Telemedicine was fundamentally born

Telemedicine was fundamentally born during the ‘space race’ between the USA and the former USSR. The National Aeronautics and Space Administration (NASA), the USA military and USA government funded many telemedicine projects. NASA was keen to build up a distant monitoring system to manage the health of American astronauts in space (Sullivan, 2001). Generally “Telemedicine involves the use of modern information technology, especially two-way interactive audio/video communications, computers, and telemetry, to deliver health services to remote patients and to facilitate information exchange between primary care physicians and specialists at some distances from each other” (Bashshur, 1997).

In this Information Age, telemedicine and computer driven treatment methods are being used in the field of treatment of disease including cancer in different ways. eHealth created a new medium that changed the environment of the entire health sector and its relationship with its constituencies. It has had a profound impact on various socioeconomic and political aspects of society. The information system brings delivery of health services in a much more convenient and cost-effective way, offering great opportunities to develop the efficiency of the health sector. However, the route of change also gives rise to new challenges and difficulties, especially in developing countries, where were not many successful initiatives. This is the result of the massive deficiencies in basic infrastructure, human capacity and financial resources, along with the attendant political and cultural constraints. These factors are crucial and impede the adoption of eHealth, many models and frameworks that were built to assist in the process of adoption in developing countries have been adapted from the experiences in the implementation of e-Western developed countries health. While there are important lessons to be learnt, these frameworks have limited application in Africa and developing countries in other regions.

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2 – Thesis Outline

The study presents examination of the subject background, data collection, analysis, findings and discussion for the issues and concerns of eHealth in Sudan. The findings of the study will contribute to the identification of the critical factors in eHealth in Sudan, and to the development of adoption of a system of user-friendly approach to eHealth

Chapter One: Introduction

Presents the background of the subject of this study and explains the research problem; the purpose; the objectives and the main research questions to be answered, and what this research will contribute in the field of health informatics

Chapter Two: The literature review

Reviews the literature in order to provide a clear vision of the concept of eHealth and the main characteristics, including: definitions, benefits, challenges and stages of eHealth in Sudan

Chapter Three: Methodology

Addresses important choices, resources and information on the principles of design research. This information is to help to make the right decision on the nature of the research problem and how it should be investigated. There are different options in terms of research approaches and techniques that can be used in the research design

Chapter Four: Data analysis and findings 

Presents the findings of the data analysis techniques used. Figures and tables are effectively used to present the research findings

Chapter Five: Conclusions and discussions

Gives a brief summary of the main research findings, followed by a discussion of their theoretical and practical implications.

3, Concepts of eHealth

The use of emerging information and communication technology, especially the Internet, for improving or enabling health and health care can be defined as eHealth and this ‘eHealth’ term bridges both the clinical and nonclinical sectors and includes both individual and population health-oriented tools (Eng, 2001). The nature and functions of eHealth services are expanding rapidly, so it is difficult to define eHealth accurately. For the hospital care setting, eHealth refers to electronic patient administration systems; laboratory and radiology information systems, electronic messaging systems; and, telemedicine, teleconsultations, telepathology, teledermatology etc. In case of the home care setting, examples include teleconsultations and remote vital signs monitoring systems used for diabetes medicine, asthma monitoring and home dialysis systems. For the primary care setting, eHealth can refer to the use of computer systems by general practitioners and pharmacists for patient management, medical records and electronic prescribing. Electronic Health Record can act as a fundamental building block of all these applications. It allows the sharing of necessary information between care providers across medical institutions (Ali E, 2008)

eHealth in Developing Countries

Health systems in low- and middle-income countries continue to face considerable challenges in providing high-quality, affordable and universally accessible care. In response, policy-makers, donors and programme implementers are searching for innovative approaches to eliminate the geographic and financial barriers to health. This has resulted in mounting interest in the potential of eHealth (the use of ICT for health) and m-health (the use of mobile technology for health, a subset of eHealth) in low- and middle-income countries, (Bulletin of the World Health Organization 2012)

Developing countries are experiencing an unprecedented increase in the number of users of cell phone and internet technologies, as well as a decline in the price of devices and services. As a result, many health programme implementers and policy-makers are exploring the extent to which e- and m-health (henceforth referred to simply as eHealth) can help address the challenges faced by resource-constrained health markets in terms of the availability, quality and financing of health care. This increasing interest is evidenced by the growing number of events, web sites and literature focused on eHealth, including the Saving Lives at Birth Grand Challenge, the recent Health Affairs thematic issue on eHealth in the developing world, the m-health summits that took place in Washington, DC, United States of America, and Cape Town, South Africa, and the survey recently conducted by the World Health Organization on the use of m-health by its Member States (Trevor, L, Christina, S, Gina, L & Julian, S 2011).

Despite the increased interest – perhaps bordering on excess – in some individual programmes, in low- and middle-income countries the eHealth field is still relatively nascent. Few programmes have gone to scale and implementation has typically been fragmented and uncoordinated. To date, the literature on eHealth in low- and middle-income countries has largely consisted of articles describing single uses of technology in health care delivery, as well as theoretical discussions and recommendations surrounding the implementation of eHealth-based programmes and policies, with few examinations of the actual global landscape of these programmes. One exception is a white paper commissioned by Advanced Development for Africa that lays out a series of case studies and provides best-practice recommendations from eHealth experts. Another paper reviews the evidence on the impact of eHealth in low- and middle-income countries. The aforementioned WHO survey of Member States’ utilization of m-health presents a systematic landscaping of health programmes; nevertheless, the survey relied on local government knowledge, which is often limited when it comes to the private sector, where much of the eHealth activity is taking place.

By analyzing health programmes in low- and middle-income countries that engage the private sector, our paper fills gaps in the eHealth literature and provides new insight into several central questions. It examines specifically the geographic distribution of technology-enabled programmes, the key issues technology can address in the health sector, and the key challenges posed by the adoption and implementation of technology for health-related purposes (Trevor, L, Christina, S, Gina, L & Julian, S 2011).

4- 2.11.1 Executive Summary

The eHealth Strategy study was assisted by, indeed in great part based on, design and implementation of eHealth solutions in several countries. This eHealth Strategy study also builds on the study of the Sudan requirements for TeleMedicine links, which was requested through and funded by the ITU, and which led to the actual operational start in April 2005 of a Sudan National TeleMedicine Network with pilot links between four remote general hospitals and Khartoum University Teaching Hospital.

At present, the Sudan health sector, led by the Federal Ministry of Health and the State Ministries of Health, is in the middle of a major, ongoing reform of the managerial technical and clinical aspects of the health sector, including the delivery of the medical care services. The underlying theme of such reform is to increase the capacity of the health care institutions (hospitals, health centres, laboratories, etc…) to deliver more and better quality medical care and to gradually strengthen these institutions to independently manage their own human, financial and other resources. These responsibilities were until hitherto the FMOH’s responsibility; but the FMOH is gradually limiting its role to setting national health policy and strategy, monitoring their implementation and progress thereon, and conducting evaluation and audit

One of the key features of the “ongoing reform”, referred to above, is the concerted effort to explore more, and increase the current, uses of “Information and Communication Technologies (ICT)” support to the National Health Care Services, including its clinical, public health and managerial aspects – referred to briefly as “eHealth support”. Cost-effective eHealth support is indeed the most worthwhile avenue for the Sudan.

This eHealth Strategy study started with a rigorous analysis of the requirements of a wide range of users in hospitals, health centres and their various technical and administrative support services, both in Khartoum and several other States. It also included an analysis of the capacities and potential for running and managing eHealth technological support

The study established, and recommended, the following Users Requirements to be adopted as the priorities for eHealth Support:

• Users require support to manage their day-to-day functions particularly to reduce the burden of reporting and search for and access to needed data and information
• Users demand the means to network and communicate, over distance and substance, with other parts of the health sector, both as providers and requesters of information and related services
• Users require updated and clear rules for information flow within the health sector and access to commonly needed data bases, a few of which already exist but most need to be developed based on standards that are respected nation-wide
• The recently launched TeleMedicine Network is apparently filling a major need, and more nation-wide TeleMedicine links are called for
• Professionals require and demand access to the increasingly available courses and training opportunities accessible over the Internet, e.g. Continuous Professional Development/Continuous Medical Education (CPD/CME) courses
• Institutions require that their minimum human resources requirements be verified and provided for
• Professionals and patients alike require greater levels of security and confidentiality of personal data and related transactions
• Professionals demand that the relevant legislation be updated
• All levels of users demand to be informed and truly involved in eHealth, as it is appreciated as a major development affecting the scope and quality of their work

The following priorities are specified by, (Mandil, 2005):

1) The development of a National Health Information Platform that networks all the Sudan health sector institutions and supports all forms of communications between them this could be referred to as “Aafya-Net” or “Shabakat Al-Aafya”

2) The development of a National Health Care Management Information System, comprising mainly of MISs for hospitals and health centres, and aimed at the direct support of the day-to-day health care services. This NHC/MIS also sets the core for key services such as Electronic Medical Records

3) The extension of the current National TeleMedicine Network to ensure at least one site in each of the remaining 22 states, and to launch the TeleEducation services

4) The development of a National Health Data Dictionary to hold, and make publicly available, all the standards of data items and related procedures

5) The enforcement of a strict Digital Security on all eHealth support

It is recommended to start the implementation of the above five priorities. Nation-wide implementation could take 5-15 years. It is recommended to start with the implementation of a core of the proposed NHC/MIS in as many health care institutions as possible, initially a pilot of 12 hospitals and 12 related health centres. An approximate budget of US$ 5.3 million is proposed.

Much of the actual development work should be outsourced to contractors and local service enterprises. But, it is necessary and recommended that the MOH IT Team be strengthened in calibre and in number of professionals, to be the necessary professional counterparts to such services providers.

5- 3.8 Data Analysis Procedures

Data analysis is an ongoing activity, which not only answers your question but also gives you the directions for future data collection. Data Analysis Procedures (DAP) help you to arrive at the data analysis (Bala, 2005). The uses of such procedures put your research project in perspective and assist you in testing the hypotheses with which you have started your research. Hence with the use of DAP, you can

• convert data into information and knowledge, and
• explore the relationship between variables.

Understanding of the data analysis procedures will help you to

• appreciate the meaning of the scientific method, hypotheses testing and statistical significance in relation to research questions
• realize the importance of good research design when investigating research questions
• have knowledge of a range of inferential statistics and their applicability and limitations in the context of your research
• be able to devise, implement and report accurately a small quantitative research project
• be capable of identifying the data analysis procedures relevant to your research project
• show an understanding of the strengths and limitations of the selected quantitative and/or qualitative research project
• demonstrate the ability to use word processing, project planning and statistical computer packages in the context of a quantitative research project and report
• be adept of working effectively alone or with others to solve a research question/ problem quantitatively.

The literature survey which you carried out guides you through the various data analysis methods that have been used in similar studies. Depending upon your research paradigm and methodology and the type of data collection, this also assists you in data analysis. Hence once you are aware of the fact that which particular procedure is relevant to your research project (Bala, 2005), you get the answers to:

• What kinds of data analysis tools are identified for similar research investigations? and
• What data analysis procedures should you use for your purpose?

There are numerous ways under which data analysis procedures are broadly defined. Fig. 3.1 diagram makes it evident.

There are, in fact, a number of software packages available that facilitate data analysis. These include statistical packages like SPSS, SAS, and Microsoft Excel etc. Similarly tools like spreadsheets and word processing software are multipurpose and very useful for data analysis (Bala, 2005).

6 – 3.10 The Health Metrics Network (HMN)

The Health Metrics Network (HMN) was launched by World Health Organization (first edition 2005, second edition 2008) to help countries and other partners improve global health by strengthening the systems that generate health-related information for evidence-based decision-making. HMN is the first global health partnership that focuses on two core requirements of health system strengthening in low and low-middle income countries. First, the need to enhance entire health information and statistical systems, rather than focus only upon specific diseases. Second, to concentrate efforts on strengthening country leadership for health information production and use.

In order to help meet these requirements and advance global health, it has become clear that there is an urgent need to coordinate and align partners around an agreed-upon “framework” for the development and strengthening of health information systems. It is intended that the HMN Framework1 shown in Fig. 3.2 will become the universally accepted standard for guiding the collection, reporting and use of health information by countries and global agencies. Through its use, it is envisaged that all the different partners working within a country will be better able to harmonize and align their efforts around a shared vision of a sound and effective national health information system (“national HIS”). As shown in Fig. 3.2, the HMN Framework consists of two major parts:

Components and Standards of a Health Information System (left-hand column of Fig. 3.2) which describes the six components of health information systems and provides normative standards for each.

Strengthening Health Information Systems (right-hand column of Fig. 3.2) which describes the guiding principles, processes and tools that taken together outline a roadmap for strengthening health information systems.

A crucial early step in this roadmap is the need for an effective assessment of the existing national HIS – both to establish a baseline and to monitor progress. In order to assist countries in this key activity HMN has developed this assessment tool which describes in detail how to undertake a first baseline assessment.

Such an assessment is complex, as overall system performance depends upon multiple determinants – technical, social, organizational and cultural. Assessment therefore needs to be comprehensive in nature and cover the many subsystems of a national HIS, including public and private sources of health-related data. It should also address the resources available to the system (inputs), its methods of work and products (processes and outputs) and results in terms of data availability, quality and use (outcomes). Important “inputs” to assess include the institutional and policy environment, and the volume and quality of financial, physical and human resources, as well as the available levels of information and communications technology (ICT). In terms of “outputs” the integrity of data is also determined by the degree of transparency of procedures, and the existence of well-defined rules, terms and conditions for collection, processing and dissemination. Assessing “outcomes” should include quantitative and qualitative approaches, such as document reviews and interviews with in-country stakeholders at central and peripheral levels, and with external actors. Here are the defined six components of HMN framework (WHO, Framework and Standards, HMN, second edition 2008):

1. Health Information System Resource: It includes the legislative, regulatory and planning frameworks required to ensure a fully functioning health information system, and the resources that are prerequisites for such a system to be functional. Such resources involve personnel, financing, logistics support, information and communications technology (ICT), and coordinating mechanisms within and between the six components. These act as inputs in the system.
2. Indicators: A core set of indicators and related targets for the three domains of health information have been outlined in Fig. 3.3. This is the basis for a health information system oriented plan and strategy. Indicators need to be present for determinants of health, health system inputs, outputs and outcomes, and health status.
3. Data Sources: Data sources can be divided into two main categories; (1) population based approaches (censuses, civil registration and population surveys.

A number of other data-collection approaches and sources do not fit neatly into either of the above main categories but can provide important information that may not be available elsewhere. These include occasional health surveys, research, and information produced by Community Based Organizations (CBOs)

4. Data Management: It covers all aspects of data handling from collection, storage, quality-assurance and flow, to processing, compilation and analysis. Specific requirements for periodicity and timeliness are defined where critical – as in the case of disease surveillance. Indicators, Data sources and Data Management are three Processes in the system.
5. Information Products: Data must be transformed into information that will become the basis for evidence and knowledge to shape and decide on health action. Information products are the outputs.
6. Dissemination and Use: The value of health information can be enhanced by making it readily accessible to decision-makers (giving due attention to behavioural and organizational constraints) and by providing incentives for information use. Dissemination and use are the ultimate impacts of the framework.

What are the objectives of assessment?

National HIS strengthening must start with a broad-based assessment of the system’s own environment and organization, responsibilities, roles and relationships, and of the technical challenges of specific data requirements in order to:

• allow objective baseline and follow-up evaluations – assessment findings should therefore be comparable over time
• inform stakeholders – for example, of aspects of the HIS with which they may not be familiar
• build consensus around the priority needs for health information system strengthening
• mobilize joint technical and financial support for the implementation of a national HIS

strategic plan – with indications of the priority investments in the short term (1–2 years), intermediate term (3–9 years) and long term (10 years and beyond).

Stakeholders may decide to repeat the comprehensive assessment exercise at appropriate intervals. HMN is working to develop a separate monitoring tool that will permit the monitoring of progress over time.

These scorings were done based on the HMN prescribed scoring system and ranges.

3.11 National eHealth Strategy Toolkit

The World Health Organization (WHO) and the International Telecommunication Union

(ITU) launched the National eHealth Strategy Toolkit, a program to develop national strategies on eHealth. (WHO, National eHealth Strategy Toolkit, 2012)

The National eHealth Strategy Toolkit is an expert, practical guide that provides governments, their ministries and stakeholders with a solid foundation and method for the development and implementation of a national eHealth vision, action plan and monitoring framework. All countries, whatever their level of development, can adapt the Toolkit to suit their own circumstances. Representing one of the most significant collaborations in recent years between the World Health Organization and the International Telecommunication Union, the Toolkit is a landmark in understanding what eHealth is what it can do, and why and how it should be applied to health care today.

Introduction to the National eHealth Strategy Toolkit

The Toolkit: What it is and who it is for

This National eHealth Strategy Toolkit reflects the growing impact that eHealth is bringing to the delivery of health care around the world today, and how it is making health systems more efficient and more responsive to people’s needs and expectations.

The Toolkit provides a framework and method for the development of a national eHealth vision, action plan and monitoring framework. It is a resource that can be applied by all governments that are developing or revitalizing a national eHealth strategy, whatever their current level of eHealth advancement.

It is a practical, comprehensive, step-by-step guide, directed chiefly towards the most relevant government departments and agencies, particularly ministries of health and ministries of information technology and communication.

Although the Toolkit is comprehensive, it does not need to be comprehensively employed.

Individual governments and their departments can tailor it to their own national policies, resources and requirements, and to the expectations of their citizens. They can choose, refine and develop the parts that are best for them and create their own unique eHealth vision.

The successful application of the Toolkit does, however, require a team experienced in strategic planning, analysis and communication process. One of the team’s early priorities should be deciding at what point to bring stakeholders into the process. This is important in managing the process itself, because the team will have to work closely and continuously with the many stakeholders, not just those from the health sector, who have an interest in eHealth and are keen to contribute. Deferring their involvement until the core team is well established and has begun its work, rather than engaging the stakeholders from the very start may prove more efficient in the long run.

Like all strategies and plans, the outcomes of this Toolkit are not static and represent a point in time understanding of what a country needs to achieve in order to address its particular goals and challenges. Changes in a country’s strategic context will require a dynamic approach to updating the eHealth vision and the associated action plan so that they remain relevant. This requires understanding the key triggers for refreshing the vision and action plan, whether these are specific events that change a nation’s strategic context for eHealth or a defined period of time after which a revision is required.

Ongoing engagement with essential health and non-health stakeholders must also be maintained. Success in implementing a national eHealth vision is heavily dependent on having the continued support and guidance of stakeholders, and thus does not reach a conclusion after a national strategy has been developed.

Continued communication is also vital. Stakeholders should be regularly informed on the progress of the programme, and in particular, any impacts or results that implementation of the progress has realized. This ensures transparency, which is essential to maintaining stakeholder support and momentum for further activity and investment in eHealth.

The Toolkit is designed in three parts, with the second and third parts building progressively on the work of the first:

• Part 1: A national eHealth vision that responds to health and development goals
• Part 2: A national eHealth action plan that reflects country priorities
• Part 3: A plan to monitor implementation and manage associated risks

Part 1 develops a national eHealth vision that responds to health and development goals. It explains why a national approach to eHealth is needed, what a national eHealth plan will need to achieve, and how it will be done.

Why: This is the strategic context for eHealth, encompassing the health of the population, the status of the health system, the health and development priorities, and the resulting implications for eHealth.

What: This is the role eHealth will play in the achievement of health-sector goals. It serves as a high-level message for policy-makers that answer the question of “where does our country want to go with health, and how will eHealth help us get there?”

How: This gives the various eHealth components – or building blocks – that must be in place to realize the national eHealth vision.

Part 2 lays out an eHealth action plan that reflects country priorities and the eHealth context. It structures activities over the medium term, while building a foundation for the long term.

Part 3 establishes a plan to monitor implementation and manage associated risks. It shows the progress and the results of implementation and helps in securing long-term support and investment.

Each of these three sections describes the activities required, along with practical advice informed by real-world experience. Countries can undertake the entire set of activities, or those specific to their contexts and constraints. How the Toolkit is used, and the end result, will depend on these factors and on each country’s priorities and vision.

Countries can focus on a range of structured activities that lead to the progressive development of a national eHealth strategy. These include:

• involving the key health and non-health stakeholders in creating a national eHealth vision and plan and its subsequent implementation.
• establishing governance mechanisms to provide improved visibility, coordination and control of eHealth activities that are occurring across the country’s health sector.
• establishing the strategic context for eHealth to provide the foundation for the eHealth vision and plan, and to enable the government to make informed decisions on whether to pursue opportunities that present themselves from the ICT industry and other stakeholders.
• forming an understanding of the current eHealth environment in terms of the programmes, projects and eHealth components that already exist.
• the Toolkit also identifies the short-, medium- and long-term goals for countries, recognizing the importance of demonstrating outcomes and benefits throughout the process of national strategy implementation, and to build and maintain momentum and support for eHealth; and thereby improve the health of their populations

Finally, while it is aimed at a specialized, professional readership, the Toolkit’s approach keeps the general public firmly in mind, recognizing that it is the public who will be the ultimate beneficiaries of eHealth in their country