e-health is a process of providing health care
via electronic means, in particular over the Internet. The term
e-health has been used to describe the variety of activities
related to the electronic exchange of health-related data, voice
or video. 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 using information and communication
technology.
This paper is commissioned in light of the
rising profile of e-health on the international policy agenda
and the emerging Indian Programme for Information Technology and
related developments in the National Health Service. Few
developments in public health today create the sense of energy
and opportunity embodied in the word "e-health". The promise of
e-health lies in the manner to build advancements in the
development of a health infrastructure. India is actively
developing and implementing technological solutions to deliver
health information and health care services across the country.
These solutions, while exciting and promising, also present new
challenges, particularly in regard to acceptable standards,
choice of technologies, overcoming traditional jurisdictional
boundaries, up-front investment, and privacy and
confidentiality.
This paper will discuss how e-health provides
the opportunity for the patients to maintain independence longer
and for the providers to monitor a condition more closely. It
also describes the barriers and challenges to and the current
status of e-health. Also, an attempt is made for presenting the
e-health status in the Indian scenario. Further, its
technological and financial barriers are illustrated and
recommendations are provided for the improvement.
[1] Introduction
Everybody talks about e-health these days,
but few people have come up with a clear definition of this
comparatively new term. Barley in use before 1999, this term
now seems to serve as a general "buzzword," used to
characterize not only "Internet medicine", but also virtually
everything related to computers and medicine. Intel referred
to e-health as “A concerted effort undertaken by leaders in
health care and hi-tech industries to fully harness the
benefits available through convergence of Internet and
health-care” [1].
In the present scenario it becomes a
frustrating exercise for a patient to physically visit the
doctor by traveling long distances under bad traffic or
weather conditions. In the Indian scenario, one has to wait in
long queues to get advice. Also, patients may contract
infectious diseases in waiting rooms. By utilizing e-health,
patients can get treatments sitting at their home without
going through all tedious exercises.
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.
As such, 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: more efficiency in health care, enhanced
quality of care, empowerment of consumers and patients,
encouragement of a new relationship between the patient
and health professionals, extension of the scope of
health care beyond its conventional boundaries, ease of
use, and excitement [1]-[3] .
There are currently thousands
of e-health web sites online offering general content on
health and medical care including hundred of thousands of
individual web pages dedicated to a broad range of topics
[2]. The
amount of health related information on the worldwide Internet
is rapidly increasing. A search using Google for “health
information” gives the results as shown in the Figure 1.
The Internet has the potential to
revolutionize health care by providing unprecedented access to
information as well as health products and services on
“e-health” sites. Millions of people worldwide are using the
Internet to obtain quality health information directly
affecting their lives, making this form of medicine an
important tool for improving health.
Cyberdocs offer appointments and 24 hours
emergency consultation from anywhere in the world. Some
physicians prescribe medication over the Internet without even
seeing their patients.
Even as its form and structure
continue to emerge, e-health is being used to change business
and medical practices. The Internet clearly drives the
development and adoption of e-health applications. It has the
reach, the infrastructure, and the acceptance to achieve wide
spread change [3].
e-health is perceived as being particularly useful in the
operational support of the new decentralized and collaborative
health care models being implemented in many countries
[4].
Health professionals are increasingly being
drawn into evaluating the Internet as a source of consumer
information for health and medicine. Practitioners report a
growing number of patients arrive at their offices either with
questions related to appropriate web sites to visit or a large
variety of health-related content gathered from the Internet.
Fig.
1: Growth rate of health information on Internet
[2] Status of e-health
Two types of e-health companies have
developed since the Internet was deregulated in the early
1990’s.
Brick and mortar companies that provide
health-related content and services.
Companies that use the web as their primary
corporate environment.
While over thousands of health care sites
already exist online, only a few hundred are exclusively
web-based. Consumer demand is very high. An estimated 60
million adults used the web to find health related information
in 1998. In a survey of 3,269 Internet users, e-health users
reported that finding disease specific information was their
number one application of the technology.
An attempt is made to get an overview of the
research in e-health. A number of e-health oriented funding
programs and repositories of knowledge of research projects
and organizations were identified and its research topics and
trends were analyzed. Freiburg University’s Health Informatics
worldwide web site (http://www.hiww.org/) provides a regularly
updated index of the most relevant links to websites on health
informatics. Around 350 organizations from 56 countries were
included in the index at the time of evaluation
[5]. The
results are tabulated in the form of bar graph (Fig. 2) and
Table 1.
It has been concluded that the maximum
research is going on in the field of Clinical Information
Management and Electronic Patient Record while Bio Medical
Cognitive Science and Consumer Health Informatics needs to be
explored further. Also a considerable research is going on in
the field of Telemedicine.
Fig.
2: Research work carried out
|
Research Areas |
Research work |
|
EPR- Electronic Patient Record |
65 |
|
CHI- Consumer Health Informatics |
10.9 |
|
MLP-Medical Language Processing |
22 |
|
CIM-Clinical Information Management |
68 |
|
TEL- Tele Medicine |
46 |
|
BCS- Bio Medical Cognitive Science |
9 |
Table
1: Research areas and research work carried out
The medical profession has been
developing e-health technology for over 35 years. The
integration of e-medicine and e-health technologies with the
Internet was the next logical step
[6].
For merging these technologies a number of
sites are already existing for billing, back office functions,
marketing, medical records processing, communications, medical
supplies and equipment. Some websites, for example www.webmd.com,
offer complete virtual offices for physicians. Also, the
patients can easily purchase prescriptions, buy products and
obtain general consumer information. Health Buddy, a portable
device developed by Health Hero Network Inc. of Mountain View,
Calif., allows physicians to “monitor” hundreds of patients at
once by processing patients daily answers to health questions
online, via a telephone look-up. Physicians may access patient
information using a password and are alerted to any signs of
trouble, including sudden weight gain or failure to take
medications. Medtronic.com is developing a new monitoring
service that will allow heart patients to use the Internet to
relay up-to-date cardiac data from their homes to physician’s
offices [7].
Fig 3
e-health connectivity
e-health care has the potential to improve the
quality of health care delivery. Typical home monitoring devices
such as blood pressure measurement systems are connected to the
personal computer in the patient’s home which is further
connected to Internet. The blood pressure measurement system
sends the data to the personal computer of the patient which
further transmits it to doctor’s PC via the Internet.
Once the health care doctor
views the data, if required, he takes immediate steps to
intervene by contacting the patient either by telephone or by
website real time messaging. Immediately the prescriptions along
with data are recorded in the personal file of patient
[8].
The electronic connection would use a home
monitor to download information such as heart rate and battery
status from an implanted pacemaker. The data would then be
automatically transmitted to a cardiologist over a secure
Internet link. Some websites provide virtual communities, chat
rooms for personal issues and discussion hours with
professionals. Most leading hospitals have online informational
services. Many managed care organizations offer informational
services as well as some types of direct care through privately
accessed parts of the Internet, known as an “intranet”. Some
sites offer daily behavioral health care news, articles,
reviews, discussion boards, cartoons, a meditation center and
thousands of links to other health care websites.
[3] Benefits and services offered by
e-health
There are a number of Internet
sites for providing services for the health care industry.
Others provide patient health and medical content. Many
sites serve multiple functions such as providing consumer
information, hosting on-line support groups and providing
business support services. Some consumer information sites
are run by nonprofit organizations such as the American Cancer
Society and provide a wide range of content. Government
agencies often provide information as part of the organization’s
public mission. For example the National Library of
Medicine offers one of the most comprehensive databases of
medical information in the world. Some commercial based health
content sites provide entry points to other areas or sites that
sell products and services and may offer additional benefits
such as the ability to store a personal medical record online at
a protected site [2].
Rather than providing static content, there are
virtual discussion areas for sharing ideas among patients and
their family regarding specific health problems and provide a
source of mutual support among people afflicted with similar
health problems. These support group sites tend to be free of
charge and are very popular.
An increasing number of Internet e-health sites
sell prescription medications and non-prescription drugs as well
as related products to patients online. Some sites provide
basic answers to specific questions submitted by visitors to the
sites. A growing number of sites provide actual medical
“consultations” including a diagnosis and will issue a drug
prescription and treatment plan based on information provided by
the visitor to the site. Some questions are answered free but
there is a charge associated with providing medical diagnosis
and treatment.
There are some e-health sites
which are designed to provide specific patient information and
services for a closed set of patients. The site provides
these services under contract with an insurance plan or employer
for covered individuals. e-health sites that provide this
facility sometimes use a password protected screen that pops up
before the registered user can enter the site. There are
many sites which are designed to provide business services for
health professionals and health care organizations. These
sites also assist the health professionals with financial
billing and maintaining records as well as accessing large
databases of content [2].
Hence it is observed that a variety of services are being
provided by the sites related to e-health.
[4] Barriers to using e-health sites
Before proceeding to deliver service using
remote technology one has to obtain training from a recognized
training organization or specialist in proper use of specific
technologies for remote patient treatment. Health care
practitioners will be seeking to deliver remote services via use
of videophones or dedicated videoconferencing equipment. Most of
the practitioners currently are not trained to use advanced
telecommunication equipment and therefore do not fully
understand the legal, ethical or practical ramification of using
such technologies.
Though e-health continues to explode and
computer medicated self-directed programs have also been shown
remarkably effective for treating a variety of disorders, but
research has not shown the efficacy of any assessment instrument
to rule out serious mental illness in the worldwide population
accessible through on Internet sites.
The next barrier is privacy. Many practitioners
do not know how to completely remove patient files from their
own computer hard drives or how to secure email transmissions to
protect patient confidentiality. Legal protections for patients
and practitioners are still in flux, while federal standards to
protect the transmission and privacy of medical information are
currently being developed.
From the clinician's
perspective, it is more difficult to determine if a person is
fully attentive or distracted during the interaction when using
remote technology. The practitioners need to be trained or
otherwise gain experience in the various possibilities for
misinterpretation when offering service to the public with
worldwide connectivity brought by the Internet. Of further
importance is the clinician's familiarity with colloquial
expressions, idioms, and local variations or word usage, this
can be crucial when working with mentally ill, suicidal or
homicidal patients [9]-[11].
Chua and colleagues evaluated whether
telemedicine and e-health for new patient referrals to
neurological outpatient clinics was as efficient and acceptable
as conventional face-to-face consultation in a randomized
controlled trial. The study was carried out between a
neurological centre and outlying clinics at two different
hospitals with the use of video conferencing equipment.
Eighty-six patients were randomized to the telemedicine group
and 82 were randomized to the face-to-face group. The outcome
measures consisted of the following: consultation process (i.e.,
number of investigations, number of drugs prescribed, and number
of patient reviews) and patient satisfaction (i.e., confidence
in consultation, technical aspects of consultation, and aspects
surrounding confidentiality). It was concluded that although
e-health may be a safe and acceptable alternative, the e-health
group had significantly more investigations (neurological
testing) and had concern regarding confidentiality and
embarrassment. This randomized trial suggests that telemedicine
may be associated with less diagnostic certainty, resulting in
more investigations and is not as well accepted as face-to-face
consultation [12].
Currently the e-heath world is still very
much a “consumer beware” environment. Identifying the
appropriate e-health site is not an easy task for most
consumers. Health professionals can play an important role in
helping patients with this issue. As such, the patients must
take the opinion of other’s practitioners too.
[5] E-health in India
India has a major role to play in the
international e-health services industry. The Ministry of
Communication and Information Technology (MCIT) has undertaken
an initiative to build the national framework for “Information
Technology Infrastructure for Health – ITIH” through health
information standards. The objective of this undertaking is to
achieve the following in the Indian health care system: (a)
Simplify administrative processes (b) Enable sharing of
information between disparate systems (c) Ensure greater access
to health care in a cost-effective manner.
Apollo Health Street Ltd. (AHSL), a subsidiary
of the Apollo Hospital group supported the MCIT in defining the
framework for ITIH in India. Though these initiatives have been
met with a lot of enthusiasm and user acceptance, their
commercial viability is still under consideration. The
government has been taking some proactive measures in a
regulatory and financial capacity to boost the e-health
environment in India. Money has been invested in telemedicine
centers in regions that lack quality health care. Standards for
telemedicine have been declared to maintain and promote quality
in health care delivery through telemedicine. A health
information infrastructure is being built to promote
standardization in the capture and dissemination of health
information. Some forward-looking state governments, such as the
government of Andhra Pradesh, are using the Internet to increase
health awareness and for promoting preventive health care. The
developments in the domestic health care environment are
promoting international business by positioning India as a
practitioner of global best practices
[13]-[15].
The presence of world-class
health infrastructure and health care professionals enables it
to be one of the leading e-health services providers in the
world. Through it was found that India has made good
progress in offering e-health services to the developed
countries. In 2002, more than $60 million in revenue was
generated through IT-enabled services. At the current growth
rate, this figure could reach over $10 billion by 2010
[14]. On the
domestic front, many e-health initiatives were taken by the
government and private sectors, most prominently telemedicine.
[6] Barriers and challenges for e-health
(a) Technology Barriers
Insufficient bandwidth is the primary technical
barrier dogging the IT-enabled health care services industry
today. Many health care claims processing companies work
directly on the clients’ databases in real time, which requires
very high bandwidth. Claims processing involves a large amount
of documentation. Current bandwidth does not support easy
transfer of scanned documents.
Many systems used in the country
are not compatible with the advanced systems of other
countries. The infrastructure problems of the country mainly
refer to the unavailability of an un-interrupted power supply,
limited Internet connectivity, lack of an efficient public
transportation system, lack of commercial spaces for business
establishment, etc [10].
Telecommunications and connectivity issues such
as bandwidth, telephone call charges, Internet access, etc need
to be addressed for growth and development of the services
sector. Additionally health care applications used today are
outdated; they are not interoperable across different platforms.
(b) Financial Barriers
The financial sector in the country with
respect to delivery of health services and the e-business
environment involving the foreign direct investment,
facilitation of e-commerce, etc. is mostly favorable. The major
issue has been regarding transactions with foreign currency.
Indian banks charge the customer for foreign currency
transactions. Nationalized banks charge up to Rs. 200-350/- per
transaction. Private banks such as ICICI charge up to 0.25% of
the transaction value. Historically the failure of medical
transcription companies has dissuaded people from investing in
health care related businesses. However things have changed
today. There are no financial barriers today. In fact, many
companies that operate in the old economy industries, such as
Godrej, TVS group and Bhilwara group are investing in medical
transcription companies. Cost differentials that the Indian
companies were offering are decreasing
[13].
Today Indian service providers offer an overall
cost reduction of around 50% to a client in the US for providing
different types of e-health solutions by using Indian manpower.
Lack of trust in the new mechanisms of payment, and credit card
culture are few of the reasons for failure in fully realizing
the potential of e-business. There is lack of transparency in
the financial sector leading to partial distrust affecting the
nature and volume of investments in the foreign country where
transparency refers to, that there should be no gaps between the
ideal and reality. For example, firms often delay
release of statements, or provide no quarterly or semi-annual
updates, or purposely omit footnotes with detailed information.
When financial statements are not
transparent, one can never be sure about a company's real
fundamentals and true risk.
There should
be a clear demarcation between central and state provision and
financing of various health services. Both health provision and
financing is considered to be a state's subject. On average, out
of the total government health spending, the state's share is
about 80 percent. To address these needs, the government, both
at central and state level, should encourage private and public
establishments to develop and reinforce the key aspects of
infrastructure that mainly refer to technology, real estate,
power, telecom, transport, etc.
India is actively promoting
e-health initiatives both independently and in collaboration
with foreign stakeholders. Most state governments are coming
forward to address the infrastructure issues and enabling a
conducive environment for the setting up of new business units
to promote cross border trade in health services
[13]-[15].
[7] Recommendations for strengthening the
Indian e-health Industry
The growth of
e-health services environment has so far been dependent on the
aggressive initiatives taken by the private sector, aided with
some friendly policies by the government. It has not had a major
impact on the domestic health care market. A more efficient and
robust domestic health care system could further strengthen our
competitive edge in the international e-health services market,
particularly the quality of our health care professionals and
communication infrastructure.
By improving
the quality of computer education there will be an increase in
the output in terms of e-professionals. Both the domestic and
international service providers can benefit from it. Also the
prices of Internet bandwidth for health care service providers
should be reduced. Higher bandwidth will increase the throughput
of Indian service firms and will also enable them to utilize
more data/picture intensive and high value-added work. This move
will also give a fillip to domestic e-health services,
especially telemedicine and tele-education. Uninterrupted power
supplies should be offered, for the same reason as mentioned for
essential services. Incubators should be built to spur the
entrepreneurial activity in areas such as biotechnology. It
should be made mandatory for all health care entities to follow
health information standards in a phased manner. This will
reduce much of the administrative costs for the government, will
reduce medical errors and will make it easy to exchange health
information among different entities in our health care
industry.
Laws must be
framed that will protect the privacy and confidentiality of
health information. This will ensure that health information is
not misused by the providers or payers who capture this
information. By doing so, India will project itself as a safe
environment to do business for international health care
companies.
Implement a
licensing mechanism to ensure quality of service for domestic
e-health service providers, as well as make the necessary
changes in the employment laws that will enable night working
hours for women in ITES (Information Technology Enabled
Services) industry. Also improve the quality of English at all
levels of the education system. There is a need of (a) ITES
qualification tests – in order to ensure a basic quality of
inputs going to the ITES industry, design an ITES employability
test and make it mandatory for everyone wanting to work in this
industry (b) Develop health care domain skills – courses in
health care administration (transcription, coding and billing)
and health care financing (health insurance) and on HIPAA
(Health Insurance Portability & Accountability Act)
should be developed and offered to both corporations and
individuals (c) International business – special courses on
international business practices and work and consumer culture
should be introduced (d) Introduce vocational courses to speed
up the skill development for ITES jobs. There is a need to
increase the number of medical and paramedical graduates per
year. This will not only help the ITES industry but also cater
to existing demands for health care in rural areas. Also the
computer literacy level in the health care system should be
increased and IT (information technology) education must be
compulsory for all medical and paramedical graduates. Incentives
must be provided to health care organizations for training their
employees in basic IT applications. Increase venture funds
for capital investment and the number of long gestation projects
in areas such as biotechnology should be increased
[13]-[17].
[8] Future of e-health
The health care industry has
traditionally been seen as conservative, and slower to adopt
technological innovations than industries such as banking,
finance and telecommunications. In 2002, IBM produced a report
outlining their vision of e-health ten years hence, in 2012
[3]. It
also identified a number of key technological enhancements that
will drive improvement in health care provision, including:
·
Increases in bandwidth
·
Advancements in wireless technologies
·
Improvements in storage capacity
·
Screen resolution enhancements
·
Decision-support system enhancements
·
Increased acceptance and use of the Web in
everyday life
·
Integrated clinical and business application
software
·
Developments in telemedicine
·
Improvements in e-business transactions
·
Developments in data warehousing and data mining
Advances in the digitization of
sensory information, in particular smell, may allow
enhance remote diagnosis through capture of data from devices
such as the ‘e-nose’, which can analyze gases exhaled from the
nose in order to determine levels of bacteria and hence the
likely presence of infection
[3],[18]-[20].
[9] e-health Internet sites
An attempt is made to summarize some health
related sites for ready reference of the readers:
·
http://www.nhsdirect.org.uk: This site offers
health information range from publicly-funded health sites such
as NHS Direct Online.
·
http://www.besttreatments.co.uk: This site offers
patients informed advice on specific conditions.
·
http://www.patient.co.uk: Online information is
also provided by many other organizations offering advice on
using the web for health care purposes. For example, Patient UK
offers resources such as leaflets on specific conditions, lists
of support groups, a directory of online resources, comparison
of medical insurance policies.
·
http://www.drfoster.co.uk: This site offers guides
on a variety of health topics as well as a utility to locate a
hospital or specialist, and to find or compare
performance-related data for specific hospitals.
·
http://www.telemed.no/: The Norwegian Center for
Telemedicine (NST) is a research and development center that
aims to gather, produce and provide knowledge about telemedicine
and e-health both nationally and internationally. The NST works
actively to ensure that telemedicine and e-health services are
integrated into health service provision.
·
http://www.atsp.org The Association of
Telehealth Service Providers is an international
membership-based organization dedicated to improving health care
through growth of the telehealth industry
·
http://www.ieha.info/ International e-health
Association (IeHA)
·
http://news.bbc.co.uk/1/hi/health/ popular news
web sites, such as the BBC’s online presence, have sections
focused on health.
·
http://www.cancerbacup.org.uk/ Organization
supporting specific conditions having web sites and providing
information for patients and their relatives and friends. For
example, Cancer BACUP offers extensive information on
cancer-related conditions.
·
http://www.bbc.co.uk/dna/ican/: Consumer-issue web
sites, such as the BBC’s iCan can be used as an efficient way to
raise consumers’ awareness of their rights and expectations,
empowering them by easing channels through which complaints can
be made, and thus impacting on health care delivery by
professionals and organizations.
·
The Telemedicine and e-health Information Service
(TEIS, http://www.teis.nhs.uk/) and the Health Informatics
Worldwide web site (http://www.hiww.org/) both provide
comprehensive lists of research activity in the e-health arena.
·
http://www.YourHeart.org.uk discussion forum is an
on-line discussion forum providing a facility for discussion on
specific health-related topics, in this case for heart patients
and their friends and relatives. Postings are moderated, but
allow patients to share experiences with one another, and
communicate with health care professionals.
·
http://www.ehealthwebsites.org/: Provides a collaborative
link between a number of websites involved in collating and
disseminating information about e-health and telemedicine.”
·
http://www.ehealthnurses.org.uk/: This network, first
established by a small group of nurses in 2000, is an
independent initiative, freely open to all nurses and health and
social care colleagues with an interest in developing e-health
in order to maximize the professional delivery of effective
patient care.
·
http://www.medcom.dk/health-telematics/: The objectives of
the Center are to strengthen the quality, service and coherence
in the health care sector by establishing electronic
communication between parties in the health care sector.
·
http://www.ihealthcoalition.org/:
The mission of the Internet health care Coalition is to improve
the quality of health care resources on the Internet.
·
http://www.isft.net/:
The ISFT
(International Society For Telemedicine) exists to facilitate
the international dissemination of knowledge and experience in
telemedicine and e-health and to provide access to recognized
experts in the field worldwide
[6]-[11].
[10] Conclusion
e-health provides immediate access to the
information that is relevant to patients as well as health care
providers. Patients are taking more responsibility and
initiative for making their own health care decisions. There
will be a major shift in the 21st century enabling
health care consumers to increase their ability to go beyond
their geographical boundary. New health care consumers will seek
information about diseases, illness prevention to intervention,
choice and types of care that are available to them.
Questions regarding security and
confidentiality issues are still hampering the development of
e-health. It is recognized that security and confidentiality of
electronic medical transactions over networks is a major concern
for both telemedicine providers and patients, and should not be
overlooked at any cost or in any way. Security and
confidentiality of electronic medical transactions over networks
is a legal and legislative issue that requires national
governments and international organizations to develop legal
frameworks and laws to govern these issues. The role of
international organizations in proposing and developing
guidelines is essential. Countries and health care institutions
that have initiated or developed e-heath activities should share
their experience and exchange information on their progress.
Countries should conduct needs assessment prior to implementing
e-health initiatives and avoid copying experience from the
developed world, especially with regard to legal, social,
cultural and technological differences.
Countries should introduce technological
developments as part of the national economic development plan.
These developments should be integrated for health care support
to bring both social and economic benefits. There should be an
integration of informatics training into education as early as
possible. Special emphasis should be put on medical informatics
training for health professionals. India should forge
partnerships for e-health projects with international
organizations and the private sector. National standardization
bodies and international agencies should develop common
standards and protocols for e-health applications.
In the end, a very important part of making
appropriate selections regarding e-health is having the
appropriate information. The consumer has to visit multiple
sites to obtain a second opinion. Visiting multiple e-health
websites is critical when seeking the reliable services over the
Internet. Of course this is the most reliable way to check the
accuracy of health information and to obtain sound medical
advice whether from the Internet or elsewhere.
[11] References
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[2]
A Guide to e-health for the Health care Professional: An
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[3]
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[4]
Rodriguez, J Roberto., Opportunities and challenges in
the deployment of global e-health. 2003. International Journal
of health care Technology and Management. 5(3/4/5).
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