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Technology Watch
Standards and e-health
 
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Photo credit: AFP
NEC Avio unveils its “Thermo Mirror” which captures the user’s surface temperature with a built-in infrared sensor and displays it on the mirror. The thermo mirror has an alarm that alerts users when they have a fever.

Electronic health (e-health) systems hold great promise for improving global access to healthcare services and health information. But the use of information and communication technologies (ICT) for gathering, storing and sharing medical information raises legitimate concerns about patient privacy and information security. Technological obstacles also hinder enjoyment of the benefits of e-health systems. These include the lack of global interoperability standards for e-health, as well as technical infrastructure barriers particularly in the developing world.

In an ITU–T Technology Watch Report, issued in January 2011, Laura DeNardis of Yale University takes a closer look at how some of these challenges can be addressed through advances in technical standards for e-health. Standards can cope with specific concerns about privacy, security, and patient identification. Standards can also create the necessary interoperability among healthcare systems, prevent single vendor lockin, reduce costs by enabling market competition, and ensure widespread adoption. The following summary focuses on the ICT aspects of e-health (the full report is available at:
http://www.itu.int/ITU-T/techwatch).

Trends

Four emerging trends in e-health are worth examining closely: genomic medicine; standardized electronic health records; remote healthcare and diagnostics; and aggregated public health data.

Genomic medicine

The medical profession has recently begun to use genetic information in direct clinical care. For example, genetic information is now being used to anticipate a patient’s response to pharmaceutical therapies, detect diseases or tumors, identify inherited conditions, or assess a patient’s likelihood of developing a specific disease.

As genomic medicine evolves, it will be exceptionally data intensive as well as computationally demanding. The future of genomic medicine in clinical practice will thus depend upon the availability of sophisticated medical information systems in provider facilities.

At present, electronic health record systems are generally not equipped to accommodate genomic data. As genetic testing, diagnosis, and treatment become more commonplace, this information will need to be held in electronic records so that it can be exchanged among healthcare providers.

Standardized electronic health records

Medical information systems have historically captured and stored patient data in proprietary formats only understood by a single system and not interoperable with other providers’ systems. Emerging standards for electronic health records are attempting to create common digital formats and structures for integrating a variety of information about a patient and allowing this information to be exchanged among medical information systems developed by different manufacturers.

The types of information recorded could include clinical observations, medical histories, treatments, immunizations, medications, allergies, symptoms, conditions and diagnostic test results, along with a history of visits to doctors or hospitals and the treatments performed. Diagnostic images and legal permissions could also be recorded.

The medical community anticipates that patients will have access to these electronic records. Patients will have a single account of their entire medical history, eliminating the need to recount their medical history every time they visit a new healthcare provider.

Electronic health records create efficiencies within health systems by reducing paperwork and avoiding redundant tests. These records can also improve the overall quality of healthcare by reducing the number of incidents involving adverse drug interactions and by providing more accurate medical histories, enabling medical providers and patients to make better-informed decisions.

To reap these benefits, national governments are increasingly opting to establish electronic health record systems. For example, Australia plans to invest more than USD 466 million to establish a “secure system of personally controlled electronic health records.” In the United States, the American Recovery and Reinvestment Act of 2009 similarly allocated many millions of dollars in contracts to provide electronic medical records. Governments either provide funding for electronic health records or offer indirect incentives such as tax breaks for healthcare providers who demonstrate use of an electronic health record system.

There are significant policy, technological, and social barriers to realizing the potential benefits of electronic health records. One infrastructural challenge, particularly in the developing world, is the inability of citizens and healthcare providers alike to obtain the ICT and telecommunication services necessary to access electronic health records.

Perhaps the most significant challenge is interoperability. Unless a critical mass of healthcare providers adheres to the same standards for electronic health records, the system will not provide the anticipated cost efficiencies and healthcare quality improvements. Personalized electronic healthcare records also raise concerns about data security and individual privacy. From a security standpoint, systems have to meet stringent authentication standards for identifying and verifying the individuals attempting to access their own records as well as for providers accessing these records. The protection of data while digitally stored or while transmitted over a telecommunication network is similarly a critical requirement.

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Photo credit: AFP
Sony displays its prototype model of a thermometer equipped with a smart card chip. This allows a mobile phone to read the data transmitted from the thermometer and to transfer such data to a server or clinic for daily health monitoring

Remote health care and diagnostics

In the developing world and in isolated geographical areas with limited access to health providers and advanced medical technologies, remote health services provided via telecommunication are increasingly filling gaps in medical care. Historically called “telemedicine,” remote healthcare services use telecommunication networks and information technology for many medical purposes including remote clinical care, diagnostics, electronic patient monitoring, and patient and provider access to medical information. None of these remote medical services is possible without telecommunication networks and standards that enable adequate interoperability, quality of service, and security.

Remote clinical careRemote clinical care increasingly enables doctors located at a distance from patients to provide electronic medical assessments, diagnoses, and treatment. This approach involves real-time and interactive communications between a doctor and a patient, either on a phone (landline or mobile) or via video communications over a computer.

Remote diagnostic processing

Other forms of remote diagnostics involve “store and forward” electronic health services. Medical information (such as a radiological image) is transmitted to a medical practitioner for later analysis. This routinely happens nowadays to save costs. But it also has great potential to bring medical expertise to areas otherwise underserved.

Electronic patient monitoring

Remote patient monitoring refers to the ability of medical providers to electronically observe a patient remotely using medical monitoring devices and telecommunication networks. For example, a medical practitioner can monitor a patient’s heart rhythms or blood pressure. This type of remote monitoring is cost-effective when used for patients with chronic conditions, the elderly, and patients recovering from specific conditions.

Mobile health care

Mobile phones are becoming a new medium for health delivery, both through voice communications and via text messages and multimedia, particularly in the developing world. This is the case both in urban areas and in poorer and more rural areas with limited computing infrastructure other than cellular phone networks.

Governments and non-governmental organizations sometimes use mobile phones to gather public health data or track general health status. Messages sent via mobile phones also help providers to keep up to date, in particular with medical advances, pharmaceutical notifi- cations, or diagnostic information about a particular patient. Remote patient-to-physician communication via a mobile device is an increasingly common part of health care, as is patient self-education and access to medical information via mobile devices.

Challenges to emerging mHealth (mobile health) applications are numerous, including how to ensure the accuracy of medical information obtained by patients via mobile devices, how to secure patient-to-provider communications over mobile networks, and how to guarantee adequate service reliability for remote monitoring functions.

Aggregated public health data

The term “aggregated health data” refers to a large body of data obtained by combining standardized digital health records in a way that removes information that would identify any individual patient.

The greatest potential public health benefit of aggregated medical data is its use in health research. Having a large digital repository documenting patient responses to medical treatments and drug therapies helps medical researchers evaluate the effectiveness of these treatments. Such data can also help inform patients seeking treatments. Another potential use is in evaluating the quality of care provided by hospitals and physicians.

Standards will play a critical role in both achieving the public health benefits of aggregated patient data and providing solutions to requirements for security, privacy, quality assurance, and interoperability. As long as electronic health records are fragmented technically, without adequate standardization among providers and vendors, meaningful public aggregation will not be possible.

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Towards e-health standardization

The role of ITU

Many standardization organizations, including ITU, work on various areas of e-health. ITU Recommendations underlie much of the telecommunications infrastructure necessary for supporting the virtual multimedia delivery of medical care, remote diagnostic services, and electronic medical records. ITU–T study groups address these infrastructural issues as well as generally addressing many emerging e-health-related requirements for security (Study Group 17), performance and quality of service (Study Group 12), multimedia coding and systems (Study Group 16), future networks including mobile and next-generation networks (Study Group 13), and a host of other areas. For example, the H.300-series, H.260-series, V.18, T.80-series, and T.800-series all have direct bearing upon e-health systems.

More specifically, e-health standardization studies are addressed by ITU–T Question 28/16: “Multimedia Framework for e-health Applications.” This high-level Question, which coordinates the technical standardization of multimedia systems to support e-health applications, is allocated to ITU–T Study Group 16, the Lead Study Group on ubiquitous applications (for example e-health and e-business). This work originally emanated from a workshop held in 2003 involving the key standardization players at the time, together with the creation of the e-health Standardization Coordination Group (eHSCG). This group is supported by ITU–T Study Group 16 and maintains a list of standards in both technical and non-technical areas of e-health on the website of the World Health Organization (WHO).

The overarching objective of the eHSCG is to “promote stronger coordination amongst the key players in the e-health standardization arena.” The eHSCG, through informal coordination on a voluntary basis, hopes to facilitate an exchange of information among standardization organizations to avoid duplication of effort. It considers the requirements of developing countries and serves as a technical rather than regulatory coordination group, albeit taking into consideration social, economic, and regulatory factors. ITU’s Telecommunication Standardization Bureau, through ITU–T Study Group 16, provides direct support for the activities of the eHSCG, including website and membership management and the provision of necessary tools to enable work by correspondence.

The study items for Question 28/16 include: the development of an overall framework for e-health applications, and telemedicine in particular; the development of a road map for e-health standards; a generic architecture for e-health applications; and specific system characteristics for e-health applications, such as video and still picture coding, audio coding, security, and directory architecture.

Question 28/16 focuses on the critical need for global interoperability among fragmented e-health systems based on different standards and seeks to provide the necessary coordination among major global players (for example medical institutions, governments, intergovernmental organizations, non-profit groups and the private sector).

ITU–T Study Group 16, works with relevant consortia and standardization bodies such as Health Level Seven (HL7), Digital Imaging and Communications in Medicine (DICOM), the International Organization for Standardization (ISO), the European Telecommunications Standards Institute (ETSI), the Internet Engineering Task Force (IETF), the Institute of Electrical and Electronics Engineers (IEEE), the International Electrotechnical Commission (IEC), and the Comité Européen de Normalisation or European Committee for Standardization (CEN). It is also looking into expanding collaboration with other entities, such as Continua Health Alliance.

HL7 issues international healthcare standards for the electronic exchange and management of health information such as clinical data and administrative information. DICOM standards are widely adopted in equipment and information systems used in hospitals, imaging centres and providers’ offices to produce, display, store, or exchange medical images. CEN develops pan-European standards.

ISO’s Technical Committee 215 focuses primarily on electronic health records. Various working groups within this committee address topics such as data structure, messaging and communication, security, pharmacy and medication, devices, and business requirements for electronic health records.

ISO/IEEE 11073 Medical/Health Device Communication Standards are a set of joint ISO, IEEE and CEN standards for medical device interoperability. In this context, medical devices include personal health devices (such as blood glucose monitors, blood pressure monitors, or thermometers) that patients use to monitor their medical conditions.

The future

In the foreseeable future, common digital formats and structures have the potential to allow for the exchange of integrated patient information among all of a patient’s medical providers. Multimedia and messaging standards can continue to improve remote clinical care, remote patient monitoring, and remote diagnostics. Aggregated public health data stored in common digital formats can improve medical research. Digitally stored genetic data can provide more customized medical care to patients. Universal standardization, whether driven through private industry collaborations or through government standards policies, is a necessary precursor for any of these e-health advances. There are three reasons for this:

Technical interoperability: e-health applications such as remote diagnostic systems and electronic medical records will only be successful if there is a high degree of interoperability among the institutional systems exchanging this information, and a high degree of compatibility among medical devices and digital systems, regardless of manufacturer.

Economic efficiency: Medical providers and public entities will invest in costly e-health solutions only if they are assured that the systems will have longevity, rather than becoming obsolete because of the introduction of yet more e-health standards options. Standards that are openly available (rather than proprietary) can help foster economic competition among compatible e-health systems and equipment made by different manufacturers or systems developers.

Public accountability: To an even greater extent than most types of technical standards, the design decisions underlying e-health standards will have public interest effects in areas such as individual privacy, non-discriminatory access to health care, and the overall public good. These decisions should be made with some type of global public accountability, and should be openly available to the public for oversight.

 

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