1. PERSPECTIVES IN E-HEALTH Roberto J. Rodrigues Regional Advisor for Health Services Information Technology Division of Health Systems and Services Development Pan American Health Organization / World Health Organization Washington, D.C. Workshop on Global Telehealth/Telemedicine and the Internet 2001 Symposium on Applications and the Internet (SAINT 2001) San Diego, January 8-12, 2001

2. DEVELOPMENT ISSUES IN E-HEALTH 4 INFRASTRUCTURE AND MARKET 4 HEALTH SECTOR ASPECTS 4 LATIN AMERICA & CARIBBEAN METRICS 4 IMPLEMENTATION 4 DEFINITION, DRIVING FORCES, AND BARRIERS

3. DEVELOPMENT ISSUES IN E-HEALTH 4 INFRASTRUCTURE AND MARKET 4 HEALTH SECTOR ASPECTS 4 LATIN AMERICA & CARIBBEAN METRICS 4 IMPLEMENTATION 4 DEFINITION, DRIVING FORCES, AND BARRIERS

4. APPLICATION OF INFORMATION AND TELECOMMUNICATIONS TECHNOLOGIES TO HEALTH AND HEALTHCARE u TELEMEDICINE PATIENT CARE APPLICATIONS u TELEHEALTH TELEMEDICINE, DISTANT EDUCATION AND TRAINING, HEALTH PROMOTION, PUBLIC HEALTH, SERVICES MANAGEMENT, TECHNICAL INFORMATION RETRIEVAL u CYBERMEDICINE INTERSECTION OF INFORMATICS WITH BIOENGINEERING, IMPLANTABLE DEVICES, PROCESS AUTOMATION, BIOSENSORS, DEVELOPMENTAL ROBOTICS, NANOTECHNOLOGY u E-HEALTH INTERNET-BASED HEALTH APPLICATIONS, INCLUDING PURELY ADMINISTRATIVE (B2B, E-COMMERCE, ETC) INTERACTIVE HEALTH COMMUNICATIONS

5. l POINT OF CARE TECHNOLOGIES l PROCESS AUTOMATION l ELECTRONIC MEDICAL RECORD (CPMR) l DATA WAREHOUSING l DATA ACCESS AND SECURITY TECHNOLOGIES l APPLICATION INTEGRATION l DECISION-SUPPORT TECHNOLOGIES EVOLUTIONARY TECHNOLOGIES

6. REVOLUTIONARY TECHNOLOGIES l ELECTRONIC COMMERCE l PUSH TECHNOLOGIES l RESOURCE ADQUISITION TECHNOLOGIES (Auction Technologies) l ON DEMAND REMOTELY-BASED APPLICATIONS (ASP) l MOBILE AND WIRELESS TECHNOLOGIES l INTELLIGENT AGENTS l INTERACTIVE TECHNOLOGIES (Voice, Writing Recognition) l ALWAYS-ON CONNECTIVITY WITH COMMUNITIES l KNOWLEDGE MANAGEMENT (Retrospective >>> Simultaneous)

7. DRIVING FORCES (1) l QUEST FOR QUALITY AND COST MANAGEMENT l RISING DEMAND FOR ADVANCED MEDICAL TECHNOLOGY l SHORT PRODUCT LIFE CYCLES / OBSOLESCENCE l DISSATISFACTION WITH HEALTH SYSTEM (CHOICE, ACCESS, QUALITY) l DISREGARD FOR CUSTOMER SERVICE l CONVENIENCE MORE IMPORTANT THAN PRICE

8. DRIVING FORCES (2) l CAPTURING LONG-TERM SERVICE RELANTIONSHIPS l INEFFICIENCY OF ADMINISTRATIVE PROCESSES (ELIGIBILITY,CLAIMS, REIMBURSEMENT, PROCUREMENT AND SUPPLY MANAGEMENT) l INCREASED DEMAND FOR DATA AND INFORMATION (DISTRIBUTED MULTIDISCIPLINARY PRACTICE, IMPROVED DOCUMENTATION) l LOGISTICS OF HEALTHCARE (DYNAMIC SCHEDULING, DATA COMMUNICATION) l ACCESS TO BIOMEDICAL KNOWLEDGE (REFERENCE, PROTOCOLS OF CARE, REGISTRIES, KNOWLEDGE BASES, EVIDEDENCE-BASED PRACTICE, CONSUMER PARTICIPATION)

9. DRIVING FORCES (3) l 26% U.S. HEALTHCARE SPENDING ARE ON ADMINISTRATIVE TASKS (HCFA) l PHYSICIANS/PAYERS BOTTLENECK 13% COST (12.7 BILLION IN 1999) l E-HEALTH B2B GROWTH (6 BILLION IN 1999 ….. 348 BILLION IN 2004) l ONLINE PROCUREMENT WILL REACH 27.3 BILLION BY 2004 l CONNECTIVITY OF THE PUBLIC TO THE INTERNET l MOBILE TECHNOLOGIES AND PORTABLE DATA MEDIA (SMART CARDS)

10. HEALTH SECTOR REQUIREMENTS SPECIFICATION l LOW DEFINITION LEVEL OF CONTENTS (DELIVERABLES) OF HEALTH INTERVENTIONS INDETERMINATION OF OBJECTIVES AND FUNCTIONALITIES l CONFLICTS IN DEFINING MINIMUM DATA SETS FOR OPERATIONAL MANAGEMENT AND CLINICAL DECSISION-MAKING l HEALTHCARE ORGANIZATIONS AND PROVIDERS TEND TO SEE THEIR OWN DATA AS THE ONLY GOOD AND VALID DATA l DISTRUST OF HEALTH PROFESSIONALS IN OFF-SITE DATA STORAGE AND ACCESS CONTROL HEALTH SECTOR BARRIERS (1)

11. ORGANIZATIONAL AND POLICY-RELATED l INFRASTRUCTURE, INVESTMENT SUSTAINABILITY AND DEPLOYMENT CAPABILITY l HEALTHCARE ORGANIZATIONS FEEL PROPRIETARY ABOUT THEIR INFORMATION -- HEALTH PLANS DO NOT LIKE TO LET PROVIDERS INTO THEIR INFORMATION CYCLE AND VICE VERSA l COMPLEXITY AND VARIETY OF OBJECTIVES, FUNCTIONS, AND TECHNICAL CONTENTS OF APPLICATIONS l NATIONAL POLICIES AND STRATEGIES FOR THE STANDARDIZATION AND COST-EFFECTIVE USE OF TECHNOLOGY AND INFORMATION l CONSISTENCY AND CONTINUITY OF POLITICAL SUPPORT HEALTH SECTOR BARRIERS (2)

12. INFORMATION TECHNOLOGY INFRASTRUCTURE l TECHNICAL RESOURCES AND WEB DEMOGRAPHICS l DATA AND COMMUNICATION STANDARDS l INCREMENTAL DEVELOPMENT X BIG BANG l TECHNOLOGICAL INNOVATION X ACTUAL USE GAP l OPEN x PROPRIETARY ARCHITECTURE l COST-BENEFIT TECHNOLOGY BARRIERS (1)

13. INFORMATION TECHNOLOGY DEPLOYMENT (1) l SECURITY, PRIVACY AND CONFIDENTIALITY l ALIGNMENT TO INSTITUTIONAL GOALS, IMPROVEMENT OF HEALTH AND EXPECTATIONS OF PROVIDERS, CLIENTS, PAYERS AND REGULATORS l INTEGRATION IN THE WORK ENVIRONMENT l PROJECT MANAGEMENT l ACCESS TO RELIABLE APPLICATIONS PRODUCTS AND SERVICES (INTEGRATION, CUSTOMER SUPPORT, SECURITY, AND TRAINING) TECHNOLOGY BARRIERS (2)

14. INFORMATION TECHNOLOGY DEPLOYMENT (2) l LACK OF INVOLVEMENT OF LINE MANAGERS l DISCONTINUITY OF INSTITUTIONAL STRATEGIES / POLICIES l LOW QUALITY OF PRIMARY DATA l OVERRIDING OF DEPARTMENTAL BORDERS AND AUTHORITIES l EDUCATION AND TRAINING OF HEALTH PROFESSIONALS l VENDOR DEPENDENCY TECHNOLOGY BARRIERS (3)

15. DEVELOPMENT ISSUES IN E-HEALTH 4 INFRASTRUCTURE AND MARKET 4 HEALTH SECTOR ASPECTS 4 LATIN AMERICA & CARIBBEAN METRICS 4 IMPLEMENTATION 4 DEFINITION, DRIVING FORCES, AND BARRIERS

16. INDIVIDUALS RECEIVING CARE INDIVIDUALS WITH HEALTH PROBLEM INDIVIDUALS EXAMINED POPULATION CONTINUOUS RECORDING OF CARE MONITOR CONTROL PREVENTIVE CARE HEALTH STATUS EPIDEMIOLOGY HEALTH PROMOTION HEALTH INFORMATION DOMAINS

17. MONTHLY PREVALENCE OF ILLNESS (ADULTS 16 YEARS AND OVER) 1,000 750 250 9 5 1 ADULT POPULATION AT RISK ADULTS REPORTING ILLNESSES OR INJURIES PER MONTH ADULTS CONSULTING PHYSICIAN PER MONTH ADULTS ADMITTED TO HOSPITAL PER MONTH ADULTS REFERRED TO SPECIALIZED MEDICAL CENTER PER MONTH ADULTS REFERRED TO ANOTHER PHYSICIAN PER MONTH WHITE KL, WILLIAMS TF, GREENBERG BG. NEJM 265:885-892, 1961

18. PERSPECTIVES OF PATIENT-BASED INFORMATION POPULATION - REFERENCE - HEALTH STATUS - SERVICE UTILIZATION AND PRODUCTION - RESEARCH

19. PERSPECTIVES OF PATIENT-BASED INFORMATION GROUPS - BY CLINICAL ATTRIBUTES CLINICAL FINDINGS REFERENCE GROUP COMPARISONS IDENTIFY ASSOCIATED ATTRIBUTES - BY INTERVENTION CHARACTERISTICS MANAGEMENT AND REPORTING PROCESS CONTROL POPULATION - REFERENCE - HEALTH STATUS - SERVICE UTILIZATION AND PRODUCTION - RESEARCH

20. PERSPECTIVES OF PATIENT-BASED INFORMATION INDIVIDUAL - SEQUENCIAL - CHRONOLOGICAL - PROBLEM-ORIENTED - PERMANENCY - HISTORICAL RECOVERY - COMMUNICATION - RECENT EVENT RECOVERY DETAIL DIFFERENT VISIONS OF DATA DIFFERENT OUTPUTS INTENSIVE DATA MANIPULATION GROUPS - BY CLINICAL ATTRIBUTES CLINICAL FINDINGS REFERENCE GROUP COMPARISONS IDENTIFY ASSOCIATED ATTRIBUTES - BY INTERVENTION CHARACTERISTICS MANAGEMENT AND REPORTING PROCESS CONTROL POPULATION - REFERENCE - HEALTH STATUS - SERVICE UTILIZATION AND PRODUCTION - RESEARCH

21. CLINICAL PRACTICE COLLECTIVE HEALTH BIOMEDICAL KNOWLEDGE THERAPY DIAG PROG PREVEN INFORMATION IN THE HEALTHCARE OF INDIVIDUALS

22. CLINICAL PRACTICE COLLECTIVE HEALTH BIOMEDICAL KNOWLEDGE PROG DIAG PREVENTHERAPY INFORMATION IN THE HEALTHCARE OF INDIVIDUALS

23. TYPOLOGY OF REQUIRED INFORMATION AND ORGANIZATIONAL LEVEL

24. DEVELOPMENT ISSUES IN E-HEALTH 4 INFRASTRUCTURE AND MARKET 4 HEALTH SECTOR ASPECTS 4 LATIN AMERICA & CARIBBEAN METRICS 4 IMPLEMENTATION 4 DEFINITION, DRIVING FORCES, AND BARRIERS

25. DISTRIBUTION OF GROSS DOMESTIC PRODUCT BY SECTOR, 1995 Source: World Bank, World Development Report 1997 Percentage of GDP Sector

26. HEALTH CONTRIBUTION TO THE SERVICES SECTOR Source: World Bank, World Development Report 1997 % HEALTH SERVICES AS PERCENTAGE OF THE SERVICE SECTOR

27. JAPAN (11%) USA (36%) EUROPE (30%) OTHER (23%) Value: 1,363 billion US dollars WORLD MARKET FOR INFORMATION AND COMMUNICATIONS TECHNOLOGIES (1998) WORLD MARKET FOR INFORMATION AND COMMUNICATIONS TECHNOLOGIES (1998)

28. 0 100 200 300 400 500 600 700 800 900 1000 90919293949596979899000102 Service revenue (US$ bn ) ActualProjected Domestic Telephone / Fax Int'l Mobile Other: Data, Internet, Leased lines, telex, etc Source: ITU World Telecommunication Development Report 1999: Mobile cellular Projection of Revenue Growth (US$ bn)

29. BY 2005 THERE WILL BE MORE THAN 1 BILLION WIRELESS PHONE SUBSCRIBERS OF THOSE, 87 PERCENT WILL BE USING INTERNET DATA SERVICES GLOBAL WIRELESS INTERNET ACCESS GROWTH

30. Developing: 6 % of hosts 84 % population Developed: 94 % of hosts 16 % population Source: ITU 1999 Challenges to the Network: Internet for Development Other 5.9% Canada & US 65.3% Europe 22.4% LAC 1.9% Australia, Japan & New Zealand 6.4% 3.7 % Developing Asia-Pacific Africa 0.3 % Global Distribution of IP Hosts

31. E-HEALTH BUSINESS IMPERATIVE l GLOBAL MARKET PLACE AND INTERACTIVE COMMUNICATIONS l LEASING, MEMBERSHIP, SERVICE AGREEMENT, STRATEGIC ALLIANCES REPLACE OWNERSHIP OF PHYSICAL ASSETS AND LONG-TERM ORGANIZATIONAL STRUCTURES l NETWORKS OF PRODUCERS, SUPPLIERS, AND CUSTOMERS l LIFE-TIME VALUE OF CUSTOMER REPLACES ONE TIME SELL l ECONOMIES OF SPEED REPLACE ECONOMIES OF SCALE l CUSTOMIZATION OF PRODUCTS AND SERVICES l MAXIMIZE CONVENIENCE AND JUST-IN-TIME PROCESSES l PRIVACY AND SECURE TRANSACTION PROCESSING l SEAMLESS APPLICATIONS

32. CLIENT Intermediaries - Distributors - Marketing Channels - Value-Added Resellers Suppliers - Insurance (Pub/Priv) - Medical Supply Indust - Pharmaceutical Indust - Knowledge Distribution Producers - Government - Health Professionals - Healthcare-providing Organizations TRADITIONAL MODEL

33. CLIENT Producers - Government - Health Professionals - Healthcare-providing Organizations FIRST ORDER NETWORKING Customer Networks - Manufacturers - Distributors - Marketing Channels - Value-Added Resellers Supplier Networks - Managed Care Orgs - Insurance (Pub/Priv) - Medical Supply Indust - Pharmaceutical Indust - Knowledge Distribution

34. CLIENT Customer Networks - Manufacturers - Distributors - Marketing Channels - Value-Added Resellers Producer Networks - Government - Health Professionals - Healthcare-providing Organizations SECOND ORDER NETWORKING Supplier Networks - Managed Care Orgs - Insurance (Pub/Priv) - Medical Supply Indust - Pharmaceutical Indust - Knowledge Distribution

35. CLIENT Customer Networks - Manufacturers - Distributors - Marketing Channels - Value-Added Resellers Producer Networks - Government - Health Professionals - Healthcare-providing Organizations Standards Coalition Networks - Technical Standards Develop / Promotion Technology Cooperation Networks - Sharing Expertise - Knowledge Dissemination Supplier Networks - Managed Care Orgs - Insurance (Pub/Priv) - Medical Supply Indust - Pharmaceutical Indust - Knowledge Distribution THIRD ORDER NETWORKING

36. FOURTH ORDER NETWORKING CLIENT Customer Networks - Self-help Groups - Special Interest Customer Networks - Manufacturers - Distributors - Marketing Channels - Value-Added Resellers Supplier Networks - Insurance (Pub/Priv) - Managed Care Orgs - Medical Supply Indust - Pharmaceutical Indust - Knowledge Distribution Producer Networks - Government - Health Professionals - Healthcare-providing Organizations Standards Coalition Networks - Technical Standards Develop / Promotion Technology Cooperation Networks - Sharing Expertise - Knowledge Dissemination

37. 1a. Internal Data Sources Creating an integrated apps environment involves collecting and normalizing data from multiple sources and database structures 1a. Internal Data Sources Creating an integrated apps environment involves collecting and normalizing data from multiple sources and database structures 1b. External Data Sources By using Web channels, information from outside the organization can merge with internal data 1b. External Data Sources By using Web channels, information from outside the organization can merge with internal data 2. EAI Technologies Numerous technologies smooth technical differences among applications and allow connection of existing systems to the integrated framework 2. EAI Technologies Numerous technologies smooth technical differences among applications and allow connection of existing systems to the integrated framework 3. Consolidated Data More realistic perspective of organizational activities 3. Consolidated Data More realistic perspective of organizational activities 4. Business Rules More effective when applied to a comprehensive set of information 4. Business Rules More effective when applied to a comprehensive set of information 5. Integrated Apps Handle organizational processes more efficiently and with better control 5. Integrated Apps Handle organizational processes more efficiently and with better control 6. Decisions Application integration helps to achieve better informed decisions 6. Decisions Application integration helps to achieve better informed decisions Databases Legacy Systems / Data EIS, ERP, CRM Partners Suppliers Customers Messaging MW CORBA COM JAVA XML EIS - Enterprise Information System ERP - Executive Reporting Program CRM - Customer Relationship Management EAI - Enterprise Application Integration COM - Component Object Model ENTERPRISE APPLICATION INTEGRATION

38. PROS u Improve organizational efficiency u Expand business vision to include outside partners / suppliers u Embrace real-time or near real-time data from all operational aspects u Offers higher-level management of business rules CONS u Clear definition of workflow and control rules u Involvement of external organizations (partners / suppliers) u Complex and expensive to implement u Difficult to find IT professionals with expertise u Rapidly evolving market

39. DATA WAREHOUSING

40. THE CONNECTED EMPOWERED CONSUMER 4 WELLNESS AND MEDICAL INFORMATION 4 SHOPPING FOR PROVIDERS AND SERVICES 4 RISK ASSESSMENT TESTING 4 BUYING PRESCRIPTION AND OVER-THE-COUNTER DRUGS 4 BUYING HEALTH PRODUCTS 4 COMMUNICATION WITH SPECIAL INTEREST GROUPS 4 E-MAIL PROVIDERS AND PAYERS

41. INFO ACCESS COMMUNITY PERSONALIZATION E-COMMERCE FULL SERVICES DIRECT CONSUMER BYPASS STOCK TRADING HEALTH SELF-CARE FUND TRANSFER PHYSICIAN ADVERTISING PHARMACEUTICALS / DEVICES E-AUCTION CUSTOMIZED NEWS HEALTH RISK APPRAISAL HMO PERSONALIZED REPORTS CHAT GROUPS ONLINE INVESTMENT CLUBS HEALTH SPECIAL INTEREST GROUPS HEALTH PROMOTION NEWS KNOWLEDGE REPOSITORIES INTERACTIVITY CONSUMER CAPABILITY / VALUE

42. DEVELOPMENT ISSUES IN E-HEALTH 4 INFRASTRUCTURE AND MARKET 4 HEALTH SECTOR ASPECTS 4 LATIN AMERICA & CARIBBEAN METRICS 4 IMPLEMENTATION 4 DEFINITION, DRIVING FORCES, AND BARRIERS

43. HEALTH INFORMATION INFRASTRUCTURE (BUSINESS RULES, ROUTINES, STANDARDS) INTERFACE EQUIPMENT / EDI / SECURITY TELECOMMUNICATION INFRASTRUCTURE SUPPLIER / PRACTITIONER / ORGANIZATIONS PATIENT/ EMPLOYER / PAYER / RESEARCHER ELECTRONIC CLEARINGHOUSES / BROKERS TRANSACTION & SERVICE PROVIDERS POLICY / REGULATORY / LEGAL NATIONAL / INTERNATIONAL MARKETS E-HEALTH COMPONENTS

44. INFLUENCE ON HEALTH-RELATED LIFESTYLE CHOICES U.S. Survey by Gómez Advisors, Inc., 2000 % SOURCES USED BY THE PUBLIC FOR PERSONAL HEALTH DECISIONS

45. SOURCES OF INFORMATION ABOUT NEW HEALTH WEB SITES U.S. Survey by Gómez Advisors, Inc., 2000 HOW THE PUBLIC LEARNS ABOUT HEALTH INFORMATION IN THE WEB %

46. U.S. PHYSICIANS USE OF COMPUTERS PERCENT Source: Pricewaterhouse Coopers Modern Physicician 2000

47. SHARED STANDARDS GOALS l Single industry-wide information model adaptable to each implementation environment - generic health information framework (modules, functions) - standard terminology and classifications (data definition) - standard health record structure (contents) - standard management/patient-oriented transactions - minimum data sets - user defined tables and queries - common data exchange protocols l Hardware/Software Platform Independence - health data networks (Internet/Intranets)

48. HEALTH DATA STANDARDS l ACCREDITATION BY INTERNATIONAL SDOs l DESCRIPTION OF STANDARD l READINESS OF STANDARD l INDICATOR OF MARKET ACCEPTANCE l LEVEL OF SPECIFICITY l RELANTIONSHIPS WITH OTHER STANDARDS l COSTS

49. l International Organization for Standardization (ISO) l Comité Europeen de Normalisation (CEN) l UN Electronic Data Interchange (EDIFACT) l Data Interchange Standards Association (DISA) l Health Level Seven (HL-7) version 3 l Digital Imaging and Communication in Medicine (DICOM) l American Society for Testing and Materials (ASTM) l American National Standards Institute (ANSI) l Institute of Electrical and Electronic Engineers (IEEE) l Agency for Healthcare Policy and Research (USDHHS) l Health Care Financing Organization (USDHHS) l Computer-based Patient Record Institute (CPRI) l Joint Commission on Accreditation of Healthcare Organizations l World Health Organization l American Medical Association l College of American Pathologists l Food and Drug Administration (FDA) l National Library of Medicine (NLM / NIH) l National Council for Prescription Drug Programs (NCPDP) LEADING HEALTH DATA STANDARDS ORGANIZATIONS

50. 4 IDENTIFIER (PATIENT, PROVIDER, SITE-OF-CARE, PRODUCT) 4 MESSAGE FORMAT (COMMUNICATIONS) 4 CONTENT AND STRUCTURE OF HEALTH RECORDS 4 CLINICAL DATA REPRESENTATION (CODES) 4 CONFIDENTIALITY, DATA SECURITY, AND AUTHENTICATION 4 COMMON MINIMUM AND EXTENDED DATA SETS 4 QUALITY HEALTH RECORD DATA STANDARDS

51. DATA INTEGRITY, SECURITY, AND PRIVACY 4 RELIABILITY Data is accurate and remains accurate 4 SECURITY Owner/users can control data transmission and storage 4 PRIVACY Subject of data can control its use and dissemination

52. 4 PHYSICAL PROTECTION Protection against intentional of accidental damage 4 INTEGRITY Prevention of unauthorized modification of information 4 ACCESS Prevention of unauthorized entry into information resources 4 CONFIDENTIALITY Protection against unauthorized disclosure of information DATA INTEGRITY, SECURITY, AND PRIVACY

53. 4 Reliability and privacy require security, but implementation of data security may impair privacy 4 Patients may be unable to consent 4 Clinically anonymous information is useless 4 Differently than in national security and defense environment where it is better to lose information than to loose it, in the health sector it is preferable to expose information than to loose it 4 In healthcare responsibility is distributed among different stakeholders 4 Security is a multidimensional problem that must be solved for each specific situation, not as a generic technical add-on DATA INTEGRITY, SECURITY, AND PRIVACY

54. SECURITY AND PRIVACY ISSUES u Highly sensitive personal and identified data u Interdisciplinary activities and multiprofessional access u Remote access to medical records u Access by clerical staff (payers, controllers, insurers) u Unobtrusive in the healthcare environment u Balance of need for access and integrity / privacy issues u Individual rights versus collective needs of public health u Great concern regarding the physical protection of records and intrusion, unauthorized use, data corruption, intentional or unintentional damage, theft, and fraud

55. l HIGH SECURITY RISK OF HEALTHCARE ORGANIZATIONS l DISTRIBUTED RECORDS AND AUTHORITY l TIMELY ACCESS IS ESSENTIAL l DATA IN USE MUST BE DECRYPTED l DATA IN TRANSIT MUST ME ENCRYPTED l MOST SECURITY VIOLATIONS ARE UNINTENTIONAL l OPERATORS ERROR IS FREQUENT REASON l MOST DAMAGING VIOLATIONS ARE INTERNAL l EXTERNAL ATTACKS ARE ON THE INCREASE IMPLEMENTING A SECURITY AND PRIVACY PROGRAM

56. Source: META Group, 2000 MAINTENANCE STAFF X SW PORTFOLIO SIZE 28 countries / 30 sectors / 16,000 sources

57. Source: META Group, 2000 SYSTEMS MAINTENANCE CONSULTING COST

58. Source: META Group, 2000

59. SOFTWARE MAINTENANCE IN KLOC X PROFESSIONAL 73 KLOC 100 KLOC 28 countries / 30 sectors / 16,000 sources

60. Source: META Group, 2000 EXTERNAL CONSULTANTS EXPENDITURE (1999) in US$ millions 28 countries / 30 sectors / 16,000 sources

61. Source: META Group, 2000 IT MARKET BASKET COST (1999) * U.S. = 1.00 28 countries / 30 sectors / 16,000 sources

62. DEVELOPMENT ISSUES IN E-HEALTH 4 INFRASTRUCTURE AND MARKET 4 HEALTH SECTOR ASPECTS 4 LATIN AMERICA & CARIBBEAN METRICS 4 IMPLEMENTATION 4 DEFINITION, DRIVING FORCES, AND BARRIERS

63. IT DEVELOPMENT AND IMPLEMENTATION INFORMATION SYSTEMS IN HEALTH CARE MANAGEMENT AND ORGANIZATIONAL ISSUES TECHNOLOGY BASE IMPLEMENTATION ENVIRONMENT

64. l 80% URBANIZATION / LARGE URBAN AREAS l INADEQUATE INFRASTRUCTURE AND DISTRIBUTION l WESTERN EUROPEAN BIOMEDICAL / SOCIAL SECURITY MODELS l VARIETY OF REIMBURSEMENT MODELS l HEALTH SECTOR REFORM HEALTH SECTOR IN LATIN AMERICA & THE CARIBBEAN

65. E-MARKET IN LATIN AMERICA

66. l >95 per cent of global IP capacity passes through the U.S. l 96 out of top 100 websites are in the U.S. l Developing countries wanting to hook up to the U.S. backbone must pay both half-circuits of the leased line l Smaller ISPs must pay bigger ones for transit l Accelerating returns to scale u High volume routes have lowest unit costs u Large hubs get larger u Resources go to the strongest NEW TECHNOLOGY NETWORKS AND FOR DEVELOPING COUNTRIES

67. IMPLEMENTATION IN LATIN AMERICA & CARIBBEAN u E-HEALTH DEVELOPMENT INTEGRATES TECHNOLOGY, GEOGRAPHY, CULTURE, LANGUAGE, AND….HEALTHCARE SYSTEMS u NO SINGLE COOKBOOK OR TRANSLATEDSOLUTION u MOST USERS PREFER A CAREFULLY CRAFTED PARTNERSHIP TO A PURE VENDOR-CLIENT RELATIONSHIP u LEASING / OUTSOURCING u LEADERSHIP u GROWING MARKET WITH GREAT POTENTIAL BUT IDENTIFICATION OF OPPORTUNITIES AND MARKET DEVELOPMENT MAY BE A LONG AND DIFFICULT PROCESS

68. www.paho.orgwww.paho.org Pan American Health Organization Organización Panamericana de la Salud Organização Panamericana da Saúde Pan American Health Organization Organización Panamericana de la Salud Organização Panamericana da Saúde http://165.158.1.110/english/hsp/hsphsi.htm

69. PAHO/WHO HEALTH SERVICES IT DEVELOPMENT INDICATORS INITIATIVE Regional Advisor for Health Services Information Technology Division of Health Systems and Services Development Pan American Health Organization / World Health Organization Washington, D.C.

70. INFORMATION TECHNOLOGY METRICS l STANDARDIZED INFORMATION (CONSISTENCY, COMPARABILITY) l SYSTEM / APPLICATION ENVIRONMENT RANKING l MONITOR CHANGES l FOLLOW TRENDS l QUANTITATIVE AND QUALITATIVE INDICATORS NOT EVERYTHING THAT CAN BE COUNTED COUNTS, AND NOT EVERYTHING THAT COUNTS CAN BE COUNTED ALBERT EINSTEIN

71. LIMITATIONS OF INFORMATION TECHNOLOGY METRICS l LACK OF STANDARDIZED DEFINITIONS FOR IT COMPONENTS l DATA ON IT RARELY COLLECTED ON A SYSTEMATIC BASIS l ABSENCE OF COST DATA l INFORMATRION ON HOW IT IS BEING ACTUALLY USED l EVALUATION OF POSITIVE AND NEGATIVE IMPACTS l RAPIDLY CHANGING TECHNOLOGY HEALTH INFORMATION TECHNOLOGY DEVELOPMENT INDICATORS

72. u INFRASTRUCTURE general population aptitudes; physical IT and telecom infrastructure; market openness; information distribution capability u EXTENT OF IT INSERTION IN SOCIETY penetration computers; labor force and revenues in the computer and telecommunications sectors u UTILIZATION OF IT BY THE HEALTH SECTOR penetration of information systems in the private and public sectors; implementation of regulatory aspects u IMPACT state-of-the-art, appropriateness; technical effectiveness; effect on policy, structures organization, equity and privacy

73. PERCENTAGE OF ADULT ILLITERACY (1998) Source: PAHO Basic Indicators PERCENT AVERAGE

74. AVERAGE YEARS OF EDUCATION FOR AGE 25+ (1999) Source: World Bank Health Report YEARS

75. MAIN (FIXED) TELEPHONE LINES X 100 INHABITANTS (1999) Source: International Telecommunication Union and PAHO Basic Indicators NUMBER

76. WAITING TIME FOR NEW WIRED CONNECTION IN YEARS (1998) Source: International Telecommunication Union YEARS

77. ANNUAL RESIDENTIAL SUBSCRIPTION AS PERCENTAGE OF GNP x CAPITA (1997) Source: International Telecommunication Union and PAHO Basic Indicators PERCENT COST OF WIRED CONNECTION

78. WIRELESS TELEPHONE SUBSCRIBERS x 100 INHABITANTS (1999) Source: International Telecommunication Union and PAHO Basic Indicators NUMBER

79. Millions LATIN AMERICAN AND CARIBBEAN TELECOMMUNICATIONS MARKET 7 50 12.7 54 69 25.3 Source: International Telecommunication Union, Jan 2000

80. PERSONAL COMPUTERS x 100 INHABITANTS (1998) NUMBER Source: International Telecommunication Union and PAHO Basic Indicators

81. PERCENTAGE OF POPULATION CONNECTED TO THE INTERNET (1999) PERCENT (LOG) Source: International Telecommunication Union and PAHO Basic Indicators

82. INTERNET HOSTS x 1,000 INHABITANTS (JAN 2000) NUMBER (LOG) Source: International Telecommunication Union and PAHO Basic Indicators

83. INTERNET SERVICE PROVIDERS (JAN 2000) Source: International Telecommunication Union NUMBER (LOG)

84. INFORMATION TECHNOLOGY GROWTH, 1985-1995 & 1995-2000 Source: International Data Corporation, 1996 PERCENT

85. INTERNET USE - PHYSICIANS IN BRAZIL 42,744 PHYSICIANS 1999 SURVEY 5858 4242 %

86. INTERNET USE - PHYSICIANS IN BRAZIL 24,603 PHYSICIANS SITE FROM WHERE INTERNET IS ACCESSED 1999 SURVEY % 85 10