e-Health and the Public Health Informatics in the Master of Public Health Programme in the Medical University of Varna Iskra Mircheva Medical University, Varna, Bulgaria
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Abstract Information and communication technologies are penetrating into medicine and healthcare and force major quality changes in all healthcare systems putting forward new requirements to the traditional methods of education in this field. eHealth is the use of emerging technologies, especially the Internet to improve or enable health and healthcare. It is one of the major priorities in the framework of the eEurope 2005 Action Plan, and thus challenges adequate communication and education of healthcare professionals. eHealth requires from the health professionals to have knowledge and skills not only in the field of public health, medicine and the other health related specialties but also in the field of information management and communication of electronically stored medical and health data. This requires both health professionals and patients to be adequately educated and trained. Facing the challenges eHealth states to the health system and in accordance to the National Health Strategy “Better health for a better future of Bulgaria” and following the WHO eHealth Report EB115/39 the Medical University of Varna steps forward to adequate tailoring of the informatics curricula offered to its master of public health students. The aim of this paper is to give proof for the necessity of such education and to outline the main topics of its content. Keywords: e-health, public health informatics
Introduction The beginning of the 21st Century marks an evident change of the healthcare focus – from the treatment of an illness to health promotion, from the health of the individual to the health of the population. Modern healthcare is dominated by the necessity of integrating and processing information. The work of medical practitioners at all levels is becoming more information intensive as sophisticated medical equipment and computer applications are more widely used. The quantity of health and medical knowledge is constantly increasing, so its acquisition, organization and storage are impossible without the use of advanced information and communication technologies.
At the same time, demands on healthcare budgets are increasing in the face of medical and scientific advances, an ageing population and changing patient expectations. Digital technologies are becoming more important in health management both at individual practitioner level and at national and regional level. They offer the potential to improve health status, reduce health care costs, to deliver health care services at a distance, to avoid unnecessary duplicate examinations, to reduce health disparities, enhance clinical care and public health services, empower people to take grater control of their own health etc. The Internet created new opportunities and challenges to the traditional health care information technology industry. Accordingly the term “eHealth” appeared, perhaps just because similar e-words (e-commerce, e-learning, e-business etc.), have already entered the everyday language. Barely in use before 1999 this term now seems to serve as a general motto, used to characterize not only "Internet medicine", but also virtually everything related to computers and medicine. G Eysenbach defines eHealth as ”an emerging field in 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.” eHealth is the use of technology and electronic communication to support the delivery and management of healthcare services. eHealth offers the rich potential of supplementing traditional delivery of services and channels of communication in ways that extend our ability to meet the needs of our patients. Benefits include enhanced access to information and resources, empowerment of patients to make informed healthcare decisions, streamlined organizational processes and transactions, and improved quality, value, and patient satisfaction. “eHealth includes the development, application and implementation of technology to improve effectiveness in healthcare. But it also includes getting it out there wherever
it's needed in the service and making it happen across the service. It includes the use of telemedicine and clinical systems used for diagnosis and care pathways. We also apply the term to the policies and protocols that assure the confidentiality and security of sensitive data. Most of all it includes those aspects that support major change of working practice training, support and Organisational Development.”1 Finally, according to WHO “eHealth means the use of ICT for health”2. This broad focus creates new opportunities for effective public health action, through the collaboration and contribution of many stakeholders citizens, health professionals, institutions, health authorities, researchers, academia and industry. The new public health needs specialists who beside basic medical/public health knowledge should have the knowledge and skills to efficiently use and apply the means and methods of these technologies as well as to be aware of their shortcomings and limitations. The 21st Century healthcare requires the merging efforts of the individual and the public healthcare. The information technologies allow for the connection of the community health information with the specific data, concerning the treatment of an individual patient, as well as the access of the medical specialists and the patients to knowledge, providing maximum good health. The changes in healthcare and the achievements in the field of the information technologies definitely require the addition to the education of health professionals of a discipline, giving them the opportunity of acquiring adequate knowledge and skills for design, assessment, implementation and use of health information systems. The needs for a proper tailored curricula in informatics for the public health professionals in view of gaining knowledge and skills to design, manage, implement, assess and use eHealth applications are analyzed.
Material and methods A study3, carried out in 2002 explored the existing MPH programmes in EC. The results proved that certain topics (biostatistics, word-processing, spreadsheets, Internet skills), which we regard as basic computer literacy, are taught as part of different modules, but Public health informatics as related to eHealth is not included in any MPH programme as a compound discipline. Another study4 carried out in 2003 among the students enrolled in the MPH programme was based on simple questionnaire comprising questions aimed at defining the initial computer literacy of the students, their needs for further
education in this field and their opinion on the content of the Public health informatics module. On the basis of the comparative analysis of existing public health informatics curricula, the students’ opinion and in line with the National Health Strategy5 “Better health for a better future of Bulgaria” and having in mind the Ministerial Declaration6 and the WHO guidelines7 the major topics of the Public health informatics module in the Master of Public Health programme in the Medical University of Varna are defined.
Discussion On the necessity of specific eHealth application for the public health needs The information files needed by the public health specialists comprise millions of records and the provision of adequately fast access to them requires the design of specific databases. These databases should provide qualified access to specific users – public health professionals, medical specialists, politicians, and of course single individuals. The necessity of searching through the overall contents of vast textual databases, as for example publications, reports and recommendations (i.e. WHO recommendations and reports), tables containing generalized data, files containing data concerning the health of the different countries etc. increases with every day. The diversity and the dynamic nature of such databases, as well as the lack of or the insufficiency of key words impedes the access to them. It becomes obvious that public health needs the development of specific information systems. We could point to at least six trends in the development of information systems, required by the public health institutions: -
Development of health policies; Management of health programmes; Provision of health services; Health legislation; Public health and epidemiological surveys; Geographical information systems.
Despite the way of their actual function, design and development, these information systems should have one common feature – not to face the single individual but to be intended for groups of the populations, and if necessary to very large groups of the population8. In order to respond to the needs of the public health institutions, the process of design and development of such systems should involve public health professionals. This forces the vital requirement for adequately planed and carried out education in public health informatics for these professionals. On the other hand, one more major fact should be regarded, i.e. the transition from health information systems in general
to knowledge based systems. This poses new requirements to the renovated health and education systems of tomorrow. The health sector is realizing the potential of using ICT to extend the reach of information and knowledge to all population through access at home, work and school. It is essential to realize and accept the development of ICT infrastructure for health, and to ensure the equitable, affordable and universal access to its benefits. On the necessity of specific software for the public health needs In order to be able to make decisions concerning the overall expenses for the health care, the costs of the health services and the provision of health care, managed healthcare organizations constantly need to assess the information, concerned with the health of the population. The information systems, developed for the traditional implementations of informatics are basically focused on the identification of the information for an individual. Public health deals with the processing and the analysis of data for defined population groups or even the population as a whole and therefore needs information not only for the individuals but also for the environment they live in. That is what eHealth provides for. The processing of such information makes the traditional widely known software packages not appropriate for the needs of the public health. Our analysis shows that: -
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The standard statistical packages cannot without difficulty be used for standardization, for application of mathematical models to the models of illness and health or to calculate the sample size for a casecontrol study; The traditional data input software is not designed to manage the input of long and compound questionnaires – typical for obtaining public health and epidemiological data; The traditional graphical software can readily make bar and pie diagrams, but they cannot generate histograms and geographical maps.
Aspects of informatics in public health The trend in managed healthcare shows the increasing necessity for health employees with professional skills not only in the field of public health but also in the field of informatics9,10. The fundamental role of data and information acquisition, analysis and dissemination in the process of healthcare delivery and in public health becomes even more obvious. The curricula of business management and computer literacy do not provide the health professionals with the analytic tools they need for the management of the design and implementation of public health information systems. Apparently here comes the question of what should the informatics curriculum of the public health professionals
include so that to comply with the requirements of eHealth applications.. The informatics curricula of the public health specialists should conform to their professional career. They should have adequate competence – knowledge and skills in: -
Critical Goals and IT strategies for Health Care Enterprises; - Knowing the specificity, the nature, the structure and the utilization of databases and networks in healthcare; - Utilization of specific public health information systems, i.e. geographical information systems (GIS), public information systems, accessed through the Internet, i.e. the information systems of WHO or/and other health and public organizations; - Use of standards for unified health and medical data definition and presentation, i.e. different coding and classification systems, especially those suitable for electronically preserved data; - Use of standards for electronic data interchange; - Use and implementation of security, privacy and confidentiality standards for highly sensitive information, i.e. health and medical information. Our study, carried out in 2002 proved that the majority of the MPH programmes (92.3%) do not include topics covering those problems. None of the MPH programmes include medical/health informatics module. The analysis of the existing courses and teaching materials in informatics in Bulgaria (as such materials are usually published by all Universities in the country, they will not be cited) shows that there are no courses, handbooks and other teaching materials that are specially tailored and suitable for the needs and the potential of medical and public health students, physicians or other health and medical specialists. The existing courses and teaching materials are intended for education in basic computer skills, general informatics and information technologies. They are not directed to medicine and healthcare and do not consider their specifics and uniqueness and are absolutely illegible for the average physician or medical/public health student. Therefore there comes the necessity of organising a specialised education in informatics for medical and public health specialists. The aims of such an education can be formulated as follows: -
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To give the students basic theoretical, methodological and practical knowledge in the field of health and medical informatics; To acquaint the students with the opportunities and the restrictions of the application of information technologies in healthcare; To prepare the students to participate in the development and the implementation of eHealth application and knowledge based systems;
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To facilitate the education process by acquainting both students and teachers with the means and methods of computer aided learning; To teach the students how to analyze and use health information on the basis of theories and methods from other areas as biomedical engineering, computer sciences, communications etc; To assist the students in developing the skill of reasoning which should help them for the continuous education during their life-long professional career.
professionals, so that they know, understand and use in the best possible way the available resources in view to their active participation in the design, implementation, use and assessment of eHealth applications. The study of public health informatics will improve their skills in information management, problem solving and decision-making. This module covers the following topics: -
The Curriculum A basic program for public health informatics was developed in the Medical University of Varna. It complies with the recommendations of the International Medical Informatics Association11 and EC for the education in health and medical informatics12 and is in line with the requirements stated by EC for eHealth applications. The program is flexible and can easily be adapted to different forms and levels of education, depending on the needs and the background of the students. Some topics of this program are used for teaching medical informatics to the students of medicine and healthcare management13. The public health informatics curriculum comprises of two modules: Module 1 - Introduction to informatics. The aim of this module is to give the students basic knowledge of computers and computer applications in medicine and healthcare, so that they could readily use them. The module covers the following topics: -
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Use of computers in medicine and healthcare. A classification of the different applications of computers, computer technology and information systems in medicine and healthcare is discussed. In this context the roles of man and computer in information management in the field of medicine and healthcare are explained. Systems and hardware. The logical and physical design of computer systems and peripherals are presented and attention is paid to basic computer skills: (1)operating systems, (2)word-processing, (3)spreadsheets, (4)graphics packages, (5)general statistics packages, (6)databases, (7)networks, (8)communication skills including e-mail and Internet, (9)bibliography and library search, i.e. Medline etc. and (10)different commercially available software packages.
Module 2 - Introduction to public health informatics. This module covers the basics or general knowledge of public health informatics. As it is aimed to non-computer specialist it conforms to their competence and abilities. The aim of this module is to increase the sophistication of the future health
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Health and medical data, information and knowledge, data documentation. Health and medical data and information are discussed in terms of types, utilization, quality and communication. The process of data acquisition, documentation, communication and methods of storage of public health and medical data in databases are described. Various types of data organisation are discussed. Standards. Special attention is paid to the standards for unified data presentation, coding and classification (ICD, SNOMED, ICPC, RCC etc.), standards for electronic data interchange (HL7, EDIFACT, IPv6 and standards developed especially for the needs of medicine and healthcare) and standards for security and confidentiality of health and medical data. Health and medical databases. Databases in health care are presented. The complexity of the application of medical databases arising from the semantic interconnection of this data and the wide variety of different goals that are to be served is explained. Attention is paid to data storage and retrieval, query languages, knowledge bases. Electronic medical record. The advantages and disadvantages of paper based and electronic medical records (EMR) are discussed. The basic principles, structures and models of EMR are presented in view to their restructuring and adaptation for use in public health information systems. Critical Goals and IT strategies for health Care Enterprises incl. methods for improving patient outcomes, reducing healthcare costs, reducing medical errors, increasing quality of care and patient satisfaction, ensuring privacy and security of patient data Decision support for clinicians and patients, administrative support, communications. Different medical decision support systems are presented (QMR etc.). Questions concerning the formalisation of medical knowledge, reference standards and the integration of electronic medical record with decision support systems are discussed. The students are acquainted with some means and techniques used in decision support. Electronic health records incl. real time retrieval and display, patient synchronization, enterprise wide
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integration, clinical adoption, clinical on-line documentation Data privacy, data security and data access including authentication, patient identifier Local, regional and national health information infrastructure Digital libraries Telemedicine Web-based Chronic disease management (diabetes management, weight management, stroke, high blood pressure management etc.) Web, e-mail, telephone-based physician consultation systems, Practical Skills – use of EpiInfo14 - the software package especially developed for the needs of public health, allowing the input of data in complex questionnaires for the purposes of epidemiology as a fundamental part of the public health as well carrying out of specific statistical analysis and adequate presentation of summarized results15
The education environment Having in mind that some of the students have basic computer literacy, module 1- introduction to informatics is optional and is included in the first MPH module “Introduction to Public Health”. The teaching methods include lectures (3 academic hours) and 12 academic hours of practical exercises in a computer laboratory. The exam is compulsory for all students and aims to evaluate their basic computer skills (test and practical skills). This module is evaluated to 1 ECTS16. The duration of Module 2 – Introduction to Public health informatics is 30 academic hours, evaluated to 3 ECTS. The teaching methods include lectures (15 academic hours) and practical exercises in a computer laboratory (15 academic hours). The exam is compulsory for all students and comprises an essay (report) and design and presentation of a case study. The MPH programme in the MU of Varna is run with the help and the financial support of OSI/ASPHER. It is relatively new (the first course graduated in September 2003). In the academic 2004/2005 the ECTS system would be applied as a step that will bring the education offered by the Medical University of Varna to the European education in this field. So the students, notwithstanding their initial background will be able to combine the knowledge they need with the knowledge they want. Concerning the educational process, new technologies for teaching and learning have been provided. A new computer room in the University Library has been equipped with up to date computers and communication resources, including satellite Internet provision. This computer room will be used
also for telemedicine. It provides direct connection to the University library, the University hospital and all university buildings, spread at a distance of 4-5 kilometers. A fast Internet provision was put into operation using radio connection in the students’ computer room that has been recently renovated. It allows the students a free access to different teaching materials and other relevant information on the net. In nearest future all students will have the opportunity of a direct use of the computer resources of the University from their homes.
Conclusion Modern development of information and communication technologies and their penetration into medicine and healthcare state the need for education of professionals, who will combine knowledge both from medicine and healthcare, as well from the field of information management. Public health professionals need to gain adequate knowledge and skills in information management. It is absolutely essential that the MPH programme should include a module of Public health informatics. The traditional informatics curricula are not suitable for the education of public health specialists. The teaching of specific public health informatics will contribute to the preparation of professionals who will be able successfully to solve the public health problems on the basis of the opportunities offered by information systems. A requirement for carrying out such education is the precise development of the tuition program and the provision of adequate computer and communication facilities.
References 1 Malcolm Chisholm, Minister for Health and Community Care, speech at ECCI Conference, Friday 28th February 2003 2 Toawards eHealth Organaiztion technologies for Health, 2004-10-29, p.1 3 Popova S., Mircheva, I., The Master of Public Health programme – comparative study?, Social Medicine, 4 (2002), 35-38 4 Mircheva I.S, Public health informatics as needed by the MPH students, Scripta Scientifica Medica, vol. 36, 2003 (under press) 5 National Health Strategy for the period 2001-2006 and Plan of Activities, approved with Resolution 267/23.04.2001 of the Council of Ministers in Bulgaria 6 Ministerial declaration, Brussels, 22 May 2003 7 Toawards eHealth Organaiztion technologies for Health, 2004-10-29, p.1 8 Harris J.R., Caldwell B., Cahill C., HEDIS in perspective: measurement to improve the public’s health in an era of accountability. American Journal of Preventive Medicine, (1998), 14(3): 9-13 9 Hasman A, Sosa M, “Education and training of health informatics in Europe”, Technology and Health Care, 2, p.61-70, 1994 10 Hasman A, Albert A, Wainwright P, Klar R, Sosa M, eds., “Education and training in health informatics: Guidelines for European Curricula”, in “Education and Training in Helath Informatics in Europe”, IOS Press, 27-49, 1995
11 Recommendations of IMIA on Education in Health and Medical Informatics, Methods of Information in Medicine, 39 (2000), 267-277 12 Council of Europe Committee of Ministers, RECOMMENDATION No.R(90)21 of the Committee to Member States on Training Strategies for Health Information Systems, adopted by the Committee of Ministers on 18 October 1990 13 Mircheva I.S, A basic program for teaching medical informatics to students of medicine, Scripta Scientifica Medica, vol. 32, 2000; 79:82 14 Dean A.G., Dean J.A., Burton A.H., Dicker R.C., EpiInfо: a general purpose microcomputer program for public health information systems, American Journal of Preventive Medicine, (1991); 7(3):178-182 15 EpiInfo –software and information at http://www.cdc.gov 16 European Credit Transfer System: http://europa.eu.int/comm/education/socrates/ects.html
