**Meet the editor**

Dr Amir Hajjam El Hassani received his PhD in Computer Science from the Université de Haute Alsace in 1990. He joined the Université de Technologie de Belfort-Montbéliard in 2002. He performs research activities at the IRTES-SeT laboratory and is responsible for the research area of eHealth. He is Editorial Board Member of four international journals. He is the author/co-au-

thor of 3 books and many international publications in refereed journals and conferences. He was Co-Chair of the first international conference eTelemed'09 and is its advisory Chair since 2010. He is member of the Science Steering Committee of the annual conferences IADIS e-Health, eHealth, e-Medisys, etc. He has organised many conferences and chaired several technical sessions. He also acts as an expert to the ANRT France, ARI Alsace and CNRST Morocco.

Contents

**Preface VII**

Pouyan Esmaeilzadeh

Chapter 1 **Global Health Through EHealth/Telehealth 1**

Chapter 3 **Supporting E-Health Information Seekers:**

Chapter 5 **Ontological Architecture for Management**

Amine Ahmed Benyahia, Amir Hajjam, Vincent Hilaire and Mohamed Hajjam

**in Teaching and Telemedicine 97**

Chapter 7 **Phonocardiogram Signal Processing Module**

Emmanuel Andrès

Chapter 4 **Codified Knowledge and Decisions in**

Chapter 2 **Interaction with Clinical Decision Support Systems:**

**a Major eHealth Project: Efforts to Introduce the Electronic Health Record in Quebec 63**

Chapter 6 **Advances and Perspectives in the Field of Auscultation,**

Masako Miyazaki, Eugene Igras, Lili Liu and Toshio Ohyanagi

**From Simple Strategies to Knowledge-Based Methods 35**  Lina F. Soualmia, Badisse Dahamna and Stéfan J. Darmoni

Duncan Sanderson, Marie-Pierre Gagnon and Julie Duplantie

**with a Special Focus on the Contribution of New Intelligent Communicating Stethoscope Systems in Clinical Practice,**

**for Auto-Diagnosis and Telemedicine Applications 117**

Ali Moukadem, Alain Dieterlen and Christian Brandt

**of Telemonitoring System and Alerts Detection 85**

**The Challenge of Having a Steak with No Knife 17**

## Contents

#### **Preface XI**

Preface

equipment.

other countries too.

In 1999, eHealth surfaced as a popular term referring to Internet-based health care delivery. Today, eHealth is making health care more efficient, allowing patients and professionals to do the previously impossible through the efficient Information and Communication Technologies (ICT). ICT are now used everywhere and play an important role in the delivery of high-quality and highly efficient health care services. Some eHealth applications have improved the quality of health care, and they are expected to lead to substantial cost savings in the near future. In today's digital society, ICT play an essential role in supporting daily life. eHealth initiatives, many of which are being undertaken in countries around the globe, have myriad benefits, including improvement of coordination and integration of health care delivery, empowerment of individuals and families for helping them manage their own health

better and prepare health care plans, and facilitation of public health initiatives.

The ICT revolution has given rise to challenges with regard to health systems. The aim of this book is to present its impact on access to health care, quality of information on health care, cost-effectiveness of health care services and the development of eHealth

In chapter 1, we start with the challenges, strategies, and trends in eHealth. The authors discuss the opportunities and benefits associated with the adoption of eHealth solutions, as well as the impact of eHealth solutions on the health system and the population. eHealth services involving advanced technologies could have a significant impact on patient care in the future, including Internet-enabled applications for chronic disease management in the community. They could also facilitate selfmonitoring of one's own health status. The authors show that eHealth will continue to evolve with advances in ICT, information science, medicine, and biotechnology. These topics are discussed in the Canadian context, but the discussions may be valid for

A clinical decision support (CDS) system is an application that analyzes data to help health care providers make clinical decisions. In chapter 2, the author discusses the interactivity between physicians and CDS as the main variable affecting health care professionals who use CDS in their day-to-day activities. It shows that if health care

## Preface

In 1999, eHealth surfaced as a popular term referring to Internet-based health care delivery. Today, eHealth is making health care more efficient, allowing patients and professionals to do the previously impossible through the efficient Information and Communication Technologies (ICT). ICT are now used everywhere and play an important role in the delivery of high-quality and highly efficient health care services. Some eHealth applications have improved the quality of health care, and they are expected to lead to substantial cost savings in the near future. In today's digital society, ICT play an essential role in supporting daily life. eHealth initiatives, many of which are being undertaken in countries around the globe, have myriad benefits, including improvement of coordination and integration of health care delivery, empowerment of individuals and families for helping them manage their own health better and prepare health care plans, and facilitation of public health initiatives.

The ICT revolution has given rise to challenges with regard to health systems. The aim of this book is to present its impact on access to health care, quality of information on health care, cost-effectiveness of health care services and the development of eHealth equipment.

In chapter 1, we start with the challenges, strategies, and trends in eHealth. The authors discuss the opportunities and benefits associated with the adoption of eHealth solutions, as well as the impact of eHealth solutions on the health system and the population. eHealth services involving advanced technologies could have a significant impact on patient care in the future, including Internet-enabled applications for chronic disease management in the community. They could also facilitate selfmonitoring of one's own health status. The authors show that eHealth will continue to evolve with advances in ICT, information science, medicine, and biotechnology. These topics are discussed in the Canadian context, but the discussions may be valid for other countries too.

A clinical decision support (CDS) system is an application that analyzes data to help health care providers make clinical decisions. In chapter 2, the author discusses the interactivity between physicians and CDS as the main variable affecting health care professionals who use CDS in their day-to-day activities. It shows that if health care professionals have an interactive relationship with a CDS, their level of involvement in the process increases and they have more control over procedures.

Preface IX

**Dr. Amir HAJJAM EL HASSANI**

Systems and Transport, Belfort,

France

University of Technology of Belfort-Montbeliard,

Institute for Transportation Research, Energy and Society -

To date, some eHealth applications have improved the quality of health care, and they are expected to lead to substantial cost savings in the near future. However, eHealth is not simply a technology but a complex technological and relational process. In this sense, clinicians and health care providers who seek to successfully exploit eHealth should pay special attention to technology, ergonomics, human factors, and organizational changes associated with the structure of the relevant health service. We hope that this book will be useful to engineers, researchers, and industry personnel, and provide them with new ideas to address not only current issues that they are

facing but also future issues.

Most health care seekers, such as patients and their families (and even health professionals), are not familiar with the medical vocabulary, which is difficult to handle. Chapter 3 presents the main techniques used for improving information retrieval through health gateways.

The combination of EHR data and data generated through remote monitoring provides an important opportunity for following up the health of a patient. The increase in our ageing population is giving rise to new challenges in terms of disabilities and chronic diseases, incidences of which are expected to increase steadily in the coming years. Chronic diseases are ongoing, and generally incurable, illnesses or conditions, such as heart disease, asthma, and diabetes. They are the leading cause of death and disability in most developed countries. Admitting all these patients to institutions such as hospitals and nursing homes appears to be unfeasible. The general tendency is to provide homecare solutions involving remote monitoring, which offer unquestionably higher quality of care and greater security than conventional practices, and ultimately better quality of life for patients. In chapter 4, the authors present an architecture that combines the semantic Web and artificial intelligence, for homecare solutions. This architecture is based on generic ontologies so as to accommodate different conditions and types of sensors and data. A decision support base on an inference engine is used for following up the health of a patient and the detection of anomalies and abnormal situations and for responding appropriately, by providing recommendations and/or informing the patient's physician.

In the context of remote monitoring, the feasibility and accuracy of an Internet-based system for teleauscultation, involving the use of an electronic stethoscope, were evaluated. The results indicated that teleauscultation may be considered a reliable method for assessing cardiac patients. Chapter 5 reviews recent technological advances and presents an evaluation of promising innovations and perspectives in the field of auscultation. It focuses on the development of new intelligent communicating stethoscope systems in clinical practice and in the context of teaching and telemedicine. It shows that conventional auscultation is subjective and not easily shared. Modern medical technology allows us to optimize auscultatory findings and hence make a correct diagnosis by physically characterizing sounds through recordings, visualization, and automated analysis systems.

In a cardiac auscultatory system, many signals can be treated and monitored, e.g., ElectroCardioGram (ECG), PhonoCardioGram (PCG), Echo/Doppler and pressure monitor. The main point of interest in chapter 6 is the PCG signal. The author proposes a robust and generic PCG segmentation method that is useful in real-life conditions (clinical use, home care, professional use, etc.).

To date, some eHealth applications have improved the quality of health care, and they are expected to lead to substantial cost savings in the near future. However, eHealth is not simply a technology but a complex technological and relational process. In this sense, clinicians and health care providers who seek to successfully exploit eHealth should pay special attention to technology, ergonomics, human factors, and organizational changes associated with the structure of the relevant health service. We hope that this book will be useful to engineers, researchers, and industry personnel, and provide them with new ideas to address not only current issues that they are facing but also future issues.

VIII Preface

physician.

professionals have an interactive relationship with a CDS, their level of involvement in

Most health care seekers, such as patients and their families (and even health professionals), are not familiar with the medical vocabulary, which is difficult to handle. Chapter 3 presents the main techniques used for improving information

The combination of EHR data and data generated through remote monitoring provides an important opportunity for following up the health of a patient. The increase in our ageing population is giving rise to new challenges in terms of disabilities and chronic diseases, incidences of which are expected to increase steadily in the coming years. Chronic diseases are ongoing, and generally incurable, illnesses or conditions, such as heart disease, asthma, and diabetes. They are the leading cause of death and disability in most developed countries. Admitting all these patients to institutions such as hospitals and nursing homes appears to be unfeasible. The general tendency is to provide homecare solutions involving remote monitoring, which offer unquestionably higher quality of care and greater security than conventional practices, and ultimately better quality of life for patients. In chapter 4, the authors present an architecture that combines the semantic Web and artificial intelligence, for homecare solutions. This architecture is based on generic ontologies so as to accommodate different conditions and types of sensors and data. A decision support base on an inference engine is used for following up the health of a patient and the detection of anomalies and abnormal situations and for responding appropriately, by providing recommendations and/or informing the patient's

In the context of remote monitoring, the feasibility and accuracy of an Internet-based system for teleauscultation, involving the use of an electronic stethoscope, were evaluated. The results indicated that teleauscultation may be considered a reliable method for assessing cardiac patients. Chapter 5 reviews recent technological advances and presents an evaluation of promising innovations and perspectives in the field of auscultation. It focuses on the development of new intelligent communicating stethoscope systems in clinical practice and in the context of teaching and telemedicine. It shows that conventional auscultation is subjective and not easily shared. Modern medical technology allows us to optimize auscultatory findings and hence make a correct diagnosis by physically characterizing sounds through

In a cardiac auscultatory system, many signals can be treated and monitored, e.g., ElectroCardioGram (ECG), PhonoCardioGram (PCG), Echo/Doppler and pressure monitor. The main point of interest in chapter 6 is the PCG signal. The author proposes a robust and generic PCG segmentation method that is useful in real-life

recordings, visualization, and automated analysis systems.

conditions (clinical use, home care, professional use, etc.).

the process increases and they have more control over procedures.

retrieval through health gateways.

#### **Dr. Amir HAJJAM EL HASSANI**

University of Technology of Belfort-Montbeliard, Institute for Transportation Research, Energy and Society - Systems and Transport, Belfort, France

**Chapter 1**

© 2012 Miyazaki et al., licensee InTech. This is an open access chapter distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

© 2012 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons Attribution License http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution,

**Global Health Through EHealth/Telehealth**

EHealth is an umbrella term that covers Health Informatics, Telehealth and other ICT (information and communications technology) solutions in health care and medicine. It has been broadly defined as "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 by

EHealth also incorporates virtual reality, robotics, multi-media, digital imaging, computer

While the primary focus of Health Informatics is the use of information systems and digital repositories in healthcare (electronic health record or EHR, medical terminologies, clinical guidelines), Telehealth refers to the use of ICT for the purpose of providing services across distance, time, social and cultural barriers. These services include both clinical services (such as telemedicine, telenursing, telerehabilitation, telepharmacy, teledentistry, or telemonitoring) and non-clinical applications (health education, research, or administrative). Telemedicine focuses primarily on the delivery of clinical care and includes a number of speciality terms such as teleradiology, telepathology, telepsychiatry, teledermatology and telesurgery. [2]

In this chapter we discuss the challenges, strategies and trends in healthcare. We also discuss the opportunities and benefits associated with the adoption of eHealth/Telehealth solutions as well as their impacts on the health system and the population. Although these

One of the fundamental goals of health systems in most countries is to provide equitable access to healthcare. However, there are multiple and varying barriers to achieving this goal.

and reproduction in any medium, provided the original work is properly cited.

topics are discussed in Canadian context, they may also apply in other countries.

Masako Miyazaki, Eugene Igras, Lili Liu and Toshio Ohyanagi

Additional information is available at the end of the chapter

using information and communication technology" [1].

assisted surgery, wearable monitoring systems, health portals.

http://dx.doi.org/10.5772/47922

**1. Introduction**

## **Global Health Through EHealth/Telehealth**

Masako Miyazaki, Eugene Igras, Lili Liu and Toshio Ohyanagi

Additional information is available at the end of the chapter

http://dx.doi.org/10.5772/47922

## **1. Introduction**

EHealth is an umbrella term that covers Health Informatics, Telehealth and other ICT (information and communications technology) solutions in health care and medicine. It has been broadly defined as "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 by using information and communication technology" [1].

EHealth also incorporates virtual reality, robotics, multi-media, digital imaging, computer assisted surgery, wearable monitoring systems, health portals.

While the primary focus of Health Informatics is the use of information systems and digital repositories in healthcare (electronic health record or EHR, medical terminologies, clinical guidelines), Telehealth refers to the use of ICT for the purpose of providing services across distance, time, social and cultural barriers. These services include both clinical services (such as telemedicine, telenursing, telerehabilitation, telepharmacy, teledentistry, or telemonitoring) and non-clinical applications (health education, research, or administrative). Telemedicine focuses primarily on the delivery of clinical care and includes a number of speciality terms such as teleradiology, telepathology, telepsychiatry, teledermatology and telesurgery. [2]

In this chapter we discuss the challenges, strategies and trends in healthcare. We also discuss the opportunities and benefits associated with the adoption of eHealth/Telehealth solutions as well as their impacts on the health system and the population. Although these topics are discussed in Canadian context, they may also apply in other countries.

One of the fundamental goals of health systems in most countries is to provide equitable access to healthcare. However, there are multiple and varying barriers to achieving this goal.

In some countries these barriers include limited access to portable clean water, a trained healthcare worker or critical lifesaving drugs. Other countries face challenges with providing medical intervention or an inoculation to prevent infectious diseases from spreading in an equitable and timely manner. There are also significant disparities between urban and rural healthcare. The barriers in the rural regions include "limited local expertise, resources, economic infrastructure, reimbursement for health services, as well as difficulties in retention and recruitment of health professionals, smaller population bases, isolation, and significant distances from needed expertise and service." [3].

Global Health Through EHealth/Telehealth 3

The healthcare system faces increasing pressure to improve health service delivery, health outcomes, and to contain healthcare costs regardless of economic status of the country. These challenges are directly linked to the changes in population demographic (e.g., ageing population, increased prevalence of chronic diseases), and increased expectations and needs for more equitable access to care, improved quality of care, improved health outcomes, and improved safety of care. Recently, these challenges have become more acute because of the shortages of healthcare professionals, complexity and accelerated communicability of

To address these challenges and meet the healthcare needs of population, many countries implement strategies that include establishing national health programs, improving health service delivery systems, fostering health maintenance and disease prevention, adopting proactive approach to management of healthcare resources, fostering research and

Oh and colleagues [6] reported the results of scoping study by using the search query string "eHealth" OR "e-Health" OR "electronic health". They used the Medline and Premedline (1966-June 2004); EMBASE (1980-May 2004); International Pharmaceutical Abstracts (1970- May 2004); Web of Science (all years), Information Sciences Abstracts (1966-May 2004); Library Information Sciences Abstracts (1969-May 2004); and Wilson Business Abstracts (1982-March 2004); dictionaries and an Internet search engine. They concluded that the term eHealth encompasses a set of disparate concepts, including health, technology, and commerce. In the definitions of eHealth, technology was viewed both as a tool to enable a process, function, service and as the embodiment of eHealth itself (e.g., a health website on the Internet). They discovered that technology was portrayed as a means to expand, to

Paré and his colleagues [7] had reviewed more than 65 telemonitoring studies in the United States and Europe. The study, entitled "Systematic Review of Home Telemonitoring for Chronic Diseases", concluded that home telemonitoring produces accurate and reliable data empowers patients and influences their attitudes and behaviours, and may improve their medical conditions. They concluded that home telemonitoring produces accurate and reliable data, empowers patients and influences their attitudes and behaviours, and may

According to their study, the key clinical impact of implementing telemonitoring was a decrease in emergency room visits, hospital admissions, and average length of hospital stays. The effects of telemonitoring tended to be more consistent in pulmonary and cardiac

In order to implement comprehensive and over reaching e-health/ Telehealth service, it is vital to have all levels of governments and international organizations' cooperation and

**3. Role of local, provincial, national governments and international**

innovation and adopting standardization and integration across the health systems.

assist, or to enhance human activities, rather than as a substitute for them [6].

diseases in many countries.

improve their medical conditions.

studies than in studies on diabetes and hypertension.

**organization in promoting e-health/ Telehealth**

With advancement of ICT and financial support, we may be able to reduce the disparities between regions regardless of availabilities of local resources. For example, Canada's First Nations people are not only affected by geographical isolation, but also by chronic poverty, under- or unemployment, substance abuse, limited opportunities for education and social advancement. Most reserves are located outside of major cities where all the social amenities are available, including sophisticated health care services. Over the past two decades the federal government has initiated a process of "transferring of control" to native communities and regional organizations. As a part, health care has become an integral aspect of aboriginal self-determination. In general, chronic care patients such as diabetics fare better at their home environment [4]

While we implement eHealth/ Telehealth services, we have to be cognisant of the needs for business continuity and disaster recovery plans and solutions. The current set up for eHealth/ Telehealth services is quite fragile as the disaster recovery plans do not exist or their implementation is not adequate.

Consequently, the scope of eHealth has been expanded. The World Health Organization (WHO) defines eHealth/ Telehealth/e-commerce as follows: "Tele-health includes surveillance health promotion and public health functions. It is broader in definition than tele-medicine as it includes computer-assisted telecommunications to support management, surveillance, literature and access to medical knowledge. Tele-medicine is the use of telecommunications to diagnose and treat disease and ill-health. Telematics for health is a WHO composite term for both tele-medicine and tele-health, or any health-related activities carried out over distance by means of ICT [5].

## **2. Definition of eHealth/Telehealth through scoping studies**

The primary focus of eHealth/Telehealth is not technology. Rather, it is the adoption of the discoveries in medical sciences and advances in ICT to improve access to health services, and expand the range of these services from care to disease prevention to health maintenance to health education. The technology is just an enabler.

EHealth systems and services combined with organizational changes and the development of new skills create new opportunities to improve the healthcare system locally, nationally and globally through the collaboration and contribution of many stakeholders, including patients, health professionals, institutions, governments, researchers, academia and industry.

The healthcare system faces increasing pressure to improve health service delivery, health outcomes, and to contain healthcare costs regardless of economic status of the country. These challenges are directly linked to the changes in population demographic (e.g., ageing population, increased prevalence of chronic diseases), and increased expectations and needs for more equitable access to care, improved quality of care, improved health outcomes, and improved safety of care. Recently, these challenges have become more acute because of the shortages of healthcare professionals, complexity and accelerated communicability of diseases in many countries.

2 eHealth and Remote Monitoring

at their home environment [4]

their implementation is not adequate.

carried out over distance by means of ICT [5].

In some countries these barriers include limited access to portable clean water, a trained healthcare worker or critical lifesaving drugs. Other countries face challenges with providing medical intervention or an inoculation to prevent infectious diseases from spreading in an equitable and timely manner. There are also significant disparities between urban and rural healthcare. The barriers in the rural regions include "limited local expertise, resources, economic infrastructure, reimbursement for health services, as well as difficulties in retention and recruitment of health professionals, smaller population bases, isolation, and

With advancement of ICT and financial support, we may be able to reduce the disparities between regions regardless of availabilities of local resources. For example, Canada's First Nations people are not only affected by geographical isolation, but also by chronic poverty, under- or unemployment, substance abuse, limited opportunities for education and social advancement. Most reserves are located outside of major cities where all the social amenities are available, including sophisticated health care services. Over the past two decades the federal government has initiated a process of "transferring of control" to native communities and regional organizations. As a part, health care has become an integral aspect of aboriginal self-determination. In general, chronic care patients such as diabetics fare better

While we implement eHealth/ Telehealth services, we have to be cognisant of the needs for business continuity and disaster recovery plans and solutions. The current set up for eHealth/ Telehealth services is quite fragile as the disaster recovery plans do not exist or

Consequently, the scope of eHealth has been expanded. The World Health Organization (WHO) defines eHealth/ Telehealth/e-commerce as follows: "Tele-health includes surveillance health promotion and public health functions. It is broader in definition than tele-medicine as it includes computer-assisted telecommunications to support management, surveillance, literature and access to medical knowledge. Tele-medicine is the use of telecommunications to diagnose and treat disease and ill-health. Telematics for health is a WHO composite term for both tele-medicine and tele-health, or any health-related activities

The primary focus of eHealth/Telehealth is not technology. Rather, it is the adoption of the discoveries in medical sciences and advances in ICT to improve access to health services, and expand the range of these services from care to disease prevention to health

EHealth systems and services combined with organizational changes and the development of new skills create new opportunities to improve the healthcare system locally, nationally and globally through the collaboration and contribution of many stakeholders, including patients,

health professionals, institutions, governments, researchers, academia and industry.

**2. Definition of eHealth/Telehealth through scoping studies**

maintenance to health education. The technology is just an enabler.

significant distances from needed expertise and service." [3].

To address these challenges and meet the healthcare needs of population, many countries implement strategies that include establishing national health programs, improving health service delivery systems, fostering health maintenance and disease prevention, adopting proactive approach to management of healthcare resources, fostering research and innovation and adopting standardization and integration across the health systems.

Oh and colleagues [6] reported the results of scoping study by using the search query string "eHealth" OR "e-Health" OR "electronic health". They used the Medline and Premedline (1966-June 2004); EMBASE (1980-May 2004); International Pharmaceutical Abstracts (1970- May 2004); Web of Science (all years), Information Sciences Abstracts (1966-May 2004); Library Information Sciences Abstracts (1969-May 2004); and Wilson Business Abstracts (1982-March 2004); dictionaries and an Internet search engine. They concluded that the term eHealth encompasses a set of disparate concepts, including health, technology, and commerce. In the definitions of eHealth, technology was viewed both as a tool to enable a process, function, service and as the embodiment of eHealth itself (e.g., a health website on the Internet). They discovered that technology was portrayed as a means to expand, to assist, or to enhance human activities, rather than as a substitute for them [6].

Paré and his colleagues [7] had reviewed more than 65 telemonitoring studies in the United States and Europe. The study, entitled "Systematic Review of Home Telemonitoring for Chronic Diseases", concluded that home telemonitoring produces accurate and reliable data empowers patients and influences their attitudes and behaviours, and may improve their medical conditions. They concluded that home telemonitoring produces accurate and reliable data, empowers patients and influences their attitudes and behaviours, and may improve their medical conditions.

According to their study, the key clinical impact of implementing telemonitoring was a decrease in emergency room visits, hospital admissions, and average length of hospital stays. The effects of telemonitoring tended to be more consistent in pulmonary and cardiac studies than in studies on diabetes and hypertension.

## **3. Role of local, provincial, national governments and international organization in promoting e-health/ Telehealth**

In order to implement comprehensive and over reaching e-health/ Telehealth service, it is vital to have all levels of governments and international organizations' cooperation and

support. Governments as policy-making organizations, play a key role in formulating regulations, governing, financing, and regulating the health and business sectors.

Global Health Through EHealth/Telehealth 5

*Issues Associated with Healthcare Delivery*

serious challenges to the provision of health services.

proportion of expensive health resources.

health services is increasingly challenging.

permanent disability as a result of their adverse events.

utilization of the scarce healthcare resources.

demands on the strained healthcare budgets.

duplication of services.

future level of funding.

 Geography: Canada is a country of over 34.6 million people spread across almost 10 million square kilometres. While the majority is concentrated in a several urban areas, a significant proportion is scattered across the land in hundreds of geographically isolated communities, many in areas of extreme climatic conditions. These factors pose

 Ageing population: Seniors constitute one of the fastest growing groups in Canadian society. By 2041, about 23% of the population will be over 65, up from 12% in 1995. This growing portion of the population will inevitably require the devotion of a larger

 Shortage of health professionals: There is a general shortage of healthcare professionals. That threatens the supply of and extends wait lists for some healthcare services. Inequitable distribution of health professionals: Most health service providers live and work in large urban centres. This contributes to acute shortage of health professionals in many smaller communities and rural areas where the provision of equitable access to

 Patient safety: Several studies conducted by the Canadian Patient Safety Institute revealed that a significant number of patients experienced adverse events. One of the studies [8] revealed that an estimated 7.5% of patients admitted to acute care hospitals in Canada in the fiscal year 2000 experienced 1 or more adverse events. Also, 36.9% of these patients were considered to have highly preventable adverse events. Most of the patients who experienced adverse events recovered without permanent disability; their adverse events contributed to longer stays in hospital or temporary disability. However, a small but significant proportion of patients died or experienced a

 Increasing prevalence of public health threats: The number of incidents of chronic diseases is increasing. Furthermore, emerging threats to public health such as SARS and avian flu require a pan-Canadian health surveillance system to provide critical information to support a rapid and effective response. These factors contribute to a high

 Limited integration: Silos of care fail to provide patients and providers with timely and seamless access to the information they require and cause delays and needless

 Fragmented funding: Funding of health services is a complicating factor and a matter currently of intense scrutiny and considerable controversy. The division of political, managerial and fiscal accountability across provincial and federal lines has created tensions particularly around the question of the current level, and most appropriate

Budget constraints: New treatments and technologies cost more and put additional

 Language barriers: Canada is a culturally diverse country, which has created some health care challenges. From the last national census, of 30 million people, 18 million

EHealth was discussed at the United Nations World Summit on the Information Society in December 2003 and at the World Health Assembly in May 2005. The World Health Organisation (WHO) has established various eHealth initiatives, such as the WHO Global Observatory for eHealth (GOe) in 2005, which aims "to provide Member States with strategic information and guidance on effective practices, policies and standards in eHealth". The World Summit on the Information Society (WSIS), held with the participation of 175 countries (second phase, 16-18 November 2005, Tunis), affirmed its commitment to "improving access to the world's health knowledge and telemedicine services, in particular in areas such as global cooperation in emergency response, access to and networking among health professionals to help improve quality of life and environmental conditions".

The second global survey on eHealth was conducted by the GOe in late 2009 and was designed to build on the knowledge base generated by the first survey in 2005. While the first survey was general and primarily asked questions about the national level, the 2009 survey was designed to be thematic with far more detailed questions used to explore areas particular to eHealth. The survey has provided the GOe with a rich source of data that is being used to create a series of eight publications, the Global Observatory for eHealth series. GOe has release three reports to date: Telemedicine - Opportunities and developments in Member States; Atlas of e-Health country profiles; and m-Health. They are the most updated collection of survey data on eHealth from around the world. Over 800 eHealth experts and 114 counties have contributed to the data collection process. The mobile-Health (mHealth) survey was focused to identify the diverse ways mobile devices are being used for health around the world and their effectiveness. It is also to highlight the most important obstacles to implementing mHealth solutions and to examine if mHealth can overcome the 'digital divide'. Their report was released in June 2011. For the purpose of their study, GOe defined mHealth as a component of eHealth and support medical and public health practice by using mobile phone by capitalizing on a mobile phone's core utility of voice and short messaging service (SMS) as well as more complex functionalities and applications including general packet radio service (GPRS), third and fourth generation mobile telecommunications (3G and 4G systems), global positioning system (GPS), and Bluetooth technology [5].

It is valuable to have global data on eHealth adaption stages. The following Canadian example illustrates how adaption of eHealth/Telehealth intertwines the governments, health care providers, patients, public sectors and industries.

## **3.1. Canadian example**

Every Canadian citizen has access to publicly funded healthcare, however, the manner in which the healthcare system is structured, funded and governed varies from province to province. While each province sets its own policies, strategies and priorities, some of the challenges are common across the country.

#### *Issues Associated with Healthcare Delivery*

4 eHealth and Remote Monitoring

technology [5].

**3.1. Canadian example**

support. Governments as policy-making organizations, play a key role in formulating

EHealth was discussed at the United Nations World Summit on the Information Society in December 2003 and at the World Health Assembly in May 2005. The World Health Organisation (WHO) has established various eHealth initiatives, such as the WHO Global Observatory for eHealth (GOe) in 2005, which aims "to provide Member States with strategic information and guidance on effective practices, policies and standards in eHealth". The World Summit on the Information Society (WSIS), held with the participation of 175 countries (second phase, 16-18 November 2005, Tunis), affirmed its commitment to "improving access to the world's health knowledge and telemedicine services, in particular in areas such as global cooperation in emergency response, access to and networking among

regulations, governing, financing, and regulating the health and business sectors.

health professionals to help improve quality of life and environmental conditions".

The second global survey on eHealth was conducted by the GOe in late 2009 and was designed to build on the knowledge base generated by the first survey in 2005. While the first survey was general and primarily asked questions about the national level, the 2009 survey was designed to be thematic with far more detailed questions used to explore areas particular to eHealth. The survey has provided the GOe with a rich source of data that is being used to create a series of eight publications, the Global Observatory for eHealth series. GOe has release three reports to date: Telemedicine - Opportunities and developments in Member States; Atlas of e-Health country profiles; and m-Health. They are the most updated collection of survey data on eHealth from around the world. Over 800 eHealth experts and 114 counties have contributed to the data collection process. The mobile-Health (mHealth) survey was focused to identify the diverse ways mobile devices are being used for health around the world and their effectiveness. It is also to highlight the most important obstacles to implementing mHealth solutions and to examine if mHealth can overcome the 'digital divide'. Their report was released in June 2011. For the purpose of their study, GOe defined mHealth as a component of eHealth and support medical and public health practice by using mobile phone by capitalizing on a mobile phone's core utility of voice and short messaging service (SMS) as well as more complex functionalities and applications including general packet radio service (GPRS), third and fourth generation mobile telecommunications (3G and 4G systems), global positioning system (GPS), and Bluetooth

It is valuable to have global data on eHealth adaption stages. The following Canadian example illustrates how adaption of eHealth/Telehealth intertwines the governments, health

Every Canadian citizen has access to publicly funded healthcare, however, the manner in which the healthcare system is structured, funded and governed varies from province to province. While each province sets its own policies, strategies and priorities, some of the

care providers, patients, public sectors and industries.

challenges are common across the country.

speak English, 7 million French and 5 million a mother-tongue other than English or French (official languages). Not being able to speak either official language is an obstacle for newcomers when seeking or obtaining healthcare.

Global Health Through EHealth/Telehealth 7

Canada's total healthcare expenditure was approximated at \$121.4 billion in 2003/2004 fiscal year and \$140 billion in 2005/2006 fiscal year. Although the Canadian health system is described as publicly funded, nearly 30% of funding comes from non-public sources, such as

As indicated in the 2003 Report on Canadian Hospital IT: Top Issues, Applications and Vendors, less than 2% of healthcare funding in hospitals is spent on information technology majority of which (over 80%) is spent on maintaining existing infrastructure and only 17% is

Public spending on eHealth is heavily influenced by Canada Health Infoway. Canada Health Infoway is an independent not-for-profit organization whose members are Canada's

While the initiatives led by Infoway and its public sector partners are an integral part of the pan-Canadian strategy to improve the health system, there are numerous challenges

 Privacy and security: Concerns about personal privacy and information confidentiality and the recent proclamation of Privacy and Confidentiality legislation across the provinces and territories is a considerable challenge to the development of interjurisdictional data sharing arrangements and to storage and manipulation of data

 Standardization and interoperability: There is a growing recognition that compliance with health informatics and technology standards is critical to achieving interoperability among eHealth solutions. However, given the number of health informatics and technology standards, their state of maturity and adoption, and lack of universal interoperability standards for eHealth, the challenge of building plug-and-play interoperable systems requires significant expertise and continuing

 Integration with service delivery: the integration of technology with the service delivery system is a key critical success factor for a wide adoption of eHealth solutions. Technology suitability: Deployment of eHealth solutions that are suitable and wellaligned with the healthcare workflows is critical. Some challenges still remain to be addressed. For example, some of the technologies remain unproven in extremes of climate and in far-north locations. There are also limitations imposed by the fragility and newness of certain technologies and products in situations where ongoing technical

 Technology acceptance: Public and professional acceptance of the new technology solutions and new ways of service delivery remains a significant risk factor and a

maintenance and operational services are limited or do not exist.

devoted to development of new information technology solutions.

14 federal, provincial and territorial Deputy Ministers of Health.

involved in the implementation of these initiatives. Examples include:

insurance companies and individuals.

For more detailed information see [9]

holdings (especially patient records).

challenge to be addressed.

*EHealth-Related Considerations:*

effort.

#### *Recent Trends in Delivery of Healthcare Services*

Notwithstanding the provincial variations, several major trends have emerged that have a direct impact on adoption of eHealth. These trends include:

#### *National Health Strategies for Health Information*

In 2001, Canada Health Infoway was launched to develop Health Information Strategy and deploy information management and information technology solutions across the country. Infoway is an independent, not-for-profit organization whose members are 14 federal, provincial and territorial Deputy Ministers of Health.

Canada Health Infoway invests in partnership with provincial and territorial governments and regional health authorities across Canada to implement and reuse compatible health information systems that support a safer, more efficient healthcare system.

Infoway and its public sector partners have hundreds of projects, either completed or underway, delivering electronic health record (EHR) and point-of-service solutions to Canadians – solutions that bring tangible value to patients, providers and the healthcare system.

To accomplish its mission, vision and goal, Canada Health Infoway invests in health information technology solutions in priority areas, including the Registries, Interoperable Electronic Health Records, Diagnostic Imaging Systems, Drug Information Systems, Laboratory Information Systems, Public Health Surveillance, Telehealth, Innovation and Adoption, and Info structure.

Canada's total healthcare expenditure was approximated at \$121.4 billion in 2003/2004 fiscal year and \$140 billion in 2005/2006 fiscal year. Although the Canadian health system is described as publicly funded, nearly 30% of funding comes from non-public sources, such as insurance companies and individuals.

As indicated in the 2003 Report on Canadian Hospital IT: Top Issues, Applications and Vendors, less than 2% of healthcare funding in hospitals is spent on information technology majority of which (over 80%) is spent on maintaining existing infrastructure and only 17% is devoted to development of new information technology solutions.

Public spending on eHealth is heavily influenced by Canada Health Infoway. Canada Health Infoway is an independent not-for-profit organization whose members are Canada's 14 federal, provincial and territorial Deputy Ministers of Health.

For more detailed information see [9]

#### *EHealth-Related Considerations:*

6 eHealth and Remote Monitoring

service providers.

system.

Adoption, and Info structure.

healthcare organizations.

electronic health information systems.

*National Health Strategies for Health Information*

provincial and territorial Deputy Ministers of Health.

*Recent Trends in Delivery of Healthcare Services*

speak English, 7 million French and 5 million a mother-tongue other than English or French (official languages). Not being able to speak either official language is an

Notwithstanding the provincial variations, several major trends have emerged that have a

Consolidation of services: Entails consolidation of healthcare services delivery, either

Integration of services: Integration of vertical health service delivery across the

 Co-operation among service providers: Entails organizing workflows in such a way that they support the individual patient care process and facilitate co-operation among

 Partnering: Third-party provisioning of health services through various mechanisms including outsourcing, shared service organizations and partnering between several

 Alignment of federal and provincial strategies: Alignment of provincial eHealth agendas and strategies with the strong involvement of Canada Health Infoway - a federal organization created to foster and accelerate the development of pan-Canadian

 Investment in eHealth: Strong senior-level support for eHealth solutions within healthcare organizations, regional health authorities and provincial ministries of health.

In 2001, Canada Health Infoway was launched to develop Health Information Strategy and deploy information management and information technology solutions across the country. Infoway is an independent, not-for-profit organization whose members are 14 federal,

Canada Health Infoway invests in partnership with provincial and territorial governments and regional health authorities across Canada to implement and reuse compatible health

Infoway and its public sector partners have hundreds of projects, either completed or underway, delivering electronic health record (EHR) and point-of-service solutions to Canadians – solutions that bring tangible value to patients, providers and the healthcare

To accomplish its mission, vision and goal, Canada Health Infoway invests in health information technology solutions in priority areas, including the Registries, Interoperable Electronic Health Records, Diagnostic Imaging Systems, Drug Information Systems, Laboratory Information Systems, Public Health Surveillance, Telehealth, Innovation and

information systems that support a safer, more efficient healthcare system.

obstacle for newcomers when seeking or obtaining healthcare.

direct impact on adoption of eHealth. These trends include:

through hospital amalgamation or regionalization.

continuum of care primarily through regionalization.

While the initiatives led by Infoway and its public sector partners are an integral part of the pan-Canadian strategy to improve the health system, there are numerous challenges involved in the implementation of these initiatives. Examples include:

 Safety: while there is growing recognition that eHealth solutions assist in ensuring patient and health professional safety, there is also recognition that the safety of eHealth products must be addressed in a similar way as for medical devices.

Global Health Through EHealth/Telehealth 9

information and education material Connect to others who have the same / similar health conditions Participate in support groups

Collect data about health status Monitor health conditions and

Perform diagnostic procedures Perform non-invasive treatment

Collect data about health status Provide a comprehensive and secure clinical view of client health

authorized persons (e.g., healthcare professionals) from any location at

Provide access to evidence-based guidelines, studies, and health

Promote good health practices

information / knowledge anywhere

Communicate electronically with clinical systems and other services

Assist in sharing clinical expertise

Create new knowledge taking into account tacit and explicit aspects of

Organize and disseminate the

existing knowledge

Provide access to medical

information accessible to

Provide access for health

lifestyle

interventions

any time

practices

and anytime

providers

knowledge

**Trends Examples of eHealth Solutions Purpose**

eLearning systems Collaborative tools

Self-Care Personal electronic health record

Medical devices eLearning systems

sensors

card

Health information portals

Monitoring devices and bio-

Electronic health record / smart

Privacy and security solutions

Document management Data integration systems Messaging systems

Electronic health record Good health practices Health information portals

Computer-aided clinical discipline / disease-specific

communications tools for booking, referrals, clinical

practice guidelines Care pathways

Electronic clinical

documentation

systems

Collaborative tools Multimedia conferencing

E-learning systems Data mining tools Data fusion tools Rule discovery tools

Knowledge capture systems

**Consumer Health Informatics**

Client

empowerment

Personal health

Evidence-based medicine

Computer-aided decision tools

communications

Knowledge management

Clinical

**Professional Informatics**

record

The healthcare market is changing and expanding at a rapid rate and the focus is on automation, increased efficiency and effectiveness of decision making, improved outcomes and patient care provider safety through the increasing use of information technology and eHealth applications.

The following table presents some examples of trends in care delivery and eHealth/Telehealth solutions.

**Future Global Healthcare Strategies** is quite clear from the Canadian example that there are many challenges associated with an adoption of eHealth/Telehealth at the national level. There have been many pilot projects and initiatives using varied equipment and strategies. Some of the initiatives have been sustained and others were abandoned. The key factors for abandonment are costs and benefits, complexity of technologies, low level of acceptance among healthcare service providers, and lack of technical assistance.

Over a decade, Wootton had held annual conference on "Success and Failure of Telehealth" He found that despite the large number of published articles on the concept of telemedicine in the developing world, there are remarkably few examples of successful implementations. Wootton and others [10] have published a book on "Telehealth in developing world" which summarized the experience of starting and sustaining Telehealth projects in the developing world. This book has assembled large contribution of Telehealth experience from developing countries.

According to the International Telecommunication Union, there are now close to 5 billion mobile phone subscriptions in the world. In 2010, there were 143 counties which offer third generation mobile telecommunications (3G) services and several counties are even moving toward fourth generation mobile telecommunications (4G). The Internet access is essential for eHealth and two billion people are Internet users of which 1.2 billion are in developing counties [11]. Given the volume of available mobile phones in the world, the prospect of using mobile phone or devices for healthcare seems promising.

Therefore, it is reasonable for the WHO to pay special attention to mHealth, following the extensive survey of eHealth activities among the member countries. Fourteen categories of mHealth services were surveyed: health call centres, emergency, toll-free telephone services,

eHealth applications.

developing countries.

eHealth/Telehealth solutions.

 Safety: while there is growing recognition that eHealth solutions assist in ensuring patient and health professional safety, there is also recognition that the safety of

 Education and training: Education of sufficient numbers of information technology, information management and health informatics specialists to implement, operate, manage and continue the development and improvement of the technologies and the

The healthcare market is changing and expanding at a rapid rate and the focus is on automation, increased efficiency and effectiveness of decision making, improved outcomes and patient care provider safety through the increasing use of information technology and

The following table presents some examples of trends in care delivery and

**Future Global Healthcare Strategies** is quite clear from the Canadian example that there are many challenges associated with an adoption of eHealth/Telehealth at the national level. There have been many pilot projects and initiatives using varied equipment and strategies. Some of the initiatives have been sustained and others were abandoned. The key factors for abandonment are costs and benefits, complexity of technologies, low level of acceptance

Over a decade, Wootton had held annual conference on "Success and Failure of Telehealth" He found that despite the large number of published articles on the concept of telemedicine in the developing world, there are remarkably few examples of successful implementations. Wootton and others [10] have published a book on "Telehealth in developing world" which summarized the experience of starting and sustaining Telehealth projects in the developing world. This book has assembled large contribution of Telehealth experience from

According to the International Telecommunication Union, there are now close to 5 billion mobile phone subscriptions in the world. In 2010, there were 143 counties which offer third generation mobile telecommunications (3G) services and several counties are even moving toward fourth generation mobile telecommunications (4G). The Internet access is essential for eHealth and two billion people are Internet users of which 1.2 billion are in developing counties [11]. Given the volume of available mobile phones in the world, the prospect of

Therefore, it is reasonable for the WHO to pay special attention to mHealth, following the extensive survey of eHealth activities among the member countries. Fourteen categories of mHealth services were surveyed: health call centres, emergency, toll-free telephone services,

eHealth products must be addressed in a similar way as for medical devices. Sustainability: There is a growing recognition that the deployment of eHealth solutions goes beyond technology and involves change management and further investment. Financial and human resources must be invested in the management and operations of

the eHealth solutions to realize their full potential and be sustainable.

systems remains a challenge that needs to be addressed.

among healthcare service providers, and lack of technical assistance.

using mobile phone or devices for healthcare seems promising.

Global Health Through EHealth/Telehealth 11

Identify and stratify medical risks and recommend preventative measures for population

Prescribe and monitor remotely clients' compliance with the care

extraordinary population-wide risks (e.g., pandemic, environment

Facilitate collaboration among health stakeholders, including: Communities of practice / interest Service providers across different care areas, including acute, community, continuing care, mental health and other areas

Mine and analyze clinical, organizational and economic information across facilities and service areas to monitor and measure efficiency and

delivery system

delivery planning

management practices

Provide access to data

heterogeneous systems

Ensure quality of data and information (e.g., accuracy,

completeness, consistency, clarity, currency, relevancy, timeliness)

Facilitate data exchange between

effectiveness of the health service

Perform forecasting and service

Develop and disseminate best

Coordinate response to

contamination)

plan

**Trends Examples of eHealth Solutions Purpose**

ePharmacy systems Electronic health record Drug interaction systems Drug dispensing devices

Multimedia conferencing

eLearning systems Knowledge management

Data mining tools Workflow management Forecasting tools

Search engine tools Data cleansing tools Data mining tools

Pattern-based tools Ontology tools

tools

Integration Virtual electronic health record Middleware Integration broker

Data fusion and rule discovery

Teleconsultation applications

Best management practices

Virtual health team Collaborative tools

**Healthcare Business Management**

**Data Management and Protection**

Proactive business management

Data and

information quality

systems

systems

Medication management

Evidence-based medicine

**Service Delivery** Remote sensing and

monitoring

Remote service

Population-based

care

delivery

**Trends Examples of eHealth Solutions Purpose**

practice guidelines Electronic health record Good health practices Health information portals Clinical support systems

Computer-assisted clinical

Bio-sensors and wearable

Implantable devices Smart medical devices

Telemonitoring

Telelearning

Personalized care New diagnostic and treatment modalities

engineering

screening tools

decision-making

Telehealth systems

Telemedicine applications

Genomic and molecular

stratify health risks and recommend preventative measures for individuals

medicine technologies, including sequencing, genotyping, gene expression profiling, and protein

Specialized tools to identify and

Population identification and

Specialized tools to aid in

products

Combine the new knowledge with the existing practices and clinical

Provide tools for rigorous scientific

Monitor individuals with critical /

Monitor individuals who work / live in extreme conditions

Improve access to health and education services for people living in areas with limited access to these

Facilitate collaboration among the health stakeholders, including service providers and service

Provide a tool for continuing medical / health education

appropriateness of care

Participate in the development of care plans and assessment of the

Facilitate collaboration among the health stakeholders, including service providers and service

Facilitate population based health

Predict the evolution of disease in

Predict and prevent diseases

evaluation of collected facts Develop and disseminate practice guidelines and health practices Provide access to medical journals

standards

and studies

services

recipients

recipients

planning

populations

chronic conditions

Global Health Through EHealth/Telehealth 13

EHealth/ Telehealth networks can be destroyed or disabled in few seconds by natural disasters like in Japan. Numerous natural disasters such as tsunami, hurricanes, earth quakes, ice storms, tornados, forest fires or floods can significantly affect people's ability to access basic necessities, such as food, shelter, and healthcare regardless of economic status of the country. In addition, there are numerous active wars and battle zones around the

Over the past decades there has been a substantial increase in the number of people affected by disasters and the subsequent socio-economic losses. In 2007, 414 disasters resulting from natural hazards were reported. They killed 16,847 people, affected more than 211 million others and caused over 74.9US\$ billion in economic damages. Last year's number of reported disasters confirmed the global upward trend in natural hazard-related disasters, mainly driven by the increase in the number of hydro-meteorological disasters. In recent decades, the number of reported hydrological disasters has increased by 7.4% per year on average. (Annual Disaster Statistical Review: Numbers and Trends 2007, Center for

Therefore, disaster recovery should be an integral part of planning, development and adoption of ICT solutions in health. It is not a matter of if, but when disaster is going to

An example of such as a policy has been developed by eHealth Ontario (2009) which states; "Business continuity management processes must be implemented to identify and limit to acceptable levels the business risks and consequences associated with major failures or disasters, considering both the disruption of eHealth Ontario services and the capability and

The potential consequences of disasters, security failures, and service disruptions must be analyzed to determine the criticality of services and supporting IT infrastructure

Integrated plans must be developed, implemented, and tested to ensure that all critical business services are maintained or can be restored on a prioritized basis, to an acceptable level and within the required time-scales, in the event of failure. Business continuity commitments for critical services must be incorporated into Service Level Agreements with

 timely restoration of service disrupted by a failure within a system, process, or function emergency recovery of service at an alternate location in the event of a disaster or

The mission of the Organisation for Economic Co-operation and Development (OECD) is to promote policies that will improve the economic and social well-being of people around the world. The OECD provides a forum in which governments can work together to share

limited recovery of critical services in the event of major loss of staff."

experiences and seek solutions to common problems such as healthcare.

happen. It is essential to have a policy and a disaster recovery plan for eHealth

world where basic livelihood have been threatened.

Research on the Epidemiology of Disasters).

time to resume essential operations.

clients. Disaster Recovery plans should be tested annually.

Contingency plans must provide for the following [13]:

prolonged outage at the primary site

components.

**Table 1.** Examples of eHealth trends and solutions

managing emergencies and disasters, mobile telemedicine, appointment reminders, community mobilization and health promotion, treatment compliance, mobile patient records, information access, patient monitoring, health surveys and data collection, surveillance, raising health awareness, and decision support systems. According to mHealth document [12], mobile phones are used to call a call center, emergency calls, medical consultations but not for health promotion or decision support or surveillance in developing countries. In case of disaster, they will use mobile phone or toll free call. As they move forward with mHealth, it is a vital importance to establish a policy for protecting privacy and security of health data [13].

According to Paré et al. (2011), implementation of mobile device with customized homecare nursing software helped to structure and organizes the nursing activities in patients' homes. There were 137 homecare nurses and they were asked to complete a structured questionnaire and 101 had completed (74% response rate).The nurses reported significant level of satisfaction with the quality of clinical information collected. A total of 57 semistructured interviews were conducted and most nurses considered the software to be user friendly. A questionnaire was mailed out to approximately 1240 patients and 223 patients responded. They reported that nurses who used mobile computing device during their home visits seemed to manage their health condition better and provided superior homecare services. The use of mobile computing had positive and significant effects on the quality of care provided by homecare nurses.

## **4. Disaster recovery plan**

As we move forward with the ICT supported healthcare, we must ensure the security, integrity, business continuity and recovery of healthcare data and services after a disaster, either manmade or natural. Advancement of technology and adoption of ICT solutions have contributed to escalating amount of digital data in business and public sectors. It is quite common for health care to be affected by earth quakes, fire, floods and severe storms in resource rich counties.

EHealth/ Telehealth networks can be destroyed or disabled in few seconds by natural disasters like in Japan. Numerous natural disasters such as tsunami, hurricanes, earth quakes, ice storms, tornados, forest fires or floods can significantly affect people's ability to access basic necessities, such as food, shelter, and healthcare regardless of economic status of the country. In addition, there are numerous active wars and battle zones around the world where basic livelihood have been threatened.

12 eHealth and Remote Monitoring

Security Security tools

**Table 1.** Examples of eHealth trends and solutions

quality of care provided by homecare nurses.

**4. Disaster recovery plan**

resource rich counties.

and security of health data [13].

**Trends Examples of eHealth Solutions Purpose** Messaging system Enterprise application integration system

Persistent security

Integrate systems at different levels e.g., network, data, application level

Protect systems and networks through providing security services e.g., authentication, authorization,

Protect data, information, knowledge in the environment where security services may not be

auditing

available

managing emergencies and disasters, mobile telemedicine, appointment reminders, community mobilization and health promotion, treatment compliance, mobile patient records, information access, patient monitoring, health surveys and data collection, surveillance, raising health awareness, and decision support systems. According to mHealth document [12], mobile phones are used to call a call center, emergency calls, medical consultations but not for health promotion or decision support or surveillance in developing countries. In case of disaster, they will use mobile phone or toll free call. As they move forward with mHealth, it is a vital importance to establish a policy for protecting privacy

According to Paré et al. (2011), implementation of mobile device with customized homecare nursing software helped to structure and organizes the nursing activities in patients' homes. There were 137 homecare nurses and they were asked to complete a structured questionnaire and 101 had completed (74% response rate).The nurses reported significant level of satisfaction with the quality of clinical information collected. A total of 57 semistructured interviews were conducted and most nurses considered the software to be user friendly. A questionnaire was mailed out to approximately 1240 patients and 223 patients responded. They reported that nurses who used mobile computing device during their home visits seemed to manage their health condition better and provided superior homecare services. The use of mobile computing had positive and significant effects on the

As we move forward with the ICT supported healthcare, we must ensure the security, integrity, business continuity and recovery of healthcare data and services after a disaster, either manmade or natural. Advancement of technology and adoption of ICT solutions have contributed to escalating amount of digital data in business and public sectors. It is quite common for health care to be affected by earth quakes, fire, floods and severe storms in Over the past decades there has been a substantial increase in the number of people affected by disasters and the subsequent socio-economic losses. In 2007, 414 disasters resulting from natural hazards were reported. They killed 16,847 people, affected more than 211 million others and caused over 74.9US\$ billion in economic damages. Last year's number of reported disasters confirmed the global upward trend in natural hazard-related disasters, mainly driven by the increase in the number of hydro-meteorological disasters. In recent decades, the number of reported hydrological disasters has increased by 7.4% per year on average. (Annual Disaster Statistical Review: Numbers and Trends 2007, Center for Research on the Epidemiology of Disasters).

Therefore, disaster recovery should be an integral part of planning, development and adoption of ICT solutions in health. It is not a matter of if, but when disaster is going to happen. It is essential to have a policy and a disaster recovery plan for eHealth

An example of such as a policy has been developed by eHealth Ontario (2009) which states;

"Business continuity management processes must be implemented to identify and limit to acceptable levels the business risks and consequences associated with major failures or disasters, considering both the disruption of eHealth Ontario services and the capability and time to resume essential operations.

The potential consequences of disasters, security failures, and service disruptions must be analyzed to determine the criticality of services and supporting IT infrastructure components.

Integrated plans must be developed, implemented, and tested to ensure that all critical business services are maintained or can be restored on a prioritized basis, to an acceptable level and within the required time-scales, in the event of failure. Business continuity commitments for critical services must be incorporated into Service Level Agreements with clients. Disaster Recovery plans should be tested annually.

Contingency plans must provide for the following [13]:

The mission of the Organisation for Economic Co-operation and Development (OECD) is to promote policies that will improve the economic and social well-being of people around the world. The OECD provides a forum in which governments can work together to share experiences and seek solutions to common problems such as healthcare.

As identified by the OECD, there is "an absence, in general, of independent, robust monitoring and evaluation of programmes and projects" [14]. In this context, there is a very real need to benchmark for the first time in a consistent and comparable manner eHealth deployment, take-up, and impact in hospitals across the EU27.

Global Health Through EHealth/Telehealth 15

Many of the hospitals in EU are operationalizing the disaster recovery plan within the hospital except Denmark, Ireland and Sweden are the only three countries where the strategy is driven by either regional or national health care IT program more than by the

Due to the nature of the service, it is essential to restore hospitals' critical clinical information. In EU, almost half the hospitals' critical clinical information system operations can be restored within 24 hours in the event that a disaster were to cause the complete loss of data at the hospital's primary data centre. However, 10% of hospitals say that this can only be done in less than one week. Shockingly, 1% says that it would take up to a month

Immediate recovery is possible in more than half of the hospitals in Luxembourg and Sweden. More than nine out of ten hospitals in Austria, Bulgaria, and Sweden would restore data immediately or within 24 hours. The response time is longer than 24 hours for more

EHealth/Telehealth will continue to evolve with advances in ICT, information science, medicine and biotechnology. The new generation of healthcare providers and patients will be far more comfortable with new technologies, new applications and services, and innovative service delivery methods. There is also a growing recognition that eHealth provides an opportunity for healthcare providers to improve health systems and transform

[1] Eysenbach, G (2001). What is e-health? J. med. internet. res. 3 (1). Available:

[2] e-Health; Open Clinical (2011). Available: http://www.openclinical.org/e-Health.html.

and, even worse, in another 1% of hospitals it would take more than a month.

than half of the hospitals surveyed in Finland, Greece and Norway.

them from the 'Diagnose and Treat' to 'Predict and Prevent' models.

http://www.jmir.org/2001/2/e20/. Accessed 2012 April 29.

and Lili Liu

hospital's own strategy.

**5. Conclusion**

**Author details**

Masako Miyazaki\*

Toshio Ohyanagi

**6. References**

Corresponing Author

 \*

Eugene Igras

*University of Alberta, Canada*

*IRIS Systems, Inc., Canada*

*Sapporo Medical University, Japan*

Accessed 2012 April 29.

The OECD [15] has used a case study approach to explore the various handicaps, incentives, enabling of secure exchanges of information, and the use of benchmarking in relation to eHealth with an aim to determine which practices can improve the adoption and use of ICT. It undertook six case studies, three of which were in Europe (the Netherlands, Spain and Sweden). Internationally, it also explored the situation in Australia, Canada and the United States of America (USA). This study therefore plays a vital role in discovering the eHealth deployment, take-up, and impact in hospitals across the EU27.

According to eHealth Benchmarking III [16] was prepared based on the result of survey conducted by Deloitte, in association with Ipsos Belgium and with the support of Diane Whitehouse of The Castlegate Consultancy, on behalf of the Information Society and Media Directorate-General European Commission (EC).

They had surveyed 906 acute hospitals; targeted Chief Information Officers (CIOs) in all the hospitals and Medical Directors in 280 of the hospitals: CIOs were asked about the availability of eHealth infrastructure and applications in their hospitals; whereas Medical Directors were asked about priority areas for investment, impacts and perceived barriers to the further deployment of eHealth. The survey was carried out in 2010 in all 27 Member States of the European Union (EU) and in Croatia, Iceland, and Norway [16].

Their method of data collection and analysis were clearly stated and processes of cross validation were included within and between the questionnaires for the Medical directors and CIOs. Within this study, they have inquired about their disaster recovery plan doe the acute hospitals in EU.

Disaster recovery implies the ability to recover those mission-critical computer systems that are required to support the business's continuity – in this case, the business is the hospital. There were more than 80% of the hospitals have an enterprise archive strategy for long-term storage and disaster recovery.

Enterprise archive strategies relate to "a comprehensive information archiving strategy aligned with an organisation's goals and performance needs.

All the hospitals surveyed in eight European countries (Austria, Croatia, Cyprus, Denmark, Estonia, Iceland, Norway, and Sweden) have an enterprise archive strategy for long-term storage and disaster recovery. The similar trend exists in Belgium, Germany, Spain and the UK. However France and Italy are both below the EU+ average. Of the hospitals that have an enterprise archive strategy, for most of them it is driven by the hospital's own strategy. Only in a few hospitals is it driven by national or regional healthcare IT programmes. "IBM - Information Lifecycle Management Services - Enterprise Archive - North America." [17].

Many of the hospitals in EU are operationalizing the disaster recovery plan within the hospital except Denmark, Ireland and Sweden are the only three countries where the strategy is driven by either regional or national health care IT program more than by the hospital's own strategy.

Due to the nature of the service, it is essential to restore hospitals' critical clinical information. In EU, almost half the hospitals' critical clinical information system operations can be restored within 24 hours in the event that a disaster were to cause the complete loss of data at the hospital's primary data centre. However, 10% of hospitals say that this can only be done in less than one week. Shockingly, 1% says that it would take up to a month and, even worse, in another 1% of hospitals it would take more than a month.

Immediate recovery is possible in more than half of the hospitals in Luxembourg and Sweden. More than nine out of ten hospitals in Austria, Bulgaria, and Sweden would restore data immediately or within 24 hours. The response time is longer than 24 hours for more than half of the hospitals surveyed in Finland, Greece and Norway.

## **5. Conclusion**

14 eHealth and Remote Monitoring

acute hospitals in EU.

storage and disaster recovery.

As identified by the OECD, there is "an absence, in general, of independent, robust monitoring and evaluation of programmes and projects" [14]. In this context, there is a very real need to benchmark for the first time in a consistent and comparable manner eHealth

The OECD [15] has used a case study approach to explore the various handicaps, incentives, enabling of secure exchanges of information, and the use of benchmarking in relation to eHealth with an aim to determine which practices can improve the adoption and use of ICT. It undertook six case studies, three of which were in Europe (the Netherlands, Spain and Sweden). Internationally, it also explored the situation in Australia, Canada and the United States of America (USA). This study therefore plays a vital role in discovering the eHealth

According to eHealth Benchmarking III [16] was prepared based on the result of survey conducted by Deloitte, in association with Ipsos Belgium and with the support of Diane Whitehouse of The Castlegate Consultancy, on behalf of the Information Society and Media

They had surveyed 906 acute hospitals; targeted Chief Information Officers (CIOs) in all the hospitals and Medical Directors in 280 of the hospitals: CIOs were asked about the availability of eHealth infrastructure and applications in their hospitals; whereas Medical Directors were asked about priority areas for investment, impacts and perceived barriers to the further deployment of eHealth. The survey was carried out in 2010 in all 27 Member

Their method of data collection and analysis were clearly stated and processes of cross validation were included within and between the questionnaires for the Medical directors and CIOs. Within this study, they have inquired about their disaster recovery plan doe the

Disaster recovery implies the ability to recover those mission-critical computer systems that are required to support the business's continuity – in this case, the business is the hospital. There were more than 80% of the hospitals have an enterprise archive strategy for long-term

Enterprise archive strategies relate to "a comprehensive information archiving strategy

All the hospitals surveyed in eight European countries (Austria, Croatia, Cyprus, Denmark, Estonia, Iceland, Norway, and Sweden) have an enterprise archive strategy for long-term storage and disaster recovery. The similar trend exists in Belgium, Germany, Spain and the UK. However France and Italy are both below the EU+ average. Of the hospitals that have an enterprise archive strategy, for most of them it is driven by the hospital's own strategy. Only in a few hospitals is it driven by national or regional healthcare IT programmes. "IBM - Information Lifecycle Management Services - Enterprise Archive - North America." [17].

States of the European Union (EU) and in Croatia, Iceland, and Norway [16].

deployment, take-up, and impact in hospitals across the EU27.

deployment, take-up, and impact in hospitals across the EU27.

aligned with an organisation's goals and performance needs.

Directorate-General European Commission (EC).

EHealth/Telehealth will continue to evolve with advances in ICT, information science, medicine and biotechnology. The new generation of healthcare providers and patients will be far more comfortable with new technologies, new applications and services, and innovative service delivery methods. There is also a growing recognition that eHealth provides an opportunity for healthcare providers to improve health systems and transform them from the 'Diagnose and Treat' to 'Predict and Prevent' models.

## **Author details**

Masako Miyazaki\* and Lili Liu *University of Alberta, Canada*

Eugene Igras *IRIS Systems, Inc., Canada*

Toshio Ohyanagi *Sapporo Medical University, Japan*

## **6. References**

<sup>\*</sup> Corresponing Author

	- [3] Alverson, DC, Shannon, S, Sullivan, E, Prill, A, Effertz, G, Helitzer, D, Beffort, S Preston, A (2004). Telehealth in the Trenches: Reporting Back from the Frontlines in Rural America". Telemed. j. e-Health 10: Sup 2, S95 – S109. Available:

**Chapter 2**

© 2012 Esmaeilzadeh, licensee InTech. This is an open access chapter distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

© 2012 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons Attribution License http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution,

**Interaction with Clinical Decision**

**Support Systems: The Challenge**

**of Having a Steak with No Knife**

Organizations invest in IT systems with the hope of cutting costs, increasing the quality of products or services [1]. But if users do not accept the systems, the organizations can not benefit significantly from the new systems. On the other hand, if users accept new IT systems they become more willing to make use of the new systems [2]. The usage of a newly introduced system can be a sign of the IT system success [3]. Therefore, finding the reasons that motivate people to use or understand the source of resistance to use new IT systems, is

The use of IT in health care practices has increased recently [5]. A variety of IT systems such as clinical information systems, personal digital assistants, electronic patient records and other applications have gradually become established in the healthcare industry. Clinical IT applications in healthcare are regarded as a key element in raising the quality of medical care. However, factors affecting the healthcare professionals' adoption behavior regarding IT systems are not completely clear yet [6,7,8]. The concern of having new clinical IT systems

With reference to a study done by Walter and Lopez [8] two types of IT are available in medical care environment. The first one is Electronic Medical Records (EMR) systems which are computer systems that allow users to create, store, and retrieve patient charts on a computer. The second one is Clinical Decision Support (CDS) system that is classified as a decision support system. A CDS System is regarded as an application of Decision Support System (DSS), which takes patient data as input and generates decision- specific advice [11,12]. These systems are referred to as knowledge-based systems that use patient data and series of reasoning techniques to generate diagnostic and treatment options and care

and reproduction in any medium, provided the original work is properly cited.

unused is still one of the biggest issues for the clinical IT developers [9,10].

Additional information is available at the end of the chapter

important to both system designers and developers [4].

Pouyan Esmaeilzadeh

http://dx.doi.org/10.5772/48350

**1. Introduction**

## **Interaction with Clinical Decision Support Systems: The Challenge of Having a Steak with No Knife**

Pouyan Esmaeilzadeh

16 eHealth and Remote Monitoring

April 29.

17:313 – 317.

14: 109–14.

April 2012.

Accessed 2011 May 13.

Accessed 2012 April 30.

reports/docs/health\_glance\_en.pdf.

[3] Alverson, DC, Shannon, S, Sullivan, E, Prill, A, Effertz, G, Helitzer, D, Beffort, S Preston, A (2004). Telehealth in the Trenches: Reporting Back from the Frontlines in Rural America".

[5] Global Observatory for eHealth series (2011). Health Canada, 1-3. Available:

http://www.who.int/goe/publications/goe\_mhealth\_web.pdf). Accessed 2012 April 29. [6] Oh, H, Rizo, C, Enkin, M, Jadad, A (2005). What is eHealth: a systematic review of

[7] Paré, G, Sicotte, C, Moreault, M-P, Poba-Nzaou, P, Nahas, G, Templier, M (2011). Mobile computing and the quality of home care nursing practice. J. telemed. telecare.

[8] Baker, GR, Norton, PG, Flintoft, V, Blais, R, Brown, A, Cox, J, Etchells, E, Ghali, WA, Henert, P, Majumdar, SR, O'Beirne, M, Palacios-Derfingher, L, Reid, RJ, Sheps, S Tamblyn, R (2004). The Canadian Adverse Events Study: the incidents of adverse events

[9] Pan-Canadian Health Information Privacy and Confidentiality Framework 2005. Available: http://www.hc-sc.gc.ca/hcs-sss/pubs/ehealth-esante/index\_e.html. [10] Wootton R (2008). Telemedicine support for the developing world. J. telemed. telecare.

[11] The world in 2010: ICT facts and figures. Geneva, International Telecommunications Union, 2010. Available: http://www.itu.int/ITU-D/ict/material/FactsFigures2010.pdf.

[12] .WHO. Mobile health (mHealth). Available: http://www.who.int/goe/mobile\_health/en/.

[13] eHealth Ontario (2009). Available: http://www.ehealthontario.on.ca/pdfs/Privacy/

[14] OECDHealth at a Glance Europe 2010 (2010). Available: http://ec.europa.eu/health/

[15] OECD Health Data 2011 (2011) Available: http://www.oecd.org/document/

[16] eHealth Benchmarking III; SMART 2009/0022 (2011). Final Report; Deloitte & Ipsos Belgium. Available: http://ec.europa.eu/information\_society/eeurope/i2010/docs/ benchmarking/ehealth\_benchmarking\_3\_final\_report.pdf. Accessed 2012 April 29. [17] Data and information management services – enterprise archive. Available: http://www-935.ibm.com/services/us/index.wss/offering/its/a1030346. Accessed 2012

http://hsc.unm.edu/som/telehealth/docs/telemedjournalarticle.pdf. Accessed 2012 April 29. [4] Health Canada, 2011: http://www.hc-sc.gc.ca/fniah-spnia/index-eng.php. Accessed 2012

Telemed. j. e-Health 10: Sup 2, S95 – S109. Available:

http://www.who.int/goe/publications/ehealth\_series\_vol1/en/;

published definitions. J. med. internet res. 7(1). Available: http://www.jmir.org/2005/1/e1/). Accessed April 30, 2012.

Information\_Security\_Policy.pdf. Accessed 2012 April 29.

30/0,3746,en\_2649\_37407\_12968734\_1\_1\_1\_37407,00.html

among hospital patients in Canada. JAMC 25.

http://www.who.int/goe/publications/ehealth\_series\_vol2/en/index.html;

Additional information is available at the end of the chapter

http://dx.doi.org/10.5772/48350

## **1. Introduction**

Organizations invest in IT systems with the hope of cutting costs, increasing the quality of products or services [1]. But if users do not accept the systems, the organizations can not benefit significantly from the new systems. On the other hand, if users accept new IT systems they become more willing to make use of the new systems [2]. The usage of a newly introduced system can be a sign of the IT system success [3]. Therefore, finding the reasons that motivate people to use or understand the source of resistance to use new IT systems, is important to both system designers and developers [4].

The use of IT in health care practices has increased recently [5]. A variety of IT systems such as clinical information systems, personal digital assistants, electronic patient records and other applications have gradually become established in the healthcare industry. Clinical IT applications in healthcare are regarded as a key element in raising the quality of medical care. However, factors affecting the healthcare professionals' adoption behavior regarding IT systems are not completely clear yet [6,7,8]. The concern of having new clinical IT systems unused is still one of the biggest issues for the clinical IT developers [9,10].

With reference to a study done by Walter and Lopez [8] two types of IT are available in medical care environment. The first one is Electronic Medical Records (EMR) systems which are computer systems that allow users to create, store, and retrieve patient charts on a computer. The second one is Clinical Decision Support (CDS) system that is classified as a decision support system. A CDS System is regarded as an application of Decision Support System (DSS), which takes patient data as input and generates decision- specific advice [11,12]. These systems are referred to as knowledge-based systems that use patient data and series of reasoning techniques to generate diagnostic and treatment options and care

© 2012 Esmaeilzadeh, licensee InTech. This is an open access chapter distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. © 2012 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons Attribution License http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

planning. Typically, clinical IT is designed to enhance decision-making in health care environment and in this study the emphasis is on CDS systems.

Interaction with Clinical Decision Support Systems: The Challenge of Having a Steak with No Knife 19

surgeons, and other specialty doctors. For the entire mentioned group, the possibility of working with clinical information systems to deliver proper treatment and health care to

Professionals have some distinct and professional characteristics whereby they are viewed different from other non-professionals. Due to the scope of this study, the special characteristics of healthcare professionals are put at the center of attention. Healthcare professionals' professionalism has long been based on a defined set of values. The most important feature is healthcare professional autonomy and the other features are patient sovereignty, physician confidentiality, and habits of learning. According to Raelin [22], professional autonomy is defined as the control that professionals have over the processes

Patient sovereignty is defined as paternalism or the traditional model of doctor-patient relationship that includes official instruction and the patient's values in shared decisionmaking is not really emphasized in this type of communication [23]. Physician confidentiality is an important issue in the relationship between patients and physicians specifically in the disclosure of a patient's personal health information, medical histories

The increasing body of medical knowledge is a main concern to all types of doctors. Their habits of learning are associated with their subjective ability to keep themselves professionally updated on new medical findings. This includes spending time on attending

With reference to the findings of an exploratory study conducted by Chau and Hu [25], some unique characteristics are believed to be held by healthcare professionals. Three characteristics have been proposed as the main characteristics of this group. The first one is specialized training that reveals their domination over knowledge which has been obtained during a lengthy period of education. As stated by Watts [21], they devote a considerable portion of their youth preparing for the profession. Their body of knowledge is directly associated with the lives of patients. In this profession even a slight mistake can be fatal. Therefore, the heightened emphasis has been placed on specialized training of healthcare

The second characteristic is professional autonomy. Based on this characteristic, healthcare professionals proclaim that they are in the best position to drive, organize, and regulate their own practice. They are judged mainly through a peer review process in which professionals evaluate each other. As mentioned by Zuger [26], professional autonomy has clearly been the most important value. This advantage provides healthcare professionals with a sense of pride, and accomplishment. In addition, they take special power, prestige, and authorities,

as well as they are put at the top of the hierarchy in the health care profession.

**4. The unique characteristics of healthcare professionals**

patients is reasonable.

and content of their work.

professionals.

and symptoms to physicians without any distress.

courses/congresses and medical readings [24].

There is enough evidence to state that healthcare professionals are different from other IT users in terms of accepting technology and may respond differently to clinical IT [13,14]. Their different IT adoption behavior is attributed to their professional characteristics such as specialized training, professional autonomy and professional work context. Healthcare professionals are highly sensitive to changes in their work setting especially they are more concerned about the kind of changes that are perceived as a threat to their professional autonomy [15,16,17,18]. On the other hand, different features of CDS such as guidelines and instructions given by those systems can affect healthcare professional's IT acceptance.

It means that the healthcare professionals' CDS adoption may be affected by their perceived level of interactivity with the CDS system. Therefore, the feature and nature of instructions and guidelines given by IT to healthcare professionals in terms of problem-solving process may be considered as an element that invalidate their professional autonomy [19]. Thus, the antecedent of healthcare professionals' perceived threat to professional autonomy is the rules, instructions and diagnostic options provided by the CDS.

## **2. Theory of professionals**

While a variety of definitions for the term professional have been suggested, this study uses the definition from sociology. According to the classic work of Larson [19], professionals are defined as "members of occupations with special power and prestige based on special competence in esoteric bodies of knowledge linked to central needs and values of the social system". With attention to the study conducted by Sharma [20], members of some professions have been called professionals, in light of their command of focal as well as demanding knowledge that they possess. This list includes the holders of five professions namely financial analysts, lawyers, university professors, accountants and finally physicians.

It should be mentioned that generally, the medical profession has been thought of as the model or symbol of professionals based on the nature of the knowledge owned by physicians compared to the others. According to Watts [21] in all public polls which were taken in the USA in the second half of 20th century, the public selected physicians as the most honored professionals.

## **3. Types of healthcare professionals**

In this study, the focus is on IT adoption behavior of healthcare professionals. Based on a review a literature, different types of medical workers are considered as healthcare professionals. Generally, healthcare professionals or medical professionals are distinguished from others as professionals specialized in serving diagnosis and treatment to patients' medical issues and disease. This group encompasses all physicians such as general practitioners, internists, pediatrics, radiologists, geriatrics, gynecologists, pathologists, surgeons, and other specialty doctors. For the entire mentioned group, the possibility of working with clinical information systems to deliver proper treatment and health care to patients is reasonable.

## **4. The unique characteristics of healthcare professionals**

18 eHealth and Remote Monitoring

planning. Typically, clinical IT is designed to enhance decision-making in health care

There is enough evidence to state that healthcare professionals are different from other IT users in terms of accepting technology and may respond differently to clinical IT [13,14]. Their different IT adoption behavior is attributed to their professional characteristics such as specialized training, professional autonomy and professional work context. Healthcare professionals are highly sensitive to changes in their work setting especially they are more concerned about the kind of changes that are perceived as a threat to their professional autonomy [15,16,17,18]. On the other hand, different features of CDS such as guidelines and instructions given by those systems can affect healthcare professional's IT acceptance.

It means that the healthcare professionals' CDS adoption may be affected by their perceived level of interactivity with the CDS system. Therefore, the feature and nature of instructions and guidelines given by IT to healthcare professionals in terms of problem-solving process may be considered as an element that invalidate their professional autonomy [19]. Thus, the antecedent of healthcare professionals' perceived threat to professional autonomy is the

While a variety of definitions for the term professional have been suggested, this study uses the definition from sociology. According to the classic work of Larson [19], professionals are defined as "members of occupations with special power and prestige based on special competence in esoteric bodies of knowledge linked to central needs and values of the social system". With attention to the study conducted by Sharma [20], members of some professions have been called professionals, in light of their command of focal as well as demanding knowledge that they possess. This list includes the holders of five professions namely financial analysts, lawyers, university professors, accountants and finally

It should be mentioned that generally, the medical profession has been thought of as the model or symbol of professionals based on the nature of the knowledge owned by physicians compared to the others. According to Watts [21] in all public polls which were taken in the USA in the second half of 20th century, the public selected physicians as the

In this study, the focus is on IT adoption behavior of healthcare professionals. Based on a review a literature, different types of medical workers are considered as healthcare professionals. Generally, healthcare professionals or medical professionals are distinguished from others as professionals specialized in serving diagnosis and treatment to patients' medical issues and disease. This group encompasses all physicians such as general practitioners, internists, pediatrics, radiologists, geriatrics, gynecologists, pathologists,

environment and in this study the emphasis is on CDS systems.

rules, instructions and diagnostic options provided by the CDS.

**2. Theory of professionals**

most honored professionals.

**3. Types of healthcare professionals**

physicians.

Professionals have some distinct and professional characteristics whereby they are viewed different from other non-professionals. Due to the scope of this study, the special characteristics of healthcare professionals are put at the center of attention. Healthcare professionals' professionalism has long been based on a defined set of values. The most important feature is healthcare professional autonomy and the other features are patient sovereignty, physician confidentiality, and habits of learning. According to Raelin [22], professional autonomy is defined as the control that professionals have over the processes and content of their work.

Patient sovereignty is defined as paternalism or the traditional model of doctor-patient relationship that includes official instruction and the patient's values in shared decisionmaking is not really emphasized in this type of communication [23]. Physician confidentiality is an important issue in the relationship between patients and physicians specifically in the disclosure of a patient's personal health information, medical histories and symptoms to physicians without any distress.

The increasing body of medical knowledge is a main concern to all types of doctors. Their habits of learning are associated with their subjective ability to keep themselves professionally updated on new medical findings. This includes spending time on attending courses/congresses and medical readings [24].

With reference to the findings of an exploratory study conducted by Chau and Hu [25], some unique characteristics are believed to be held by healthcare professionals. Three characteristics have been proposed as the main characteristics of this group. The first one is specialized training that reveals their domination over knowledge which has been obtained during a lengthy period of education. As stated by Watts [21], they devote a considerable portion of their youth preparing for the profession. Their body of knowledge is directly associated with the lives of patients. In this profession even a slight mistake can be fatal. Therefore, the heightened emphasis has been placed on specialized training of healthcare professionals.

The second characteristic is professional autonomy. Based on this characteristic, healthcare professionals proclaim that they are in the best position to drive, organize, and regulate their own practice. They are judged mainly through a peer review process in which professionals evaluate each other. As mentioned by Zuger [26], professional autonomy has clearly been the most important value. This advantage provides healthcare professionals with a sense of pride, and accomplishment. In addition, they take special power, prestige, and authorities, as well as they are put at the top of the hierarchy in the health care profession.

As stated by Watts [21], and Montague et al. [27], the last item is professional work arrangements where healthcare professionals become health care providers, hospitals became health care facilities, and a patient acts as both the product and the client in such a system. Also, in this setting, two other occupational groups (para-professionals and nonprofessionals) work with healthcare professionals. These two groups, the role they play in healthcare organizations and their relevance to this study is addressed in the following section.

Interaction with Clinical Decision Support Systems: The Challenge of Having a Steak with No Knife 21

On the basis of having professional autonomy, professionals are given some special rights. First, professionals take advantage of having more access to critical resources than nonprofessionals. A survey conducted by Freidson [33] shows that as long as professionals are not provided with adequate resources such as equipment and staff, they can claim that their

Second, professionals have power over the tasks carried out by non-professionals (ones who do not have professional qualification, skills as well as knowledge and are involved in administrative duties, clerical and office work) and para-professionals (ones who possesses only partial professional skills such as technicians that assist professionals in performing

It should be added that the advantage of having control over subordinate groups is more considerable in those organizations with existing hierarchies among various working groups. A hospital is regarded as an organization in which different work-related groups (physician assistants, nurses, medical technicians, and administration) possess different levels of medical knowledge and among all; physicians are placed at the top of the hierarchy. The following figure (Figure-1) shows the hierarchy of different occupational

work groups involved in a hospital, based on their level of medical knowledge.

Healthcare professional (medically-qualified doctors)

**Figure 1.** The hierarchy in healthcare organizations based on level of medical knowledge

One view toward any new computerized system is that IT can reduce dependence on specific personnel [37]. These rules, procedures, and recommendations designed and embedded in IT can weaken their claim on possession of special competence in problem solving. Moreover, these instructions can invalidate their decision making skills in terms of deciding what to do for treatment of their patients. As stated by Harrison et al. [38], healthcare professionals feel uncomfortable when they face regulations and instructions generated by a clinical decision system that advises them on what to do. This is because they believe that they can treat their patients based on their specialized knowledge,

Nurses

Administration

**6. Theory of interactivity**

work cannot be accomplished in the best way.

Physician Assistants

their work) and can control the tasks carried out by them [36].

## **5. Professional autonomy: The central privilege**

According to Starr [28] at the start of the second half of the 20th century, healthcare professionals are viewed as the holders of desirable autonomy and respect within the health care industry. In accordance with Abbott [29], being members of a profession is certainly conducive to professional autonomy. Based on a study by Adams [30], professional autonomy is considered as a key factor of the medical profession. Drawing on a recent study by Walter and Lopez [8], professional autonomy is viewed as a precious privilege given to professionals and they do not like to lose it in their workplace. Throughout this research the term professional autonomy is used to refer to having control over the state of affairs, course of actions, practices, or components of their work in relation to their own collective and finally, individual conclusion for applying their profession's body of knowledge and capability [31].

As pointed out by Freidson [32], based on professional autonomy which is granted to professionals, individuals outside the profession (non-professionals) do not know how to evaluate the practices of the professionals due to lack of required knowledge. Relying on professional autonomy, physicians are provided with separate bylaws and arrangement within hospitals [28].

Professional autonomy generates two main expectations of professionals. On the one hand, they are required to practice with extreme conscientiousness and without any direct surveillance. One the other hand, they are trusted to take on the necessary measures in carrying out their tasks [33]. Previous studies have reported that it is very difficult to evaluate the physicians' performance due to the unstructured nature of their practice [34]. This view is supported by Wilson et al. [35] who point out that some usual objective measures like revenue or number of published articles, which are applicable to measure individual outputs in other practices, cannot be used to evaluate professionals especially physicians.

A peer review process is being utilized in professional settings in order to validate the evaluation of professionals based on subjective analysis of objective measures. According to Walter and Lopez [8], one of the most important characteristics of professional autonomy is being analyzed by peers instead of non-professionals who are outside the profession. Therefore, it is becoming increasingly difficult to ignore the importance of professional autonomy that indicates the possession of esoteric body of knowledge which the outsiders are not aware of.

On the basis of having professional autonomy, professionals are given some special rights. First, professionals take advantage of having more access to critical resources than nonprofessionals. A survey conducted by Freidson [33] shows that as long as professionals are not provided with adequate resources such as equipment and staff, they can claim that their work cannot be accomplished in the best way.

Second, professionals have power over the tasks carried out by non-professionals (ones who do not have professional qualification, skills as well as knowledge and are involved in administrative duties, clerical and office work) and para-professionals (ones who possesses only partial professional skills such as technicians that assist professionals in performing their work) and can control the tasks carried out by them [36].

It should be added that the advantage of having control over subordinate groups is more considerable in those organizations with existing hierarchies among various working groups. A hospital is regarded as an organization in which different work-related groups (physician assistants, nurses, medical technicians, and administration) possess different levels of medical knowledge and among all; physicians are placed at the top of the hierarchy. The following figure (Figure-1) shows the hierarchy of different occupational work groups involved in a hospital, based on their level of medical knowledge.

**Figure 1.** The hierarchy in healthcare organizations based on level of medical knowledge

## **6. Theory of interactivity**

20 eHealth and Remote Monitoring

section.

capability [31].

within hospitals [28].

physicians.

are not aware of.

As stated by Watts [21], and Montague et al. [27], the last item is professional work arrangements where healthcare professionals become health care providers, hospitals became health care facilities, and a patient acts as both the product and the client in such a system. Also, in this setting, two other occupational groups (para-professionals and nonprofessionals) work with healthcare professionals. These two groups, the role they play in healthcare organizations and their relevance to this study is addressed in the following

According to Starr [28] at the start of the second half of the 20th century, healthcare professionals are viewed as the holders of desirable autonomy and respect within the health care industry. In accordance with Abbott [29], being members of a profession is certainly conducive to professional autonomy. Based on a study by Adams [30], professional autonomy is considered as a key factor of the medical profession. Drawing on a recent study by Walter and Lopez [8], professional autonomy is viewed as a precious privilege given to professionals and they do not like to lose it in their workplace. Throughout this research the term professional autonomy is used to refer to having control over the state of affairs, course of actions, practices, or components of their work in relation to their own collective and finally, individual conclusion for applying their profession's body of knowledge and

As pointed out by Freidson [32], based on professional autonomy which is granted to professionals, individuals outside the profession (non-professionals) do not know how to evaluate the practices of the professionals due to lack of required knowledge. Relying on professional autonomy, physicians are provided with separate bylaws and arrangement

Professional autonomy generates two main expectations of professionals. On the one hand, they are required to practice with extreme conscientiousness and without any direct surveillance. One the other hand, they are trusted to take on the necessary measures in carrying out their tasks [33]. Previous studies have reported that it is very difficult to evaluate the physicians' performance due to the unstructured nature of their practice [34]. This view is supported by Wilson et al. [35] who point out that some usual objective measures like revenue or number of published articles, which are applicable to measure individual outputs in other practices, cannot be used to evaluate professionals especially

A peer review process is being utilized in professional settings in order to validate the evaluation of professionals based on subjective analysis of objective measures. According to Walter and Lopez [8], one of the most important characteristics of professional autonomy is being analyzed by peers instead of non-professionals who are outside the profession. Therefore, it is becoming increasingly difficult to ignore the importance of professional autonomy that indicates the possession of esoteric body of knowledge which the outsiders

**5. Professional autonomy: The central privilege**

One view toward any new computerized system is that IT can reduce dependence on specific personnel [37]. These rules, procedures, and recommendations designed and embedded in IT can weaken their claim on possession of special competence in problem solving. Moreover, these instructions can invalidate their decision making skills in terms of deciding what to do for treatment of their patients. As stated by Harrison et al. [38], healthcare professionals feel uncomfortable when they face regulations and instructions generated by a clinical decision system that advises them on what to do. This is because they believe that they can treat their patients based on their specialized knowledge,

experience, skills and competence. According to Lowenhaupt [39], healthcare professionals become more anxious when someone or something (such as a computer system, here is CDS) shows he/it has more knowledge than them regarding what to be done with their patients.

Interaction with Clinical Decision Support Systems: The Challenge of Having a Steak with No Knife 23

system. Therefore, this situation inevitably results in low level of perceived control over

Interactivity has been defined in the literature in diverse ways [42]. Based on a review of the literature, interactivity is generally delineated as a property of the technology, the communication setting, or the perceptions of users [43]. In the first part of the definition, features of technology provide the set of interface actions that the systems allow and the degree of interaction changes based on user skills and competencies. The second part of the definition points to the communication setting as the locus of interactivity and specifies that interactive processes can be observed in the form of message exchanges (e.g., [44]). The control that users practice over the content of mediated exchanges is at the core of both message-related and technology-oriented

According to Steuer [45] interactivity is defined as the "extent to which users can participate in modifying the form and content of a mediated environment in real time". Likewise, Neuman [46] stated that interactivity is "characterized by increased control over the communication process by both the sender and receiver". Williams, Rice, and Rogers [47] put forward interactivity as "the degree to which participants in a communication process have control over, and can exchange roles in, their mutual discourse". Based on Jensen [48] interactivity is "a measure of a media's potential ability to let the user exert an influence on the content and/or form of the mediated communication'. In the media literature, interactivity is regarded as a key motive for users' social responses to

Stromer-Galley [50] has brought up the matter of categorizing the different types of interactivity into two general dimensions: interactivity as a product and interactivity as a process. The first type is related to interaction with content, dealing with the control that users apply over the selection and presentation of online content, such as text, audiovisuals, multimedia, and other features of the interface [50]. McMillan [43] has mentioned that product interactivity is a type of user-to-system interaction, whereas Stromer-Galley [50] previously used the term media interaction. Also Rafaeli [51] call such interactions as reactive communication. The second type of interactivity addresses personto-person conversations which are mediated by the technology. Massey and Levy [52] have called this process interpersonal interactivity. McMillan [43] has employed the term user-to-user for this form of interaction while Stromer- Galley [50] referred this to the

According to McMillan and Hwang [42], three elements come out commonly in the interactivity literature: direction of communication (responsiveness and exchange), user control (participation and features) and time (timely feedback and time required for retrieving information). Many studies have taken Human-to-Computer Interaction (HCI) into account to explain the ways humans can gain control over computers and other new media, such as video games [53, 54]. Reeves and Nass [49] have stated that with attention to

processes and procedures of patients' treatment.

definitions of interactivity.

computers [49].

human interaction.

Bucy [40] has mentioned that there is a slight difference between interactivity and social interaction in the form of person-to-person conversation or face-to-face communication. On the one hand, interactivity can be viewed as a special sort of mediated social interaction, like online chat, discussion forums, or teleconferencing. On the other hand, it can appear as impersonal interactions with media content or nonhuman agents such as computer game playing, e-commerce transactions, and various other forms of content interactivity. Perceived level of interactivity is largely based on the belief that the interactive nature of the clinical system can assist in creating cooperation between healthcare professionals and clinical IT systems. Perceived level of interactivity with CDS can be divided into three parts. 1. Interactive features of CDS itself. 2. being responsive to customized needs of healthcare professionals. 3. Interaction between healthcare professionals and CDS.

In this study, the effect of level of healthcare professionals' interactivity with a new CDS is examined on the perceived threat to professional autonomy. Based on the interactivity theory which explains human – computer perceived interaction; a high level of interactivity can be demonstrated in simultaneous, reactive and continuous exchange of information [41] that assists in conducting users' tasks. A higher perceived level of interactivity with a system causes higher degree of control that healthcare professionals have during the interaction with an IT system. Higher level of control consequently may result in the less threat perceived from the system to their professional autonomy and in turn they become more prone to use the new IT. This issue indicates that when healthcare professionals perceive low level of control over the health care process due to the function and features of the new CDS, they become less likely to use the system. In other words, if healthcare professionals perceive that the regulations given out by CDS may threaten their professional autonomy and CDS acts as their supervisor directing them what to do without their interference, they perceive this kind of IT (with low level of interactivity) as encroaching on their professional autonomy. Thus, different level of interactivity with CDS system is conducive to different perception toward using that system. For instance, healthcare professionals may perceive a low level of interactivity with the CDS in comparison with the EMR.

As a result, perceived level of interactivity is largely based on the belief that the interactive nature of the clinical system can assist in creating cooperation between the healthcare professionals and the IT system. If healthcare professionals perceive that the nature of new CDS is interactive, they perceive more control and in turn they perceive less threat to their professional autonomy [8]. As a result, we propose that low level of perceived interactivity with CDS leads to low level of involvement in performing activities with the aid of the CDS system. Therefore, this situation inevitably results in low level of perceived control over processes and procedures of patients' treatment.

22 eHealth and Remote Monitoring

done with their patients.

professionals and CDS.

EMR.

experience, skills and competence. According to Lowenhaupt [39], healthcare professionals become more anxious when someone or something (such as a computer system, here is CDS) shows he/it has more knowledge than them regarding what to be

Bucy [40] has mentioned that there is a slight difference between interactivity and social interaction in the form of person-to-person conversation or face-to-face communication. On the one hand, interactivity can be viewed as a special sort of mediated social interaction, like online chat, discussion forums, or teleconferencing. On the other hand, it can appear as impersonal interactions with media content or nonhuman agents such as computer game playing, e-commerce transactions, and various other forms of content interactivity. Perceived level of interactivity is largely based on the belief that the interactive nature of the clinical system can assist in creating cooperation between healthcare professionals and clinical IT systems. Perceived level of interactivity with CDS can be divided into three parts. 1. Interactive features of CDS itself. 2. being responsive to customized needs of healthcare professionals. 3. Interaction between healthcare

In this study, the effect of level of healthcare professionals' interactivity with a new CDS is examined on the perceived threat to professional autonomy. Based on the interactivity theory which explains human – computer perceived interaction; a high level of interactivity can be demonstrated in simultaneous, reactive and continuous exchange of information [41] that assists in conducting users' tasks. A higher perceived level of interactivity with a system causes higher degree of control that healthcare professionals have during the interaction with an IT system. Higher level of control consequently may result in the less threat perceived from the system to their professional autonomy and in turn they become more prone to use the new IT. This issue indicates that when healthcare professionals perceive low level of control over the health care process due to the function and features of the new CDS, they become less likely to use the system. In other words, if healthcare professionals perceive that the regulations given out by CDS may threaten their professional autonomy and CDS acts as their supervisor directing them what to do without their interference, they perceive this kind of IT (with low level of interactivity) as encroaching on their professional autonomy. Thus, different level of interactivity with CDS system is conducive to different perception toward using that system. For instance, healthcare professionals may perceive a low level of interactivity with the CDS in comparison with the