1. 4th International RHINO Workshop
Measuring and Improving Routine Health
Information System Performance
Enterprise Architecture & eHealth
Guanajuato, Mexico
March 11, 2010

2. Survey
Please, raise your hand those who live in
developing countries and:
Use SMS (mobile phone messages) daily
Have an email account
Access email daily as part of your professional activity
Do Internet banking
Use MSN or Skype for live communication
Other uses?

3. Questions:
What is(are) the purpose(s) of a HIS?
Consider either electronic or paper-based HIS
What is eHealth?

4. WHO’s Definition
eHealth is the combined use of electronic
communication and information technology in the
health sector.
For clarity, in this presentation:
eHealth is the broadest concept
An electronic HIS is a system that uses eHealth
concepts.

5. Why the sudden concern with eHealth?
The vast majority of resource-impoverished
countries:
Do not have national eHealth policies;
Have vertical health information systems for diseases
such as AIDS, Malaria and TB, often donor-funded;
Lack proper HR on Health Informatics;
Do not have access to standards;
Do not appreciate the complexity of national eHealth
infrastructure.
From: eHealth Enterprise Architecture for Emerging and Developing
Countries, PPT presentation as part of NWIP for ISO

6. Why it is Urgent
There are duplicative activities from stakeholders
defining sets of data to be collected and reported, e.g.
Millennium Development Goals.
Global South countries urgently need an architectural
framework from which to conceive eHealth systems, plan
implementations, make build-or-buy decisions, decide on
acquisitions and undertake related activities.
Low resource countries that are starting to use IT in
health must make the right decisions now in order to be
able to support interoperability and scalability of
applications.
From: eHealth Enterprise Architecture for Emerging and Developing
Countries, PPT presentation as part of NWIP for ISO

7. Multitude of Guidelines Documents
Adapted from: WHO Indicator and Metadata Registry (IMR) DMX-HD
Aggregate Data Exchange, Patrick Whitaker, IER/HSI/HCI

8. Fragmented Indicators
Indicator Source
HIV prevalence among population aged 15-24 years www.mdgmonitor.org/goal6.cfm
Percentage of young women and men aged 15–24 who data.unaids.org/pub/Manual/2007/20070411_ungass_core_in
are HIV infected dicators_manual_en.pdf
Proportion of population aged 15-24 years with
www.mdgmonitor.org/goal6.cfm
comprehensive correct knowledge of HIV/AIDS
Percentage of population aged 15-24 years with
www.unmillenniumproject.org/goals/gti.htm
comprehensive correct knowledge of HIV/AIDS
Percentage of young people who both correctly identify
ways of preventing the sexual transmission of HIV and www.theglobalfund.org/documents/me/M_E_Toolkit.pdf
who reject major misconceptions about HIV
Percentage of young women and men aged 15–24 who
both correctly identify ways of preventing the sexual data.unaids.org/pub/Manual/2007/20070411_ungass_core_in
transmission of HIV and who reject major dicators_manual_en.pdf
misconceptions about HIV transmission
Ratio of orphaned children compared to non-orphaned
www.theglobalfund.org/documents/me/M_E_Toolkit.pdf
children aged 10-14 who are currently attending school
Ratio of school attendance of orphans to school
www.unmillenniumproject.org/goals/gti.htm
attendance of non-orphans aged 10-14 years
Current school attendance among orphans and among data.unaids.org/pub/Manual/2007/20070411_ungass_core_in
non-orphans aged 10–14 dicators_manual_en.pdf
Percentage of people with advanced HIV infection
www.theglobalfund.org/documents/me/M_E_Toolkit.pdf
receiving antiretroviral combination therapy
Proportion of population with advanced HIV infection
www.mdgmonitor.org/goal6.cfm
with access to antiretroviral drugs
Adapted from: WHO Indicator and Metadata Registry (IMR) DMX-HD
Aggregate Data Exchange, Patrick Whitaker, IER/HSI/HCI

9. Fragmented Indicators
Proportion of population aged 15-24 years with
comprehensive correct knowledge of HIV/AIDS
Percentage of population aged 15-24 years with
comprehensive correct knowledge of HIV/AIDS
Percentage of young people who both correctly identify
ways of preventing the sexual transmission of HIV and
who reject major misconceptions about HIV
Percentage of young women and men aged 15–24 who
both correctly identify ways of preventing the sexual
transmission of HIV and who reject major
misconceptions about HIV transmission
Adapted from: WHO Indicator and Metadata Registry (IMR) DMX-HD
Aggregate Data Exchange, Patrick Whitaker, IER/HSI/HCI

10. Strong Conviction
It is impossible to deliver services to thousands and
millions of people using craft production methods;
Industrial production processes must be used if we
are to provide millions of people with good health
services;
eHealth can:
improve quality,
reduce costs,
optimize the use of resources, and
extend the reach of health services

11. eHealth: 5 Main Axes
The Electronic Health Record
Follow up treatment – notifiable diseases
Provide help to health workers at point-of-care
Health System Organization
Deploy the reference – counter-reference model
Management of Health Care Facilities
Hospital and HC units management
Connected Health
Integrate persons within the community
Management of the Overall Services Network
Operate the health system

12. A Model for eHealth
Diag Centers Clinics
Suppliers
Hospitals
Internet
Technology Inidividuals
(Patients)
HMOs
Doctors
Datacenter
Strategic Management
Community

13. A Model for eHealth
Community
Architecture!

14. What is an Architecture?
An Architecture is the fundamental organization of
something, embodied in:
Its components;
Their relationships to each other and the
environment,
And the principles governing its design and evolution
Adapted from “Manhattan II Architecture Overview, Geneva, Switzerland, 22 June 2007”

15. What is an Enterprise?
A collection of entities that share a common set of
goals
Government agency or ministry
An entire organization
Part of an organization
A district (and its facilities)
A facility (and its departments or clinics)
Adapted from “Manhattan II Architecture Overview, Geneva, Switzerland, 22 June 2007”

16. So what is “Enterprise Architecture”?
The description of a current or future structure for
an organization's processes, information
systems, personnel and organizational subunits
so that they align with the organization's core
goals and strategic direction.
This is achieved by applying a comprehensive and
rigorous methodology.
Although often associated strictly with information
technology, EA relates more broadly to the practice
of business optimization in that it addresses
business architecture, performance management
and process architecture as well.
Adapted from “Manhattan II Architecture Overview, Geneva, Switzerland, 22 June 2007”

17. Architecture and Engineering
Simple Problem:
• Simple Solution!
My Dog’s House:
• Can be built by a single person;
• Simple modeling;
• Simple tools;
• Little consequences;
• Little impact;
• Can be undone.
Adapted from

18. A House
• Is built by a team
• Needs modeling
• Takes well defined processes
• Uses robust tools
• Becomes part of the environment
• Must abide by regulations
• Not easily undone.
Adapted from

19. The Project of a House: Architecture
Adapted from

20. Questions:
Which one is the “House”?
The HIS, the Health Enterprise or both?
Which of them deserve(s) an Architecture?
The HIS, the Health Enterprise or both?

21. Health and eHealth Architecture
The Health Enterprise deserves a formal good-
quality Architecture that describes processes,
information systems, personnel and
organizational subunits so that they align with
the organization's core goals and strategic
direction.
eHealth deserves an Architecture that will ensure it
“sticks” to the Health Enterprise’s needs.
The link between the two Architectures is so strong
it is difficult to separate them, and a good Enterprise
Architecture encompasses an HIS Architecture.

22. The Open Group Architecture Framework
http://www.opengroup.org/architecture/togaf9-doc/arch/

23. Essential Purpose of a HIS
To support the Health Enterprise to achieve its goals
by:
Collecting, storing, processing, & analysing data;
Ensuring data quality and privacy;
Automating processes;
Auditing;
Supporting clinical & administrative decision making;
.....
Implementing policies;
Being the “engine” of the Health Enterprise.

24. Published Enterprise Architectures
NIH Enterprise Architecture Framework
Australian Government Architecture Reference Models v1.0
launched by the Australian Government Information
Management Office 2007-06-18, with the
US Federal Enterprise Architecture (FEA) reference models,
from Office of Management and Budget eGov area. These
reference models, which include XML formats for EA
reference model data transfer. A single-volume consolidated
model is available (June 2006 version and will be updated
annually).
US DOI US Department of the Interior architecture, with
mappings between US FEA reference models
US DoD BEA - September 2006 Version of the US DoD
Business Enterprise Architecture, with associated browseable
dictionary, and printable diagrams.
Source “Manhattan II Architecture Overview, Geneva, Switzerland, 22 June 2007”

25. The Health Enterprise Architecture
Developing an Architecture for a Health Enterprise is
highly desirable but is far from being common place;
The concept is becoming more widespread and
pieces of it are being used in Health;
Also, organizations as the Health Metrics Network
are looking for ways to speed up the adoption of the
concept by countries to describe their Health
Systems.

26. Fragmentation
The absence of a proper Health Enterprise
Architecture or a Health System for a country tends
do lead to siloed, vertical Health Programs, and
vertical HIS that fragment not only the information
but also the delivery of care itself.
Question:
Can you give an example of a vertical systems and
the associated fragmentation of information and/or
care?

27. Health (Enterprise) Architecture
Four Layers Representative Questions Addressed
Business 1. Who are the key decision makers, what are their roles and behaviors
insofar as decision making is concerned?
Architecture
2. What are the essential questions & requirements of users?
3. What are the business domains and processes (functions)
4. Who will be responsible for managing the HIS?
Data 1. What are the essential core and common data necessary to support the
organization’s business architecture?
Architecture
2. How will the sources of these data be extracted linked and transformed
for use from existing operational systems?
Applications 1. What are the priority applications that a core HIS must deliver?
Architecture 2. What applications are best included within a single platform design versus
those applications that are best maintained as separate operational
systems?
3. How should the user interface work?
Technical 1. What are the requirements for information to be captured, data entered,
tagged, communicated and managed?
Architecture
2. What is the minimum information and communication technology
capacity needed across the country to support access to the applications
and dissemination of information?

28. Strong Conviction
Although we usually lack a Health Enterprise Architecture,
there are eHealth practices and architectures that can be used
to deploy flexible, useful, adaptable, reliable, robust and lasting
HIS;
We also believe that some general health enterprise
requirements can only be conceived if eHealth is present:
Nation-wide identification of individuals;
Operating the reference and counter-reference model;
Real-time notification o diseases;
Support to HC workers at the point of care;
Data collected once and used many times.

29. eHealth Architecture Initiative
ISO, the International Organization for
Standardization, is developing a project of an
“eHealth Enterprise Architecture for Emerging and
Developing Countries”;
This initiative somehow places the eHealth
Architecture pushing forward the Enterprise
Architecture.
That’s the tail wagging the dog!

30. eHealth Enterprise Architecture for
Emerging and Developing Countries
Beatriz de Faria Leao
Patrick Whitaker
Jan Talmon
1| Health Care Informatics|March 9, 2010

31. Motivation
The vast majority of resource-impoverished countries:
Do not have national eHealth policies;
Have vertical health information systems for diseases such
as AIDS, Malaria and TB, often donor-funded;
Lack proper HR on Health Informatics;
Do not have access to standards;
Do not appreciate the complexity of national eHealth
infrastructure.
2| Health Care Informatics|March 9, 2010

32. Why it is urgent
There are duplicative activities from stakeholders
defining sets of data to be collected and reported, e.g.
Millennium Development Goals.
Global South countries urgently need an architectural
framework from which to conceive eHealth systems, plan
implementations, make build-or-buy decisions, decide on
acquisitions and undertake related activities.
Low resource countries that are starting to use IT in health
must make the right decisions now in order to be able to
support interoperability and scalability of applications.
3| Health Care Informatics|March 9, 2010

33. SKMT and Glossary
Standards Knowledge Management Tool (SKMT) -
developed as a tool to support classification of health
informatics standards.
Complimentary to NWIP for Knowledge Management
of Health Information Standards– replaced former
preliminary work item on EHRS Standards Classification
Framework.
Glossary work – is progressing well with all ISO terms
and definitions entered into the SKMT soon.
4| Health Care Informatics|March 9, 2010

34. Registry of Open Access Data Standards
(ROADS)
Data needed for patient care, Monitoring and Evaluation (M&E), policy
development, and international reporting.
Awareness of standards, cost, and access remain obstacles to their
widespread adoption and implementation in economically-
disadvantaged countries.
Involvement in the standards process by these countries has been
limited, introducing a bias towards creating standards appropriate for
high-income countries.
WHO is supporting both ROADS and SKMT with funding from the
Rockefeller Foundation.
Development of tools to facilitate standards adoption in low-income
countries would expand the standards development process and
promote standards use.
5| Health Care Informatics|March 9, 2010

35. eHealth Enterprise Architecture
for Emerging and Developing Countries: TR Structure
Part 1: Environmental Scan
Current international initiatives in the area of eHealth
systems.
Part 2: Business Requirements
Framework for identifying business requirements that
define an eHealth enterprise architecture in
economically-constrained countries.
6| Health Care Informatics|March 9, 2010

36. eHealth Enterprise Architecture
for Emerging and Developing Countries: TR Structure
Part 1: Environmental Scan
Current international initiatives in the area of eHealth
systems.
Part 2: Business Requirements
Framework for identifying business requirements that
define an eHealth enterprise architecture in
economically-constrained countries.
6| Health Care Informatics|March 9, 2010

37. 14639-2 - eHealth Enterprise Architecture for Emerging and
Developing Countries Part 2: Business Requirements
Part 2 represents the core contribution of this TR. It provides a
framework for identifying business requirements that define an
eHealth enterprise architecture for economically-constrained
countries taking into account different levels of capacity and maturity.
Underlying Principles
– The eHealth architecture should support and facilitate access to
health research, information and educational materials for
managers, providers, researchers, and the general population.
– It should facilitate the construction of eHealth systems to support
the wellness of the individual, family, and community.
– Furthermore, It should be an essential resource to system
designers, developers and implementers.
7| Health Care Informatics|March 9, 2010

38. eHealth Enterprise Architecture for Emerging and Developing
Countries: Scope and Audiences
8| Health Care Informatics|March 9, 2010

39. Experts
Australia:
– Ken Tallis, Anthony Maeder, Richard Dixon Hughes
Brazil:
– Beatriz de Faria Leão, Rigoleta Dutra
Canada:
– Derek Ritz
Kenya
– Samuel Cheburet
Netherlands:
– J.L.Talmon
New Zealand:
– Mike Mair
US:
– Robert Owens
9| Health Care Informatics|March 9, 2010

40. Basic Ideas for eHealth Architecture
Build and use conceptual models
Comply with standards
Demand Interoperability
Build Unique Identifiers
Ask for web-based design
Consider SOA Architecture
Use Software Engineering tools
Build capacity
Say “no” to siloed systems

41. The Electronic Health Record
Operational
Evidences
Evidences
Support Delivery
Support Delivery Management
of Care
Clinical
Knowledge
Knowledge Management
Quality
EHRS Assessement
Pseudo-anonymized
Data
(datawarehousing) Strategic
Management
Information at the
Point of Care Billing & Others
Best Practices Operational Knowledge & True
Automation Support Decision Support Management

42. Which standards are essential?
Information content
Capture, describe, edit, store and retrieve
Vocabularies to express the content
Terminologies
Communications
File formats, protocols
Security
Protect data, role-based access.

43. Essential Identification within the Country
Identify People Uniquely
Individuals, patients, health workers
Identify Health Workers Uniquely
All types of workers and their profiles
Identify Health Organizations Uniquely
Who they are and what they do
What they have (equipment)
Identify Relationships Among Them
Who works where and when and in which role
Can organize the Reference and Counter-Reference Model
Answers to who attended whom and where

44. A Conceptual Model for Health Information
National Domain Tables
Registries and Vocabularies R
o
Hospitals and l
Healthcare Units e
Health Workers Users (Patients)
-
b
a
Electronic Health s
Record e
Exams d
Emergency
A
Primary c
Care Specialties Inpatients c
e
s
s
HC Services
Flow Control
Management Assessment C
o
n
Beds Emergency
Billing t
Health
r
Consultations Exams Authorization Surveillance
o
Auditing l

45. Interoperability of HIS
No single HIS can encompass all the requirements
of an enterprise;
Something will always happen outside the reach of
the Health Enterprise and its HIS;
Therefore, HISes need to “Interoperate”;
“Interoperability is the ability of two or more systems
to exchange information and to use the information
that has been exchanged” (IEEE);
The only way to interoperate is by sticking to
standards.

46. Real World HIS
Systems Interoperability
Health
Enterprise
External
Players
Data Repository
XML
HL7
LOINC
Standards

47. Conclusion
eHealth can change Health
No single system can sort out all problems
Need standards for Interoperability
Say No to “Siloed Systems”
Enterprise-wide unique IDs are essential
Need for ICT infrastructure
HR capacity building
An eHealth Architecture is a must
Think big, act step by step
Give ourselves time to learn
Build upon existing initiatives

48. References
eHealth Connection
www.ehealth-connection
ISO TC-215 eHeath Enterprise Architecture for Developing
Countries
www.iso.org/iso/pressrelease.htm?refid=Ref1275
TOGAF – The Open Group Architecture Framework
www.togaf.org
Health Metrics Network
www.healthmetricsnetwork.INFO
Vital Wave Consulting.
Health Information Systems in Developing Countries. A
Landscape Analysis, May 2009, www.vitalwaveconsulting.com

49. São Paulo City Health Information System
The largest city in South
America, with 12M
inhabitants and some
22M in the Metropolitan
Area.
Basic Figures (2009):
700 Heath Care Units
SIGA Saúde is São Paulo City’s System 15 M Users
for Managing the Public Health System. 1 M PC Cons/month
It belongs to São Paulo City. 35% Reduction/wait time
SIGA Saúde has been developed using 2M prescriptions/month
open-source, free-software concepts.

50. Ensuring Equity and Integrality of Care
Patient Flow Management
High Complexity - Hospitals
Private University Public
Hospital Hospital Hospital
Electronic Health Record
Medium Complexity
Counter-reference
reference
Diagnostic Diagnostic
Polyclinic Specialties
Center Center
Physician Primary Physician Physician Primary Primary
Office Care Unit Office Office Care Unit Care Unit
Entry Level Primary Care

51. SIGA Saúde Building Blocks
Nation-wide patient ID
Captures encounter data set
Nation-wide Identifiers
Health workers, units & equipment
Concepts, Policies & Norms
Family health program
National immunization program
Municipalization of care on a capitation basis
Automatic disease notification

52. Schematic Representation
Heath Care
SMS-SP
Management
(Surveillance, Audit and Billing)
Dept of Health
Internet
Patient Flow
Control
(Consultations, Procedures, Beds)
Ambulatory
Electronic Health Record
(Primary, Specialties, High Complexity)
SP City Datacenter
Secure Access

53. Encounter Data Set
Type of Attendance
Special Programs
Anamnesis, Physical Exam, History
Diagnosis Work-Related
Disease Communication
Disabilities
Procedures carried-out Notifiable Disease
Communication
Requested procedures
Medications High-Complexity
Procedure Order Form
Course of Action

54. Notifiable Disease Report

55. Primary Care Units in São Paulo City

56. ERROR: undefined
OFFENDING COMMAND: YJPgZ4rq
STACK: