INTERACTIVE COMMUNICATIONS IN HEALTH AND HEALTHCARE: THE IMPACT OF TELECOMMUNICATIONS

1. INTERACTIVE COMMUNICATIONS IN HEALTH AND HEALTHCARE: THE IMPACT OF TELECOMMUNICATIONS IN THE PRACTICE OF MEDICINE Roberto J. Rodrigues Regional Advisor for Health Services Information Technology Division of Health Systems and Services Development Pan American Health Organization / World Health Organization Washington, D.C. 25th WORLD CONGRESS OF INTERNAL MEDICINE Cancún, Mexico - June 5, 2000

2. INTERACTIVE COMMUNICATIONS IN HEALTH AND HEALTHCARE • TELEMEDICINE • PATIENT CARE APPLICATIONS • TELEHEALTH • TELEMEDICINE, DISTANT EDUCATION AND TRAINING, • HEALTH PROMOTION, PUBLIC HEALTH, SERVICES MANAGEMENT, • TECHNICAL INFORMATION RETRIEVAL • CYBERMEDICINE • INTERSECTION OF INFORMATICS WITH BIOENGINEERING, • IMPLANTABLE DEVICES, PROCESS AUTOMATION, BIOSENSORS, • DEVELOPMENTAL ROBOTICS, NANOTECHNOLOGY • e-HEALTH INTERNET-BASED HEALTH APPLICATIONS, INCLUDING PURELY ADMINISTRATIVE (B2B, E-COMMERCE, ETC)

3. INTERACTIVE COMMUNICATIONS IN HEALTH AND HEALTHCARE APPLICATION OF INFORMATION AND TELECOMMUNICATIONS TECHNOLOGIES TO INDIVIDUAL AND COLLECTIVE HEALTH AND TO HEALTHCARE PRACTICE….. “DISTRIBUTED (NETWORKED) BIOMEDICAL INTELLIGENCE AND HEALTH SERVICES OPERATION”

4. INTERACTIVE COMMUNICATIONS IN HEALTH AND HEALTHCARE • CLINICAL AND ADMINISTRATIVE DATA TRANSPORT • ADMINISTRATIVE AND FINANCIAL TRANSACTIONS • REMOTE ACCESS TO DATABASES • SUPPORT OF COOPERATIVE TECHNICAL TASKS • TELECONFERENCING • TELEDUCATION • TELEMONITORING / TELEPRESENCE • ROBOTIC INTERVENTIONS

5. INTERACTIVE COMMUNICATIONS IN HEALTH AND HEALTHCARE • HEALTH SECTOR ASPECTS • INFORMATICS AND TELECOMMUNICATIONS INFRASTRUCTURE & MARKET • EXPERIENCE WITH ICT PROJECTS IN LATIN AMERICA & THE CARIBBEAN

6. INTERACTIVE COMMUNICATIONS IN HEALTH AND HEALTHCARE • HEALTH SECTOR ASPECTS • INFORMATICS AND TELECOMMUNICATIONS INFRASTRUCTURE & MARKET • EXPERIENCE WITH ICT PROJECTS IN LATIN AMERICA & THE CARIBBEAN

7. CLINICAL AND PUBLIC HEALTH PRACTICE MANAGEMENT AND ORGANIZATION INFORMATION SYSTEMS IN HEALTH CARE IMPLEMENTATION ENVIRONMENT TECHNOLOGY BASE

8. NATIONAL / INTERNATIONAL MARKETS SUPPLIERS OF PRODUCTS & SERVICES POLICY / REGULATORY / LEGAL FINANCIAL PRACTITIONER / ORGANIZATIONS / PAYER / PATIENT/ EMPLOYER / RESEARCHER/ CITIZEN INTERFACE EQUIPMENT TELECOMMUNICATION INFRASTRUCTURE HEALTH INFORMATION INFRASTRUCTURE

9. FACILITATING FACTORS • APPRECIATION OF THE BENEFITS OF INFORMATION • ACCEPTANCE OF TECHNOLOGY • INCREASED APPLICATION DEVELOPMENT PRODUCTIVITY AND QUALITY OF PRODUCTS • VARIETY OF PLATFORMS AND APPLICATIONS • USER-FRIENDLY INTERFACES • DIFFUSION OF COMPUTER SKILLS • HEALTHCARE REFORM

10. HEALTHCARE REFORM RE-ENGINEERING OF FORM AND PROCESS OF CARE • Provider mix (public, managed care, and private) • Competition among service providers • Decentralized care and resource management • Participation of payers and clients in delivery decisions • Increased coverage, access, and equity • Cost-benefit perspective of health interventions • Emphasis in appropriate decision making • Information needed to support different • perspectives (managers, payers, public health, • service providers, clients, quality control)

11. HEALTHCARE REFORM INCREASED NEED FOR DATA & INFORMATION • Distributed delivery of healthcare services • Multidisciplinary approach to health practice • External pressures for cost reduction and recovery • Increasing demand to improve documentation • Consumer participation

12. HEALTHCARE REFORM NEW LOGISTICS OF HEALTHCARE • Demand for timely and dynamic service booking • and scheduling • Demand for fast patient-related data communication and access to integrated multi-institutional patient clinical and administrative data

13. HEALTHCARE REFORM ACCESS TO BIOMEDICAL KNOWLEDGE • Bibliographical reference • Clinical protocols • Patient-based disease registries • Knowledge bases • Evidence-based clinical practice • Consumer informatics

14. EVOLUTIONARY TECHNOLOGIES • POINT OF CARE TECHNOLOGIES • PROCESS AUTOMATION • ELECTRONIC MEDICAL RECORD (CPMR) • DATA WAREHOUSING • DATA ACCESS AND SECURITY TECHNOLOGIES • APPLICATION INTEGRATION • SOFTWARE COMPONENT TECHNOLOGIES • DECISION-SUPPORT TECHNOLOGIES

15. REVOLUTIONARY TECHNOLOGIES • ELECTRONIC COMMERCE (E-commerce) • “PUSH TECHNOLOGIES” • RESOURCE ADQUISITION TECHNOLOGIES (Auction Technologies) • MOBILE AND WIRELESS TECHNOLOGIES • INTELLIGENT AGENTS • INTERACTIVE TECHNOLOGIES (Voice, Writing Recognition) • CONNECTIVITY WITH COMMUNITIES • KNOWLEDGE MANAGEMENT (Retrospective >>> Simultaneous)

16. FULL SERVICES E-COMMERCE PERSONALIZATION CONSUMER CAPABILITY / VALUE COMMUNITY INFO ACCESS INTERACTIVITY

17. FULL SERVICES DIRECT CONSUMER BYPASS STOCK TRADING HEALTH SELF-CARE E-COMMERCE FUND TRANSFER PHYSICIAN ADVERTISING PHARMACEUTICALS / DEVICES E-AUCTION PERSONALIZATION CONSUMER CAPABILITY / VALUE CUSTOMIZED NEWS HEALTH RISK APPRAISAL HMO PERSONALIZED REPORTS COMMUNITY INFO ACCESS CHAT GROUPS ONLINE INVESTMENT CLUBS HEALTH SPECIAL INTEREST GROUPS HEALTH PROMOTION NEWS KNOWLEDGE REPOSITORIES INTERACTIVITY

18. · PHYSICIAN-CENTERED · LOCAL MONOPOLY FOR CARE · BUSINESS SECURITY · EMPLOYER INFLUENCE · INSURANCE CONTROL · ORDERLY TRANSITIONS · STANDARDIZATION · CENTRAL MANAGEMENT · ENTREPRENEURIAL · PUBLIC REGULATED PROCESSES · PROVIDER TEAMS · DISAPPEARANCE OF CAPTIVE MARKETS · COMPETITION · BUSINESS RISK-TAKING · INTERNATIONALIZATION · CUSTOMIZATION · SPEED OF CHANGE · DISTRIBUTED NETWORKED MANAGEMENT NEW MODEL · INVESTMENT · PUBLIC / PRIVATE PARTNERSHIPS · OUTCOMES RESEARCH · EVIDENCE-BASED APPROACH TO PRACTICE

19. INTERACTIVE COMMUNICATIONS IN HEALTH AND HEALTHCARE “HEALTHY” INDIVIDUALS 95% SICK INDIVIDUALS 5% SICK INDIVIDUALS THAT REQUIRE DISTANT HEALTHCARE .05% “GREATEST PRESENT IMPACT IN THE AREA OF HEALTH PROMOTION AND PROFESSIONAL COMMUNICATIONS AND EDUCATION” Source: Sauer, F. et al. (Telemedicine Today , Feb 2000)

20. HEALTH SECTOR ISSUES AND CHALLENGES • Low definition level of deliverables of health interventions • Indetermination of objectives and desired functionalities • Conflicts in the definition of minimum data sets • Organizational and policy-related constraints • Infrastructure , investment sustainability,anddeployment capability • Policies and strategiesfor cost-effective use of technology • Consistency and continuity of political support

21. INTERACTIVE COMMUNICATIONS IN HEALTH AND HEALTHCARE • HEALTH SECTOR ASPECTS • INFORMATICS AND TELECOMMUNICATIONS INFRASTRUCTURE & MARKET • EXPERIENCE WITH ICT PROJECTS IN LATIN AMERICA & THE CARIBBEAN

22. INFORMATION TECHNOLOGY MARKET GROWTH AUTOMATION OF PROVIDER AND CONSUMER OPERATIONS MILLIONS OF USERS 1,000 AUTOMATION OF FRONT-OFFICE AND REMOTE SITES 100 BACK-OFFICE AUTOMATION 10 1970 1980 1990 2000 2010 2020 SOURCE: INTERNATIONAL DATA CORPORATION

23. INFORMATION AND TELECOMMUNICATIONS TECHNOLOGY APPLICATIONS CURRENTLY ADOPTED OR PLANNED TO BE ADOPTED BY THE U.S. HEALTHCARE SECTOR %

24. WORLD MARKET FOR INFORMATION AND COMMUNICATIONS TECHNOLOGIES (1998) JAPAN (11%) OTHER (23%) USA (36%) EUROPE (30%) Value: 1,363 billion US dollars

25. Selected “New Economy” Corporations Ranked by Market Capitalization, Jan 2000

26. Global Distribution of IP Hosts Developed:94 % of hosts16 % population Developing:6 % of hosts84 % population Australia, Japan & New Zealand 6.4% 3.7 % Canada & Developing US Other Asia-Pacific 65.3% 5.9% LAC Europe 1.9% 22.4% Africa 0.3 % Source: ITU 1999 “Challenges to the Network: Internet for Development”

27. “Old economy” network Hybrid analogue/digital Circuit-switched Highly regulated Priced per minute Distance-sensitive pricing Generally state-owned and operated Accounting rate system means cash flows from net traffic generating to net traffic receiving countries “New economy” network All digital IP (packet-switched) Largely unregulated Priced per megabyte Distance-insensitive pricing Generally privately-owned and operated Peering and transit system means cash flows from net traffic receiving to net traffic generating countries TELECOMMUNICATIONS INFRASTRUCTURE

28. CONSEQUENCES OF “NEW ECONOMY” NETWORKS FOR DEVELOPING COUNTRIES • >95 per cent of global IP capacity passes through United States • 96 out of top 100 websites in the United States • Loss of revenue from incoming telephone calls • Developing countries wanting to hook up to the US IP backbone must pay both half-circuits of the leased line • Smaller ISPs must pay bigger ones for transit • Accelerating returns to scale • high volume routes have lowest unit costs • big hubs get bigger • resources go to the strongest

29. HEALTH INFORMATION TECHNOLOGY DEVELOPMENT INDICATORS • INFRASTRUCTURE general population aptitudes; physical IT and telecom infrastructure; market openness; information distribution capability • EXTENT OF IT INSERTION IN SOCIETY penetration computers; labor force and revenues in the computer and telecommunications sectors • UTILIZATION OF IT BY THE HEALTH SECTOR penetration of information systems inthe private and public sectors; implementation of regulatory aspects • IMPACT state-of-the-art, appropriateness; technical effectiveness; effect on policy, structures organization, equity and privacy

30. MAIN (FIXED) TELEPHONE LINES X 100 INHABITANTS (1999) NUMBER Source: International Telecommunication Union and PAHO Basic Indicators

31. MAIN (FIXED) TELEPHONE LINES (1999) LINES X1,000 INHABITANTS Source: International Telecommunication Union

32. LATIN AMERICAN AND CARIBBEAN TELECOMMUNICATIONS MARKET Millions 69 54 50 25.3 12.7 7 Source: International Telecommunication Union, Jan 2000

33. WAITING TIME FOR NEW WIRED CONNECTION IN YEARS (1998) YEARS Source: International Telecommunication Union

34. NUMBER OF FAULTS x 100 LINES PER YEAR (1998) NUMBER OF FAULTS Source: International Telecommunication Union

35. CABLE SUBSCRIPTIONS AS PERCENTAGE OF TELEVISION RECEIVERS (1998) PERCENT Source: International Telecommunication Union

36. ANNUAL RESIDENTIAL SUBSCRIPTION AS PERCENTAGE OF GNP x CAPITA (1997) PERCENT Source: International Telecommunication Union and PAHO Basic Indicators

37. PERSONAL COMPUTERS x 100 INHABITANTS (1998) NUMBER Source: International Telecommunication Union and PAHO Basic Indicators

38. PERCENTAGE OF POPULATION CONNECTED TO THE INTERNET (1999) PERCENT (LOG) Source: International Telecommunication Union and PAHO Basic Indicators

39. INTERNET HOSTS x 1,000 INHABITANTS (JAN 2000) NUMBER (LOG) Source: International Telecommunication Union and PAHO Basic Indicators

40. INTERNET SERVICE PROVIDERS (ISP) (JAN 2000) NUMBER (LOG) Source: International Telecommunication Union

41. Number of Internet Hosts in Latin America and the Caribbean July 1998 - January 1999 - July 1999 - Number of hosts registered under geographic domains, e.g: br, mx, cl, ar - Figures do not reflect number of hosts registered in the country under organizational domains, for example domains type ".com," ".net," ".org." Source: RedHUCyT (OAS)

42. Number of Internet Hosts in Latin America and the Caribbean July 1998 - January 1999 - July 1999 - Number of hosts registered under geographic domains, e.g: br, mx, cl, ar - Figures do not reflect number of hosts registered in the country under organizational domains, for example domains type ".com," ".net," ".org." Source: RedHUCyT (OAS)

43. Number of Internet Hosts in Latin America and the Caribbean July 1998 - January 1999 - July 1999 - Number of hosts registered under geographic domains, e.g: br, mx, cl, ar - Figures do not reflect number of hosts registered in the country under organizational domains, for example domains type ".com," ".net," ".org." Source: RedHUCyT (OAS)

44. LATIN AMERICA AND CARIBBEAN HOSPITALS

45. HOSPITAL INFORMATION SYSTEMS IN LATIN AMERICA & THE CARIBBEAN TOTAL NUMBER OF HOSPITALS = 16,566 COMPUTERIZED 5,230 (83,45%) 31.57% 6,267 (37.83%) WITH IS 62.17% 6.25% 10,299 WITHOUT IS NOT COMPUTERIZED 1,037 (16.54%) HSP/HSO DIRECTORY OF LATIN AMERICA AND CARIBBEAN HOSPITALS, 1996-1997

46. COUNTRIES WITH COMPUTERIZED HOSPITAL INFORMATION SYSTEM NUMBER / % NUMBER / % COUNTRY COMPUTERIZED % TOTAL COUNTRY COMPUTERIZED % TOTAL HOSPITALS HOSPITALS ARGENTINA 812 / 2780 29.2 %15.50 % MARTINIQUE 3 / 6 50.0% 0.05 % BAHAMAS 4 / 5 80.0 % 0.07 % MEXICO 693 / 3033 22.8 % 13.25 % BARBADOS 1 / 8 12.5 % 0.01 % NETHERLANDS ANT 6 / 11 54.5 % 0.11 % BELIZE 1 / 10 10.0 % 0.01 % NICARAGUA 12 / 78 15.3 % 0.22 % BERMUDA 1 / 2 50.0 % 0.01 % PANAMA 13 / 55 23.6 % 0.24 % BOLIVIA 58 / 385 15.0 % 1.10 % PARAGUAY 57 / 236 24.1 % 1.08 % BRAZIL 2313 / 6124 37.7 %44.22 % PERU 262 / 443 59.1 % 5.00 % CHILE 144 / 385 37.4 % 2.75 % PUERTO RICO 64 / 90 71.1 % 1.22 % COLOMBIA 417 / 1023 39.6 %7.97 % ST LUCIA 2 / 6 33.3 % 0.03 % COSTA RICA 19 / 33 57.5 % 0.36 % SURINAME 4 / 13 30.7 % 0.07 % CUBA 37 / 243 15.2 % 0.70 % TRINIDAD & TOBAGO 1 / 64 1.5 % 0.01 % DOMINICAN REP 30 / 213 14.0 % 0.57 % TURKS & CAICOS 1 / 1 100.0 % 0.01 % ECUADOR 59 / 299 19.7 % 1.12 % URUGUAY 66 / 111 59.4 % 1.26 % EL SALVADOR 23 / 77 29.8 % 0.43 % US VIRGIN ISLANDS 5 / 23 21.7 % 0.09 % GUADELOUPE 6 / 10 60.0 % 0.11 % VENEZUELA 54 / 348 15.5 % 1.03 % GUATEMALA 36 / 145 24.8 % 0.68 % HAITI 3 / 103 2.9 % 0.05 % 5,230 / 16,566 31.7 % 100.0 % HONDURAS 23 / 89 25.8 % 0.43 % ARG / BRA / COL / MEX = 80.94 % HSP/HSO DIRECTORY OF LATIN AMERICA AND CARIBBEAN HOSPITALS, 1996-1997

47. TECHNOLOGY ISSUES AND CHALLENGES • DATA AND COMMUNICATIONSTANDARDS • OPEN x PROPRIETARYARCHITECTURE • ANALYSIS OF COST-BENEFIT • CAPACITY TO PURCHASE AND MAINTAINEQUIPMENT / PRODUCTS • ALIGNMENT TOINSTITUTIONAL GOALS, IMPROVEMENT OF HEALTHANDEXPECTATIONS OF PROVIDERS, CLIENTS, PAYERS AND REGULATORS • SECURITY, PRIVACY AND CONFIDENTIALITY • EDUCATION AND TRAININGOF HEALTH PROFESSIONALS

48. INTERACTIVE COMMUNICATIONS IN HEALTH AND HEALTHCARE • HEALTH SECTOR ASPECTS • INFORMATICS AND TELECOMMUNICATIONS INFRASTRUCTURE & MARKET • EXPERIENCE WITH ICT PROJECTS IN LATIN AMERICA & THE CARIBBEAN

49. HEALTH SECTOR IN LATIN AMERICA & THE CARIBBEAN • 80% URBANIZATION / LARGE URBAN AREAS • INADEQUATE INFRASTRUCTURE AND DISTRIBUTION • WESTERN EUROPEAN BIOMEDICAL AND SOCIAL SECURITY MODELS • HEALTH SECTOR REFORM

50. EXPERIENCE WITH HEALTH ICT IN LA & C • INCREASING NUMBER OF INFORMATICS PROJECTS IN THE REGION • OUTSOURCING AS MOST COMMON STRATEGY • ALTHOUGH IT PROJECTS SINCE EARLY 70’s ...LIMITED EXPERIENCE • INFORMATION PROJECT DEVELOPMENT • NEEDS ASSESSMENT • PROCUREMENT • PREPARATION OF REQUEST FOR PROPOSALS • EVALUATION OF PROPOSALS / VENDORS • SELECTION OF VENDORS / SUPPLIERS • CONTRACTING SERVICES, PRODUCTS, AND TECHNOLOGY