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Published by Mark Hawker
Introduction to e-health and its effects on consumer health informatics and professional clinical informatics. Future projections are discussed along with some conclusions on the current state of the field.
Introduction to e-health and its effects on consumer health informatics and professional clinical informatics. Future projections are discussed along with some conclusions on the current state of the field.

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Published by: Mark Hawker on Oct 30, 2008
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The growing digital economy has seeninnovative technologies such as digitalmarketplaces, mobile communication, next-generation games consoles and socialnetworking becoming more ubiquitous in oureveryday lives. The “mashing up” of dataacross the World Wide Web through webservices has given consumers greater controlover all kinds of information. Advancementsin commercial applications such as
Wii Fit 
an exercise and fitness video gamedeveloped by Nintendo and released in mid-2008 in the UK – are only the tip of theiceberg when it comes to achieving fullypervasive healthcare where the aim is to“make healthcare available to anyone,anytime, and anywhere by removing location,time and other restraints”. Developments inmobile computing such as the Apple
using haptic (touch) technologies, electronictagging through Radio-FrequencyIdentification (RFID), miniaturisation of laptops such as the ASUS
Eee PC 
, andmobile broadband are making informationmore accessible than ever before. A GrandChallenge is to achieve the level of interoperability championed in thecommercial sector within healthcare deliveryin a way that is convenient to both consumersand providers. The role of e-health is tointegrate the complex networks of peopleand technologies ideally utilisingstandardised guidelines and practices toempower the delivery, governance andmanagement of innovative information-sharing products and services amongsthealthcare consumers and providers.The coupling of public sector services and theUK Government have slowed many “big-bang” adoptions achieved in the commercialsector due to issues including increasedaccountability and bureaucracy. However, the“joining up” of public services as part of 
Transformational Government 
policies –aimed at designing and delivering publicservices around the needs of citizens – andnew integration opportunities createdthrough the Electronic Patient Record (EPR)and Summary Care Record (SCR) are sure toprovoke interesting technologicalinnovations. For example,
Google Health
isexperimenting with sharing personal healthinformation, such as medical records andprescription histories, to authorised web sites– something which is strived for by the NHSincarnation of 
. Lord Darzi’s(2007; 2008) NHS
Next Stage Reviews
, whichwere commissioned by the Prime Minister,Chancellor of the Exchequer, and Secretary of State for Health, put e-health into context. Todeliver the vision of a fair, personalised,effective and safe NHS the focus must be to:give patients and the public better quality of service by treating them with dignity asindividuals; increasing the transparency of services through single points of access tohealthcare information; and, giving themmore ‘clout’ through better choice andpersonal control of their care; look beyondincreasing the capacity of the NHS byimproving the effectiveness, efficiency andquality of care through locally-led, patient-centred and clinically-driven change.In this bulletin we will investigate two areas of healthcare innovations, consumer healthinformatics and professional clinicalinformatics, discussing some of theapplications being developed. We will thenlook at future directions and draw someconclusions on where we feel healthcaredelivery will be supported by informationtechnologies in the future.
White Rose HIP Health Technology Bulletins
The White Rose HealthInnovation Partnership(WRHIP) aims to acceleratenew health-relatedtechnologies by facilitatinginteractions betweenacademia, industry and theNHS using an
approach.The new projects fundedas part of this initiative arebuilt upon a foundation of excellence in healthinnovation by thePartnership’s members.This series of HealthTechnology Bulletins offeran introduction to thisresearch excellence andcover a broad range of clinical and technologyareas.Each bulletin is written togive a general introductionto the topic area alongwith short case studies of clinical applications of newknowledge. Information isalso presented on whereto learn more about thesenew technologies andhealth challenges, andhow to access the networkof health innovationprofessionals establishedby the Partnership.
Consumer Health Informatics
The role of e-health in consumer health informatics has beenaround for over two decades primarily concentrating on the oldor vulnerable. With innovations in technology and ways of working in public health there is a paradigm shift that is movinghealth information management at home from curing into caringand supporting. Improved accessibility of digital media channelssuch as interactive television, next-generation games consolesand the WWW has, and will continue to, lead us towards newpartnerships of trust between consumers and providers.Communication tools such as
– a secure onlinehealth organiser similar to commercial products such as
, Microsoft
Practice Fusion
– are attemptsby the NHS to give patients and the public greater visibility of their healthcare information. This is achieved by giving themaccess to personalised services through integrations with
Chooseand Book 
and the NHS
Care Records Service
. Research at earlyadopter sites has shown that the public's awareness, perceptionsand uptake of 
and the Summary Care Record (SCR)varies greatly. More work is required to raise their profile and toeducate the public of the potential benefits of such innovations.Assistive technologies are used to aid people with difficulties inactivities of daily living, for monitoring and rehabilitation. Theseinclude blood-glucose monitoring systems for diabetes sufferersand projects such as the alcohol education tool,
, beingdeveloped at the University of Leeds. Gaming technologies suchas the
Nintendo Wii 
are shifting healthcare monitoring topreventative and “healthy lifestyle” applications with games suchas
Wii Fit 
which build upon other fitness technologies such aspedometers. Country-wide healthy-living schemes such as
Feel Great Britain
headed by Nintendo are becoming commonplaceand yet are working independently from the NHS who couldbenefit from the attitudes of participants and provide incentivesfor better health.In commercial sectors there is a growing interest in healthy livingand well-being information. Adoptions of social networking sitessuch as
have influenced start-ups of social networking sites dedicated to personal healthcare such as
iMedix, MedHelp, trusera
. Such sites offervirtual communities enabling users to share experiences with
people locally and across the world. Social networking is agrowing area of healthcare innovation and has been the topic of a masterclass headed by the NHS
Faculty of Health Informatics
,features in the
Armchair Involvement 
programme at the NHS
Institute for Innovation and Improvement.
Consumer health informatics is a rapidly expanding field of e-health which will continue to grow and mature alongsidecommercial innovations. Currently there is a poor connectionbetween the commercial and specific “healthy lifestyle” uses of technology but with appropriate integration with
and the SCR users could begin to see
Wii Fit 
scores beingdirectly linked into their personal health records and madeavailable to their GP during consultations. The key to success willbe to harmonise working between commercial and publicsectors. This will create innovative pervasive healthcare productsthat work “out-of-the-box” rather than requiring additional efforton behalf of consumers.
Professional Clinical Informatics
Contemporaneous to the advances in consumer healthinformatics is the application of technologies to complementtraditional and innovative models in the delivery andmanagement of healthcare organisations. Environmentalcomplexities call for more process-driven and qualitativeperspectives in addition to current functional areas, tasks androles models. Innovative models such as business process re-engineering; Six Sigma/change acceleration process; and, totalquality management are seen as the way forward for healthcaremanagement thinking. It would be advisable for technologyproviders offering professional clinical informatics tools tosupport these more flexible models in their applications.The implementation of the NHS-wide broadband network,
, aspart of the
National Programme for IT 
has enabled many newdata and voice communications opportunities. The “spine”facilitates the Choose and Book, Electronic Prescription Service,Care Records Service and the Picture Archiving andCommunication Systems (PACS) as well as tools such as e-maildirectory service
. Successful innovations include the Yorkshire Air Ambulance which has cut average response timesby 6 minutes and Cornwall and Scilly Isles PCT which providestelecare and telemedicine applications such as video-conferencing across their Community of Interest Network (CoIN).Clinical decision aids and management tools are well-documented, especially computerised physician order entry(CPOE) or ‘order comms’ and systems such as the PACS.Advantages include increased compliance with guidelines,eliminating the time gap between point of care and point of service, and cost and efficiency gains from the digitisation of image processing. Clinical decision support systems (CDSS) suchas
have yet to penetrate in the UK – due to lack of access to IT resources, location of access points and poordiffusion – but have shown promising results in trials in Indiawhen used as an education tool for young graduates.With the exception of PACS, which has revolutionised radiology,the diffusion of clinical informatics systems has been poor outsideof primary care. The reasons for this are complex but include the:lack of cost-benefit models for estimating financial implications of systems. These are exacerbated by the difficulty in quantifyingsavings of improving quality of care; lack of understanding of newrisks generated by implementing systems; need for staff involvement and adequate training and understanding to operatenew systems; and, perceptions of new technology increasing staff workloads. Developments need to be made to tackle each factorto improve the rate of adoption of new innovations.Unlike consumer health informatics professional clinicalinformatics relates to the workflows of professionals. It may bemore difficult to penetrate this market unless thorough cost-benefit analyses are conducted with staff involvement; even thenideas may be rejected if not suited to clinical practice and can beshown to improve patient safety and quality of care.Developments in clinical decision aids have the potential tobecome good education tools for junior professionals but haveproved less successful when used to mimic day-to-dayprofessional knowledge. Systems must be responsive to the wayclinicians and hospitals work rather than focusing on theaccompanying technology.
E-health is more than just information technologies. E-healthshould be envisaged as a new way of working which integratescomplex networks of people and technologies to provide a moreconsumer-centric healthcare system where information isaccessible, relevant and reliable. As the commercial worldcontinues to push the boundaries of innovation with ubiquitoustechnologies health informaticians must also explore new ways toimplement the vision of pervasive healthcare. E-health willcontinue to expand and its role in the public domain will mature,as a recent study by Pew Internet shows that 75% of Internetusers searched for healthcare information in the US betweenOctober and November 2007. Insights into gaming industryparticipation and Healthy People programmes are gainingincreased media attention and are slowly becoming part of oureveryday lives.What makes the transition so difficult is the lack of maturity andresearch into the benefits of new paradigms such as Web 2.0. Aswith any technological project, change is the only constant factor.The lack of knowledge of potential benefits of innovations mustbe addressed by improving information technologycompetencies and links between academic research andhealthcare practice. This will be a two-fold process: increasing theliteracy of health professionals should better enable them tohighlight areas where new technologies could support theirworkflows; and technologists must improve their knowledge of the healthcare domain so they are able to create more effectivehealthcare innovations. Advancements in the commercial worldwill continue to drive rapid innovation and it will be up to healthprofessionals and technology providers to push the boundaries of healthcare and make it more accessible to all regardless of location, time and other constraints.
Future Projections
The applications of today should be used as a stepping stone forcreating the innovations of tomorrow. There is a long way to goto achieving interoperability between systems which stems from alack of understanding of standards already available to healthtechnology providers. Future-proofed and well-researchedstandards are being ignored in favour of bespoke solutions toissues such as coding and user interface design. These solutionsmay seem appropriate in the short-term but may lead toproblems in the future when it comes to linking systems betweensuppliers. As authors, we have provided some tips as a guide forfuture innovations.There are a multitude of resources available from the NHSrelating to data models and dictionaries to aid system designs.The NHS
Data Model and Dictionary 
provides an excellentresource which describes programmable objects using theindustry-standard Universal Modelling Language (UML) includingup-to-date object validation procedures for each object. Otheruseful resources are provided such as National AdministrativeCodes Service (NACS) and the Terminology Reference DataUpdate Distribution Service (TRUD) which provide standard datasets for structures such as SNOMED-CT – a clinical codingstandard which facilitates communications between healthcareprofessionals in clear, unambiguous terms and supersedes thelegacy Read-coded nomenclature. Global standards are alsoavailable including HL7 – an international clinical messagingstandard – and ICD10 – an international standard for diseaseclassification adopted by the World Health Organisation. Designtips are given by the Microsoft
Common User Interface
programme which is striving towards a common look and feel forall NHS systems.In conjunction with systems resources, there are also interestingdevelopments in design methodologies which can be used toimprove involvement between technology providers andhealthcare professionals. The role of agile software developmentis one that is well-suited to the complex nature of healthcareinteractions. Agile working increases the interactions betweenstakeholders and provides timely feedback on the validity of ideas. In addition, allocating local “clinical champions” tomanage projects at each stage should help increase rapportbetween professionals and providers increasing the positiveperceptions and usability of new systems. While here are nostrong cases either for or against agile working practices, it isessential to adopt a flexible work ethic and to constantly reviewand amend elements that are not working as well in the currentenvironment. An iterative approach is essential to ensure time isnot wasted; rather it is used as a building block for futuredevelopments.These are just a summary of resources which should act as aspringboard for future research. It is essential for technologyproviders to keep abreast of the cutting-edge in standards andthinking as it is an area which has been poorly understood in thedesign of current systems. Adhering to well-researched standardsand responding to external pressures will help provide better,future-proof e-health applications. The adage of not re-inventingthe wheel has never been truer in today’s connected world and itis essential to support rapid application development whichincreases interoperability and improves patient safety.

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