Global health is an expansive multi-sectoral area that links not only to the main policy areas of development, humanitarianism, research and health, but also to trade and foreign policy. At its core lie the endeavours towards a worldwide improvement of health; the reduction of disparities; and the protection against global health threats. Trying to define the term "global health", one could argue that it refers to the health problems, issues and concerns that transcend national boundaries; these may be influenced by circumstances or experiences in other countries, and are best addressed by cooperative actions and solutions. Therefore, in the words of Jan Paehler of the European Commission - EuropeAid, "addressing global health requires coherence of all internal and external policies and actions based on agreed principles". The term "global" also emphasises some inherent distanceless features; for instance, a potentially contagious person or product can now travel anywhere in the world within 1-2 days.
A parallel trend is the eHealth concept, which focuses on a horizontal application of health solutions at a global scale. The main eHealth challenge in the years to come will be to extend its applicability to almost all population. So far, what has been acknowledged by all involved is that its rapid development is causing many changes, the social outcomes of which will be varied. Those who win on eHealth will be best placed to take advantage of such changes; those who lose will not only be left behind technologically, but also be deprived of the expanded services on offer. Maximising the number of "winners" involves many challenges, which can best be addressed under an eHealth agenda operating on a global perspective, in short a "global eHealth agenda".
The global scale of eHealth
Global eHealth as a concept emerged during the past decade, when it became evident that the health needs at both global and local level were complementary and that the distance-independent services of eHealth could indeed offer solutions. Indeed, as early as 2001, a New York surgeon performed remote gallbladder surgery on a patient in France. Since then, remote laparoscopic procedures have also been performed in Canada.
The term "global eHealth", which first appeared around 2000 in a non-systematic fashion, has recently acquired a new meaning and an enhanced significance. The formal definition of 2003, which was also consistent with the accepted goals and terms used by the World Health Organisation (WHO), stated that "global eHealth is the sustainable global integration of information and communication technologies into the practice of protecting and promoting health across geo-political, temporal, social and cultural barriers - including research and education - in order to facilitate health, public and community health, health systems development and epidemiology."
Although still at an early stage, policies affecting eHealth, and health in general, on a global scale have started appearing. The Council of the European Union, for example, adopted a series of conclusions on its Foreign Affairs meeting in Brussels on the 10th of May 2010. These view health as a human right, which is essential for development, and propose a series of actions to:
· reduce inequalities in healthcare
· increase protection against global health threats
· uphold values of solidarity towards equitable and universal coverage of quality health services
· improve health information systems in partner countries via benchmarking through comparable data and evaluation of the impact of global and national policies on social determinants of health and equity
It is of interest to note that the Council's conclusions embed the global dimension of eHealth in the general plea to use ICT to improve health information systems.
Of relevance is also the policy initiative on trans-continental cooperation on eHealth between the European Commission and the US Department of Health. The Memorandum of Understanding, signed last December in Washington D.C., aims to create new markets and growth opportunities for industry in the eHealth sector in both the EU and the US. The document addresses issues which affect the global market potential of eHealth, such as the need for a joint vision on international interoperability standards for electronic health record systems and the strategies to develop a skilled health IT workforce.
However, the global eHealth agenda still does not encompass all possible regions and peoples, and this issue is something that should be effectively addressed. Despite various international health-related initiatives, notably by the WHO, health policy largely remains the sovereign domain of individual countries. As observed by the WHO's Global Observatory for eHealth, limited systematic research has been carried out to inform eHealth policy and practice. In our view, in order to be effective, global eHealth must become fully integrated into existing national, international and global health-related structures, at both process and policy levels. Barriers to such efforts rise high: existing borders and boundaries, unevenly motivated stakeholders who influence health care and technology activities (particularly in developing countries), changes in governance, differing policy agendas and (sometimes) absence of political will. A notable example is Australia. As the Australian School of Business reports, although many companies, such as the Sydney-based iSOFT, are world-scale players in eHealth, the government has, as yet, no national strategy on eHealth and consequently no substantial funds committed for such systems at a national scale.
Is there a global eHealth strategy?
So far, and despite its rapid development, policy on eHealth per se have been mostly limited to industrialised countries, thus creating a global eHealth policy void. Notable efforts can be found in North America and in Europe, where, thanks to the lead provided by the European Commission, most Members of the European Union exhibit strategic approaches to eHealth. Among those, Nordic countries, such as Finland, Sweden, Denmark and Norway (a member of EEA and EFTA) are in the lead regarding both strategies as well as implementation of eHealth services, notably telemedicine at scale.
What usually is the case however, even in countries where eHealth policy development is evident, is that nascent eHealth strategies are often indirectly related or focused on ICT, rather than specifically on eHealth. Consequently, there are two strategic options for further enhancing global eHealth (one efficient and one less so):
1. Continued ad hoc development followed by policy realignment. This is the status quo so far, and unfortunately it further confuses policy actions and prevents streamlined global eHealth. It seems that under this strategy it will require years of retrospective policy realignment to bring the disparate approaches together. Meanwhile, many potential benefits of global eHealth may be denied to large parts of the world's population.
2. Progressive and collaborative complementary policy development. This refers to a more concise approach, which would initiate a process to guide global eHealth policy development, aiming at realising faster the benefits of global eHealth. The goal would be to identify common principles that can be agreed with relative ease, and then to use these to encourage development of domestic policy that is in line with global eHealth principles. The outcome would be the removal of administrative and political barriers to global eHealth.
Key EU initiatives on eHealth
The EU is among the most active regions in the world in adopting and promoting eHealth practices and structuring a relevant agenda. Member States have shown that they are keen to take an eHealth agenda forward, drawing on best practices and experience from across the Union. This should enable a move towards a "European eHealth Area"; a framework built on a wide range of European policies and initiatives. This initiative is about coordinating actions and promoting synergies between related policies and stakeholders, so as to develop better solutions, prevent market fragmentation and disseminate best practices. Specific objectives are to create an electronic health record architecture by supporting the exchange of information and standardisation; to set up health information networks between points of care that will coordinate reactions to health threats; to ensure online health services such as information on healthy living and illness prevention; and to develop teleconsultation, ePrescribing, eReferral and eReimbursement capabilities.
This venture is supported by the "Europe 2020" strategy, introduced by the European Commission in March 2010. This initiative aims at smart, sustainable, inclusive growth with greater coordination of national and European policy. eHealth is seen as a means towards its goals of raising employment, reducing the number of Europeans living below national poverty lines by 25% etc.
One of the seven flagship initiatives launched in the context of the "Europe 2020" strategy is the "Digital Agenda for Europe" (DAE), which was adopted in May 2010. DAE is structured along seven problems and solution areas. The last one deals with ICT-enabled benefits for EU society which inter alia covers sustainable healthcare and ICT-based support for dignified and independent living. The actions identified are diverse and include pilot actions to equip Europeans with secure online access to health data for patients (by 2015), widespread deployment of telemedicine services (by 2020), propose a recommendation defining a minimum set of patient data for interoperability of patient records to be accessed or exchanged electronically across Member States (by 2012), and fostering EU-wide standards, interoperability testing and certification of eHealth systems by 2015 through stakeholders dialogue.
Furthermore, within the EU take place numerous large scale pilots concerning eHealth, among which are:
· epSOS: cross-border secure access to patient health information, particularly patient summaries and ePrescriptions.
· epSOS II: extended the previous epSOS project to twenty three countries, will test and validate new services; international cooperation on interoperability.
· Renewing Health: measures the effectiveness and cost effectiveness of Telemedicine solutions, providing large scale evidence for diabetes, CVD and COPD. It includes the participation of regional healthcare authorities in nine Member States or associated countries.
The role of international cooperation
i) Sharing best practice: eHealth is an emerging sector. Consequently, relevant solutions are being implemented in few countries only. While some EU Member States are among the world leaders in the field, innovative solutions are experimented in many third countries, including the developing ones. There is considerable demand for further action to promote best practices and share experience in this area. Currently, for example, the Employment and Social Dimension of the Information Society collects best practices on the employment and social inclusion aspects of eHealth and healthcare in the knowledge society. The Commission has identified thirteen indicators of best practices in European acute hospitals in terms of eHealth, which are classified into four sets: Infrastructure, applications, integration and security.
ii) Benchmarking: Benchmarking has two broad objectives: First, to enable valid comparisons between nations. Second, to provide evidence of eHealth benefit resulting from the use of eHealth applications to accelerate deployment. As identified by the Organisation for Economic Co-operation and Development (OECD), there is an absence of independent, robust monitoring and evaluation of programmes and projects concerning eHealth. In this context, there is a real need to benchmark for the first time in a consistent and comparable manner the eHealth deployment, take-up, and impact in hospitals across the EU27. The Commission services are working with the OECD to identify a small set of survey items that have the same meaning across nations.
At EU level, the Commission presented during the eHealth week the result of a survey on Benchmarking deployment of eHealth services in acute hospitals in 30 European countries (the survey was carried out by Deloitte Consulting on behalf of the European Commission). The survey shows the increasing role of eHealth applications in Europe's hospitals and the progress made in the last few years. This exercise will contribute to the discussion on the development of eHealth indicators and eHealth statistical methodologies with the OECD and other third countries. Overall, the survey findings could be compared and contrasted with a wide range of countries, so as to provide indicative comparison of take up in hospitals.
Furthermore, benchmarking is also covered in the EU-US cooperation. The, Memorandum of Understanding paves the way in which work undertaken by the US Department of Health and Human Services and by the EU can be compared. An important step towards improving the present situation and increasing coherence is seen in the development of an eHealth indicator framework for quantitative benchmarking that covers key groups of health actors and key eHealth-related activities.
iii) Development of standards: Standards are very much related to and crucial for interoperability. That is because they provide the specifications which are necessary for systems to communicate meaningfully with each other.. Despite its importance for eHealth, the concept of interoperability remains underdeveloped, also within the EU. This is also the case if the target is international interoperability of electronic health records, which would allow the transfer of electronic health record across countries so as to match the increasing mobility of people between countries. The main obstacles to international interoperability are:
· The lack of widely used eHealth standards, resulting in interoperability problems. Many of the conflicting standards are proprietary.
· The lack of the 'right' eHealth standards. The health sector is in need of effective standards developed specifically for particular applications and concrete cases.
· For health service providers, this situation may imply that their computerised systems remain stand-alone and unable to exchange data with each other in-house or externally. In particular, solutions for electronic health records are often isolated without data exchange and interoperability.
· eHealth interoperability has various facets including semantic and technical interoperability, which makes the goal of achieving international interoperability more complex. The EU-US Memorandum of Understanding acknowledges that the development of internationally recognised and utilised interoperability standards for electronic health record systems holds immediate importance and potential for cooperation between the two regions.
iv) Cooperation with international organisations: According to the OECD study, 'Improving health sector efficiency: The role of information and communication technologies' of 2010, health care 'systems' across OECD countries are largely organised in the form of separate 'silos', consisting of groups of large and small medical practices, treatment centres, hospitals, and the people and agencies that run them. At present, nothing really links these isolated structures into a system within which information is easily shared and compared. Therefore, there is an urgent need for further harmonisation and co-operation at the international level, as it has been previously described in the "benchmarking" section. EU's ongoing initiatives (e.g. epSOS) aim at tackling market fragmentation within the EU. However, cooperation with international organisations allows the EU to put forward EU approaches and solutions in the international arena and, at the same time, to benefit from international experience in eHealth projects (for instance, WHO has a few ongoing initiatives on eHealth).
The case of the EU-US Memorandum of Understanding
Last December (2010), Commission's Vice-President Neelie Kroes and the United States Secretary of Health and Human Services, Kathleen Sebelius signed a Memorandum of Understanding (MoU) on eHealth to promote a common approach on the interoperability of electronic health records and on education programmes for information technology and health professionals. The aim of the MoU is to create new markets and growth opportunities for industry in the eHealth sector in both the EU and the US. This has also signalled to stakeholders that the respective administrations aim at achieving compatible solutions in the field of interoperability and, in broader terms, at coordinating their efforts where appropriate. The MoU singles out two main areas: interoperability standards and specifications, and strategies for the development of a skilled health IT workforce.
The Commission services (DG INFSO) and the US administration (ONC) have been closely cooperating for years in the areas of interoperability of health systems and global market development, sharing information and best practices. The main objective of this cooperation has been to foster interoperability and benefit operators and investors willing to expand their activities in the EU and in the US, creating market opportunities for market players. Stakeholders are extensively involved to identify targets and future topics. A few meetings have been held so far to explain the scope of the MoU and present on-going activities.
Furthermore, following the signature of the MoU, the European Commission organised in May 2011 a workshop on the EU-US cooperation on eHealth to present the "ongoing and planned actions" together with the Office of the National Coordinator for Health Information Technology in the US. The covered topics at the workshop were namely Interoperability of patient summaries (epSOS), semantic interoperability, benchmarking, certification, skills development, and re-use of EHR for research.
It is worth noting that the Large Scale Pilot epSOS has been identified as a key instrument to bring forward the EU-US cooperation. In fact, the recent extension of epSOS - which has brought the project from 12 to 23 national administrations - includes some support activities in the context of EU-US cooperation. The first practical outcomes of this presentation are tentatively expected for 2012, notably in the area of EHR interoperability. In practice, the EU-US cooperation via epSOS should allow interoperability of EU and US EHR, and potentially allow the exchange of health records across the Atlantic.
In parallel to the signature of the MoU, European External Action Service (EEAS) funded a project (ARGOS) supporting EU-US cooperation on eHealth. ARGOS has created a transatlantic observatory promoting mutual understanding between EU and US stakeholders (amongst others for both the Eurorec institute for Health records and the American Medical Informatics Association) on interoperability and certification, indicators and tools, modelling and simulation of human physiology. More specifically, the observatory will promote mutual understanding and learning among EU and US policy researchers and policy makers on the following general challenges with global dimension:
· Improving health and well-being of citizens through accelerating eHealth strategy development and through supporting large scale eHealth infrastructure implementations;
· Supporting R&D in eHealth to promote the benefits from the pursuit of consistent strategies.
Potential for eHealth in the Third World and developing countries
The EU has an active role in promoting eHealth in developing countries, either by improving health information systems in partner countries, by allowing benchmarking through comparable data, or by evaluating the impact of global and national policies on social determinants of health and equity. As it has been previously mentioned, exposure to eHealth varies significantly among countries and especially among geographical regions, with third world and developing countries lagging behind. This means that these countries have perhaps the most to gain. The main gain will be increased access to, and greater equity of, health care to their large, under-served populations, which could be at reach via the use of ICT application to the health sector (remote monitoring, telemedicine, etc). Significant investment in time, effort and funding will be needed to raise their health and eHealth infrastructure to the required levels,
Meanwhile, the World Health Organisation (WHO) is already taking action towards improving the facilities and opportunities of developing countries in embracing eHealth. In the first place, the WHO has established an eHealth Standardisation Coordination Group, which facilitates the exchange of information and works towards the creation of cooperation mechanisms. In addition, and since 2005, the WHO has launched the Global Observatory for eHealth (GOe), which combines coordination regionally so as to monitor the development of eHealth worldwide. The Observatory claims an ever increasing role in shaping and monitoring the future of health services, especially in low- and middle-income countries.
There are three more noteworthy WHO projects on eHealth with the view to help developing countries in the field. The first one is related to the Global Mobile Health (mHealth) Initiatives, like the Royal Tropical Institute (KIT) mHealth Information Portal, an ePlatform which provides information on the current use and potential of mHealth in developing countries. The portal offers a searchable database of resources which includes mHealth-projects, articles, project reports, case studies, presentations and links to mobile and healthcare organisations. Furthermore, it profiles mHealth projects in low- and middle income countries in Africa and the Middle East, Asia-Pacific and Latin America and the Caribbean.
The second project is the Health Academy, established in 2003, which helps countries (especially developing ones) to integrate eHealth into their health systems and services. Fundamental relevant pilot projects were set up in Egypt and Jordan. Finally, the WHO promotes the Health Metrics Network (HMN), which appeals for greater investment in information systems to track progress and accountability in women's and children's health, especially in underdeveloped countries, where records are incomplete and/or missing. The HMN's priority strategic initiative, called MOVE-IT, aims to improve monitoring of vital events - births, deaths and causes of death - through innovation and the use of information technologies.
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Nature of documentation: Article