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Global eHealth and Informatics

Hyeoun-Ae Park / Heimar F. Marin

INTRODUCTION

Nursing and healthcare informatics are often described as sciences in the literature (Nelson & Staggers, 2014). eHealth is usually defined more broadly as a set of activities, processes, or means for the delivery of health services using information and communication technologies at both the macro and the micro levels. For example, the World Health Organization (WHO) describes eHealth as the use of information and communication technologies (ICT) for health. Thus, eHealth activities include the use of ICT for treating patients, conducting research, educating the health workforce, tracking diseases, and monitoring public health (World Health Organization, n.d.-a).

eHealth has been further described by the WHO as the transfer of health resources and healthcare by electronic means, encompassing the following three main areas (World Health Organization, n.d.-b):

1.   The delivery of health information, for health professionals and health consumers, through the Internet and telecommunications

2.   Using the power of IT and e-commerce to improve public health services, e.g., through the education and training of health workers.

3.   Using e-commerce and e-business practices in health systems management

As a profession, nursing has championed and contributed to several international health informatics and eHealth initiatives (Abbott & Coenen, 2008; Coenen, Marin, Park, Bakken, 2001; Saba, Hovenga, Coenen, McCormick, & Bakken 2003). This chapter represents a revision of a chapter, authored by Coenen, Bartz, and Badger, which appeared in the sixth edition of this book. The purpose of this revised chapter is to inform nurses about these initiatives; to describe the influence of nurses on these initiatives; and to describe the ongoing influence of these initiatives in care delivery, education, administration, and research.

This chapter includes a description of the roles of international health organizations in global eHealth and informatics, a discussion of eHealth applications in the global health environment with particular emphasis on nursing, and an exploration of healthcare issues and trends concerning global eHealth and nurses worldwide.

INTERNATIONAL ORGANIZATIONS INFLUENCING EHEALTH AND NURSING

With advances in healthcare technology, international health-related organizations have focused their efforts on exploiting the potential of eHealth for improvements in healthcare delivery and infrastructure. New programs and organizations are being established to respond to the development and growth of eHealth policy and applications internationally.

International Council of Nurses (ICN)

Founded in 1899, the International Council of Nurses (ICN) is the world’s first and most extensively reaching international organization for health professionals. ICN is a federation of more than 130 national nurses associations and represents more than 20 million nurses worldwide. The mission of ICN is to represent nursing worldwide, advance the nursing profession, promote the well-being of nurses, and advocate for health in all policies.

ICN is involved in initiatives related to professional nursing practice, nursing regulation, and socio-economic welfare for nurses. ICN promotes quality nursing care for all, with and through a competent and satisfied nursing workforce. ICN supports the advancement of experientialand research-based nursing knowledge, which are hallmarks of a respected nursing profession (ICN, 2019).

ICN represents the profession of nursing in many international venues, including the United Nations, WHO, the World Health Professions Alliance, and other organizations discussed below. As the international voice for nursing, ICN has a program that takes eHealth as its focus.

ICN’s long-standing engagement in eHealth is manifested primarily through the International Classification for Nursing Practice (ICNP). ICNP is a terminology for nursing that provides an international standard for facilitating the description and comparison of nursing practice locally, regionally, nationally, and internationally. Other important ICN eHealth activities have included the ICN Telenursing Network, which aimed to involve and support nurses in the development and the application of telehealth technologies, and Connecting Nurses, which provided an online forum for nurses worldwide to share ideas, advice, and innovations. ICN seeks to transform nursing and improve health through the visionary application of ICT. ICN aims to support eHealth practice, to be recognized as an authority on eHealth, and to promote nurses as experts in the eHealth international community.

World Health Organization (WHO)

WHO is the authority for directing and coordinating health within the United Nations system. Each year, WHO holds the World Health Assembly (WHA) in Geneva, Switzerland, which is the decision-making body of WHO. ICN is a “non-State actor in official relations with WHO.” WHO provides leadership on global health matters such as shaping the health research agenda, setting norms and standards, articulating evidence-based policy options, providing technical support to countries, and monitoring and assessing health trends (WHO, n.d.-b).

World Health Organization Family of International Classifications (WHO FIC) Network WHO has long maintained and used the International Classification of Diseases (ICD) for national and international reporting of morbidity and mortality statistics. In addition to ICD, WHO has developed the International Classification of Functioning, Disability and Health (ICF) for documentation and reporting of functional abilities and health. A newer endeavor under the leadership of the WHO FIC Network is the development of the International Classification of Health Interventions (ICHI) which is a classification of interventions for use across all health professions (WHO, 2019). ICNP is recognized as a Related Classification within WHO-FIC.

International Medical Informatics Association (IMIA)

Established in 1979, the International Medical Informatics Association (IMIA) is an independent, nongovernmental organization made up of national medical informatics associations, institutional (academic and corporate) and affiliate members, and honorary fellows. IMIA plays a global role in the application of information science and technology in the fields of health and biomedical informatics (IMIA, 2020).

International Medical Informatics Association—Nursing Informatics Special Interest Group (IMIA-NI SIG) IMIA has a Special Interest Group (SIG) that focuses on nursing informatics. Membership includes over 25 society representatives and observer members. The SIG meets regularly at related informatics conferences. The focus of IMIA-NI SIG is to foster collaboration among nurses and others who are interested in Nursing Informatics to facilitate development in the field. IMIA-NI SIG aims to share knowledge, experience, and ideas with nurses and healthcare providers worldwide about the practice of Nursing Informatics and the benefits of enhanced information management (IMIA-NI SIG, 2019).

International Organization for Standardization (ISO)

The International Organization for Standardization (ISO) is the world’s largest developer of voluntary international standards. ISO standards provide state-of-the-art specifications for products, services, and best practices to make the industry more efficient and effective. ISO was founded in 1947, and since then has published more than 22,656 reports that address almost all aspects of technology and business, including health (ISO, n.d.-a).

ISO Technical Committee 215: Healthcare Informatics ISO Technical Committee (TC) 215 for Healthcare Informatics has as its scope the standardization of health information resources, including health information and communications technology to facilitate the capture, interchange, and use of health-related data, information, and knowledge to support and enable all aspects of the health system. The Committee aims to promote interoperability between independent systems, to enable compatibility and consistency of health information and data, and to reduce duplication of effort and redundancy (ISO, n.d.b). ISO TC 215 is responsible for new technical standards that involve nursing informatics. ISO TCs are composed of a set of different countries’ Technical Advisory Groups (TAGs). The TAGs for TC 215 include individuals from standards development organizations, professionals, governmental or commercial organizations, as well as individuals representing themselves.

One of the most important products of ISO for nursing is the international standard ISO 18104:2014 (Health informatics—Categorical structures for representation of nursing diagnoses and nursing actions in terminological systems) (ISO, n.d.-c). The purpose of ISO 18104 is to establish a nursing reference terminology model consistent with the goals and objectives of other specific health terminology models in order to provide a more unified reference health model. This ISO standard has been used to evaluate and support the ongoing development of nursing terminologies, especially in supporting the definition of high-level schemata in developing logic-based compositional terminologies such as ICNP (Hardiker & Coenen, 2007; Marin, Peres, & Dal Sasso, 2013).

SNOMED International

SNOMED International is a not-for-profit organization based in the United Kingdom. Its primary purpose is to develop and maintain SNOMED Clinical Terms (SNOMED CT). The organization focuses on supporting the implementation of interoperable, semantically accurate health record documentation (SNOMED, n.d.-a).

As the voice for nursing internationally and as the developer of the ICNP, ICN is aware of the need to collaborate with SNOMED International to assure nursing domain content is available to nurses in SNOMED International member countries. In 2010, ICN announced a collaborative agreement with SNOMED International (previously the International Health Terminology Standards Development Organization [IHTSDO]) to advance terminology harmonization and foster interoperability in health information systems, and to provide a vehicle for transforming ICNP-encoded data into SNOMED CT (ICN, 2018). A significant result of these harmonization efforts has included tables of equivalencies that can support data transformations between ICNP and SNOMED CT concepts.

International Society for Telemedicine and eHealth (ISfTeH)

The International Society for Telemedicine and eHealth (ISfTeH) is a nonprofit organization with close ties to WHO and ICN, as well as other international organizations. Its mission is to facilitate the international dissemination of knowledge and experience, as well as to support developing countries in the fields of telemedicine and eHealth. ISfTeH is primarily an umbrella organization for national telemedicine and eHealth organizations and for individuals and academic centers working to integrate telehealth strategies and applications in healthcare. It promotes and supports telemedicine and eHealth activities worldwide, supports developing countries in the field of telemedicine and eHealth, and assists the start-up of new national organizations.

ISfTeH Telenursing Working Group The ISfTeH Telenursing Working Group is open to all interested nurses and other healthcare providers. Its mission is to provide a forum for the exchange of knowledge and experiences of nurses and others who are working with or supporting nurses’ use of eHealth applications (ISfTeH, n.d.). The objective of the ISfTeH Telenursing Working Group is to support technology, business, and professional actions for telehealth nursing. These actions include:

•   advocating for increased use and evaluation of telehealth services by nurses;

•   stimulating innovative ideas and promoting initiatives for further development of eHealth;

•   supporting interdisciplinary telehealth collaboration for improved healthcare delivery and outcomes;

•   advancing nurses’ knowledge and skills in telehealth through the dissemination of research findings, education programs, and practice guidelines; and

•   advocating for the ethical use of telehealth services.

Nurses from around the world are active participants in the annual ISfTeH conference, Med-e-Tel, describing their work and research in eHealth, telehealth, and nursing.

Healthcare Information and Management Systems Society (HIMSS)

HIMSS is a global, not-for-profit organization focused on better health through ICT. HIMSS leads collaboratives and conferences to promote the positive use of ICT in healthcare. The HIMSS conferences in the United States, Europe, and Asia Pacific showcase exhibitors that represent commercial and noncommercial interests in the health ICT industry (Healthcare Information and Management Systems Society, n.d.-a).

HIMSS Nursing Informatics Community In 2003, the HIMSS Nursing Informatics Community was founded in response to the increased recognition of the role of the nurses in health informatics. This HIMSS community seeks to reach out to all nurses and promote the involvement of those working in nursing informatics. The HIMSS Nursing Informatics Community provides domain expertise, leadership, and guidance to the organization’s activities, initiatives, and collaborations with the global nursing informatics and eHealth communities (Healthcare Information and Management Systems Society, n.d.-b).

Technology Informatics Guiding Education Reform (TIGER)

TIGER began in 2006 with support from over 70 organizations (Healthcare Information and Management Systems Society, n.d.-c). The focus of TIGER is on the development of a clinical workforce that can use technology to improve the delivery of care. HIMSS currently hosts TIGER. One of its key products is a Virtual Learning Environment that acts as a portal to online resources that support educational reform.

Health Level 7 (HL7) International

Health Level 7 (HL7) International is a not-for-profit, standards development organization dedicated to providing a comprehensive framework and related standards for the exchange, integration, sharing, and retrieval of electronic health information that supports clinical practice and the management, delivery, and evaluation of health services. “Level 7” refers to the seventh level of the ISO seven-layer communications model for Open Systems Interconnection (OSI) at the application level. The vision of HL7 International is to create the best and most widely used standards in healthcare in order to improve care delivery, optimize workflow, reduce ambiguity, and enhance knowledge transfer among all stakeholders, including healthcare providers, government agencies, the vendor community, fellow standards development organizations, and patients (HL7 International, n.d.).

HL7 International Nurses Group The HL7 International Nurses Group was started in 2009 during an HL7 International Working Group meeting. The goals of the HL7 International Nurses Group are to explore how nurses can become more involved in the HL7 International community, to exchange information, and to ensure that nursing practice and nurses are included in use cases and criteria for the HL7 International standards (HL7 International, 2019).

APPLICATIONS IN GLOBAL EHEALTH AND INFORMATICS

With new technologies, the collection, storage, and transmission of health data and information are changing how health care is delivered. Nurses are leading advances in eHealth worldwide. In this section, selected applications for eHealth are discussed to provide an understanding of current nursing research, education, and practice in this area. Specifically, examples of innovations in the advancement of the electronic health record (EHR) and telehealth are described.

Electronic Health Record (EHR)

The EHR is a longitudinal electronic record of patient health information generated by one or more encounters across the care delivery setting. Optimally, the EHR supports and enhances the quality of care with content appropriate to the healthcare setting and processes that enable decision support, outcomes reporting, and ease of use. As one of the major innovations in healthcare, the EHR has brought both challenges and hope for improved health care delivery systems and better health outcomes for people worldwide.

There has been steady growth in the adoption of national EHR systems with a 46% increase from 2010 to 2015 according to WHO’s global survey on eHealth (WHO, 2016). Out of 121 countries participated in the survey, 57 countries reported having introduced a national EHR systems. Countries answered no national EHR systems still have some form of EHR system used in local or regional facilities. These countries with national EHR systems have strongly supported and promoted standardization, interoperability, and information sharing among healthcare providers.

The ability to document healthcare using standardized, interoperable system applications is recognized as essential to unleashing the tremendous capacity offered by information sharing through the EHR. Electronic capture, storage, and retrieval of comparable health data across providers, settings, and specialties are the basis for measuring value of the EHR.

Recent initiatives by international groups of nursing informatics experts include the following efforts to promote resources and tools for interoperable systems:

•   As a unifying international framework for nursing terminology, ICNP has great potential for describing nursing practice, facilitating care transitions, and using consistent and accurate data for decision-making and policy development. It is only through its use, internationally, in the EHR that the full potential of ICNP will be realized. In addition to commercial software vendors and healthcare organizations being early adopters, several countries have endorsed ICNP as a national standard for nursing.

•   For countries implementing SNOMED CT as an interdisciplinary terminology for healthcare, nurses need to be involved and engaged in assuring the representation of the nursing domain content. As noted earlier in this chapter, ICN has partnered with SNOMED International to facilitate the harmonization of ICNP and SNOMED CT concepts (SNOMED, n.d.-b).

•   With its worldwide influence, WHO has an opportunity to advance the reporting of health and illness globally through partnering with other professional organizations such as ICN in the achievement of standardization and interoperability. WHO–ICN collaborations have focused on harmonizing ICNP and ICF (Kim & Coenen, 2011) and in the development of the International Classification of Health Interventions.

In addition to the potential of interoperable data and information, the EHR has the potential to change the relationship between provider and consumer. Imagine, as a nurse, that the clients you interact with within healthcare episodes, be they individuals, families, or communities, can access their health data and information in real time electronically. As the EHR evolves, nurses will use this new technology to support the shift from a providercentered health system to a consumer-centric model of healthcare. Various EHR applications will facilitate nurses’ access to their patients and the patients’ access to their health providers.

Telehealth and mHealth in the eHealth Environment

Nurses are already using telehealth applications in their work. Telehealth nursing extends the capability and reach of nurses and aims to improve access and quality while managing healthcare costs. While the use of technology changes the care delivery medium and may necessitate new competencies, the nursing process and scope of practice are not significantly different in telenursing, whether in direct care nursing, education, or management (Schlachta-Fairchild, 2007).

Research in this area is growing, and there are many examples, including those conducted by nurses themselves (Farquharson et al., 2012; Kowitlawakul, 2011) and by nursing students (Chaung, Cheng, Yang, Fang, & Chen, 2010; Glinkowski, Pawlowska, & Kozlowska, 2013); in ICU (Rincon & Bourke, 2011), surgery (Inman, Maxson, Johnson, Myers, & Holland, 2011), orthopedics (Jones, Duffy, & Flanagan, 2011), and neurology (Young-Hughes & Simbartl, 2011); and in the field of communicable diseases (Côté et al., 2011), noncommunicable diseases (Baldonado et al., 2013; Wakefield et al., 2012), and mental health (Badger, Segrin, Pasvogel, & Lopez, 2013; Sands, Elsom, Marangu, Keppich-Arnold, & Henderson, 2013).

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