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1. The Need For Health Strategies
And How To Build Them
Lincoln A Moura Jr, EE, MSc, DIC, PhD
lamoura@uol.com.br
+55 11 984266276

2. Disclaimer
• I am not a public servant nor do I represent any sphere of
government;
• For a living, I work for Accenture Brasil, as a member of its
Health Team, but this presentation reflects only my
personal experience, my views and my sole understanding;
• Any mention to my previous work as a PAHO consultant at
the MoH of Brazil is simply intended to make methods and
results more tangible to the audience. Anything I may
comment is of public knowledge.

3. A Personal History – 1977-1979
• As an Electrical and Electronic Engineer student I
felt very frustrate by the lack of perception of how
“people” would benefit from Technology;
• In my 3rd year, in 1974, I got hold of a folder
describing a Master´s Degree in Biomedical
Engineering, at COPPE in Rio de Janeiro,
including research topics such as “high-frequency
ECG” and “medical signal processing”. I
Immediately fell for it and, in 1977, began my
graduate studies in BioMedical Engineering;
• My research topic was “Online Cardiac Arrhythmia
Detection from a Single ECG Lead”. The computer
I used was a DEC PDP-12 with 16 kBytes of
memory! Photo Source
http://www.computerhistory.org/

4. A Personal History – 1980-1985
• After my MSc, in 1979, I started working at the
brand new São Paulo Heart Institute (InCor) as
Head of R&D;
• There were four HP 2100 series computers with
amazing 512 kBytes of memory and 10 Mbytes of
storage on a removable 12- inches hard-drive.
Photo Source https://upload.wikimedia.org/

5. A Personal History – 1985-1988
• In 1986, I was a PhD student working at Imperial
College, on the 3D reconstruction of medical
structures;
• I had my own MicroVAX II, with “astonishing” 16
Mbytes of memory and 256 Mbytes on a hard-
drive;
• I was able to process images of 512 x 512 pixels
and volumes of 256 x 256 x 256 voxels.
Photo Source http://home.claranet.nl/users/pb0aia/cm/lvrx3.jpg

6. A Personal History – Today
• Anyone of us has some sort of smartphone with 16 Gbytes of memory,
high-speed processor, high-res display in full color, with plenty of additional
technology: GPS, Graphics, telecomm, Wi-Fi, voice and natural language
processing, biometrics and several sensors such as those for positioning,
speed, magnetic compass, proximity and the like;
• The amount of data we generate on a daily basis is simply astound.
Photo Source https://upload.wikimedia.org/

7. Conclusions
Photo Source https://upload.wikimedia.org/
• A drastic change from focusing in a single object at a time...
• Signals (ECG, Arterial Pressure, Blood Flow, ....)
• Images (MRI, X-rays, US, Nuclear Medicine,...)
• The EMR, EHR, CCR...
• ...to gathering and processing all available information of value:
• Social determinants of health (stress, environment, habits,
status...)
• Individualized health data from several and disparate sources
• Health surveillance data (georeferenced data on diseases)
• Five “Vs” for Big Data:
• Variety
• Velocity
• Volume
• Veracity
• Value

8. Digital Disrupture
Adapted from Accenture research
Mobile Cloud
Connected
Visual
Augmented
Ubiquitious
Social
Personalized
Content
Self‐service
Gamefication
Architecture
Interoperable
Efficient
Flexible
Sources
Processing
Big Data
Prediction
Analytics Sensors
Wearables
Digestíble
Implantable
Internet of Things

9. Clear Message to Us
Photo Source https://upload.wikimedia.org/
• Patients from both public and private sector are more aware, want
better services and are willing to use e-services, in general;
• Goverments and health care organizations want to be more efficient so
as to improve access to better and more resolutive care;
• Goal: better health at a suitable cost.

10. For Patients, “Value” is Neither Outcomes nor Cost
“In your own words, how would you define “value” in healthcare?
Please be specific.” (unaided response)
Source: Quintiles, The New Health Report 2011
Physicians
Patients
Neither Cost or Outcome
Cost
Outcome
Not Sure
Cost & Outcome
Cost
Cost & Outcome
Outcome
Neither Cost or Outcome
Not Sure
10 20 30 40
The Patient Experience

11. eHealth Waves
• First Wave – circa 2000
– Investment in eHealth in countries like UK, USA, Canada, Australia, Sweden, Denmark
and New Zealand;
– Successes, Disappointments and (some big) Failures
• Second Wave
– Increased and widespread perception that eHealth is VERY IMPORTANT to all countries
no matter their maturity level;
– ISO
– WHO-ITU
– WHA 66.24
– Several countries started working on National eHealth Strategies
• Current State
– Consolidate the value of eHealth Strategies, including policies but not limited to them.

12. eHealth is Worth it:
The economic benefits of
implemented eHealth solutions
at ten European sites
Source: eHealth Impact, 2006

13. ROI in eHealth in the European Communitiy
Source: eHealth Impact, 2006

14. Important Observation
• The time required for eHealth benefits to overcome effort is around 7 years,
which tipically implies in a change in national or regional government, and,
therefore, involves major risk of lack of continuity.
• Governance is a major problem when deciding for eHealth Programs.

15. eHealth Waves
• First Wave
– Investment in eHealth in countries as UK, USA, Canada, Australia, Sweden, Denmark and
New Zealand;
– Successes, Disappointments and Failures
• Second Wave
– Increased and widespread perception that eHealth is VERY IMPORTANT to all countries
no matter their maturity level;
– ISO
– WHO-ITU
– WHA 66.24
– Several countries started working on National eHealth Strategies
• Current State
– Consolidate the value of eHealth Strategies, including policies but not limited to them.

16. WHA Resolution 66.24 – 27th May 2013
eHealth standardization and interoperability
URGES Member States:
(1) to consider, as appropriate, options to collaborate with relevant stakeholders, including national
authorities, relevant ministries, health care providers, and academic institutions, in order to draw
up a road map for implementation of ehealth and health data standards at national and subnational
levels;
(2) to consider developing, as appropriate, policies and legislative mechanisms linked to an overall
national eHealth strategy, in order to ensure compliance in the adoption of ehealth and health data
standards by the public and private sectors, as appropriate, and the donor community, as well as
to ensure the privacy of personal clinical data;
(3) to consider ways for ministries of health and public health authorities to work with their national
representatives on the ICANN Governmental Advisory Committee in order to coordinate national
positions towards the delegation, governance and operation of health-related global top-level
domain names in all languages, including “.health”, in the interest of public health;
– .

17. ISO TR 14.639 eHealth Architecture Roadmap

18. Part 1
National eHealth
Vision
Part 2
National
eHealth
Action
Plan
Part 3
National
eHealth
Monitoring &
Evaluatiion
The Inspiration

19. Some Countries with published eHealth Strategy Initiatives
• Kenya
• New Zealand
• Norway
• Philippines
• Qatar
• Rwanda
• Saudi Arabia
• Scotland
• South Africa
• Sweden
• Switzerland
• Tanzania
• United States
• Uruguay
• Argentina
• Australia
• Brazil
• Canada
• England
• Ghana
• Iran
• Ireland

20. Question: Existing Initiatives
What´s the best way to describe your own country?
• We have some health information systems, mostly for local use
• We have nationwide health information systems but we lack policies
• We do have policies and strategies but they are not integrated
• We have Health IT policies and some action and investment on them
• Yes, we do have a robust Strategy supported by actions and investment

21. eHealth Waves
• First Wave
– Investment in eHealth in countries as UK, USA, Canada, Australia, Sweden, Denmark and
New Zealand;
– Successes, Disappointments and Failures
• Second Wave
– Increased and widespread perception that eHealth is VERY IMPORTANT to all countries
no matter their maturity level;
– ISO
– WHO-ITU
– WHA 66.24
– Several countries started working on National eHealth Strategies
• Current State
– Consolidate the value of eHealth Strategies, including policies but not limited to them.

22. Some Data on Brazil
• 5th largest country in the world; larger
than continental USA.
• 200 million inhabitants;
• The Brazilian National Health System is very well conceived
but is not deployed evenly;
• More than 120 million Internet users;
• Brazilians are among those who spend the largest amount of
hours on the Internet;
• IRS forms are available/filled-in only electronically and via the
Internet;
• The national voting system is fully electronic: results in 4 hours,
for 135 million voters;
• 30 billion e-commerce transactions in 2014.
• Feel comfortable with IT, not paranoid at all

23. SUS – The Brazilian National Health System
• Universal Access
– Health is a Right of All (~160M individuals rely on SUS)
• Full Coverage, Free of Charge
– All Services and Procedures
• SUS principles:
– Equity of access - Integrality of care
– Universality of care - Administrative decentralization
• Funding and Management are Shared across Spheres
– Federal, State and Municipal Spheres
• Private Health Plans for Those Willing to Pay
– ~ 1,100 Health Plan Organizations (cover ~ 40M individuals)
– ANS (National Agency of Supplementary Health) regulates the sector
A fair (although old) description of SUS can be found on:
http://www.paho.org/english/sha/prflbra.htm

24. SUS – Referral Counter-Referral Model
Polyclinics
Dagnostic
Centers
Specialized
Centers
Doagnóstic
Centers
Office
PC
Facility
FH
Team
PC
Facility
FH
Team
Prvate
Hospitals
University
Hospital
Public
Hospital
Primary CarePrimary Care
Hi-Complexity (Hospitals)Hi-Complexity (Hospitals)
Counter-referral
MédiumCompelxityMédiumCompelxity
Office
Equity of Access
TheElectronicHelthRecord
Entry LevelEntry Level

25. SUS – Funding Model
City City City City City City
MoH
Federal Govmt
National Health
Council
State Health
Council
City Health
Council
City Health
Fund
2 and 3-Party
Committees
National Health
Fund
State Dept
of Health

26. Background for the Brazilian Initiative
• Brazil has a long tradition in the use of Health Information Systems;
• Several initiatives have been developed trying to make the SUS systems
interoperate with each other;
• PNIIS – the National Policy on Health Information and Health Informatics is in
its final process of construction;
• Expectation around use of eHealth as a significant strategy to support SUS
has increased, in a similar way to what occurs in countries like England,
Canada, New Zealand, USA and Australia, among others;
• As from 2012, DATASUS and the Ministry of Health have promoted a series of
workshops on EHR Systems for SUS and the country.
• It was then recognized that there was a need for a National eHealth Strategy
to guide the initiatives of eHealth in Brazil.

27. eHealth Strategy Objectives
• Define a Strategic Vision
– Identify Strategic Recommendations
– Likely to find the need for some Immediate Action (extension to the Toolkit)
Strategic Vision
Guidance
and
Alignment
t
Projects, Systems & Initiatives

28. Part 1
National eHealth
Vision
Part 2
National
eHealth
Action
Plan
Part 3
National
eHealth
Monitoring &
Evaluatiion
The Inspiration

29. The ITU-WHO Method for a National eHealth Strategy
http://www.itu.int/pub/D-STR-E_HEALTH.05-2012

30. Building an Initial Vision
• What would you expect eHealth to do for your country?
• Write a statement of the form:
By 20XX, eHealth will ............, by...................
Adapted from WHO/ITU National eHealth Strategy Toolkit

31. The Building Blocks of the Strategy
http://www.itu.int/pub/D-STR-E_HEALTH.05-2012

32. Grouping the Building Blocks
Leadership and Governance
Strategy
and
Investment
Work ForceLegislation,
Policy and
Compliance
Services and Applications
Standards & Interoperability
InfrastructureInfrastructure
Organizational Resources Infostructure
Infrastructure Human Resources

33. Main Task
• Identify and assess the main existing eHealth projects or initiatives that are likely to impact
the eHealth Vision.
• Identify aspects of
• Organizational Resources
• Infostructure
• Infrastructure, and
• Human Resources
That are required to deliver the proposed eHealth Vision.

34. The Method
Identify the
Required
Building Blocks
Identify Existing
Building Blocks
Propose Acions
to deal with the
identified Gaps
Existing
Initiatives
Which building blocks do exist?
Which can be reused?
What is needed to allow for reuse?

35. Question: Legislation, policy and compliance
• What data protection legislation and regulatory frameworks exist?
• Which areas do existing data protection legislation and regulatory frameworks
address, such as individual's’ choice to opt in or opt out of the collection of their
personal health information;
• Do existing legislation and regulatory frameworks support or constrain the
sharing of health information across geographical and health sector
boundaries?
• Who is responsible for regulating compliance with data protection legislation, in
particular across the nation’s health sector?
• What risks do existing data protection legislation and regulatory frameworks
pose to the growth and development of the national eHealth environment?
• ………

36. Question: Legislation, policy and compliance
Existing legislation and regulatory frameworks in you country support the sharing
of health information across geographical and health sector boundaries?
• Strongly disagree
• Disagree
• Neither agree nor disagree
• Agree
• Strongly agree

38. The Proposed Strategic Actions
1. Reduce eHealth fragmentation within the National Health System
2. Strengthen overall Governance of eHealth within the Federal Govmt
3. Define thorough legislation to support eHealth
4. Establish a robust eHealth Architecture
5. Define and deploy interoperable eHealth services
6. Promote infrastructure as a service (IaaS)
7. Propose and deploy a reference Architecture for IaaS
8. Develop eHealth capacity building / certificates for Health Workers
9. Promote access to Health Information by the population

39. Conclusion
• eHealth can change Health
• Technology is a problem, but NOT “the” problem
• No single system can sort out all problems
• Need for Standards for Interoperability
• Say “No” to Siloed-Systems
• National Unique IDs are Essential
• Need for ICT Infrastructure
• HR Capacity Building
• Good Methods are Required
• Think Big, Analyze the Roadmap, Walk Step by Step
• Give ourselves time to learn