facilitated through electronic data interchange (EDI), had been adopted by the manufacturing and retail industries to improve the timeliness of deliveries and reduce overall cost. Some governmental organizations, such as the Healthcare Finance Administration (HCFA), which became the Center for Medicare and Medicaid Services (CMS), and state and local Departments of Health (DOH) required rapid reporting of events or validation of eligibility using fax or electronic dial-up. With the expansion of the Internet in the 1990’s, e-commerce started to attract more interest in the healthcare arena. [29]

Another area of this technology boom was the expansion of wireless technology, which facilitated the immediate access to anyone or the Internet from anywhere. The explosive growth of cell phones, personal digital assistants (PDA’s) and other wireless tools from the mid-1990’s to the present fueled the need for immediate information. Consumers were becoming increasingly technology literate. 

The competing demands for instant access to information and transactions as well as the increased availability of technical equipment supported rapid growth of the information delivered through various web services. Companies such as WebMD, A.D.A.M., Micromedix and others arrived to fill the demand for immediate healthcare information. The federal government assisted by providing funds to the National Library of Medicine to obtain MedlinePlus, KidsHealth and other similar websites.

Some Boundaries

The use of technology to assist in the delivery of quality patient care covers a vast area from biomechanical devices to robotics to the electronic medical record to email. Sometimes, the term “E-health” has been used very loosely to include any electronic healthcare-related activity. To provide better focus, it may be helpful to establish some boundaries around the definition: 

1.      E-health is not a surrogate for the clinician. It does provide the means to extend the reach of the provider beyond a face-to-face patient encounter, with the advantage of expanding the delivery of limited resources and expertise. For instance, using electronic images and pictures, diagnoses may be made from a remote location, either within or outside the facility. 

2.      E-health provides delivery of useful medical information via the Internet, kiosks or other electronic means that may facilitate patient education and provider decision-making. 

3.      E-health facilitates collaboration between providers and other caregivers through file sharing, email and electronic medical record systems. 

4.      E-health does not replace existing infrastructure applications. Instead, it facilitates those processes to expedite delivery and improve the quality of the services provided both locally and remotely. It operates within the walls of the health facility and across geographic boundaries. 

5.      E-health is not another name for e-commerce in the healthcare industry. However, the facilitation of business processes among employers, employees, insurers, suppliers, clinicians, patients, administrators and regulators may include examples of E-health. 

6.      E-health is not the routing hardware or the networking software, but it uses those to deliver the information needed to achieve the primary goal.

7.      E-health uses these means, as well as other telecommunications services, to deliver the information and processes necessary for the ultimate outcome of patient care: improved health status. E-Health Systems Architecture

The infrastructure that supports e-health includes several dimensions [4]

1.      Internet: universal access to information and sites with or without predefined security authorizations; 2.      Extranet: secure, remote connections between predefined participants. This might have included the e-commerce arena; 

3.      Intranet: support for a communications infrastructure within the enterprise, which may deliver access to internal and core data systems to all participants in the healthcare delivery process; 

4.      Core Data Systems: function-based systems that support the key processes of the enterprise. These may be financial, clinical or administrative systems at any of the partners in the e-health arena. Included in this group are systems such as the computerized patient record (CPR), PACS, admission and appointment systems, financial patient accounting systems as well as the internal infrastructure systems. 

5.      E-Mail: exchange of information between two or more partners using some combination of the internet/extranet/intranet. This may be considered to be an application using the architecture. However, it has become an essential reason for adoption of the e-health framework by caregivers and patients. 

6.      Telecommunications: the physical and technical layer that enables the connections and interchange of information through various media: wireless, fiber, cable, satellite, and other new and emerging means. Voice and email are interchangeable on some of the new devices. Recording, storing and transmitting this information falls within the boundaries of E-Health. 

7.      Hardware: computers, pagers, personal digital assistants (PDA’s), PC tablets telephones, servers and other hardware provide the physical support for this infrastructure. 

 
The relatively seamless interaction of these layers permits the exchange of information and transactions that provides the environment for E-health. The rapid development of new technologies is also reflected in the adoption of many tools, often significantly less expensive than the prior generation.

 

E-Health Constituency

The community served by E-Health is broad and varied. It includes clinical providers at all levels and locations: single physician offices, large practices, hospitals and universities. Nurses are another important provider set in this view, as are allied health personnel who provide care and treatment in a variety of settings, both clinical and remote. Support personnel, including administrators and ancillary services may also participate in this environment. Insurers and employers are active members of the E-Health activities, as are employees who need to verify their coverage or reimbursement status. Patients of all ages, nationalities and geography are also part of the E-Health constituency. Technologists for various arenas are also participants: clinical engineering, information technology and telecommunications as well as medical students and researchers.

In 2002, there were several studies [19] done to examine who is the constituency for E-Health. The users were primarily women performing health information searches. The top four disease conditions researched were cancer, obesity, hypertension and diabetes. About 70% of the study respondents indicated that on-line health information influenced treatment decisions. The Gartner Group reported that personal health records will depend on patient-entered information. [14] 

The easy availability of information and communication between patient and provider, patient and payer, provider and referred provider, clinician to clinician and so forth, provide an environment conducive to improved communications, smoother workflow and, perhaps, better quality patient care leading to better outcomes.

 

Internal Relationships

One emerging use of the E-Health technologies is in the growth and expansion of the local intranet facilities. While this communication vehicle may be used internally to the facility, this technology provides the “baby-steps” needed to build the strong dependence and comfort with the basic browser tools. 

The use of an intranet portal can place a portfolio of end-user functions within a simple, familiar browser wrapping such as Microsoft Internet Explorer. Finding the “killer app,” or the reason sine qua non for the intranet, may be as simple as establishing effective tools such as telephone directory, shuttle bus schedules and daily news items. These elements attract the regular, repeated user because they are part of the everyday routine. The convenience helps to ease the user to try other functions, such as clinical applications, order entry and chart review. With the convenience of analytical tools, subsequent use of information for reporting or analysis becomes simpler as well.

Because of the browser familiarity, Intranet access might be simpler than other applications for the casual or non-technical employee. Delivered through a personal computer or a touch-screen kiosk, a well-designed end-user interface might lead the employee to seek out additional information, build skills or provide patient care in a more informed manner. 
 

Conclusion and a Call to Action

E-Health is emerging as a complex effort to deliver complex and coordinated health care services in a simple manner. To continue the early successes of this endeavor, all the constituencies involved must invest and participate to make this technology framework grow with the demand.

The participation includes the following elements:

1. Continue research to document findings to share experiences and information. Successes are good – but learning from the “less than successes” is also an integral part of this process.

2. Continue to debate on the evolution of the definition and scope of E-Health. Does it include treatment? Is it only an information tool?

3. Continue to pilot new technologies and programs; to assisting to promote solutions for the development of the EHR and Patient Safety improvements

4. Continue to integrate these new internet technologies in the daily workflows

5. Continue to expand the training and familiarity with the E-Health services for patients and providers so that new information and techniques become small, frequent, natural incremental steps rather than investing in a “Big Boom” approach.

6. Use E-Health to improve the delivery of healthcare to those who might be more difficult to reach: the homebound, the migrants, the uninsured and underinsured.

7. Recognize that no single entity will own this technology explosion. However, all who agree to work using consistent standards, common formats and language, will be successful in these new endeavors.

8. Identify ways to charge for the services provided through E-Health, either in overall cost reductions or other mechanisms, such as charging for research and training in information access and usage. However, charges should not be a barrier to receiving care. 

In any case, the definition will not restrict the growth of E-Health as driven by the patients, the providers and the payers. The confidence of the patients will be supported by the willingness of providers to move in this direction.

Publish, Interact, Transact, Integrate and Transform – these are the steps that will reinforce the movement towards a more robust and expansive E-Health model. 
 
The E-Health Portals should make healthcare and information more accessible with the end goal of improving patient care and the health status of all. “The use of technology to ultimately improve patient outcomes is not going away.” [1]

 

References:

[0] American Telemedicine Association, "A Guide to E-Health for the Healthcare

Professional: An Introduction", http://www.atmeda.org/E-Health/guide.htm,
2001

[1] Kathryn Bingman, “E-Health Solutions Series,” Cerner 2001.

[2] Boston Consulting Group, “Vital Signs: E-Health in the United States”, January 2003, http://www.bcg.com/publications/files/Vital_Signs_Rpt_Jan03.pdf

[3] California Health Care Foundation, iHealth and Technology Program.
http://www.chcf.org/programs/ihealth/

[4] Joseph M.DeLuca & Rebecca Enmark, “E-Health: The Changing Model of Healthcare,” Frontiers of Health Services Management, Vol. 17, No. 1, Fall 2000, pp. 3-15.

[5] T.R. Eng, “The E-Health Landscape: A Terrain Map of Emerging Information and Communication Technologies in Health and Health Care,” The Robert Wood Johnson Foundation, Princeton, N.J., 2001. http://www.rwjf.org/publications/publicationsPdfs/E-Health.pdf

[6] Federal Trade Commission [on-line]. Retrieved February 7, 2002 from Microsoft Internet Explorer on the World Wide Web. http://www.ftc.gov/fdac/features/2000/

[7] Food and Drug Administration, “Cipro (Ciprofloxacin Hydrochloride) for Inhalation Anthrax,” http://www.fda.gov/cder/drug/infopage/cipro/, retrieved March 3, 2003.

[8] Laura Gatland, “The Online Pharmacy Phenomenon”, Focus on Health, my.webmd.com/content/Article/11/1691_50039.htm, WebMD, 1999.

[9] D.C. Gee, Attorney at Law (2000) [on-line]. Important information for e-health companies. Retrieved October 16, 2001 from Microsoft Internet Explorer on the World Wide Web. Available: http://www.skpgo.com/

[10] John P. Glaser, “Management Response to the E-Health Revolution,” Frontiers of Health Services Management, Vol. 17, No. 1, Fall 2000, pp. 45-48.

[11] John Glaser and Jerry Sheehan, “Enhancing the Internet for Health Applications,” HIMSS Target Issues: E-Health, HIMSS, Chicago, IL, 2001, pp 1-12.

[12] Albert L. Greene, “ E-Health: Realizing the Vision,” Frontiers of Health Services Management, Vol. 17, No. 1, Fall 2000, pp. 33-37. This article concentrates on the 4 “c’s” necessary for e-health: content, commerce, connectivity and care.

[13] Mary Griskewicz, “HIMSS SIG develops proposed e-health definition,” HIMSS News, July 2002 Vol 13 No. 7, p. 12. Page 21 of 23 E-Health Defined 5/5/2003

[14] Thomas Handler and others, “Healthcare Provider Predictions: IT Advances for 2003,” COM-18-8198, December 11 2002, Gartner Research, Stamford, CT.

[15] Harris Interactive, 2002; Boston Consulting Group, 2001; Manhattan Research, 2002.

[16] Health on the Net Foundation (HON), www.hon.ch/HONcode/policy.html
HIMSS, “Section II: National Preparedness & Response (NPR)” and “Section IV:National Health Information Infrastructure (NHII),” HIMSS Advocacy Dispatch, Jan 31, 2003. www.himss.org.

[17] Healthcare Insurance Portability and Accountability Act (HIPAA), http://www.hhs.gov/ocr/hipaa/

[18] J. G. Hodge, Jr., L.O. Gostin, and P.D. Jacobson (1999). Legal issues concerning electronic health information: Privacy, quality, and liability. JAMA 282(15), pg.1466-1473.

[19] James Holincheck, “HCM and B2E Technology: Key Issues”, Research Note: K-19-1068, Gartner Research, Jan 17, 2003.

[20] Julie E. Kendall and Kenneth E. Kendall, “ Web Pull and Push Technologies: The Emergence and Future of Information Delivery Systems,” pp. 265-287, from Kenneth E. Kendall, editor, Emerging Information Technologies: Improving Decisions, Cooperation and Infrastructure, Sage Publications, CA, 1999.

[21] Leapfrog Group, “Patient Safety: A Time for Leaps,” www.leapfroggroup.org/safety.htm

[22] Marlene Maheu, Ph. D. , “TelE-Health: DELIVERING BEHAVORIAL TELE-HEALTH VIA THE INTERNET E-HEALTH,” Feb 1, 2000, http://telE-Health.net/articles/deliver.html

[23] Jennifer Marconi, “E-Health: Navigating the Internet for Health Information Healthcare”, Advocacy White Paper. Healthcare Information and Management Systems Society, May, 2002.

[24] Missouri Department of Health & Senior Services, “2002 Consumer’s Guide to Hospital Surgery Volume,” Mar 26, 2002. http://www.health.state.mo.us/Publications/vpgwelcome.html

[25] National Library of Medicine, www.nih.nlm.gov

[26] Pew Internet and American Life Project, “Counting on the Internet: Most expect to find key information online, most find the information they seek, many now turn to the Internet first.” http://www.pewinternet.org/reports/toc.asp?Report=80

[27] Pew Internet and American Life Project, “Vital Decisions: How Internet users decide what information to trust when they or their loved ones are sick,” May 22, 2002, http://www.pewinternet.org/reports/toc.asp?Report=59 Page 22 of 23 E-Health Defined 5/5/2003 Page 23 of 23 E-Health Defined 5/5/2003

[29] Vladimir Zwass, “Structure and Macro-Level Impacts of Electronic Commerce: From Technological Infrastructure to Electronic Marketplaces,”, pp. 289-315, from Kenneth E. Kendall, editor, Emerging Information Technologies: Improving Decisions, Cooperation and Infrastructure, Sage Publications, CA, 1999. 

 





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