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ACKNOWLEDGEMENT

This Module is a collaborative effort of MOH and Universities with technical and financial
assistance from the Data use Partnership (DUP) Project. We would like to acknowledge all who
contribute for the development of this Module.

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 ACRONYMS

CDSS Clinical Decision Support System

CIS Clinical Information System
CME Continuing Medical Education
COE Computerized Order Entry
DHIS2 District Health Information System
eHMIS electronic Health Management Information System
EHR Electronic Health Record
EMR Electronic Medical Record
ePHEM electronic Public Health Emergency management
EPSA Ethiopian Pharmaceutical Supply Agency
eRIS electronic Regulatory Information System
GIS Geographic Information System
GTP Growth and Transformation plan
HRIS Human Resource Information System
HSTP Health sector transformation Plan
ICTs Information and Communications Technologies
ICT4D Information and Communications Technologies for Development
LAN Local Area Network
MDR Medscape Drug Reference
MOH Ministry of Health
MPI Master Patient Index
PHR Personal Health Record
PMS Practice Management Software
SMS Short Messaging Service
UHC Universal Health Coverage
USAID United States Agency for International Development
WAN Wide Area Network

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 TABLE OF CONTENTS

ACKNOWLEDGEMENT .....................................................................................................ii
ACRONYMS ....................................................................................................................... iii
TABLE OF CONTENTS ...................................................................................................... iv
LIST OF TABLES AND FIGURES ....................................................................................vii
LIST OF TABLES............................................................................................................vii
LIST OF FIGURES ..........................................................................................................vii
MODULE INTRODUCTION............................................................................................ viii
MODULE OBJECTIVES .................................................................................................. viii
CHAPTER ONE ........................................................................................................................ 1
ELECTRONIC HEALTH ...................................................................................................... 1
1.1 INTRODUCTION ................................................................................................... 1
1.2 SESSION OBJECTIVES ........................................................................................ 1
1.3 SESSIONS CONTENTS ......................................................................................... 2
1.3.1 Concepts of eHealth ......................................................................................... 2
1.3.2 Domains of eHealth .......................................................................................... 5
1.3.3 Ethiopian eHealth policy and strategy ............................................................. 6
1.3.4 Global eHealth experiences ............................................................................ 15
1.4 ACTIVITIES ......................................................................................................... 18
1.5 SUMMARY........................................................................................................... 19
1.6 SELF-ASSESSMENT QUESTIONS .................................................................... 20
CHAPTER TWO ..................................................................................................................... 21
ELECTRONIC HEALTH RECORDS................................................................................. 21
2.1 INTRODUCTION ................................................................................................. 21
2.2 SESSION OBJECTIVES ...................................................................................... 21
2.3 SESSION CONTENTS ......................................................................................... 22
2.3.1 Concepts of electronic health, medical and personal record system .............. 22
2.3.2 Benefits and barriers of EHR ......................................................................... 25
2.3.3 Steps of EHR development ............................................................................ 28
2.3.4 Components of EHR ...................................................................................... 31
2.3.5 Clinical information system ........................................................................... 33

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 2.3.6 Hands on practices on EHR experiences in Ethiopia ..................................... 37
2.4 ACTIVITIES ......................................................................................................... 40
2.5 SUMMARY........................................................................................................... 41
2.6 SELF-ASSESSMENT QUESTIONS .................................................................... 42
CHAPTER THREE ................................................................................................................. 43
TELEMEDICINE................................................................................................................. 43
3.1 INTRODUCTION ................................................................................................. 43
3.2 LEARNING OUTCOMES .................................................................................... 43
3.3 SESSION CONTENTS ......................................................................................... 44
3.3.1 Concepts of telemedicine ............................................................................... 44
3.3.2 History of telemedicine .................................................................................. 46
3.3.3 Components of a telemedicine system ........................................................... 46
3.3.4 Types of Telemedicine ................................................................................... 53
3.3.5 Information exchange in telemedicine ........................................................... 59
3.3.6 Specialties and common application areas for TM ........................................ 61
3.3.7 Telemedicine's impact on health care delivery .............................................. 63
3.3.8 Potential benefits of telemedicine .................................................................. 63
3.3.9 Challenges related to the implementation of telemedicine ............................ 64
3.4 ACTIVITIES ......................................................................................................... 67
3.5 SUMMARY........................................................................................................... 68
3.6 SELF-ASSESSMENT QUESTIONS .................................................................... 69
CHAPTER FOUR .................................................................................................................... 70
MOBILE HEALTH.............................................................................................................. 70
4.1 INTRODUCTION ................................................................................................. 70
4.2 LEARNING OUTCOMES .................................................................................... 70
4.3 SESSION CONTENTS ......................................................................................... 70
4.3.1 Concepts of mHealth ...................................................................................... 70
4.3.2 Benefits of mHealth ....................................................................................... 73
4.3.3 Principles for mHealth interventions.............................................................. 74
4.3.4 Key considerations for mHealth interventions ............................................... 75
4.3.5 Types of mHealth applications ....................................................................... 77
4.3.6 mHealth in Ethiopia ....................................................................................... 83
4.4 SUMMARY........................................................................................................... 89
4.5 SELF-ASSESSMENT QUESTIONS .................................................................... 90
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CHAPTER FIVE ..................................................................................................................... 91
E-HEALTH ARCHITECTURE AND STANDARDS ........................................................ 91
5.1 INTRODUCTION ................................................................................................. 91
5.2 LEARNING OUTCOMES .................................................................................... 92
5.3 SESSION CONTENTS ......................................................................................... 92
5.3.1 Concepts of eHealth architecture ................................................................... 92
5.3.2 National eHealth architecture & framework components .............................. 93
5.3.3 Concepts of eHealth standards ....................................................................... 97
5.3.4 Concepts of eHealth interoperability............................................................ 100
5.3.5 The Ethiopian terminology management system and health data dictionary
106
5.4 SUMMARY......................................................................................................... 110
5.5 SELF-ASSESSMENT QUESTIONS .................................................................. 111
REFERENCES ................................................................................................................... 112

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 LIST OF TABLES AND FIGURES

LIST OF TABLES

Table 1: Stages for eHealth development (WHO: National eHealth Strategy Toolkit) .......... 15
Table 2: Difference between electronic health record and electronic medical record ............ 23
Table 3: Barriers to the acceptance of electronic medical records perceived by physicians: .. 27
Table 4: The difference between synchronous and asynchronous types of telemedicine ....... 56
Table 5: Global Implementation status of mHealth applications, WHO 2016 ........................ 82

LIST OF FIGURES

Figure 1: Countries with UHC, eHealth, HIS, & telehealth policies by year of adoption ......... 4
Figure 2: Launching DHIS2 Academy at University of Gondar ............................................. 11
Figure 3: Dhis2 Information cycle ........................................................................................... 11
Figure 4: The eRIS interface .................................................................................................... 12
Figure 5: Clinical portal in the Clinical Information system ................................................... 35
Figure 6: Telemedicine Information System ........................................................................... 46
Figure 7: Components of telemedicine system ........................................................................ 47
Figure 8: Telemedicine software components ......................................................................... 52
Figure 9: the role of mHealth in improving health outcomes .................................................. 74
Figure 10: Financial, capacity and cultural factors for introducing technology ...................... 77
Figure 11: Digital ecosystem for mHealth ............................................................................... 84
Figure 12: Mobile phone adoption in Ethiopia ........................................................................ 85
Figure 13: mHealth supporting in eHealth............................................................................... 87
Figure 14: major goals of eHealth ........................................................................................... 93
Figure 15: National eHealth system architecture .................................................................... 95
Figure 16: Interoperability between systems ......................................................................... 102
Figure 17: Dimensions of interoperability ............................................................................. 103
Figure 18: Levels of interoperability ..................................................................................... 106
Figure 19: The National Health Data Dictionary & Terminology Management Service ...... 107
Figure 20: The national health data dictionary and open concept lab ................................... 109

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 MODULE INTRODUCTION

This module has been designed to explore the use of information communication technology
and other machine interfaced technologies in health care delivery for planning and
management related issues associated with decision making process. eHealth provides a
framework to understand the types of information systems prevalent in healthcare
organizations, evaluate specific strategies related to healthcare ICT investments, and
understand the basic of clinical information systems that enable to support the decision-making
process in clinical practices. In this module, you will learn how the core competencies of
eHealth and clinical information system can be functioned implemented and applied using real-
world case studies. You will be exposed to specific concepts related to eHealth and clinical
information system like Electronic Medical Records (EMR), Telehealth and Telemedicine,
mHealth, eHealth architecture and standards in healthcare system. Upon completion of the
module, you should be able to explain the key eHealth and clinical information system
components including countries initiative and understand the eHealth enterprise architecture
for effective health information technology management, evidence based practices and
decision support and oversight requirements of healthcare IT projects, understand the
specification and selection process of healthcare projects, and apply these competencies to real-
country problems.

MODULE OBJECTIVES

At the end of this module, learners will be able to:

 Define eHealth and its components.

 Identify different eHealth systems
 Differentiate eHealth and clinical information systems
 Explain mHealth and its strategy in Ethiopia
 Describe eHealth architecture and standard

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 CHAPTER ONE

ELECTRONIC HEALTH

1.1 INTRODUCTION

Information Technology (IT) is playing an increasingly important role in all sectors of

economy and in the healthcare sector.

This chapter aimed to introduce learners on basic definition of terms related to eHealth and in-
depth description its major eHealth components. This will enable learners to have basic
knowledge on eHealth and its application areas.

The existing Ethiopian eHealth policy and strategies have been discussed to insight learners on
the national current priorities regarding eHealth. In this session learners will have an
opportunity to review the current policy, programs and strategies on eHealth.

The eHealth experiences of different countries has been explained for learners to understand
the global picture of eHealth implementation.

1.2 SESSION OBJECTIVES

At the end of this chapter learners will be able to:

1.2.1 Describe concepts of eHealth

1.2.2 List components of eHealth
1.2.3 Explain Ethiopian eHealth policy and strategy
1.2.4 Describe global eHealth experiences

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 1.3 SESSIONS CONTENTS
1.3.1 Concepts of eHealth

E-health is an emerging field in the intersection of medical informatics, public health and
business, referring to health services and information delivered or enhanced through the
Internet and related technologies. In a broader sense, the term characterizes not only a technical
development, but also a state-of-mind, a way of thinking, an attitude, and a commitment for
networked, global thinking, to improve health care locally, regionally, and worldwide by using
information and communication technology.

This definition is broad enough to apply to a dynamic environment such as the Internet and at
the same time acknowledges that e-health encompasses more than just "Internet and Medicine".
The term eHealth (e-Health) has been in use since the year 2000. It’s also frequently used as a
synonym for Health IT. It has various definitions.

The World Health Organization defines eHealth as the use of information and communication
technologies (ICT) for health. ’In a broader sense, it is concerned with improving the flow of
information, through electronic means, to support the delivery of health services and the
management of health systems” eHealth can be also considered as a means to ensure that the
right health information is provided to the right person at the right place and time in a secure,
electronic form to optimize the accessibility and quality of health care delivery, research,
education and knowledge for health system. E-Health should be viewed as both the essential
infrastructure underpinning information exchange between all participants in a healthcare
system and as a key enabler and driver for improved health outcomes for a population.

The "e" in e-health does not only stand for "electronic," but implies a number of other "e's,"
which together perhaps best characterize what e-health is all about.

The 10 e's in "e-health"

1. Efficiency - one of the promises of e-health is to increase efficiency in health care, thereby
decreasing costs. One possible way of decreasing costs would be by avoiding duplicative
or unnecessary diagnostic or therapeutic interventions, through enhanced communication
possibilities between health care providers, and through patient involvement.

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2. Enhancing quality of care - increasing efficiency involves not only reducing costs, but at
the same time improving quality. E-health may enhance the quality of health care for
example by allowing comparisons between different providers, involving consumers as
additional power for quality assurance, and directing patient streams to the best quality
providers.

3. Evidence based - e-health interventions should be evidence-based in a sense that their

effectiveness and efficiency should not be assumed but proven by rigorous scientific
evaluation.

4. Empowerment of consumers and patients - by making the knowledge bases of medicine

and personal electronic records accessible to consumers over the Internet, e-health opens
new avenues for patient-centered medicine, and enables evidence-based patient choice.

5. Encouragement of a new relationship between the patient and health professional, towards
a true partnership, where decisions are made in a shared manner.

6. Education of physicians through online sources (continuing medical education) and

consumers (health education, tailored preventive information for consumers)

7. Enabling information exchange and communication in a standardized way between health

care establishments.

8. Extending the scope of health care beyond its conventional boundaries. This is meant in
both a geographical sense as well as in a conceptual sense. e-health enables consumers to
easily obtain health services online from global providers. These services can range from
simple advice to more complex interventions or products.

9. Ethics - e-health involves new forms of patient-physician interaction and poses new
challenges and threats to ethical issues such as online professional practice, informed
consent, privacy and equity issues.

10. Equity - to make health care more equitable is one of the promises of e-health, but at the
same time there is a considerable threat that e-health may deepen the gap between the
"haves" and "have-nots". People, who do not have the money, skills, and access to
computers and networks, cannot use computers effectively. As a result, these patient
populations (which would actually benefit the most from health information) are those who

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 are the least likely to benefit from advances in information technology, unless political
measures ensure equitable access for all. The digital divide currently runs between rural vs.
urban populations, rich vs. poor, young vs. old, male vs. female people, and between
neglected/rare vs. common diseases. Evidently there is a close association between eHealth
and universal health coverage (UHC). (See figure 1)

Figure 1: Countries with UHC, eHealth, HIS, & telehealth policies by year of adoption
Source: WHO, Global diffusion of eHealth, 2016.

In addition to these 10 essential e's, e-health should also be easy-to-use, entertaining (no-one
will use something that is boring) and it should definitely exist.

The aim of eHealth is to achieve stronger and more effective communication with patients and
upgrade healthcare services and the entire healthcare sectors. It is all about digitizing healthcare
systems and records. The benefit of e-Health is that it improves various aspects of healthcare
(quality, cost-efficiency, access) by:

 Supporting the delivery of care tailored to individual patients, where ICT enables more
informed decision making based both on evidence and patient-specific data;
 Improving transparency and accountability of care processes and facilitating shared
care across boundaries;
 Aiding evidence-based practice and error reduction;
 Improving diagnostic accuracy and treatment appropriateness;
 Improving access to effective healthcare by reducing barriers created, for example, by
physical location or disability;

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  Facilitating patient empowerment for self-care and health decision making;
 Improving cost-efficiency by streamlining processes, reducing waiting times and waste.

eHealth can be used by healthcare providers to:

 Store and share information about patients, using electronic health records, radiology
results and laboratory systems.
 Support decision making by allowing communication with specialists, by allowing easy
access to information providing warnings and alerts built into patient records.
 Contact patients as needed
 Provide education and training
 Collect and store information about caseload and the performance of health facilities
 eHealth can be used in many different ways by healthcare providers to improve the
service they provide.

eHealth can be used by patients to:

 Find out information about their condition

 Find support groups on social media
 To monitor their own conditions
 In some health systems, patients can book appointments and renew prescriptions over
the internet the same way as they use the internet for banking or booking travel tickets.

1.3.2 Domains of eHealth

eHealth encompasses a wide variety of sub-domains of digital health such as:

 Electronic Health Records (EHR)

 Electronic Medical Records (EMR) (including patient records, clinical administration
systems, digital imaging & archiving systems, e-prescribing, e-booking)
 Telehealth and telemedicine
 Health IT systems
 Consumer health IT
 Virtual healthcare
 Mobile Health (mHealth)
 Big data systems used in digital health

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  Decision support tools
 Electronic human resource management information system for health
 Electronic logistic management information system for health

e-Health also covers virtual reality, robotics, multi-media (e.g. CDROM), computer assisted
surgery, wearable and portable monitoring systems, health portals. e-Health technologies with
the potential to have a significant future impact on patient care include Internet-enabled
applications for chronic diseases which could help increase citizen empowerment in health
maintenance and decision making supporting self-care.

Creating a seamless communication between different components of eHealth has been a major
challenge. This shows that interoperability is a crucial issue in eHealth. Interoperability refers
to the communication between different technologies and software applications for the
efficient, accurate, and sound sharing and use of data. This requires the use of standards; i.e.

 Rules,
 Regulations,
 Guidelines, or
 Definitions with technical specification

It is aimed to make the integrated management of health systems viable at all levels. It
enables the exchange and use of reliable data in an efficient and integrated manner.

1.3.3 Ethiopian eHealth policy and strategy

A. Policy Issues

Policy issue 1 - Safer decisions, quality of care processes to increase:

 The influence on risk management (e.g. medical errors and patient's errors) by timely
providing adequate knowledge to assist proper decisions
 The quality of care processes, i.e. declaring and following explicit reference clinical
pathways
 The mutual awareness about what other clinicians are knowing, doing or planning on
the patient

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Policy issue 2 – Sustainable evolution of healthcare

The increasing cost of healthcare requires a rationalisation of services provided without a

negative effect on quality of care, by:

 Continuity of care,
 Patient empowerment,
 Accurate governance based on routine data (with timely indicators, also to allow
for self-assessment of healthcare professionals)
B. eHealth strategy

Enhancing the use of technology and innovation is one of the major agendas included in the
current Ethiopian Health sector transformation Plan (HSTP). The aim involves enhancing use
of the existing technology, introduction of new technology, technology transfer and
development and use of local technology. It also addresses finding better ways of doing things
through more effective products, processes, services, technologies or ideas.

The national eHealth strategy of Ethiopia is aimed at guiding and streamlining the Information
and Communication Technology (ICT) solutions in the healthcare sector. The core of the
strategy is the commitment that health program will be focused on three groups of beneficiaries
(Health and healthcare providers, consumers of health and healthcare service managers).

Vision: Provision of equitable, quality and timely health services thought the use of eHealth

Mission: To adopt appropriate eHealth environment in the health sector of Ethiopia, to improve
the health outcome by bridging the equity gap and enhancing the effectiveness and efficiency
of the health service delivery.

Objectives

1. To improve access, quality, efficiency health systems through e-health application

(such as: Telemedicine, mHealth, EHR/EMR, etc)
2. To enhance evidence based planning and decision making process through timely,
accurate and comprehensive data/information management system at all levels of health
care. (Such as: DHIS2, Telemedicine, mHealth, EHR/EMR, eHRIS, etc.)

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 3. To improve the referral system (referral and service availability database, ambulatory
management information system, GIS, EHR. telemedicine, mHealth)
4. To strengthen the human resources development (eHRIS, e-learning/ tele education)
5. To enhance health and health related researches thought the promotion of electronic
data collection and exchange (such as: electronic survey and surveillance, electronic
publication, knowledge based database).
6. To enhance public access to health information exchange and dissemination on health
services (such as: web portal, call center, e-newsletter, SMS, social media, digital notice
boards).
7. To adapt eHealth standards and systems architecture to ensure harmonized and
interoperable eHealth applications (such as: guidelines, unique identifiers, facility
master list, national health data dictionary)
Strategic areas of interventions

1. Adapting e-health standards (Legal and Regulatory framework)

2. Implementing the national ICT infrastructure for e-health (Infrastructure, standards
and system for eHealth)
3. Establish governance and leadership for eHealth.
4. Educational promotion to all stakeholders on e-health (Financing and Investment for
eHealth as well as support and promote eHealth service and Applications)
5. Support Human resource development and capacity building for eHealth (HIT, IT,
informatics, care providers).

Implementation: The overall eHealth implementation will be led and governed by the MOH.
Following the guiding principles outlined in the previous section and intervention area: (a)
Systems for health management strategic Information (b) Systems for health care service
delivery (c) System for research support (d) Systems for human resource development and
HSDP IV identified five domain areas of priorities:1) HIS – eHMIS, ePHEM, EHR, IPFSMISt,
IFMIS, HRIS, LIS; 2) Telemedicine - patient centric services, referral system, remote and rural
setting; 3) MHealth – /HEP/ and MDG and HSDP targets; 4) E-learning –health workforce
training and CME; 5) Community information (CHMIS, CBHIS).
Governance: The strategy will be implemented by MOH and stakeholders working group
formed by a multidisciplinary team organized in program line and functional domain
subcommittees. The PHID directorate, HITCT will be responsible for the operation of the
eHealth. The committee will be guided by already existing MOH governance. The MOH

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governance will support eHealth development, annual operational plans for strategy
implementation, identify opportunities with key partners, approve criteria for identification and
selection of sites and area of intervention for eHealth. There will be sub committees to provide
support to eHealth initiatives and to test the compliance whose functions will be to implement
selected areas of intervention.

Monitoring and Evaluation Framework: Monitoring and evaluation are important activities
to ensure effective and efficient implementation of the strategy. Both activities will be
participatory, whereby key stakeholders shall be involved. The implementers or institutions
will be part of routine M&E process. The eHealth M&E framework will be in-line with the
established health sector M&E framework and process. In order to establish an eHealth M&E
indicators, a strategy & framework should establish a defined and structured program to
support initial evaluation and ongoing monitoring of eHealth interventions. Such a program
could provide high quality, rigorous, and comparative information on the impact of eHealth
solutions to better inform decision and policy makers and guide their actions regarding
implementation or continued support of eHealth initiatives 1) Develop key measurable
performance indicators of eHealth in-line with the existing national M&E framework.2) Set
measurable targets with time frame 3) Report on “impact” to facilitate decision making and
financing.

Conclusion: The Ethiopian Healthcare strategy generally followed the integration

“information”, “financing” and “leadership and governance” components of the health system
with the principle of harmonization “one-plan, one-budget and one-report”. Monitoring the
performance of the health sector is based on a core set of sector-wide indicators to provide a
comprehensive picture on the performance of Ethiopian health sector. The strategy
development has based on globally acceptable principles (WHO/ITU toolkit and WHO and
AU resolutions).

Key components of use of technology and innovation in the health sector involves:
 Biotechnology
 Use of eHealth services
 Telemedicine
 Tele education
 Technology transfer for vaccine and diagnostic materials production

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The current eHealth applications in Ethiopia are delivering promising results. However,
preliminary situation assessment indicates that eHealth initiatives in Ethiopia are characterized
as small scale, duplication of efforts isolated and unable to effectively communicate
(interoperable) with each other. In that recognizant, the Government of Ethiopia (GOE) has
considered developing and formulating a national eHealth strategy for coordinating and
streamlining the various eHealth initiatives underway in the country as well as establishing a
foundation for sustainable eHealth implementation.
The eHealth strategy will consider and realize standardization and implementations of national
eHealth systems that include: access to health information and knowledge-sharing planning
and decision making; health system capacity building in terms of creating enabling eHealth
environment (Human resource, legal framework, privacy and compliance and funding); and
Health Growth and Transformation plan (GTP) to pull together various disparate initiatives
into a shared vision with a process oriented roadmap to move ahead. In order to achieve and
support long-term MOH health strategic goals, the existing e-Health initiatives need to be much
more strongly integrated, interoperable and stick with standards (technology/program) without
compromising the objectives of each sub-system and establishing foundations for planning,
coordinating scaling up different e-Health efforts.

C. Current eHealth Programs in Ethiopia

1. District Health Information System (DHIS2) Software:

Ethiopia joins a growing list of countries that have adopted and are using DHIS2—an open
source software developed and maintained by the University of Oslo’s Health Information
Systems Program. DHIS2 is a web-based data capturing and
analyzing platform, ensuring the implementation and
functionality of the current HealthNet initiative is critical.

HealthNet is a broadband Internet connectivity that links health

institutions to their respective administrative health units. It
thus provides an infrastructure that will be used by DHIS2 and
other eHealth systems.

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The first Ethiopian DHIS2 Academy was launched by
the eHealthLab Innovation and Research center at the
University of Gondar on February 2019.

Figure 2: Launching DHIS2 Academy at University of Gondar

DHIS 2 supports the different facets of the information cycle including:

 Collecting data.
 Running quality checks.
 Data access at multiple levels.
 Reporting.
 Making graphs and maps and other forms of analysis.
 Enabling comparison across time (for example, previous months) and space (for
example, across facilities and districts).
 See trends (displaying data in time series to see their min and max levels).

Figure 3: Dhis2 Information cycle

Basics of DHIS2
 It helps to capture data, analysis and dissemination

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  It is an open source, web-based software platform
 It has an integrated warehouse for essential data
 It is self-service analysis and communication
 It handles routine data and events

2. Electronic Regulatory Information System (eRIS)

The Federal Ministry of Health in collaboration with United States

Agency for International Development (USAID) developed an
electronic Regulatory Information System (eRIS). The electronic
Regulatory Information System (eRIS) launched is an open
source, locally-developed and maintained software system. So that
the agency can track medicines all the way from international (or local) suppliers to the ports,
to the Ethiopian Pharmaceutical Supply Agency’s (EPSA’s) warehouses and finally to each
clinic across the country. It helps in collecting, analyzing, presenting, and disseminating
information that can influence decisions in the process of transforming the health sector.

Figure 4: The eRIS interface

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 3. eCHIS

Electronic Community Health Information System (eCHIS) is

primarily a mobile-based application that works in an offline
environment. However, it needs connectivity for data
synchronization to the server and to facilitate digital referral
linkages. The application digitalizes the existing manual family
folder and service workflows to record and report the households
and members health and related data. The application will be
primarily used by the health extension workers. In addition, it has also components for the
health centre to enable referrals and feedbacks as well as to monitor and support the effective
use of the application at the health post.

Electronic Community Health Information System is hailed for its capability to create a digital
link between unique identifiers and health information about households and individuals, and
prevent the creation of duplicative household or individual records.

It also enables electronic sharing of household and individual information between HEWs and
other staff. The application makes for the health extension workers to easily monitor updates
on patient status. One other important advantage of the application is that it facilitates a referral
linkage between the health post and health centers. Pilot-test is going to be implemented in all
the health posts under one selected Woreda of the six regions. So far, Woredas for the pilot test
from Oromia, Amhara, SNNP and Tigray were selected.

4. Other eHealth systems like;

 eHRIS
 eLMIS,
 mHealth etc. are currently on implementation.

D. Challenges of eHealth implementation in Ethiopia

a) Infrastructure
 Electricity
 Hardware
 Communication
 Application

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b) Human Resource
 IT
 Health informatics
 HIT
c) Leadership and governance
d) Financing

E. Opportunities of eHealth implementation in Ethiopia

a) Government ICT Initiatives:

Telecommunication is a central infrastructure in the implementation of eHealth programs.
Without addressing the telecommunication infrastructural issues, it will be virtually
difficult to realize the goal of e-Health implementation. The Government of Ethiopia as
part of the ICT4D process is currently implementing a number of major projects and
initiatives including: the SchoolNet, WoredaNet, AgriNet, rural connectivity and the E-
government program among others.
b) Electricity:
According to the GTP Ethiopia is performing massive electrification.
c) Hardware (Computer, Laptop, Mobile, Tablets, Printers, UPS, etc.):
Necessary ICT hardware that includes computation devices such as: computers, Servers,
Laptops, Tablets, Mobiles, Printer, Scanner, GPS handheld and other related accessories
have been made available to all levels.
d) Software (Application):
Over the years MOH have developed various national e-health application that includes; -
DHIS2, EMR, eCHIS, eHRIS, FMIS, mHealth, etc. Other initiatives includes: LIS, hub
Store IS, drug dispending, Achieving/indexing IS, Fleet MIS, Stock MIS, etc has also
developed and deployed to all levels.
e) Leadership & Governance Policies and Strategies:
There are encouraging government policies and strategies that creates favorable
opportunities for eHealth implementation.
f) Financing:
The government of Ethiopia has spent resources for ICT infrastructure building, training,
development and implementation that are foundation for eHealth initiatives. Over the years

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 the expenditures on ICT has increased. Other major resources contributors has their own
roles.
g) Human Resources:
As part of MOH’s Human Resource Strategy, HIT in diploma has been on training in TVET
collages. BSc in Health Informatics programm opened in several Universities, MSc in
Biostatistics and Health informatics at Mekele University; MSc in Health informatics at
Addis Ababa University and MPH in Health Informatics and recently, PhD program in
Public Health Informatics in University of Gondar.

1.3.4 Global eHealth experiences

Stages for eHealth development

Based on these dimensions, it is possible to describe the context for eHealth in three possible
stages.

 Experimentation and early adoption

 Development and building up
 Scaling up and going mainstream

Table 1: Stages for eHealth development (WHO: National eHealth Strategy Toolkit)

Stage Characteristics
Experimentation and  Usually small, few and disconnected eHealth initiatives
early adoption  Proof-of-concept pilots where IT is introduced in a limited context
 Projects rarely sustainable, lacking infrastructure, skills and integration
 Commercial IT market fragmented, with little local expertise
 Funding provided by aid agencies, donors and external actors
 International obligations for public health reporting cannot be met
Development and  Larger eHealth projects with greater awareness of potential
building up  Applications emerge but remain vertical, fragmented and not scalable
 Commercial IT market, with international and local IT vendors
 Aid agencies and donors are still funders; private sector investment in
development and adoption of cost-effective technologies
 Public-private partnerships increase in number
 International obligations for public health reporting can sometimes be met
through vertical systems
 Examples: telemedicine networks, limited adoption of EMR, procurement
and stock tracking systems, and mHealth trials.

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Scale up and  Investment and adoption scales up
mainstream  Commercial IT market with larger vendors, both international and local
 Health sector takes a leading role in planning and using eHealth
 Health IT industry is active
 International obligations for public health reporting can be met
 HIS are increasingly linked, but still face problems due to legacy systems
 Examples: hospital and care networks, home health monitoring, chronic
disease management applications, personal health records.

There are several further points to review, independent of what stage the national eHealth
context is in. If a country is:

 In the first stage, strategic planning should focus on the enabling environment
 In the second stage, the priority should be on legal, policy and standards aspects
 In the third stage, focus should be on users, monitoring and evaluation.

Finally, the countries eHealth context components are related to strategic aspects, which will
also be considered in this framework. Most of these components are related to the enabling
environment; only infrastructure is related to the IT environment.

Global eHealth implementation status

Electronic health has been a priority for the World Health Organization (WHO) since 2005. A
report of the third global survey on eHealth, 2016 indicated that:

 83% countries reported at least one m-Health initiative;

 Use of telehealth continues to grow, and tele radiology is most widespread (77%).
 E-Learning for medical students education in over 84% of countries
 47% of countries reported electronic health record (EHR) systems
 78 % of reported legislation protecting the privacy of personal information
 54% of countries reported legislation to protect privacy of electronic patient data
 58% of countries reported national telehealth policy
 80% of countries reported health organizations use social media for health promotion
 17 % of countries reported national policy regulating big data use in health sector

Noting the potential impact that advances in information and communication technologies
could have on health-care delivery, public health, research and health-related activities for the

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benefit of both low- and high-income countries; aware that advances in information and
communication technologies have raised expectations for health; respecting human rights,
ethical issues and the principles of equity, and considering differences in culture, education,
language, geographical location, physical and mental ability, age, and sex; recognizing that a
WHO eHealth strategy would serve as a basis for WHO’s activities on eHealth;

The WHO urges member states in its report:

 To consider drawing up a long-term strategic plan for developing and implementing

eHealth services in the various areas of the health sector, including health administration,
which would include an appropriate legal framework and infrastructure and encourage
public and private partnerships;
 To develop the infrastructure for information and communication technologies for health
as deemed appropriate to promote equitable, affordable, and universal access to their
benefits, and to continue to work with information and telecommunication agencies and
other partners in order to reduce costs and make eHealth successful;
 To build on closer collaboration with the private and non-profit sectors in information
and communication technologies, so as to further public services for health and make use
of the eHealth services of WHO and other health organizations, and to seek their support
in the area of eHealth;
 To endeavor to reach communities, including vulnerable groups, with eHealth services
appropriate to their needs;
 To mobilize multisectoral collaboration for determining evidence-based eHealth
standards and norms, to evaluate eHealth activities, and to share the knowledge of cost-
effective models, thus ensuring quality, safety and ethical standards and respect for the
principles of confidentiality of information, privacy, equity and equality;
 To establish national centers and networks of excellence for eHealth best practice, policy
coordination, and technical support for health-care delivery, service improvement,
information to citizens, capacity building, and surveillance;
 To consider establishing and implementing national electronic public-health information
systems and to improve, by means of information, the capacity for surveillance of, and
rapid response to, disease and public-health emergencies;

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 1.4 ACTIVITIES

Explore and evaluate current eHealth initiatives in Ethiopia

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1.5 SUMMARY

 The World Health Organization defines eHealth as the use of information and
communication technologies (ICT) for health.
 The aim of eHealth is to achieve stronger and more effective communication with
patients and upgrade healthcare services and the entire healthcare sectors.
 Key sub-domains of e-Health:
 EHR/EMR
 Telemedicine and telecare services
 mHealth
 Decision support tools
 Internet-based technologies and services
 Big data
 Key components of use of technology and innovation in the Ethiopian health sector
involves:
 Biotechnology
 Use of eHealth services
 Telemedicine
 Tele education
 Technology transfer for vaccine and diagnostic materials production

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 1.6 SELF-ASSESSMENT QUESTIONS

Choose the best answer

1. One of the following is the advantage of eHealth?

a) It improves access to care c) It reduces cost of care
b) It improves quality of care d) All
2. One of the following is broader field?
a) e-Health c) Telemedicine
c) mHealth d) EMR
3. One is true about eHealth
a) Compromise quality of healthcare
b) Enhance organizational efficiency
c) Substitute human element
d) Relatively poor in information security than manual recording

4. “ENAT Messenger” automatically calculate expected delivery date (EDD) of a pregnant

women and sent text message reminders to alert the health extension worker. This
application is a typical example for?
a) DHIS-2 c) Mobile Health (mHealth)
b) eHMIS d) Telemedicine
5. One is INCORRECT about DHIS2?
a) Captures data, analysis & dissemination d) Open source & web-based platform
b) Handles routine data and events e) None
6. One is a key components of technology and innovation involved in the Ethiopian health
sector:
a) Biotechnology c) Tele education
b) Telemedicine d) All
7. What are the challenges and opportunities in Ethiopia?

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 CHAPTER TWO

ELECTRONIC HEALTH RECORDS

2.1 INTRODUCTION

The increased role of IT in the healthcare sector has led to coining of a new terminology, “Health
Informatics,” which deals with the use of IT for better healthcare services. Health informatics applications
often deal with the health record of individuals, in digital form, which is referred to as the Electronic Health
Record (EHR).

In this chapter learners will be informed with the definitions, benefits and components of electronic health
records. This will provide a basic knowledge for learners. Additionally, advanced clinical information
system has been discussed to give a scientific and technical clue and to be able to understand its applicability
in the Ethiopian context.

The global and national experiences of electronic health records was briefly discussed for learners to
understand the global and national picture of its implementation status. In this session learners will be
informed to explore different EMR software platforms and evaluate its applicability in Ethiopian context.

Generally, this chapter aimed to provide basic knowledge and give best practices for learners to address their
gaps in knowledge, attitudes and skill on electronic medical recording systems.

2.2 SESSION OBJECTIVES

At the end of this session, learners will be able to:

2.2.1 Describe the concepts of electronic health, medical and personal record system
2.2.2 Describe benefits and barriers of HER/EMR
2.2.3 Identify common steps for developing EHR system
2.2.4 Identify the components of electronic health record
2.2.5 Explain clinical information system
2.2.6 Describe hands-on practices on electronic health record system

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 2.3 SESSION CONTENTS
2.3.1 Concepts of electronic health, medical and personal record system

The terms Electronic Health Record (EHR), Electronic Medical Record (EMR) and Personal
Health Record (PHR) have often been used interchangeably, but there are differences among
each of the terms as defined below.

A. The Electronic Health Record (EHR)

An electronic record of health-related information on an individual that conforms to nationally

recognized interoperability standards and that can be created, managed and consulted by
authorized clinicians and staff across more than one healthcare organization. Electronic health
records are built to go beyond standard clinical data collected in a provider’s office and are
inclusive of a broader view of a patient’s care. EHRs contain information from all the clinicians
involved in a patient’s care and all authorized clinicians involved in a patient’s care can access
the information to provide care to that patient. EHRs also share information with other health
care providers, such as laboratories and specialists.

It is a longitudinal systematic collection of electronic health information for a patient generated

by one or more interactions in any care setting. This digitally-stored information should be
shareable across different healthcare settings in order to follow patients wherever they go to
the specialist, the hospital, or even across the country.

The purpose of EHR is to provide an electronic equivalent of an individual’s health record for
use by providers and staff across more than one health care organization. An EHR is inter-
organizational, that is, two or more health care organizations contribute to the record which
becomes an aggregation of one record focused around a person’s comprehensive health history
rather than being one provider’s record. EHR is intended to support efficient, high-quality
integrated health care, independent of the place and time of health care delivery.

B. The Electronic Medical Record (EMR):

It is a term often used interchangeably with EHR but there exist certain differences between
them.

EMR is an electronic record of health-related information on an individual that can be created,

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gathered, managed and consulted by authorized clinicians and staff within one healthcare
organization. This is a digital version of the paper charts in the health facilities. EMRs contain
notes and information collected by and for the clinicians in that office, clinic, or hospital and
is mostly used by providers for diagnosis and treatment. EMRs are more valuable than paper
records because they enable providers to track data over time, identify patients for preventive
visits and screenings, monitor patients, and improve health care quality.

The difference between EHR and EMR

The key difference between an electronic medical record and an electronic health record is the
ability to meaningfully exchange or share information. Therefore, an electronic health record
is an electronic record of health-related information on an individual that conforms to
nationally recognized interoperability standards and that can be created, managed, and
consulted by authorized clinicians and staff across more than one health care organization.
Rather than originating from and being tethered to one provider, the information in an EHR is
drawn from multiple providers and is meant to be a comprehensive, longitudinal record of
an individual’s relevant health history. Another key difference is that although an EHR is
managed and used by authorized providers, it is considered patient-focused rather than
provider-focused.

Table 2: Difference between electronic health record and electronic medical record

EMR EHR
A record of medical care created, managed, A repository of individual health records that
and maintained by one health care organization reside in numerous information systems and
(intra-organizational) locations (inter-organizational)
Integration of health care data from a Aggregation of health-related information into
participating collection of systems from one one record
health care organization
Consulted by authorized clinicians and staff Consulted by authorized clinicians and staff
within one health care organization across more than one health care organization
Data continuity throughout one health care Data interoperability across different
organization organizations

Functions of the EHR/EMR

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  Supports structured data collection using a defined vocabulary.
 Accessible at any or all times by authorized individuals.
 Contains a problem list - patient’s clinical problems and current status
 Supports systematic measurement and recording of data to promote precise and routine
assessment of the outcomes of patient care
 Can be linked with other clinical records of a patient—from various settings and time
periods—to provide a longitudinal (i.e. lifelong) record of events that may have
influenced a person’s health
 Can assist the process of clinical problem solving by providing clinicians with decision
analysis tools, clinical reminders, prognostic risk assessment and other clinical aids.
 Can be linked to both local and remote databases of knowledge, literature and
bibliography or administrative databases and systems so that such information is
readily available to assist practitioners in decision making.
 Addresses patient data confidentiality.
 Can help practitioners and health care institutions manage the quality and costs of care.

An EHR/EMR typically includes information such as:

 Patient demographics
 Medical history
 Medications and allergies
 Immunization status
 Laboratory test results
 Radiology images
 Vital signs
 Personal statistics like age and weight
 Progress notes and problem details
 Billing information

C. Personal Health Record (PHR):

An electronic record of health-related information on an individual that conforms to nationally

recognized interoperability standards and that can be drawn from multiple sources while being
managed, shared and controlled by the individual. Personal Health Record Contain the same

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types of information as EHRs; diagnoses, medications, immunizations, family medical
histories, and provider contact information; but are designed to be set up, accessed, and
managed by patients. Patients can use PHRs to maintain and manage their health information
in a private, secure, and confidential environment. PHRs can include information from a variety
of sources including clinicians, home monitoring devices, and patients themselves.

2.3.2 Benefits and barriers of EHR

A. Benefits

Paper-based records have several limitations, including but not limited to:

 Accessibility problems,
 Inadequate organization of information,
 Incompleteness and fragmentation of information,
 Redundancy,
 Security problems,
 Difficulties in reusing data, and
 Legibility issues.

EHR including EMR offer many benefits over paper records:

A. General benefits:

 Accessibility: EHR can be used by more than one person at a time, and can be accessed
from multiple locations.
 Support for multiple views: EHR can offer different visualizations tailored to user-
specific needs. Clinical information is complex, and the way it is presented to
providers impacts the way they interpret it.
 Improved communication between providers: healthcare teams are composed of
many members, and depend on adequate communication to coordinate actions. EHR
facilitate the exchange of information between collaborating providers.
 Communication with patients: EHR can also improve communication with patients.
A growing number of EHR are being linked with personal health records (PHRs) with
this goal.

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  Data aggregation: EHR can support the creation of groups and summaries from big
volumes of data.
 Access to knowledge bases: EHR provide contextual access to knowledge bases when
providers need it.
 Integration with clinical decision support system (CDSS): one of the main reasons
for collecting clinical data in a controlled manner is to offer support for clinical
decisions in the form of contextual information, alerts and reminders.
 Improved data integrity: readable, better organized, accurate, complete
 Improved productivity: access data whenever, wherever for timely decision
 Increased quality of care: tailored views, “dash-board”
 Increased satisfaction for caregivers: easy access to client data and related services

B. Benefits for healthcare provider:

 Decreased redundant data collection
 Allowed data comparison from prior visits
 Ongoing access, update record at bedside
 Improved documentation and quality of care
 Supported timely decision
 Better/faster/simultaneous data access
 Improved documentation, reporting
 Prompted to ensure administration of treatments and medications
 Supported automation of critical pathways/workflows
 Improved efficiency: eligibility, early warning of status changes

C. Benefits for healthcare enterprise/organization

 Better record security
 Fewer lost records
 Instant notice of eligibility/procedure authorization
 Decreased need and cost for record storage, x-ray film, filing
 Decreased length of stay due to waiting
 Increased compliance with regulatory requirements

D. Benefits for patient/clients

 Decreased wait time for treatment

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  Increased access/control over health information
 Increased use of best practices/decision support
 Increased ability to ask informed questions
 Greater clarity to discharge instruction
 Increased responsibility for own care
 Alerts and reminders for appointments and scheduled tests
 Increased satisfaction and understanding of choices

B. Barriers

Despite the potential gains in quality, efficiency and safety that EHR can provide, several
barriers exist to their adoption and implementation. When forming strategic plans for the
adoption and implementation of EHR, decision makers should consider the risks that these
barriers pose to the objectives of an organization, and ways to overcome them.

Table 3: Barriers to the acceptance of electronic medical records perceived by physicians:

Financial High start-up costs

High ongoing costs
Uncertainty about return on investment (ROI)
Lack of financial resources
Technical Lack of computer skills of physicians and/or staff
Lack of technical training and support
Complexity of the system
Limitation of the system
Lack of customizability
Lack of reliability
Interconnectivity/standardization
Lack of computers/hardware
Time Time to select, purchase and implement the system
Time to learn the system
Time to enter data
More time per patient
Time to convert the records
Psychological Lack of belief in EHR
Need for control
Social Uncertainty about the vendor
Lack of support from external parties
Interference with doctor-patient relationship
Lack of support from other colleagues
Lack of support from management
Legal Privacy or security concerns

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 Organizational Organizational size
Organizational type
Change process Lack of support from organizational culture
Lack of incentives
Lack of participation
Lack of leadership

2.3.3 Steps of EHR development

A strategic plan for a large-scale EHR implementation requires high-level leadership (national
or ministerial), to facilitate policy-making and ensure project governance. This can be broken
down into the following aspects,

a) Review the national eHealth strategy context

b) Set up a coordinating team
c) Conduct a situation analysis
d) Set goals and objectives
e) Develop a work plan and monitoring system
f) Communicate and disseminate.

Readiness assessment: countries should begin with a full assessment of their readiness to
adopt EHRs, including through looking at infrastructure, standards adoption, business and
clinical processes, education and training, human resources capacity and public willingness.
The assessment process should be tailored to specific needs of the country, and will require
resources, including staffing.

Nine common steps to a successful EHR implementation

1. Create an implementation team

2. Configure the software
3. Identify hardware needs
4. Transfer data
5. Optimize pre-launch workflows
6. Consider the room layout
7. Decide on the launch approach: “big bang” vs. incremental
8. Develop procedures for when your EHR is down
9. Initiate a training plan

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Step 1 Create an implementation team

Typically this team will include physicians, nurses, receptionists, medical assistants,
compliance office staff and administrative staff. Clinical members play dual roles by teaching
EHR skills to colleagues and also bringing clinical challenges back to the implementation team.
Three important roles to consider include: lead physician, project manager and lead super user.

Lead physician: The lead physician guides the organization throughout implementation,
serving as a link between the front-line users and the technical and administrative staff. It is
best if the lead physician is also in practice.

Project manager: The project manager works closely with the vendor and all staff in the
practice to keep stakeholders focused on their timelines, track the progress of projects and
manage day-to-day issues.

Lead super user: The lead super user will function as the in-house expert in the new EHR. The
lead super user configures the EHR software, creates templates and order sets, and also
develops revised workflows or standard operating procedures to address issues raised by front-
line users.

Step 2 Configure the software

First, work with your health IT vendor to configure your EHR to meet appropriate security
measures. This may require that you conduct a risk assessment..

Practices can also consider customizing software to optimize workflow.

1. Develop a list of build elements external to the EHR such as: demographics imported
from the practice management software (PMS), computerized order entry (COE),
treatment regimens/protocols, medication management settings, standing orders,
default patient history settings and billing/charge master updated with new codes and
consents.
2. EHR software can be modified to create specialty- or physician-specific templates,
which are used to support documentation. Discuss customization options and cost with
your EHR vendor.

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Step 3 Identify hardware needs

Some practices reduce the time spent logging into the system multiple times each day by
providing every worker with their own laptop or tablet to carry from room to room.

System hardware (i.e., server and network) needs depend on the type of EHR purchased

Step 4 Transfer data

1. Determine the approach for migrating data from the former recordkeeping system or
other PMS modules to the new EHR. A practice can assign existing staff to assist with
this process. Alternatively, the practice can hire additional or temporary staff who can
upload demographics and past medical, social, family and medication histories prior to
the patient’s next visit.
2. Prepare a checklist of items to be entered into the EHR. This will ensure that no critical
information is missed during the transfer.
3. Establish the amount of time required to transfer information for the average patient.
This can help the practice properly distribute workload and set realistic dates of
completion among staff transferring data.

Step 5 Optimize pre-launch workflows

It is best to optimize workflows before EHR implementation. Problems resulting from

inefficient workflows or insufficient support staff will be exacerbated during the
implementation of an EHR.

Step 6 Consider the room layout

Placement of the computer in the exam room impacts patient care.

Step 7 Decide on the launch approach:

“Big bang” vs. incremental

Some practices convert all users over to the EHR for all functions and all patients on the same
day—the “big bang” approach. This has the advantage of minimizing the time spent managing
both a paper record and the new electronic system simultaneously. It can also be highly
disruptive and small glitches can be amplified.

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Other practices implement their EHR incrementally, turning on certain functions in a step-wise
approach (i.e., starting with e-prescribing, and a few months later adding visit note
documentation functionality). Another incremental approach is to implement the EHR in
certain sites or departments and slowly roll out to the rest of the organization, learning and
tweaking the process along the way.

Step 8 Develop procedures for when your EHR is down

What will you do in the event of a power outage or severe system malfunction? It is wise to
develop procedures for periods when the EHR is down so that physicians and staff have clear
instructions about workflows when the EHR is unavailable. Some key components of
downtime procedures include how the downtime will be communicated to physicians, staff and
patients and how the patient care flow will continue (e.g., check-in and visit documentation).
Downtime procedures and supplies should be available electronically and on paper for greater
accessibility. Some practices compile the procedures in a three-ring binder and store additional
copies offsite.

Step 9 Initiate training

Training staff and physicians is critical to ensuring EHR implementation success. Create a
training plan to make sure everyone has the necessary knowledge and skills to use the EHR at
the time of launch.

2.3.4 Components of EHR

The basic key components of an EHR includes:

1. Patient Management Component:

 This component is required for patient registration, admission, transfer and

discharge (ADT) functionality.
 Patient registration includes key patient information such as demographics,
insurance information, contact information etc.
 When a patient is registered in an EHR for the first time, a unique ID (often called
“Medical Record Number”) is generated.

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  Whenever a patient has an encounter with the organization, another unique
“encounter” number is generated. In EHR environment, this component may also
generate a Master Patient Index (MPI).

2. Clinical Component:

 This component comprises of multiple sub-components e.g. electronic

documentation, nursing component etc.
 This component can make use of clinical decision support tools such as drug-drug,
drug-allergy, and drug-diagnoses interactions.
 This module also allows providers to enter multiple orders from order sets.
 Electronic documentation by providers allows them to document notes such as
History & Physical, consults, discharge summaries, operative notes etc.
 Multiple tools may be used to enable electronic documentation such as templates,
speech recognition and transcription services.
 The pharmacy system allows for maintaining a drug formulary, filling
prescriptions and crosschecking any orders that are placed by providers in the
EHR.
 Nursing component allows for collection of key patient information such as vital
signs, input and output etc.
 This component also allows for medication administration record (MAR), barcode
medication charting and nursing documentation.

3. Laboratory component:

 Lab components are typically divided into two subcomponents;

1) Capturing results from lab machines, and

2) Integration with orders, billing and lab machines.

 The lab component may either be integrated with the EHR or exist as a standalone
product.

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 4. Radiology Information System:

 Radiology information system (RIS) and Picture Archiving & Communications

System (PACS) are used to manage patient workflow, ordering process, results
and the images themselves.

5. Billing System

 The billing system (hospital and professional billing) is used to capture all charges
generated in the process of taking care of patients.
 These charges generate claims, which is submitted to insurance companies, tracked
and completed.
 One of the successes of using the data captured by EHR's is the ability to track
organizational expenses, inventory, and revenue cycle performance.
 These basic tasks were very complicated in the pre-EHR era.

In General, most EHRs contain the following information:

 Patient's demographic, billing, and insurance information

 Physical history and physicians orders
 Medication allergy lists
 Nursing assessments, notes, and graphics of vital signs
 Laboratory and radiology results
 Trending labs, vital signs, results, and activities pages for easy reference
 Links to important clinical information and support
 Reports for quality and safety personnel

2.3.5 Clinical information system

A Clinical Information System (CIS) is a computer based system that is designed for collecting,
storing, manipulating and making available clinical information important to the healthcare
delivery process.

Clinical Information Systems may be limited in extent to a single area (e.g. laboratory systems,
ECG management systems) or they may be more widespread and include virtually all aspects
of clinical information (e.g. electronic medical records).

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Clinical Information Systems provide a clinical data repository that stores clinical data such as
the patient’s history of illness and the interactions with care providers. The repository encodes
information capable of helping physicians decide about the patient’s condition, treatment
options, and wellness activities as well as the status of decisions, actions undertaken and other
relevant information that could help in performing those actions.

Some of the areas addressed by Clinical Information Systems are:

 Clinical Decision Support: This provides users with the tools to acquire, manipulate,
apply and display appropriate information to aid in the making of correct, timely and
evidence-based clinical decisions.
 Electronic Medical Records (EMRs): this contains information about the patient, from
their personal details, such as their name, age, address and sex to details of every aspect
of care given by the hospital (from routine visits to major operations).
 Training and Research: Patient information can be made available to physicians for the
purpose of training and research. Data mining of the information stored in databases
could provide insights into disease states and how best to manage them.

A Clinical Information Systems (CIS) provide access to relevant clinical data, and are one of
the foundational elements of an Electronic Health Record (EHR). CIS support continuity of
care across the entire spectrum of health services and improve patient care. CIS includes:

 Admission/Transfer/Discharge system
 Laboratory information system
 Radiology information system
 Pharmacy information system
 Picture Archival and Communication System
 Departmental clinical systems
 Critical care information system
 O.R. clinical information system
 Anesthesia clinical information system
 Cardiology clinical information system and
 Others
 Clinical Portal

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 Figure 5: Clinical portal in the Clinical Information system

Benefits of clinical information system

Easy Access to Patient Data

Improved Drug Prescription and Patient Safety
More time for direct patient care
Improved workers job satisfaction and retention
Legibility
Computerized order entry
Elimination of transcription error
Integration of care plans
Smart alerts
Administrative report generation
Quality improvement projects
Research

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Clinical information system security policy

1. Access control lists

Principle: Each identifiable clinical record shall be marked with an access control list naming
the people or groups of people who may read it and append data to it. The system shall prevent
anyone not on the access control list from accessing the record in any way.

2. Record opening
Principle: A clinician may open a record with herself and the patient on the access control list.
Where a patient has been referred, she may open a record with herself, the patient and the
referring clinician(s) on the access control list.

3. Control
Principle: One of the clinicians on the access control list must be marked as being responsible.

4. Consent and notification

Principle: The responsible clinician must notify the patient of the names on record’s access
control list when it is opened, of all subsequent additions, and whenever responsibility is
transferred. His consent must also be obtained, except in emergency or in the case of statutory
exemptions.

5. Persistence
Principle: No-one shall have the ability to delete clinical information until the appropriate time
period has expired.

6. Attribution
Principle: All accesses to clinical records shall be marked on the record with the subject’s
name, as well as the date and time. An audit trail must also be kept of all deletions.

7. Information Flow
Principle: Information derived from record A may be appended to record B if and only if B‘s
access control list is contained in A’s.

8. Aggregation control
Principle: There shall be effective measures to prevent the aggregation of personal health
information.

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In particular, patients must receive special notification if any person whom it is proposed to
add to their access control list already has access to personal health

9. The Trusted Computing Base

Principle: Computer systems that handle personal health information shall have a subsystem
that enforces the above principles in an effective way. Its effectiveness shall be subject to
evaluation by independent experts.

Barriers of Clinical Information Systems

Despite the benefits being offered by Clinical Information Systems, there are barriers that
hinder its impact. These include some of the following:

 Initial cost of acquisition

 Privacy and Security.
 Clinician Resistance

2.3.6 Hands on practices on EHR experiences in Ethiopia

1. SmartCare Software

SmartCare was a portable, integrated EMR system that was used by three African countries
(Zambia, Ethiopia, and South Africa), and presumably is the largest EMR system in use in
Africa. The system was designed in Africa to be robust in environments with limited
infrastructure. The system also offers a touch screen interface to minimize the learning curve.
This comprehensive EMR system has different components (modules) that can be used in the
various units of healthcare facilities. The main modules of SmartCare include:
 Registration,
 Outpatient department,
 Inpatient (to admit, follow, and discharge patients in wards),
 Tuberculosis,
 Pediatrics,
 HIV/AIDS (to manage patients in antiretroviral therapy clinics),
 Antenatal care,
 Postpartum,
 Pharmacy,

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  Drug stock control,
 Laboratory (to store and send laboratory results to the requesting clinic),
 eHMIS (to generate monthly, quarterly, and annual reports), and
 Finance

Installation of the network, server infrastructure, and the EMR system at all hospital sites was
conducted by TUTAPE. After implementation, 5 day-long onsite user training sessions were
provided to all health professionals of each hospital. Additionally, TUTAPE computer and
network experts were responsible to provide continuous on-call service for technical assistance
during system failure. A Comprehensive Evaluation of Electronic Medical Record System
showed that SmartCare was found that 61.4% of the health professionals reported over all
dissatisfaction with the software and Physicians were more dissatisfied. Generally, health
professionals’ use of the EMR is low and they are generally dissatisfied with the service of the
implemented system.

However, the MOH currently withdraw SmartCare software from its health system and
working on developing new EHR platforms.

2. TenaCare

TenaCare was a series of national eHealth and mHealth applications. The suite consists of:

 Electronic medical record system,

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  Health management information and disease surveillance system,
 Analytics dashboard

All of these applications work together to enhance health systems and improve the quality of
health service delivery. With TenaCare, healthcare facilities can capture, store, analyze and
communicate patient information, all in a digital format. In addition, health administrators can
access real-time data, to make better, more efficient and evidence-based decisions.

The TenaCare Suite consists of:

A. TenaCaree-HMIS/PHEM: It is part of the TenaCare Suite developed to automate the

paper-based HMIS including disease surveillance systems. It helps to collect, make
sensible use and report public health indicators.
B. TenaCare-EMR: It enables health facilities to record individual patient health
information.
C. TenaCare-CHIS: It is a computerization of the health post information system or also
called as community health information system is to improve the effectiveness and
efficiency of the community health extension worker’s day to day activities.
D. TenaCare-HRIS: Enhance the availability of timely and accurate human resource for
Health data.
E. TenaCare-Score card: Visualization and analysis of selected indicators.
F. TenaCare-SPA+: Service Provision Assessment Plus Survey
G. TenaCare-mHealth: for alert notification

3. Integrated Digital Health Management System

It is an electronic health recording system started piloting in Black Lion Comprehensive

Specialized Hospital. Yet there is no published evidence on effectiveness of its implementation
status.

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2.4 ACTIVITIES

1. Evaluate the Ethiopian EMR/EHR implementation status. Discuss areas of success,

failure and its reasons?
2. Explore open source EMR software and evaluate its applicability in Ethiopia?

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2.5 SUMMARY

 EHR is a longitudinal systematic collection of electronic health information for a

patient generated by one or more interactions in any care setting
 EMR contains notes and information collected by and for the clinicians in that specific
office, clinic, or hospital setting and is mostly used by providers for diagnosis and
treatment.
 PHR is also frequently used, and refers to EHRs that are designed to be set up,
accessed, managed and controlled by patients in a private, secure and confidential
environment.
 Benefits of EMR/HER
o Easy for data access
o Helps for standardization
o Easily data update
o Improves quality of care
o It reduces costs of medical care
o Reduce loss of time
 The basic key components of an EHR includes:
o Patient Management Component
o Clinical Component
o Laboratory component
o Radiology Information System
o Billing System

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 2.6 SELF-ASSESSMENT QUESTIONS

Choose the best answer

1. Which one is specifically designed to be set up, accessed, managed and controlled by
patients in a private, secure and confidential environment?
A. Telemedicine C. PHR
B. EMR D. All
2. Which one is a limitation of paper-based records?
A. Accessibility problems, C. Redundancy
B. Inadequate information, D. All
3. An assessment that looks at infrastructure, standards adoption, business and clinical
processes, education and training, human resources capacity and public willingness
A. Effectiveness assessment C. Readiness assessment
B. Implementation assessment D. Acceptability assessment
4. Converting all users over to the EHR for all functions and all patients on the same time is
A. Big-Bang C. Both
B. Incremental D. None
5. One of the following is NOT included under clinical information systems?
A. Clinical Decision Support C. Training and Research
B. Electronic Medical Records D. None

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 CHAPTER THREE

TELEMEDICINE

3.1 INTRODUCTION

The use of technology to deliver health care from a distance, or telemedicine, has been
demonstrated as an effective way of overcoming certain barriers to care, particularly for
communities located in rural and remote areas. In addition, telemedicine can ease the gaps
in providing crucial care for those who are underserved, principally because of a shortage
of sub-specialty providers.

Telehealth is increasingly helping to address some health care barriers in developing

countries to have connected health. Connected health aims to maximize healthcare
resources through optimal use and the provision of more flexible digital health options for
consumers and clinicians to achieve better health outcomes. Telemedicine is one of the
approaches to create connected health.

This chapter consists definition of telemedicine and telehealth, history, basic concepts and
types of Telemedicine, components of a Telemedicine system, public health/clinical
specialties for application of TM and common health care areas, Telemedicine's Impact on
Health Care Delivery, potential Benefits and challenges related to the implementation of
Telemedicine.

3.2 LEARNING OUTCOMES

After studying this chapter, learners will be able to:

3.2.1 Describe concepts of telemedicine

3.2.2 Describe history of telemedicine
3.2.3 Discuss components of a telemedicine system
3.2.4 Describe types of telemedicine
3.2.5 Discuss the types of data/ information and information exchange in
telemedicine

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 3.2.6 Identify public health/clinical specialties for application of TM and common
health care areas
3.2.7 Describe telemedicine's impact on health care delivery
3.2.8 Identify benefits of telemedicine
3.2.9 Identify potential challenges related to the implementation of telemedicine

3.3 SESSION CONTENTS

3.3.1 Concepts of telemedicine

Telemedicine sometimes used interchangeably with telehealth which refers specifically to

remote clinical services that focus on a curative aspect of care. In contrast, telehealth is broader
in scope and includes disease prevention and digital health promotion as well as curative care.
Therefore, telemedicine can actually be considered as a sub-domain of telehealth.

Tele-health: It is the use of telecommunication techniques for the purpose of providing

telemedicine, medical and health education over a distance.

Where Telehealth and telemedicine technologies help to provide health services remotely, we
call it connected health. The Connected health aims to maximize healthcare resources through
optimal use and the provision of more flexible digital health options for consumers and
clinicians to achieve better health outcomes.

Tele-care: Tele-care is a term given to offer remote care for elderly and vulnerable people,
providing the care and reassurance needed to allow them to remain living in their own homes.

Telemedicine: the definition of telemedicine is somewhat controversial. Some definitions

(such as the definition given by the World Health Organization include all aspects of healthcare
including preventive care. The American Telemedicine Association uses the terms
telemedicine and telehealth interchangeably, although it acknowledges that telehealth is
sometimes used more broadly for remote health not involving active clinical treatments.

The American Telemedicine association define telemedicine as "use of medical information

forwarded from one place to another through electronic communication means in order to
increase the patient's health status”.

On the other hand, World Health Organization (1997) define as: “Telemedicine is the delivery
of health-care services, where distance is a critical factor, by health-care professionals using
ICTs for the exchange of valid information for diagnosis, treatment and prevention of disease

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and injuries, and for the continuing education of health-care providers as well as research and
evaluation, all in the interests of advancing the health of individuals and their communities”.
The prefix ‘tele’ derives from the Greek word for ‘at a distance’ hence, more simply,
telemedicine is medicine at a distance. As such it encompasses the whole range of medical
activities including diagnosis, treatment and prevention of disease, continuing education of
health care professionals and consumers.

Telemedicine doesn't have to use high technology and its application ranges from simple
telephone consultation to highly complex Tele-surgery.

But Telemedicine is not:

 a new technology

 a new branch of medicine

 Completely new and

 a replacement of health workers

Tele-Medicine Information System

A telemedicine information system consists of three major domains acquisition spoke,

telecommunication and center of excellence hubs. Acquisition spoke is about capturing the
required healthcare data of the patient/client. Telecommunication is mainly used for
transferring the captured. Center of excellence hub is a destination where the health data sent
for second party opinion.

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 Figure 6: Telemedicine Information System

3.3.2 History of telemedicine

The exact date when telecommunications first were used in health care is unknown. It is known
that telegraph was used during American Civil War to transmit casualty lists and order medical
supplies.

In the early 1900s, people living in remote areas of Australia used two-way radios, powered by
a dynamo driven by a set of bicycle pedals, to communicate with the Royal Flying Doctor
Service of Australia.

In 1967 one of the first telemedicine clinics was founded by Kenneth Bird at Massachusetts
General Hospital. The clinic addressed the fundamental problem of delivering occupational
and emergency health services to employees and travelers at Boston's Logan International
Airport located three congested miles from the hospital. The first interactive telemedicine
system, operating over standard telephone lines, designed to remotely diagnose and treat
patients requiring cardiac resuscitation was developed and launched by an American company,
MedPhone Corporation, in 1989. A year later under the leadership of its President/CEO S Eric
Wachtel, MedPhone introduced a mobile cellular version, the MDPhone. Twelve hospitals in
the U.S. served as receiving and treatment centers.

Evolution of technology also changes the system of telemedicine.

 Point to Point System -in the early time, one patient end connects to One Specialist
within the hospital

 Point to Multi Point System - One patient end at a time connect to any of the
specialists’ end within the hospital.

 Multi Point to Multi Point System - Several patients’ end simultaneously connect to
different specialists’ end at different hospitals at different geographical locations

3.3.3 Components of a telemedicine system

Successful implementation of Telemedicine requires appropriate equipment and some kind of

telecommunication medium. However Successful Telemedicine requires more than the technology. The
following are the essential components for the successful implementation of Telemedicine:

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 Figure 7: Components of telemedicine system

1. Trained people: For any telemedicine system to work in a real clinical situation suitable,
committed and trained personnel are essential. People with the necessary skills to
undertake the clinical components are required at both ends of any telemedicine link. This
means that there must be trained staff at the referring end of the link and at the specialist
or consulting end of a Telemedicine link who are able to handle the patient contact
required.

2. Technology: The technology is in many ways the most straightforward part of

telemedicine system and once a working link has been established it can largely be ignored.
Many of the equipment required may already be available for other purposes and can be
shared if planned properly. Reliability is a requirement for all medical equipment and
telemedicine equipment is not exception. For telemedicine all the equipment needs to
function properly, since any malfunction will break the chain of required for a successful
link.

The technology required for a telemedicine link can be divided as follows:

I. Equipment to capture the clinical information at each site

II. The telecommunications link: needed to transmit information between the

sites.

III. Equipment to display the information at each site

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 IV. Telemedicine Software

I. Equipment to capture the clinical information at each site

A. High definition examination camera

B. Digital medical equipment like:

Telemedicine Medical Devices: Quality medical devices are useful for successful clinical
telemedicine applications; rely heavily on the clarity of medical images and data collected
during the patient encounter. Developers need to work on the development of reliable medical
devices and equipment that deliver superior quality medical images and precise patient data,
even in difficult and remote telemedicine applications. All the medical devices should have a
capability to integrating with other third-party devices as well.

List of medical devices commonly used for telemedicine

 Examination Cameras  ECGs

 Medical Scopes  Retinal Camera

 Stethoscopes  Ultrasound Probes

 Vital Signs Monitors

Types of device Example

Common diagnostic devices Stethoscope, Otoscope, Dermoscope, Vital signs monito

Common imaging devices Echocardiogram, Angiogram, Ultrasound, Microscope

Common surgical devices Laparoscope, Endoscope, Duodenoscope, Colonoscope

1. Examination cameras

The General Examination Camera enables

healthcare professionals to assess a patient from an
entirely remote location. This examination camera
was developed specifically for telemedicine
applications to capture and display high resolution
video and images of a patient encounter. With only
4 buttons to keep things simple, this is the first

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camera to combine power zoom, auto or manual focus, frame capture and electronic image
polarization into one small, single-hand operated camera.

2. Medical Scopes

There are different types of medical Scopes that can be used for telemedicine service. The
following are some of the medical scopes,

a) ENT Otoscope: The Ear/Nose/Throat

Otoscope, is use to cover the full range of ear,
nose and throat examinations. This device is
unique because it combines the functionality
of a high-performance otoscope, a short sinus
scope and an oral exam scope into a single
diagnostic device, with an exceptionally clear, wide field of view. The video ENT
Otoscope is used in telemedicine applications to perform pneumatic otoscope exams in
order to obtain an exceptionally clear view of the out-ear canal, ear drum and middle
ear.

b) Dermo scope: The Derma-scope is ideal for use

in telemedicine applications that require a visual
observation of the epidermis. This superior
surface contact microscope is used to help
examine skin lesions and provide high resolution
images to a remote specialty provider, or to
document and archive an existing condition.

c) Stethoscopes: Telephonic Stethoscope

Synchronized Quality Auscultation at a Low
Bandwidth. The core of many clinical telemedicine
assessments are the heart and/or lung sounds. The
Telephonic Stethoscope delivers high quality
electronic auscultation to remote physicians using
low data bandwidth. This stethoscope, developed
for telemedicine applications, creates an audio
signal of the auscultation sounds and transmits it

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 electronically in real time. This allows the clinician
(local user) and remote physician (remote user) to
hear the patient's heart/lung sounds at the same time
so they can work together to treat the patient.

3. Vital sign Monitor:

Vital sign Monitor is the ideal medical device to quickly

capture and measure a patient's physiological statistics at
the start of a clinical telemedicine exam. Clinicians of all
skill levels can easily take accurate blood pressure, body
temperature, pulse rate and respiratory rate in a matter of
seconds.

4. ECG:

Digital ECG is a PC-based resting electrocardiograph system perfect for telemedicine

applications because it makes patient diagnostic information more readily available for both
the clinician and remote consulting physician.

5. Retinal Camera:

The Non-Mydriatic Retinal Camera is an ophthalmic

instrument used to capture high resolution color and
monochrome images of the retina and the anterior
segment of the human eye. It is ideal for telemedicine
programs that include primary care or ophthalmology
services because it aids in diabetic screening and early
detection of glaucoma and other eye diseases.

6. Abdominal USB Ultrasound Probe:

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The Abdominal USB Ultrasound Probe is perfect for OB, GYN or other internal examinations
that require quick and easy access to high quality
ultrasound images, for telemedicine applications. All
you need is a laptop, tablet or desktop computer with a
USB port and you will be able to save, send and print
images taken with the probe.

II. Telecommunications link:

It’s needed to transmit information between the sites, includes:

 Telecommunication network
 Internet
 LAN, WAN…
III. Equipment to display the information at each site.
 Computers
 Projector
 TV sets
 Mobile (Telephone)
 Tape Recorder / Speaker

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IV. Telemedicine Software:

It is the other technology components for telemedicine.

Figure 8: Telemedicine software components

Content for Telemedicine Software

The typical data captured for Telemedicine are:

 Patient Demographics: name and patient Id, and address
 Patient History: Past illness, Present illness, Treatment details etc.
 Details of Examinations, Investigations and Diagnosis: General/Physical Examination and
observations
 Attachment of Images: Images captured directly through medical equipment, scanned
images, photograph, etc.
 Attachment of Files: (other than images) related to patient examination and history.
 Report(S): Based on examinations, the report can be either structured (depending on the
clinical protocol involved) or unstructured.
Selecting telemedicine technology

Before selecting the technology, it is necessary to consider the nature of the information to be
transmitted between the sites, factors to be considered include:

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 1. The types of information to be transmitted,
2. The quantity of information to be transferred,
3. Security and privacy.
Also, the following factors should be considered when we select telemedicine technology.
 volume of data to be transferred (depends on the type of service, application and the
quality of service) required
 Transfer speed
 Infrastructure and telecommunication facilities available
 Price of the service
 Required interfaces of the equipment in use to the telecommunication network

For Example: Required transfer time of an X-ray image with the size of 64 Mb: PSTN 64
KB 17min with compression 35 Sec, B-ISDN &ATM 155Mbps 0.4 sec with compression
0.02 sec

3.3.4 Types of Telemedicine

The scope and categorization of telemedicine practice have changed as the technology has
developed. There are different categorizations. The common thread of all telemedicine application
is that a client of some kind (e.g. patient or health care provider) obtains an opinion from someone
with more expertise in the relevant field, when the two parties are separated in space, in time or
both. Telemedicine can be classified on the basis of:

 The interaction between the client and the expert

 The type of information being transmitted

A. Classification based on interaction between the client and the expert

The type of interaction is usually classified as either prerecorded (also called store and forward)
or real time (also called synchronous).

I. Store-and-forward type of telemedicine

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Asynchronous Transmission of recorded health history through an electronic communications
system to a practitioner, usually a specialist uses information to evaluate the case outside of a real-
time or live interaction. It involves acquiring medical data (like Medical images, Bio-signals etc.)
and then transmitting this data to a doctor or medical specialist at a convenient time for
assessment offline. It does not require the presence of both parties at the same time. A properly
structured medical record preferably in electronic form can be a component of this transfer. E.g.
Tele Dermatology, Radiology, and Pathology are common specialties that are conducive to
asynchronous telemedicine.

Pre-recorded: Information is acquired and stored

in some format, before being sent, for expert
interpretation (e.g. Tele radiology).

Digital images, video, audio, observation of daily

living (ODLs), and clinical data are captured and
"stored" on the client computer or mobile device;

At a convenient time, data transmitted securely

("forwarded") to a clinic at another location where
they are studied by relevant specialists. The opinion
of the specialist is then transmitted back. Based on
the requirements of the participating healthcare
entities, this roundtrip could take 1 minute to 48
hours.

In the simplest form of telehealth application, basic vital signs like blood pressure, weight, pulse
oximeter, and blood sugar values are monitored and trended for long term chronic care.

In many specialties, such as dermatology, radiology and pathology, an immediate response is not
critical, making these specialties conducive to store-and-forward technologies

Benefit of store and forward types of telemedicine

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  Store-and-forward telehealth is an efficient way for organizations to handle referrals
because specialists can take on a certain amount of workload during their unscheduled
down times.

 Consultants need a relatively small amount of time per case to respond to a telehealth
consultation.

 Store-and-forward tele-health has been shown to be an effective pre-surgical tool for

accurately estimating operative times for patients needing surgery.

 The expert triage model provides a needed consultation service in those areas without
access to particular specialties.

 Secondary benefits to S & F tele-health include effective triage so that waiting times
for appointments with specialists are reduced as are the appointment backlogs for
specialty clinics.

 Access for specialty care is thereby improved

 Additional benefits include better documentation, archiving, and educational

opportunities.

 Store-and-forward tele-health decreases patient travel costs.

Challenges of store and forward types of telemedicine

 The sending site incurs much of the equipment expense and manpower to create an
S&F tele-health case.

 There is no/little reimbursement for the sending (referring) site;

 There is no/little financial incentive for the sending clinician to take the time to create
and send the S & F tele-health case.

II. Real-Time (Synchronous)

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It is live, and two-way interaction between a patient and health care provider using audiovisual
telecommunications technology. Interactive telemedicine services provide real-time interactions
between patient and health care provider.

In Real-time types of telemedicine there is no appreciable delay between the information being
collected, transmitted and displayed. (e.g. Tele-psychiatry)

Many activities such as history review, physical examination, psychiatric evaluations and
ophthalmology assessments can be conducted comparably to those done in traditional face-to-face
visits. In addition, "clinician-interactive" telemedicine services may be less costly than in-person
clinical visit. In real-time telehealth, a telecommunications link allows instantaneous
interaction. Videoconferencing equipment is one of the most common forms of real-time (or
"synchronous") telemedicine.

Peripheral devices can also be attached to computers or the video-conferencing equipment which can aid
in an interactive examination. With the availability of better and cheaper communication channels, direct
two-way audio and video streaming between centers through computers is leading to lower costs.

Table 4: The difference between synchronous and asynchronous types of telemedicine

Real Time S&F

Require schedule Yes No
Requires in person presenter and or on-site technical facilitator Usually No
Requires specific specialist clinic time Yes No
May result in a “no-show” DNKA=didn’t keep appointment Yes No
Requires equipment investment, maintenance, and training Yes Yes
Requires higher network bandwidth Yes No

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 III. Remote Patient Monitoring

Personal health and medical data collection from an individual

in one location via electronic communication technologies,
which is transmitted to a provider in a different location for
use in care and related support. Also known as self-monitoring
or testing. It enables medical professionals to monitor a patient
remotely using various technological devices and primarily
used for managing chronic diseases. These services can
provide comparable health outcomes to traditional in-person
patient encounters, supply greater satisfaction to patients, and
may be cost-effective

B. Classification based on the type of information being transmitted

The information transmitted between the two sites can take many forms, including data and text,
audio, still images and video pictures. Combining the type of interaction and the type of
information to be transmitted telemedicine can be classified as tele-radiology, tele-psychiatry, tele-
pathology, tele-dermatology, tele-ophthalmology, etc. Some scholars also categorize telemedicine
as:

 Teleconsultation
 Telemonitoring
 Tele-education
 Telesurgery

Teleconsultation: The medical consultation is at the heart of clinical practice. Therefore,

teleconsultation is to support clinical decision making. It is the most common telemedicine service.

A teleconsultation can take place between two or more careers without patient involvement or
between one or more careers and a patient. The simplest example is a telephone conversation
between two physicians to obtain a second opinion.

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Telemonitoring: is the use of a telecommunications link to gather routine or repeated data on a
patient’s condition. The acquisition process may be manual, in which case the patient records the
data and transmits them by telephone, computer/modem system.

The process of using audio, video, and other telecommunications and electronic information
processing technologies to monitor the health status of a patient from a distance.

Alternatively, the acquisition may be entirely automated so that continuous data can be submitted
either in real time or in store-and-forward mode.

E.g. a cardiologist checks up the progress of a heart transplant patient while away on a business
trip or enjoying in Sodore, reviewing the patient’s chart, looking at live heart rhythms and talking
to the patient

Tele-education: We can distinguish several types of tele-education depending on who is the

recipient and what the purpose of the transmission is:

 clinical education from teleconsultation

 clinical education via the Internet

 academic study via the Internet

 public education via the Internet

Tele-surgery: Compared with the other ‘tele’ applications discussed so far, tele-surgery is in its
infancy. It is practiced in two ways.

I. Tele-monitoring, the assistance given by specialists to surgeons carrying out a surgical

procedure at a remote location. Typically, the assistance is offered via a video and audio
connection that can extend elsewhere in the building or over a satellite link to another
country. Clearly, there is a strong element of tele-education in tele-monitoring.

II. Telepresence surgery, which guides robotic arms to carry out remote surgical procedures.
The links allow large movements of the surgeon’s hands to be scaled down so that very
precise, tremor-free incisions can be made. The technique known as movement scaling
has the potential to allow doctors to repair damage inside vessels.

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 3.3.5 Information exchange in telemedicine

Different clinical situations generate very different types of clinical information. There are many
possible sources of data that can be used in telemedicine applications. In some cases, this can be
relatively simple information, such as concentrations of a metabolite. In others more qualitative
and subtle information is needed, as in psychiatric assessments, where observations of posture,
speech and mental state are required.

Not all information will be needed at every site. Tele-psychiatry application will probably require
ordinary commercial videoconferencing equipment instead of very high-quality audio or video
signals. Tele-monitoring service will require only data and text transfer, without audio and video.

The clinical need for any telemedicine project must be carefully assessed before making decisions
about what equipment will be required to avoid disproportionate setup.

The volume of digital information to be transferred matters the type of technology to be used. One
method by which the total volume of information can be reduced is to compress it first, and then
decompress it on reception. This is not always an acceptable technique for medico legal reasons
(i.e. only the original raw signal may be considered acceptable)

The types of information that are relevant to telemedicine can be divided into five broad categories:

a. Documents,
b. Electronic medical records,
c. Still images,
d. Audio
e. Video.
I. Documents
Documentary information (e.g. reports, letters or static medical records) can be transmitted in
digital form, if the information already exists as a computer text file. Paper documents can be
digitized using scanner or a document camera, and then transmitted as still images. Non-urgent
cases, copies of written records can be posted to the consultant end of the link in advance, or paper
documents can be faxed before or during a telemedicine session.

II. Electronic medical records

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Traditional paper-based records are gradually being replaced by electronic medical records
(EMRs). Efforts are underway to create a highly interoperable EMR system, where data can flow
across the health-care continuum seamlessly. EMRs will allow instant access to a patient’s record,
including the business operations such as billing and reimbursement. Hence, we can directly
transfer patient EMR for telemedicine consultation in both S&F and real time communications

III. Still images

For many telemedicine purposes, a simple photographic image may be sufficient. For instance,
low-cost digital cameras now provide very good imaging quality and may be adequate to capture
an image of a skin lesion for tele-dermatology or a view down a microscope for tele-pathology.
Alternatively, an inexpensive flatbed scanner can be used to digitize photographs or charts such as
electrocardiogram (ECG) traces for relatively simple diagnoses, such basic equipment may be
more than adequate, e.g. for emergency room assessment of X-rays of a simple fracture. Another
inexpensive method is to capture still images using a video camera, possibly one that is specially
designed for imaging documents. In addition, many diagnostic instruments now provide a video
output, for example ultrasound scanners. Still images can be recorded with a video capture card
on a personal computer (PC) and a suitable screen capture program.

IV. Audio
At its simplest, voice transmitted by telephone or radio can be used for some remote diagnoses.
Telephones use analogue Transmission, which is therefore susceptible to noise and loss of quality,
particularly over long distances. Digital signal transmission offers many advantages, particularly
since digital signals can be transmitted over networks for long distances without degradation.

It is also possible to process a digital signal in various ways, including compressing it so that a live
or recorded voice requires less data to be transmitted than the original signal. Most modern PCs
are equipped with a sound card that is suitable for capturing audio for telemedicine purposes and
no special equipment is required other than a suitable microphone.

In some cases, it is also possible to connect these cards directly to the equipment that is being used;
for example, the audio output of an ultrasound scanner can be connected to the PC. Another option
is simply to use an ordinary telephone line as the audio portion of the session. This frees up more
bandwidth for video.

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 V. Video
A common view of telemedicine is that it only involves real-time video images transmitted
between remote sites for the purposes of consultation between a doctor and a patient. In cases
where video transmission is considered appropriate, the issue arises of what video quality is
required, since unsurprisingly the higher than quality, the higher the cost of the equipment and the
transmission.

A wide range of telemedicine equipment and accessories is available commercially. The benefit
of using commercial suppliers is the technical assistance that they can provide, which includes
setting up the working connection and (in most cases) a help desk for technical problems.

3.3.6 Specialties and common application areas for TM

A. Specialty areas:

Mental Health, Cardiology, Dermatology, Pediatrics, Radiology, Home Health, Orthopedics,

Neurology, Oncology, General Surgery and ophthalmology are the clinical specialties in which
telemedicine application can be used. Among the above specialty areas, tele-mental health, tele-
cardiology, tele-dermatology, tele-radiology and tele-ophthalmology are the most used specialty.

B. Common health care application areas:

I. Rural Health:

One of the greatest challenges in rural health is assuring that medical expertise is available when
it is needed and where it is needed. This is difficult for remote rural healthcare facilities because
they are often unable to attract, afford or retain specialty providers. Telemedicine helps to solve
these issues by allowing access to specialists regardless of location. This is done using live video
conferencing, or real-time medical image sharing/communication portals. The specialist can
examine the patient, review vital signs and patient history, provide assessment, diagnosis and
treatment.

Telemedicine also helps rural facilities to train and retain clinicians because telemedicine allows
on-the-job experience and remote participation in grand rounds.

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 II. Prison Facilities:

Telemedicine allows prison facilities to deliver high quality care without cost and dangers of
transportation or need for physicians in the facility. Telemedicine has proven effective for primary
care, disease prevention, etc.

III. School-Based Health Centers:

School-based TM programs significantly keeping children healthier & reducing absences due to
illness. Telemedicine helps to manage chronic conditions such as asthma, diabetes & obesity.
School nurse is an isolated health care provider so, telemedicine allows a school nurse to remotely
access expert medical opinion in need. This means a student can be treated without missing school
for a doctor appointment.

IV. Disaster Relief:

The benefits for disaster relief are similar to rural health. Telemedicine helps to deliver healthcare
quickly after a disaster has hit. It provides on-site healthcare providers with rapid access to
advanced medical expertise and emergency triage capabilities that would not be possible without
the use of real-time patient assessment technologies.

V. Shipping and Transportation:

The use of telemedicine on cargo ships, cruise ships, private yacht, or commercial airplanes can
help avoid the high cost of evacuations and unscheduled diversions that are caused from a medical
emergency. Telemedicine allows access to advance healthcare expertise; triage advice as well as
diagnosis and treatment regardless of where the ship or plane be.

VI. Industrial Health:

Industrial sites such as mines, drilling platforms or industrial campuses highly depend on the health
of their employees to operate. They must respond to an unpredictable set of health needs to support
sometimes hundreds of employees. Telemedicine avoids the high cost evacuations and assures that
the worker receives the best possible treatment and is available to support operations as soon as
possible.

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 3.3.7 Telemedicine's impact on health care delivery

Cost of Care: The cost of telemedicine should be analyzed in relation to how it improves the
health of a population by preventing or treating a disease. The measurement of potential cost
savings associated with a telemedicine application depends on the interest group (e.g., patient,
health maintenance organization, provider, society). For example, telemedicine decreases the
opportunity costs for patients in seeking care (by reducing travel expenses to visit a specialist).

Quality of Care: These dimensions include the technical capacity that addresses the safety and reliability
of the technology used, diagnostic accuracy and impact, and patient outcomes

Access to Care: Access to health services reflects the “fit” between health care resources
(including hospitals, clinics, and doctor’s, specialists) and the health care needs of the people they
serve. The three primary types of barriers to access in relation to telemedicine: infrastructure,
financial, and personal/cultural barriers, and the ways telemedicine can eliminate those and
possibly introduce new ones because of the technology use.

3.3.8 Potential benefits of telemedicine

Telemedicine can be beneficial to patients in isolated communities and remote regions, who can
receive care from doctors or specialists far away without the patient having to travel to visit them.
Recent developments in mobile collaboration technology can allow healthcare professionals in
multiple locations to share information and discuss patient issues as if they were in the same place.
Remote patient monitoring through mobile technology can reduce the need for outpatient visits
and enable remote prescription verification and drug administration oversight, potentially
significantly reducing the overall cost of medical care. Telemedicine can also facilitate medical
education by allowing workers to observe experts in their fields and share best practices more
easily. Additionally, some patients who feel uncomfortable in a doctor’s office may do better
remotely. For example, white coat syndrome may be avoided. Patients who are home-bound and
would otherwise require an ambulance to move them to a clinic are also a consideration.

We can summarize the benefits of telehealth and telemedicine as:

 Reduction in healthcare costs

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  Increased patient access to healthcare especially in underserved areas

 Improved quality and continuity of care

 Improved access to healthcare colleagues by remote care providers

 Increased accuracy in care delivery

 Optimized use of digital health assets

 Improved scope of medical services offered

 Greater access to continuing medical education

 Reduced time to diagnosis and treatment with expedited consultations

 Improved gathering of digital health data in remote areas

 Increased productivity of healthcare staff

3.3.9 Challenges related to the implementation of telemedicine

The downsides of telemedicine include the cost of telecommunication and data management
equipment and of technical training for medical personnel who will employ it. Virtual medical
treatment also entails potentially decreased human interaction between medical professionals and
patients, an increased risk of error when medical services are delivered in the absence of a
registered professional, and an increased risk that protected health information may be
compromised through electronic storage and transmission. There is also a concern that
telemedicine may actually decrease time efficiency due to the difficulties of assessing and treating
patients through virtual interactions; for example, it has been estimated that a tele dermatology
consultation can take up to thirty minutes, whereas fifteen minutes is typical for a traditional
consultation. Additionally, potentially poor quality of transmitted records, such as images or
patient progress reports, and decreased access to relevant clinical information are quality assurance
risks that can compromise the quality and continuity of patient care for the reporting doctor. Other
obstacles to the implementation of telemedicine include unclear legal regulation for some tele-
medical practices and difficulty claiming reimbursement from insurers or government programs
in some fields.

Challenges to implementation: Technology alone does not produce success.

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Some success factors like champion, coordinator, education and training, engagement of care
providers, availability of services, technical and program support, stable technology, funding &
reimbursement mechanisms should be in place for the successful implementation of telemedicine.
The factors that contribute for the failure of telemedicine implementation can be:

A. Technology related

B. Behaviour related

C. Financial Related

D. Legislative- Licensure, Reimbursement, Policy

A. Technology related:

 Scarcity of high-bandwidth telecommunication networks in rural areas

 Compatibility of old equipment with telemedicine

 Reliability of Technology
 Connections: Ease and Reliability of Contact and Interface Standards
 Peripheral Equipment: Quality – Digital vs. Digitized and Transmission Protocols
B. Behaviour:

 Resistance to Telemedicine –fear that nurses are delegating tasks to machines

 Lack of Public Awareness
 Lack of information technology knowledge and usage among healthcare professionals
and clients
 Change Management – understanding the capabilities and limitations of the technologies
and applying them appropriately
 Poor Leadership
 Organizational and Work-Flow Change. The changes in work-flow that are necessary to
migrate to an electronic system are significant and difficult to undertake without a clear
business case or incentives.
C. Legislative- Licensure, Reimbursement, Policy

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  Licensure

 Legal, ethical responsibilities

 Cross jurisdictional issues

 Privacy and confidentiality of information

 Reimbursement – what is reimbursed and who is going to pay for it?

 Policy

 Lack of uniform standards

 Liability

 Who is responsible for the patient?

 Anyone can establish a web site to offer consulting

D. Financial

 The initial Cost is very high– hardware, software, implementation and

organizational change

 Increase of healthcare costs because of improving the quality of service

 Telemedicine System are not used very often

 Who is going to pay for the expenses?

 Who is responsible to sustain/add programs?

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3.4 ACTIVITIES

A 35 years old patient came to a hospital complaining of generalized body swelling which initially
started from the abdomen and gradually involved other body parts. The physician at consulting
hospital made a chest x-ray. Based on the x-ray and clinical finding he suspected a TUMOR IN
THE LUNG. Under normal condition the patient has to travel to the referral hospital (600 km) to
have the right diagnosis.

The resulting final diagnosis was not a tumor but localized fluid collection in the lung.
Based on the above case scenario:
1. Which type of TM service is appropriate for the above scenario?

2. What are the benefits this patient got from above TM service?

(Hint: think the benefits related to cost, related to medical or any other dimension).

3. Do you think that the physician working at the referring hospital got benefits from above
TM service? If yes what benefits he got?

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3.5 SUMMARY

 Telemedicine is the delivery of health care and the exchange of health care
information across distances.
 Telemedicine encompasses the whole range of medical activities including
diagnosis, treatment and prevention of disease, continuing education of health care
professionals and consumers.
 Tele-health is the use of telecommunication techniques for the purpose of providing
telemedicine, medical education, and health education over a distance.
 Telemedicine is not a new technology, not a new branch of medicine, not completely
new and, not a replacement of health workers.
 Trained people, technology, funding and process are the components of telemedicine system.
 Telemedicine can be classified on the bases of the interaction between the client and
the expert and the type of information being transmitted.
 Based on interaction between the client and the expert it can be classified as:
 Store and forward
 Real time and
 Remote patient monitoring

Benefits of telemedicine includes:

 Improved Access: Covers previously unserved or underserved areas.

 Improved quality of care: Enhanced decision making through collaborative
efforts.
 Reduced isolation of healthcare professionals: Peer and professional contacts for
patient consultations and continuing education.
 Reduced costs: Decreased necessity for travel & optimum uses of resources

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 3.6 SELF-ASSESSMENT QUESTIONS

1. Telehealth differs from Telemedicine in that;

A. Telemedicine is a broader term than telehealth and emphasizes the provision of
information to health care providers and consumers.
B. Telehealth encompasses Telemedicine but it is a broader term that emphasize the
provision of information to health care providers and consumers.
C. Telemedicine uses the internet to provide professionals with information while telehealth
does not.
D. Transmission of still images is only for telemedicine.
2. All are benefits of telemedicine except.
A. Loved one remain in their community with family support
B. Early diagnosis prior to escalated medical episodes
C. Cost saving from travel extensively
D. None
3. A robotic arm to carry out remote surgical procedures is
A. Tele-education surgery C. Tele-mentoring surgery
B. Telepresence surgery D. All
4. Which one of the following factors need to be considered before selection of Telemedicine
technology?
A. Information security and privacy C. Type of information to be transmitted
B. Quantity of information to be transferred D. All
5. In telemedicine there are two ends, patient-end and physician’s-end; one of the following is
common for both patient-end and physician’s-end?
A. Internet, telecommunication, LAN, WAN C. Digital X-Ray Machine
B. Digital vital sign monitor D. None
6. Which one of the following is correct about telemedicine?
A. Telemedicine is not new technology
B. Telemedicine is a new branch of medicine
C. Telemedicine is replacement of health workers
D. None

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 CHAPTER FOUR

MOBILE HEALTH

4.1 INTRODUCTION

Within digital health, mHealth (mobile health) encompasses all applications of

telecommunications and multimedia technologies for the delivery of healthcare and health
information. The term is most commonly used in reference to using mobile communication
devices, such as mobile phones, tablet computers and PDAs, and wearable devices such as smart
watches, for health services, information and data collection.

This chapter consists definitions of mHealth, types of m-health applications and the mHealth frame
work in Ethiopian context. Besides, it covers the experiences of mHealth interventions in Ethiopia.

4.2 LEARNING OUTCOMES

At the end of this session, students will be able to:

4.2.1. Describe concepts of mHealth

4.2.2. Identify benefits of mHealth
4.2.3. List principles for mHealth interventions
4.2.4. Identify key considerations for mHealth Interventions
4.2.5. Describe the different types of mHealth applications
4.2.6. mHealth in Ethiopia

4.3 SESSION CONTENTS

4.3.1 Concepts of mHealth

The rapid development of a variety of new technologies is making a huge impact on healthcare
fields. One of those technologies is mobile health (mHealth) systems. There are various definitions
of mHealth. The Global observatory for eHealth of the World Health Organization defines

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mHealth as “medical and public health practice supported by mobile devices, such as mobile
phones, patient monitoring devices, personal digital assistants, and other wireless devices”.
However, these definitions of mHealth are not universally accepted as of yet. Alternatively,
mHealth may mean the use of mobile devices to monitor or detect biological changes in the human
body, while device management entities, such as hospitals, clinics, or service providers, collect
data and use them for healthcare and health status improvement.

The mHealth field has emerged as a sub-segment of eHealth, the use of information and
communication technology (ICT), such as laptops, tablets, mobile phones, PDAs communications
satellite, patient monitors, etc, which can be used for text, voice or image communication, and can
collect, process and report data for health services and information.

These devices have a range of functions from mobile cellular communication using text messages
(SMS), photos and video (MMS), telephone, and World Wide Web access, to multimedia playback
and software application support. Technological advances and improved computer processing
power mean that single mobile devices such as smart phones and PDA phones are increasingly
capable of high level performance in many or all of these functions.

The features of mobile technologies that may make them particularly appropriate for improving
health care service delivery processes relate to their popularity, their mobility, and their
technological capabilities. The popularity of mobile technologies has led to high and increasing
ownership of mobile technologies, which means interventions can be delivered to large numbers
of people.

“mHealth and eHealth are inextricably linked where both are used to improve health outcomes
and their technologies work in conjunction. For example, many eHealth initiatives involve
digitizing patient records and creating an electronic ‘backbone’ that ideally will standardize access
to patient data within a national system. mHealth programs can serve as the access point for
entering patient data into national health information systems, and as remote information tools that
provide information to health care clinics, home providers and health workers in the field. While
there are many stand-alone mHealth programs, it is important to note the opportunity mHealth
presents for strengthening broader eHealth initiatives.”

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With the continuous and enormous spread of mobile technologies, mHealth has evolved as a new
subfield of eHealth. While eHealth is broadly focused on information and communication
technologies, mHealth seeks to explore more into mobile devices and wireless communication.
Since mobile phone penetration has exceeded other infrastructure in low and middle-income
countries (LMICs), mHealth is seen as a promising component to provide pervasive and patient-
centered care.

mHealth is one aspect of eHealth that is pushing the limits of how to acquire, transport, store,
process, and secure the raw and processed data to deliver meaningful results. mHealth offers the
ability of remote individuals to participate in the health care value matrix, which may not have
been possible in the past. In many cases remote users are valuable contributors to gather data
regarding disease and public health concerns.

The motivation behind the development of the mHealth field arises from two factors. The first
factor concerns the myriad constraints felt by healthcare systems of developing nations. These
constraints include high population growth, a high burden of disease prevalence, low health care
workforce, large numbers of rural inhabitants, and limited financial resources to support healthcare
infrastructure and health information systems. The second factor is the recent rapid rise in mobile
phone penetration in developing countries to large segments of the healthcare workforce, as well
as the population of a country as a whole. With greater access to mobile phones to all segments of
a country, including rural areas, the potential of lowering information and transaction costs in order
to deliver healthcare improves. This rapid adoption of technology globally brings with it the
opportunity for mHealth to have a different impact than traditional health services, and on a greater
scale

Basic SMS functions and real-time voice communication serve as the backbone and the current
most common use of mobile phone technology. The appeal of mobile communication technologies
is that they enable communication in motion, allowing individuals to contact each other
irrespective of time and place. This is particularly beneficial for work in remote areas where the
mobile phone, and now increasingly wireless infrastructure, is able to reach more people, faster.

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As a result of such technological advances, the capacity for improved access to information and
two-way communication becomes more available at the point of need.

4.3.2 Benefits of mHealth

In many developing countries, much of the population, especially in rural areas, does not have
access to the health care system due to resource constraints, system inefficiencies and a lack of
awareness about services that are offered. The inadequate presence of health facilities and
providers in many communities has been compounded by a lack of access to modern
communication technologies, which further limits citizens’ awareness of how to receive health
services and education and providers’ ability to deliver them. Yet a number of developments will
change this situation. Increased efforts by governments to strengthen health systems are bringing
access to care closer to the people who need it, and the revolution in mobile communications is
providing a way to further strengthen the health system and bridge gaps that still exist. At the
confluence of these trends lies mobile health (mHealth).

Users of m-health services and applications range from individual patients and providers of health
related goods and services to healthcare workers. mHealth can contribute to achieving universal
health coverage (UHC) through making services available to remote populations and underserved
communities and providing mechanisms for data exchange on patients and services. It can be used
to increase access to and provision of health services in areas where there is little infrastructure to
support the internet (or other technologies) or traditional health services, but where mobile
communications technology infrastructure has been prioritized. Supplying the technology for
mobile communications is cheaper than providing in-person services.

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 Figure 9: the role of mHealth in improving health outcomes

4.3.3 Principles for mHealth interventions

The five core principles

The five core principles, also known as the Green tree Principles, are:

1. Health centric: The design should be people-oriented, meaning that the technology is
designed to meet the health needs of people, rather than making health needs fit the technology.
2. Field-based systems: The system should be non-theoretical and based on field evidence.
3. Collaborative and parallel processes: The architecture should encourage transparency, local
control and open competition.
4. Digital technology: The technology architecture should be open-standards, interoperable,
agile, iterative and rapid.
5. Sustainability: The system should be supported by adequate resources to ensure scalability
and sustainability.

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 4.3.4 Key considerations for mHealth interventions

1. Financial Considerations
 Airtime: Airtime (voice, SMS and data use) costs are one of the most significant cost
categories associated with any mHealth deployment. Anticipating costs requires creating
models that can predict the airtime associated with any application. Ensuring adequate funding
may entail negotiating lower rates or volume discounts with Ethiotelecom.
 Device costs: While device costs constitute a smaller percentage of project costs than is often
assumed, the cost of acquiring (and replacing) devices on a large scale is considerable. As with
airtime, negotiating lower prices or volume discounts with providers can reduce costs.
 Training: Any new program or change to current practices requires a thorough training
program in order to succeed. The cost of paying trainers and the time lost by HEWs to attend
training are major components, as is continuing or refresher training and the creation of training
materials.
 Maintenance: Devices break and need to be fixed, while back-end systems require updating
and maintenance in order to function properly. Paying for continuous support may constitute
a quarter or more of the total cost of ownership (TCO) for a technology deployment.
 Capital expenditures: In addition to device costs, equipment such as servers and peripherals
may need to be purchased to support an mHealth program.
 Operating expenditures: Costs related to the distribution of devices, the creation of content
and the administration of programs are often overlooked but can be substantial.
 Business model: In order to be sustainable, mHealth program requires a business model that
will ensure adequate balancing of revenues and expenditures, which may help determine
funding needs beyond initial grants or program revenues.
 Return on investment: An analysis of the return on investment, including not only all costs
associated with a deployment, but also health outcome benefits and potential savings resulting
from an intervention, is critical to determining whether an mHealth program or application is
worth the resources it would require.

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2. Capacity Considerations
 Data capacity: mHealth interventions often involve substantial data transmission, storage
and processing. Current systems must be assessed for their capacity to handle the
requirements of any proposed solution.
 Human capacity: Human resources are required to ensure the functioning of any
implementation, including technical, managerial, administrative and operational skills.
Given the early age of mHealth, locating and retaining experienced professionals in the
field can be challenging.
 Infrastructure: Implementations will only succeed if the required infrastructure is in place
to support them. Program requirements thus must be compared to current capacity.
 Technical capacity: Trained support staff, whether outsourced or provided in-house, is
needed to support any program or initiative.
 Administrative capacity: In addition to the human capacity needed to implement
programs, administrative structures need to be in place to ensure program functioning.
3. Culture Considerations
 Privacy concerns: Successful mHealth programs address concerns about the
confidentiality of sensitive patient data that may be relayed using mobile technology. This
is particularly important with respect to HIV and other STIs.
 Language: Transmitting information in a language that is understood by the user
population is critical to attaining program uptake and data accuracy.
 Spending habits: Understanding how targeted intervention groups think about spending
related to mobile communications is key to creating a business model that is scalable and
sustainable.
 Diversity: Sensitivity to the vast diversity of Ethiopian culture, religion and practices can
help to create tailored approaches to deployment that increase the odds of success.
 Gender roles: Respect for norms and attitudes towards gender roles, pertaining to both
HEWs and patient populations, is essential.
 Change management and attitudes to technology: Introducing new technologies
requires introducing changes to processes and overcoming resistance to those changes, and
to technology in general.

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 Figure 10: Financial, capacity and cultural factors for introducing technology

4.3.5 Types of mHealth applications

Mobile health interventions designed to improve health care service delivery processes have been
used to provide support and services to health care providers (such as education, support in
diagnosis or patient management) or target communication between health care services and
consumers (such as appointment reminders and test result notification). SMS and app solutions are
the most common forms of mHealth applications. SMS solutions are prevalent in both high and
LMICs while app solutions are mostly used in high income countries. Common application areas
include health promotion and raising awareness using SMS and health monitoring and surveillance
using mobile apps.

The most common digital health applications for mHealth include:

 Education and awareness

 Diagnostic and treatment support
 Disease and epidemic outbreak tracking
 Remote monitoring
 Healthcare supply chain management
 Remote data collection
 Healthcare worker telecommunication and training

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  Mobile Tele health /Telemedicine

1. Education and awareness

Education and awareness programs within the mHealth field are largely about the spreading of
mass information from source to recipient through short message services (SMS). In education
and awareness applications, SMS messages are sent directly to users' phones to offer information
about various subjects, including testing and treatment methods, availability of health services,
and disease management. SMSs provide an advantage of being relatively unobtrusive, offering
patients confidentiality in environments where disease (like HIV/AIDS) is often taboo.
Additionally, SMSs provide an avenue to reach far-reaching areas such as rural areas which may
have limited access to public health information and education, health clinics and a deficit of
healthcare workers.

While other communication mediums, such as radio, television, voice-based information hotlines,
and even interactive websites can be employed in the service of education about public health
issues, SMS stands out as having several advantages over each of these: cost-effectiveness,
scalability, convenience, broad reach, and widespread popularity in the developing world. By
promoting health-conscious behavior, the mHealth education and awareness programs currently
in place have already had positive impacts. The ubiquity and low cost of SMS messages hold the
potential to shift the paradigm for health education by communicating with people in an accessible,
engaging manner that both respects their privacy and gives them the tools to make informed
choices.
Helpline: Helpline typically consists of a specific phone number that any individual is able to call
to gain access to a range of medical services. These include phone consultations, counseling,
service complaints, and information on facilities, drugs, equipment, and/or available mobile health
clinics.
2. Diagnostic and treatment support
 Diagnostic and treatment support systems are typically designed to provide healthcare

workers in remote areas advice about diagnosis and treatment of patients. In such cases,
known as telemedicine, patients might take a photograph of a wound or illness and allow a
remote physician diagnose to help treat the medical problem. Both diagnosis and treatment

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 support projects attempt to mitigate the cost and time of travel for patients located in remote
areas.
 Diagnostics and treatment support are vitally important in healthcare misdiagnosis or the
inability to diagnose a condition could have serious, even fatal, ramifications. mHealth
applications in this area are designed to provide diagnosis and treatment advice to remote
healthcare workers through wireless access to medical information databases or medical staff.
With mHealth enabled diagnostics and treatment support, patients are able to receive
treatment in their villages and homes, averting the need for expensive hospital visits, which
are beyond reach for many.
 Diagnostic and treatment applications use the phone as a point-of-care device. Health
workers’ phones are typically equipped with specialized tools, such as built-in software that
leads the worker through a step-by step diagnostic process. Once data are entered into the
system (e.g., symptoms and an image of a patient’s injury captured on the mobile phone),
remote medical professionals can diagnose the illness and prescribe treatment. By eliminating
the need for patient travel, these applications have the potential to dramatically increase access
to care.
3. Communication and training for healthcare workers

An acute shortage of healthcare workers is a major challenge facing developing country health
sectors. Training new cadres of health professionals and empowering current workers in order to
increase job satisfaction and reduce attrition are essential to meeting human capital needs.
Connecting health workers with sources of information via mobile technology is a strong basis for
empowerment, as it provides the support they need to perform their functions effectively and self-
sufficiently. There is also a pressing need to improve communication among different health units
to facilitate more efficient patient care.

mHealth projects within the communication and training for healthcare workers subset involve
connecting healthcare workers to sources of information through their mobile phone. This involves
connecting healthcare workers to other healthcare workers, medical institutions, ministries of
health, or other houses of medical information. Improved communication attempt to increase
knowledge transfer amongst healthcare workers and improve patient outcomes through such
programs as patient referral processes.

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4. Disease surveillance and epidemic outbreak tracking

Collection of time-sensitive data on health problems is growing, giving patients and practitioners
greater scope for immediate decision making without meeting in person. Routine, emergency and
targeted data collection, management, and reporting for public health surveillance using mobile
ICT. Response to and management of emergency and disaster situations using mobile ICT.

mHealth programs in this area operate to utilize mobile phones' ability to collect and transmit data
quickly, cheaply and efficiently. Data concerning the location and levels of specific diseases (such
as Malaria, HIV/AIDS, TB) can help medical systems or ministries of health or other organizations
identify outbreaks and better target medical resources to areas of greatest need. Such mHealth
programs can be particularly useful during emergencies, in order to identify where the greatest
medical needs are within a country.

Outbreaks of communicable diseases often begin in pockets, and, when left undetected, can
develop into epidemics. Recent instances of such devastating outbreaks abound, from cholera and
TB to dengue fever and Severe Acute Respiratory Syndrome (SARS). Deployment of mobile
devices, with their ability to quickly capture and transmit data on disease incidence, can be decisive
in the prevention and containment of outbreaks. Prior to the adoption of mobile networks, public
health officials relied upon written, satellite, and radio communication for such emergency
tracking.

5. Remote monitoring including chronic disease management

The optimization of care for chronically ill patients is also being identified as a possibly effective
field of application. In particular, potential for success is seen for treatment monitoring models
and measures to improve adherence to treatment. Remote monitoring opens new possibilities for
treating patients in an outpatient setting, a crucial capability in developing countries where access
to hospital beds and clinics is limited. This group of applications consists of one- or two-way
communications to monitor health conditions, maintain caregiver appointments, or ensure
medication regimen adherence. Some applications may also include inpatient and out-patient
sensors for monitoring multiple conditions.

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Remote monitoring and treatment support allows for greater involvement in the continued care of
patients. Within environments of limited resources remote monitoring allows healthcare workers
to better track patient conditions, medication regimen adherence, and follow-up scheduling. Such
projects can operate through either one- or two-way communications systems. Remote monitoring
has been used particularly in the area of medication adherence for AIDS, cardiovascular disease,
chronic lung disease and tuberculosis.

Remote Monitoring example: TB patients in could be given mobile phones so that healthcare
workers (themselves former TB patients) could call these patients on a daily basis to remind them
to take their medication.

6. Supply chain management

Applications that collect data on sales and inventories help inform procurement and ordering by
suppliers, retailers, and health systems. The same actors can use other applications to track
shipments and monitor distribution of healthcare commodities. Applications that protect against
counterfeiting are helping consumers, health workers, and retailers avoid fraudulent products that
can be ineffective and even dangerous. Consumers can use mobile devices to check prices of
medical products and services—a potential boon in remote areas dominated by individual retailers
or providers.

7. Health financing

Micro insurance and health savings products are increasingly being delivered by mobile
phone to increase operational efficiency. This includes use of smartcards, vouchers,
insurance, and lending for health services linked to mobile platforms using mobile
technology. Similarly, other industries such as agriculture are using mobile phones to deliver
micro insurance products to consumers. Consumers can also receive vouchers or service
discounts for medical services using mobile applications.

8. Mobile Telehealth/Telemedicine:

Consultation between health care practitioners or between practitioners and patients using mobile
ICT.

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9. Health survey/ Remote Data Collection

Data collection is another crucial component of public health programs. Policymakers and health
providers at the national, district, and community level need accurate data in order to gauge the
effectiveness of existing policies and programs and to shape new ones. In the developing world,
collecting field information is particularly important since many segments of the population are
rarely able to visit a hospital, even in the case of severe illness. Gathering data where patients live
is vital, and information should ideally be updated and accessible on a real-time basis. The data
collection process is more efficient and reliable if conducted via smartphones, PDAs, or mobile
phones rather than paper-based surveys that must be submitted in person and manually entered in
to the central health database. These initiatives are closing the information gap that currently exists
for patient data in the developing world, enabling public officials to gauge the effectiveness of
healthcare programs, allocate resources more efficiently, and adjust programs and policies
accordingly.

10. Clinical decision support systems: Access to decision support systems using mobile ICT.
11. mLearning: Access to online educational resources using mobile ICT.

Overall, the global implementation status of different mhealth interventions is depicted bellow.
Table 5: Global Implementation status of mHealth applications, WHO 2016

mHealth program Percent

Toll-free emergency 75
Health call center 72
Appointment reminders 69
Community mobilization 64
Information 63
Mobile telehealth 62
Emergency management systems 60
Patient records 58
mLearning 53
Patient monitoring 52
Health surveys 51
Treatment adherence 48
Surveillance 48
Decision support systems 48

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 4.3.6 mHealth in Ethiopia

The national momentum within Ethiopia for health IT adoption provides a fertile ground to lay the
foundation for a sustainable mHealth architecture that can be incrementally adopted across care
settings. There were challenges facing implementations mHealth projects. Because of the
outcomes of these efforts in 2014, the Government of Ethiopia initiated the development of a
national eHealth strategy for coordinating and streamlining the active eHealth initiatives in the
country, as a basis for establishing a foundation for sustainable eHealth implementation model.

Ethiopia’s MOH, under its 5 year health sector transformation plan, also stipulated the importance
of harnessing eHealth technologies as one of the top agenda items at national level. To achieve
this vision, the MOH has ranked mHealth as one of the five priority areas of the country’s eHealth
strategy.

Yet mHealth programs cannot fix all organizational or operational issues because they do not exist
in a vacuum. Instead, they exist within a larger ecosystem a “digital ecosystem” with other health
technology initiatives, both current and planned. It is thus imperative that the design and
deployment of mHealth applications, solutions and projects happen in alignment with this
ecosystem.

Solutions that both support and improve on technology initiatives in health information systems,
supply chain management and human resources, and that integrate into the country’s health
ecosystem will also be most useful to the workers delivering care to communities throughout
Ethiopia. The ideal digital ecosystem should be simple enough to manage yet complex enough to
grow. As such, the MOH mHealth digital ecosystem should be comprised of three layers the
administrative, collaboration and application layers, depicted below.

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 Figure 11: Digital ecosystem for mHealth

 Administrative Layer: In this layer, the prime player is the administrator (MOH) who is
also the ultimate owner of projects. The administrator plans, develops and manages
strategies and policies regarding technology, finance, maintenance, training and other
content that resides in database servers in a location designated by the administrator.
 Collaboration Layer: The collaboration layer is a neutral layer comprised of the
infrastructure necessary to connect end-users and project managers to applications and
solutions provided by developers. Rules meant to ensure alignment with MOH goals would
be developed and applied to establish a neutral framework within which software and
device developers can build applications, solutions and projects that consumers can use.
Each application and solution would have to align with the rules and principles to
successfully integrate into this neutral layer. The rules would not only qualify (or
disqualify) applications and solutions, they would also qualify end-users, linking users to
applications and solutions according to their needs and wants.
 Applications Layer: The applications layer is a development layer that houses all the
applications, solutions and projects (including mHealth interventions) that may be of
interest to end-users. mHealth applications would comply with collaboration layer rules

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 and integrate with Ethiopian health technology initiatives in health information systems,
human resources, laboratory management, telemedicine and logistics management.

Why mHealth in Ethiopia?

In many developing countries, much of the population, especially in rural areas, does not have
access to the public health care system due to resource constraints, system inefficiencies and a lack
of awareness about services that are offered. The mHealth spectrum ranges from simple mobile
phone-based applications for the transfer of health information on basic handsets via short message
service (SMS) to highly sophisticated diagnostic applications that rely on advanced equipment and
robust back-end data systems. In Africa, most mHealth interventions, especially those targeting
general populations rather than health or data workers, have used relatively simple mobile
technology and equipment.

mHealth experience in Ethiopia

There is still great potential for national adoption of mHealth capabilities across Ethiopia. The
mobile penetration in Ethiopia has been growing exponentially. In 2016, the number of mobile
subscriptions was at 51.22 million which doubled by half in short periods since 2013. It is planned
that in 2020, mobile service subscription will reach 103.7 million and that of Internet and fixed
line will be 56 million and 10 million, respectively.

Figure 12: Mobile phone adoption in Ethiopia

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Smart phone cost and availability of internet connectivity

According to EDHS 2016, overall 56% households have access to mobile phone; 88% of urban
households and 47% of rural households own a mobile phone. About 27% of women and 55% of
men owned mobile phones at the time of the survey. About 71% of urban women own a mobile
phone, compared with 15% of rural women. mHealth programs within Ethiopia are addressing the
most common issues to maintain availability of their solutions. Numerous mHealth initiatives
across the world have demonstrated the efficacy of using mobile devices to deliver such health
solutions in a cost-effective manner. The Ministry of Health (MOH) of Ethiopia has developed
and tried various national eHealth applications that include: Electronic Medical Record (EMR)
system, mHealth, Telemedicine, eLearning and other initiatives.

Global health organizations, such as the WHO, and their member organizations, have been
promoting the development and adoption of scalable health IT solutions that are sustainable in
low‑ resource care settings to mitigate these healthcare disparities. The use of mobile technology
has been shown to provide the most promising impact, given the ubiquitous use of mobile phones
in the most resource constrained areas of the world. The introduction of mobile health (mHealth)
capabilities for preventive health programs and patient engagement efforts that bridge gaps in care
for vulnerable patient populations, are gaining momentum in all global health communities.

To assess the impact of these constraints on mHealth initiatives, the Federal Ministry of Health
(MOH) sponsored a research study to evaluate the performance impacts of mHealth programs on
HEWs. The study found that 78.3% of HEWs mentioned time consuming nature of both manual
and electronic mHealth recording as a reason for stopping to use electronic forms. According to
the study, HEWs had poor English proficiency and usually preferred local language, although the
working language in the Ethiopian health system is English. This clearly highlighted the need for
mHealth solutions to support local languages and dialects for optimal use. Finally, one focus area
was to report its findings on the use of mHealth solutions by HEWs and the impact on patient care
based on their employment status and availability. They observed inconsistency in the use of
mobile solution due to an inability to backfill gaps in HEW coverage or when workers left a care
program or were unavailable due to personal commitments or conflicting work assignments.

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While there are few major mHealth initiatives in MNCH currently under way in Ethiopia, mobile
phones already play a role in the country’s health system. As noted in the previous section,
although mobile phone ownership in Ethiopia as a whole remains low, approximately 90% of
HEWs have mobile phones. And, in spite of coverage and energy constraints, HEWs are already
using their mobile phones to facilitate their work. They use mobile devices to communicate with
supervisors, health centers, Kebele heads and other HEWs and to discuss emergency situations
and protocols. In cases of emergency, they are contacted on their mobile phones, and when
vaccines are running in short supply, they sometimes call health centers for replenishment.

Yet mobile communication protocols and procedures are ad-hoc and the effectiveness of mobile
phones is not being fully realized. Furthermore, HEWs spend their own money for work-related
phone use. A recent study revealed that none of the HEWs working at resupply points are equipped
with Internet access on the mobile handsets they use, limiting their use of supply chain
management software.

Figure 13: mHealth supporting in eHealth

The current eHealth applications in Ethiopia are delivering promising results in different health
programs. More than eight mHealth projects have been implemented and four (50%) of them were
on maternal health program.

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The Federal ministry of health also uses IVR (Interactive Voice Response). The Federal Ministry
of Health aims to improve health through the Health Extension Program (HEP). On the other hand,
the number of mobile phone subscribers in Ethiopia has shown a significant increase. The use of
voice message can deliver the kind of universal access, including the portion of population that
doesn’t know how to read, to support prevention services. Interactive Voice Response (IVR) is a
phone system technology that allows a computer to interact with humans by using pre-recorded or
computer generated voice responses via Dual Tone Multi-Frequency (DTMF) signal. Objective:
The main objective of using the IVR system to improve health outcomes of selected major health
problems in Ethiopia.

Another mHealth system called Enat Messenger System, it runs text-based confirmation and
transmission services via an automated message manager. The system consists of a server, a
modem, mobile phones with solar chargers and a web-based application with a database. A system
document, user manual, and handbook for health extension workers (HEW) were developed to
support implementation. Each week, HEWs sent ANC data from their health post to the nearest
health center. The health center entered the data (sent from the health posts and the ANC data for
pregnant women following ANC at the health centre level) into the Enat system manually. Based
on the data entered, which includes last menstrual period or gestational age, the system
automatically calculated the expected delivery date (EDD) and sent text message reminders to the
respective HEWs one month and one week before a pregnant woman’s EDD. The reminder served
as a prompt for the HEW to visit the mother to assess her status. After each visit, the HEW was
expected to send an SMS confirmation back to the system to confirm the visit. The responses were
monitored by health care workers at the health center. The system could also be used to prompt
transport of a mother in labor to a health facility. Some of implementation related challenges
include: limited computer literacy of health workers, unable to fix minor problems with the system,
some HEWs lost their mobile phones, HEW failed to visit mothers on time and as a result,
confirmation messages were delayed, poor mobile network coverage and electric power outages
in some of the sites.

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4.4 SUMMARY

 m-Health is defined as a “medical and public health practice supported by mobile

devices, such as mobile phones, patient monitoring devices, personal digital
assistants, and other wireless devices”.
 m-Health and eHealth are inextricably linked where both are used to improve health
outcomes and their technologies work in conjunction.
 m-Health can contribute to achieving universal health coverage (UHC) through
making services available to remote populations and underserved communities and
providing mechanisms for data exchange on patients and services.
 The MOH mHealth digital ecosystem should be comprised of three layers the
administrative, collaboration and application layers.
 Three key Considerations for mHealth interventions include: Financial, capacity and
cultural
 The most common digital health applications for mHealth include:

 Education and awareness

 Diagnostic and treatment support
 Disease and epidemic outbreak tracking
 Remote monitoring
 Healthcare supply chain management
 Remote data collection
 Healthcare worker telecommunication and training
 Mobile Tele health /Telemedicine

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 4.5 SELF-ASSESSMENT QUESTIONS

Multiple choice Questions

1. Among the following statements one is true

A. mHealth is the diverse application of wired technologies for health care services
B. m-Health usually operate as the backbone of eHealth
C. m-Health survey is defined as the use of mobile devices for health related data collection
D. None
2. Suppose health workers at community health post take pictures of sputum smear slides of
TB patients, send it to health centers using mobile phones for laboratory and receive
feedbacks accordingly, which one of the following m-Health application is used
A. Mobile disease surveillance C. Mobile diagnosis
B. Mobile referral D. Mobile Monitoring
3. Appointment reminders will be best applicable for treatment follow-up of
A. Malaria B. Pneumonia C. Diarrheal disease D. HIV/AIDS
4. One of the following is not mobile technology
A. GPS C. Patient monitoring devices
B. Laptops D. Desktops
5. m-Health initiatives in Ethiopia are characterized by
A. Small scale B. Duplication of efforts C. Interoperable D. A&B E. All
6. Suppose a health worker from TB clinic sent SMS message to his TB patient that says “TB
is curable disease. Please take your daily anti TB medication now”. Which m-Health
application is used
A. Awareness and education C. Remote monitoring
B. Treatment reminder D. A and B E. All

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 CHAPTER FIVE

E-HEALTH ARCHITECTURE AND STANDARDS

5.1 INTRODUCTION

The healthcare domain is highly transaction-intensive and requires interactions between the
multidisciplinary team of healthcare professionals, the subject of care or patient, administration
personnel, medical insurers, suppliers and other stakeholders. Quality healthcare requires effective
collaboration and the ability to communicate essential information between and among all the
stakeholders in order to facilitate continuity of care.

To achieve adequate continuity of patient care, a continuous flow of health information is required
between systems, healthcare organizations, regions and even countries. In general, this information
is highly fragmented and distributed across multiple sources which tend to act as silos, preventing
timely and ubiquitous access to information to support the care process, clinical management,
administrative processes and data aggregation. No country is immune to this reality, which affects
both developed and developing countries. To achieve information exchange between silos, it is
necessary to ensure the interoperability of information systems through the use of standards.
Interoperability occurs only if a full set of standards in health care exist

Several core aspects of eHealth implementation are crucial. The first is the need to ensure that data
are exchangeable. Interoperable data standards are fundamental requirements that are frequently
overlooked, with the result that many sites are unable to share data thus limiting the flow of
information. Interoperability depends on agreed standards enforced across all applications.
Second, attention must be paid to data quality since this will impact the quality of decisions.
Finally, health ICT systems require skilled personnel for their development and maintenance.

This chapter consists of the concepts of eHealth architecture, standards and interoperability in the
health system.

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 5.2 LEARNING OUTCOMES

At the end of this session, students will be able to:

5.2.1 Describe concepts of eHealth architecture

5.2.2 Describe the national eHealth architecture & framework components
5.2.3 Define standard and interoperability
5.2.4 Describe the types of standards
5.2.5 Describe the types of interoperability
5.2.6 Explain the Ethiopian TMS /NHDD

5.3 SESSION CONTENTS

5.3.1 Concepts of eHealth architecture

E-Health is a cross cutting area which supports all functions and operations areas by facilitating
the automation of various Health processes. It is a key area for improving health service delivery,
promoting health, and easier information exchange on the health care organizations, assisting in
decision making processes, and improving the effectiveness of operations. In this regard,
organizations need to invest a lot of resources to use e-health systems as a supportive tool for the
effective and efficient delivery of health services.

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 Figure 14: major goals of eHealth

The adoption of information and communication technologies (ICT) to support healthcare delivery
has the potential to positively impact the quality of care, improve healthcare service efficiencies,
and enable scale- up of healthcare program especially in hard-to- reach communities in developing
countries.

The use of eHealth and mHealth should be strategic, integrated and support national health goals.
In order to capitalize on the potential of ICTs (information and communication technologies), it
will be critical to agree on standards and to ensure interoperability of systems. Health Information
Systems must comply with these standards at all levels, including systems used to capture patient
data at the point of care. Common terminologies and minimum data sets should be agreed on so
that information can be collected consistently, easily and not misrepresented. In addition, national
policies on health-data sharing should ensure that data protection, privacy, and consent are
managed consistently.

5.3.2 National eHealth architecture & framework components

The eHealth Governance Body should mandate the adoption of national eHealth architecture. This
is an essential requirement that provides a roadmap with all components for the development,

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implementation and maintenance of the national EHR. A long-term project requiring strong
methods and best practices to guarantee its scalability and robustness, the eHealth architecture
must perform a number of functions. These include: ensuring health information is consistent,
accessible and used cost-effectively for improvement of health services; supporting patients, health
professionals and managers with the adequate data for decision making; supporting evidence-
based practice and health services planning, quality and safety; and providing an organized
approach to ensuring that investments in EHR systems are aligned with the national healthcare
priorities. This architecture requires skilled human resources, health informatics standards and
interoperability and continuous and sustainable funding, backed by cooperation of all stakeholders
including government, private organizations, vendors, health professionals, and patients.

The Ethiopian Federal Ministry of Health (MOH) has recognized the benefits of e-health as a tool
to support the health sector and are involved in several e-Health applications and services. These
have been classified into the following major areas: data warehouse, electronic health records
(EMR), laboratory information system (LIS), logistic management information systems (LMIS),
geographical information systems (GIS), tele-education, telemedicine, human resource
information system (HRIS), health integrated financial information system (HIFIS), electronic
health management information system (e-HMIS).

The eHealth Architecture provides a foundational plan to support the acquisition, exchange,
sharing and use of health data.

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 Figure 15: National eHealth system architecture
Objectives of national eHealth architecture

 Maximizing ICT resource utilization through curation, publication and dissemination of

the eHealth Architecture diagram.
 Creating and maintaining an inventory of existing eHealth and mHealth applications
(Projects and Products)
 Creating and maintaining detailed eHealth architecture roadmap advising project teams on
integration paths and use of standards.
 Maximizes IT investments by creating reusable components, standardized data and a plan
for integration

Framework components

The national eHealth Architecture should include a framework with the following components:
national registries (e.g. civil registration); clinical terminologies and classifications;
interoperability; privacy, security and safety regime; EHR repositories; and census data. These
will help provide a systematic approach to developing EHR. For example, registries assure

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universality by including all citizens; people will be more willing to share their data (and providers
will be more willing to adopt EHRs) if there are clear privacy and security policies; data
warehouse/EHR repository can provide a larger perspective for health policy making; and clinical
terminology and classification can assure semantic and syntactic interoperability.

There are several challenges to creating a national infrastructure through which healthcare
networks can connect effectively to one another and provide the benefits of health information
technology. These include, but are not limited to, the development of physical components
(hardware); the links between these components (networks); and the form in which they are used,
as determined by software customization and its usability throughout the implementation and
optimization process.

Decision makers will need to invest in national infrastructure with strong security protocols in
order to promote trust and ensure that the network will handle information appropriately. They
must address concerns of service availability and disaster recovery that might otherwise jeopardize
the sustainability of an implementation project. This does not necessarily mean having to construct
a significant new national infrastructure from scratch. Rather governments, in close collaboration
with stakeholders, must identify current infrastructure availability, determine existing gaps, and
develop plans to address them.

Centralized vs. distributed architecture

One of the key decisions when managing multiple remote sites is whether to centralize all
resources or manage the infrastructure in a distributed fashion. Two methods might be utilized to
facilitate the electronic transfer of information throughout a health information network. Each has
intrinsic advantages and limitations:

The first method (M1) is based on centralized data storage. In this model, health-related data
is collected from local sources, but stored in a central repository. If an entity requests data, the
transaction is routed through the central repository. Such architecture permits local entities to
maintain autonomy while cooperating to provide data at national or regional level.

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Method two (M2) is known as a ‘federated’ or ‘distributed’ model. Each participating entity
maintains separate control of the data it gathers, typically in special ‘edge servers’ at its own
location, and shares patient-specific data on request from other entities.

Security risks are a major concern for M1, because all health related information is stored centrally.
A single breach or ‘hacking’ incident on the central data repository could therefore potentially
expose all records in the system. The risk inherent in the M2 approach is lower because information
(other than patient identifiers) is not stored centrally; however, in this model the main sources of
risk are variable because security depends on the privacy and security measures of each
independent data source. The security policy should follow local privacy and security rules.

A fundamental challenge of all models is data matching. Network requirements in terms of data
representation are extensive with M1; for M2, accurate matching of patient data is needed between
the local system and the central repository or other systems. The absence of government-issued
shared identifiers would be extremely hazardous; however other strategies or matching algorithms
could be utilized. Data collection standards and messaging formats must be consistent, and this
requires well-defined standards.

5.3.3 Concepts of eHealth standards

Electronic information systems rely on standards; in order to share and aggregate data, countries
utilizing such systems need to collect data using standard definitions and formats. In order to
exchange health data, systems must include syntax and semantic content that is clear and
unambiguous to both sender and receiver. Due to the broad scope of health information and
multiple (and often imprecise) terminologies in common use, this can pose a significant challenge.
Defining standards is a complex and labour intensive task. Fortunately, many international
organizations have taken up the work of developing and maintaining standards. This gives
countries access to well researched and defined standards that they can adopt and modify, if
necessary, for their own use.

eHealth standardization is inherently a complicated area. eHealth systems have to connect many
stakeholders hospitals, pharmacies, primary care physicians, patients in their homes, and
administrative entities such as insurance companies or government agencies. Each of these entities

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has an enormous installed base of technologies, information systems, and medical devices, often
based upon proprietary specifications. Electronically integrating these entities will be a great
challenge for technical standardization. A second requirement complicating the standards
landscape for eHealth is the inherently sensitive nature of the information, requiring a high degree
of privacy protections, quality assurance, and security. The health sector is also heavily regulated
by national authorities. New technologies can present a risk of not meeting those regulations.
Furthermore, health practitioners can be inherently risk adverse and reluctant to adopt new
technologies.

Definition of standard
Healthcare data interchange standard is an agreed-upon, universal and reliable way to record and
communicate health information. Healthcare Information Management Systems Society (HIMSS)
defines standard as a “common terminology that facilitate interoperability and integration, create
structured information models for data structure and interchange and enhance privacy & security.”
ISO defines a standard as a document, established by consensus and approved by a recognized
body that provides, for common and repeated use, rules, guidelines, or characteristics for activities
or their results, aimed at the achievement of the optimum degree of order in a given context. Simply
put, a standard is an agreed-upon, repeatable way of doing something.

Standardization provides us an effective way of communication to achieve the goal of

interoperability. HL7 is one of the healthcare standards that allow communication and integration
of healthcare systems and allow sharing of data around the globe. The important requirement is to
capture relevant information and then make it widely available for others. Therefore, the need is
to have a standard that can provide best services in terms of efficiency and reliability. HL7, as it
evolves, provides us with a technical business model to fulfill this vision of a diverse, integrated
health information system.

Standardization is key to achieving interoperability. However, the e-health standardization arena

is fraught with many challenges, which include the huge number of available standards, with many
of them competing and overlapping, and some even contradicting one another

Why Standards in health care?

 The data are of many types and form and will be used for multiple purposes..

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  We must share both data and knowledge for both improved health care
 Sharing becomes economically possible only if interoperability exists
Type of standards

Although these groupings are relevant within a national or regional context, standards in general
fall into two broad groups: proprietary or open. Proprietary standards are developed for private use
by profit-driven industry organizations. Specifications for such standards are typically not
disclosed and are subject to copyright law.

Open standards are open for use by all interested stakeholders and can be developed by for profit
and non-profit organizations. The standard specifications and necessary documentations are made
available for public use, either free of charge or at a nominal fee.

i. Data exchange standards

Healthcare data interchange standards are important aspect for achieving interoperability for health
information exchanges. There are several available standards for document sharing. These can
foster interoperability of clinical data by allowing physicians to send electronic medical
information to other providers without loss of meaning, thereby enabling improvements in patient
care.

 More commonly a healthcare standard can fall in one or more types of categories on the
basis of their functionalities as follows:
 Terminology standards: Standards that define set of rules/ coding
mechanisms/nomenclature/terms that are confirmed as vocabulary for exchange of data
from one computer system to another. They are much like a dictionary for a language.
 Messaging standards: Messaging standards define common messaging structure for
exchange and sharing of medical images, financial details and clinical information among
different service providers or hospitals.
 Document standards: Defines standard format for describing and sharing patient
demographic and medical details including prescription and disease information.
 Conceptual standards: These types of standards define a set pattern for mapping “concepts”
in a “standardized” way.

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  Application standards: Defines a common approach to integrate and interoperate diverse
applications in a seamless way.
 Legal standards: Describe the laws, regulations, and standards that govern patient
confidentiality.

ii. Others standards

Some of the important areas or domains on which standards should focus include patient
identification, disease classifications and clinical terminologies, and standards for documents and
Health Information Exchange (HIE).

The categories of standards in current use include:

 Metadata standards are a common way of describing the content of the standards
themselves.
 Messaging standards describe protocols to communicate data. Messaging is the electronic
communication of health information from the point of collection or storage to a point of
use.
 Vocabulary standards define the terms used to describe health conditions and events.
Vocabularies provide a standard method of expressing health information. For clear
communication it is vitally important to have each given health term precisely defined so
that it will not lead to confusion or be subject to corruption when received. The
International Classification of Diseases (ICD) is a list of codes to classify diseases, signs,
symptoms, abnormal health findings and external causes of illness or injury.

5.3.4 Concepts of eHealth interoperability

Definition of Interoperability

Interoperability is the ability of a healthcare system to share information and have that information
properly interpreted by the receiving system in the same sense as intended by the transmitting
system. Standardization provides us an effective way of communication to achieve the goal of
semantic interoperability. It is also defined as the ability of different information technology

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systems and software applications to communicate, exchange data accurately, effectively and
consistently to use the information that has been changed.

Interoperability in health care information is the capability of health information systems to work
together within and across organizational boundaries. It is necessary that systems agree on what
information they want to share and what standards to use. When different enterprises are integrated
it is necessary that all the systems and technologies share whole information with different
structures and formats. Such type of sharing and of information transparently is very difficult
requirement which raises the very complex issues of compatibility and interoperability.

HL7 is one of the healthcare standards that allow communication of healthcare systems and allow
sharing of data around the globe. The important requirement is to capture relevant information and
then make it widely available for others. Therefore, the need is to have a system that can provide
best services in terms of meaningful data sharing and discovery. HL7, as it evolves, helps us with
a technical business model to fulfill the vision of standard based information exchange in diverse,
integrated health information systems.

The architecture must support the integration of work of multiple disciplines, enabling integrated
teams to provide care to a single patient, including occasions when the teams are geographically
distributed and in different organizations. Individual health information must follow the patient
as s/he receive services from various providers. This requires data interoperability which is the key
to effective use of health information.

The main feature of interoperability is that the system should be compatible with each other or we
can say that a common channel where all or multiple systems can communication to each other.

Interoperability with regard to a specific task is said to exist between two applications when one
application can accept data (including data in the form of a service request) from the other and
perform the task in an appropriate and satisfactory manner (as judged by the user of the receiving
system) without the need for extra operator intervention. To be interoperable, two applications
need to agree on interfaces in each of the three layers of the “interoperability stack”: the
communication and transport layer; the document layer which involves the format of the
exchanged messages and documents as well as the coding systems used, and the business process
layer which involves the choreography of the interactions.

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 Figure 16: Interoperability between systems

Benefits of e-health interoperability

At governance level it is important to create an entity or leadership group that works towards
achieving interoperability. This group must identify the e-Health standards and interoperability
components required to enable the consistent and accurate collection and exchange of health
information across geographical and health sector boundaries. Without interoperability, health
information cannot be collected consistently, will be open to misinterpretation, and will be difficult
or impossible to share due to incompatibilities in data structures and terminologies.

The importance of interoperable e-health systems in strengthening modern-day healthcare system

is indisputable. The realization of the full benefits of e-health investments is reduced without the
ability of HISs to share information among each other. Interoperability enables timely access to
patient information whenever and wherever needed. It also reduces the need to re-capture the same
information in every system and the accompanying data capture errors that could arise from the
entry of the same information multiple times.

Interoperability has to be seen from several dimensions including, regional, geographical, point of
care, program and across technologies.

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 Figure 17: Dimensions of interoperability

Types of interoperability

There are four types of interoperability: business process, syntactic, semantic and technical
interoperability.

I. Semantic

Semantic interoperability provides interoperability at the highest level, which is the ability of two
or more systems or elements to exchange information and to use the information that has been
exchanged. Semantic interoperability takes advantage of both the structuring of the data exchange
and the codification of the data including vocabulary so that the receiving information technology
systems can interpret the data. This level of interoperability supports the electronic exchange of
health-related financial data, patient-created wellness data, and patient summary information
among caregivers and other authorized parties. This level of interoperability is possible via
potentially disparate electronic health record (EHR) systems, business-related information
systems, medical devices, mobile technologies, and other systems to improve wellness, as well as
the quality, safety, cost-effectiveness, and access to healthcare delivery.

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Semantic interoperability is also called knowledge level interoperability, is the capability of
different type of information systems, components, applications and services to exchange
information on the basis of joint, pre-established and negotiated meanings of terms and
expressions. Semantic interoperability guarantees that the message is received at the user end.
Another important use of semantic interoperability in the healthcare domain is the combination of
data from heterogeneous sources through semantic mediation. The main function of semantic
mediation is to convert health care messages that are defined in one standard format into another.

One of the challenges faced nowadays by the healthcare industry is semantic interoperability. It is
the ability of a healthcare system to share information and have that information properly
interpreted by the receiving system in the same sense as intended by the transmitting system.
Semantic Web (aka Web 3.0) provides the enabling technologies to achieve semantic
interoperability. Web Services, as a catalyst in this process, provide seamless communication of
information between healthcare systems thus providing better access to patient information and
improved healthcare. Semantic technologies are emerging and several applications ranging from
business process management to information security have demonstrated encouraging prospects
of its benefits. Role of semantics is also very vital for achieving interoperability in sharing of health
records.

Semantics is defined as the meanings of terms and expressions. Hence semantic interoperability is
“the ability of information systems to exchange information on the basis of shared, pre-established
and negotiated meanings of terms and expressions,” and is needed in order to make other types of
interoperability work.

The quest for a single, universally applicable, semantic meaning, entailed an implicit hierarchy,
whereby the local is quaint but unacceptable, the regional is a bit more organized, but still
unacceptable; the national is one step better and ultimately only the international is fully
acceptable. In other words: the international is rhetorically good, the local and regional are less
interesting and rhetorically bad. Such a quest for a single, universally valid, international meaning
is thus opposed to national, regional and local particulars, which ultimately entail too many
embarrassing details. This is excellent for scientific laws but disastrous for unique objects of
culture and art.

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Semantic interoperability enables multiple systems to interpret the information that has been
exchanged in a similar way through pre-defined shared meaning of concepts.

The semantic services are required to be stored, published and retrieved in a repository. The
semantic registry would be required for registration/publication of patient and lab domain services
semantically, so that the services can be accessed for medical research, decision support systems.

II. Syntactic

Syntactic interoperability relies on specified data formats, communication protocols, and the like
to ensure communication and data exchange. The systems involved can process the exchanged
information, but there is no guarantee that the interpretation is the same. If two or more systems
agree on communicating and exchanging of data then they are said to syntactic interoperability.
Syntactic interoperability guarantees that the message is delivered but does not guarantee that
receiver receive the message. To guarantee message content interoperability that is received at the
user end then semantic interoperability will be used.

Syntax in the traditional sense is about the structure of sentences rather than just isolated terms
combined as triples (x is a /has a y). Hence, with syntax in the traditional sense, the challenges of
syntactic interoperability become: a) identifying all the elements in various systems; b)
establishing rules for structuring these elements; b) mapping, bridging, creating crosswalks
between equivalent elements using schemas etc.; c) agreeing on equivalent rules to bridge different
cataloguing and registry systems.

III. Business process

The highest level of interoperability, organizational interoperability, facilitates the integration of

business processes and work flows beyond the boundaries of a single organization. In addition to
the presence of the three lower levels of interoperability, organizational interoperability requires
strong willingness and commitment from the concerned organizations to collaborate.

To model complex healthcare processes in well-defined business language and to capture real life
business scenarios, rather than technology-specific terminologies and grammar. To contribute the
developed platform to the open-source community so other healthcare organizations and hospitals,

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within and outside the, country can reuse and customize this solution to their specific requirements
with minimum efforts.

IV. Technical interoperability

It enables heterogeneous systems to exchange data, but it does not guarantee that the receiving
system with be able to use the ex-changed data in a meaningful way.

Figure 18: Levels of interoperability

5.3.5 The Ethiopian terminology management system and health data

dictionary

Terminology management system

Terminologies are medical terms and concepts used to describe, classify, and code the data
elements. Terminology is used to record clinical information; to facilitate the storage of clinical
Information; to support sharing and reuse of clinical information. Standardized terminologies
facilitate electronic data collection at the point of care; retrieval of relevant data, and data reuse.

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Terminology standards provide specific codes for terminologies and classifications for clinical
concepts such as diseases and medications.

Figure 19: The National Health Data Dictionary & Terminology Management Service

The national health data dictionary

The National Health Data Dictionary(NHDD) that defines concepts, indicators and other terms in
the health sector in order to improve standardization and data quality with the ultimate goal of
improving information use and health outcomes.

The NHDD is the authoritative source for indicator and data standards within the health system.
The NHDD harmonizes data definitions from multiple programs and facilitates mapping of
definitions. The Ethiopian NHDD is currently populated with indicators and data definitions from
the HMIS Data Recording and Reporting Guidelines, the NCoD, and Community Health
Information System (CHIS) Guidelines; mappings to ICD-10, SNOMED-CT, and CIEL
international standards. The goal is to institutionalize Ethiopian NHDD as the authoritative
reference of health indicator and terminology standards throughout the country.

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Purposes of NHDD

• Establish a core set of uniform definitions relating to the full range of health services

• Promote uniformity, availability, reliability, validity, consistency and completeness in the

data and incorporate national and international agreed protocols and standards
wherever possible

• Promote the national standard definitions by being readily available to all individuals and
organizations involved in the generation, use and/or development of health and health
services information

• Facilitate and promote the development of good data definitions across the health sector

A Data Dictionary helps you to:

 Improve data quality through consistently defined and standardized data

 Streamline reporting and data aggregation regardless of the source
 Analyze and compare patient data within and across populations
 Consistently monitor and evaluate quality, safety and efficiency
 Assess compliance with health care delivery standards
 Share data across information systems

Open Concept Lab (OCL)

It is the open-source Terminology Management Service (TMS) that hosts the NHDD. The open
concept lab (OCL) is a significant enhancement, providing a tool set to peruse published sources
of terminology and higher-level semantic entities like indicators and measures. It provides the
necessary synching function between the external sources of dictionaries and the dictionaries
which exist inside the health record.

 Promotes best practices by mapping directly to international definitions standards, such as

ICD-10, LOINC, and SNOMED, directly in the data dictionary
 Cloud-based architecture alleviates need for local infrastructure
 Free access to dictionaries and “starter sets” created by other organizations

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 Simple export and APIs for integrating with other platforms (e.g. OpenMRS and DHIS2)

Figure 20: The national health data dictionary and open concept lab

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5.4 SUMMARY

 The eHealth architecture must ensure that health information is consistent, accessible and
used cost-effectively for improvement of health services and providing an organized
approach to ensuring that investments in EHR systems are aligned with the national
healthcare priorities.
 Healthcare data interchange standard is an agreed-upon, universal and reliable way to
record and communicate health information
 Standardization provides us an effective way of communication to achieve the goal of
interoperability
 Interoperability is the ability of a healthcare system to share information and have that
information properly interpreted by the receiving system in the same sense as intended
by the transmitting system.
 Semantic interoperability provides interoperability at the highest level, which is the
ability of two or more systems or elements to exchange information and to use the
information that has been exchanged.
 Syntactic interoperability relies on specified data formats, communication protocols, and
the like to ensure communication and data exchange.

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 5.5 SELF-ASSESSMENT QUESTIONS

Multiple choice Questions

1. One is organizational level reason for the low adoption of eHealth in Ethiopia
A. Health workers resistance to technology C. Poor Infrastructure
B. Lack of interoperability standards D. Complex regulations E. None
2. Which of the following interoperability type focuses on data exchange
A. Semantic B. Syntactic C. Business process D. A and B
3. One of the following standard defines set of rules/coding mechanisms that are confirmed as
vocabulary for exchange of data from one computer system to another.
A. Terminology standards C. Document standards
B. Messaging standards D. Legal standards
4. One is without interoperability
A. Health information cannot be collected consistently,
B. Health information will be open to misinterpretation,
C. It will be difficult or impossible to share data due to incompatibilities
D. All
5. Standardization is key to achieving interoperability
A. True B. False

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