mustafa degerli - 2016 - e-health and e-pulse - report

E-HEALTH AND E-PULSE

Summary: This report gives information about e-Health [Definition of e-Health,

Main Players in the Field of e-Health, Success Factors for e-Health Projects, The 10 e’s in e-Heath,

Current e-Health Projects or Services of Turkey, Statistics Regarding the Health and e-Health Industries of Turkey, Comparative Statistics regarding Health, Metrics related with Health and e-

Health, EU Citizen’s Use of e-Health Services, and European Funded Projects in the field of ICT for Health and Wellbeing (e-Heath)], e-Pulse (e-Nabız) [e-Pulse (e-Nabız), Features and

Functionalities of e-Pulse (e-Nabız), Future Functionalities of e-Pulse (e-Nabız), and Security and

Privacy related with e-Pulse (e-Nabız), Legal Case related with e-Pulse (e-Nabız), Infrastructure of e-Pulse (e-Nabız), and Integration of e-Pulse (e-Nabız) with Other Systems], Comparing

epSOS (EU), NHS (England), HealtheVet (USA), HealthHub (Singapore), and e-Pulse (Turkey) [epSOS (EU), NHS (England), HealtheVet (USA), HealthHub (Singapore), Results of

Comparison regarding epSOS (EU), NHS (England), HealtheVet (USA), HealthHub (Singapore), and e-Pulse (Turkey)], and Future Works.

Mustafa Değerli METU Informatics Institute

June 2016

Ankara, Turkey


Mustafa Değerli – 2016 1

Table of Contents

Table of Contents ........................................................................................................................ 1

List of Tables ............................................................................................................................... 3

List of Figures .............................................................................................................................. 4

1. Introduction ......................................................................................................................... 5

1.1 Scope .................................................................................................................................... 5

1.2 Definitions and Abbreviations ........................................................................................... 5

1.3 References ........................................................................................................................... 7

2. e-Health .............................................................................................................................. 10

2.1 Definition of e-Health ....................................................................................................... 10

2.2 Main Players in the Field of e-Health ............................................................................. 11

2.3 Success Factors for e-Health Projects............................................................................ 12

2.4 The 10 e’s in e-Heath ....................................................................................................... 12

2.5 Current e-Health Projects or Services of Turkey .......................................................... 14

2.6 Statistics Regarding the Health and e-Health Industries of Turkey .......................... 16

2.7 Comparative Statistics regarding Health ....................................................................... 17

2.8 Metrics related with Health and e-Health ...................................................................... 18

2.9 EU Citizen’s Use of e-Health Services ............................................................................ 20

2.10 European Funded Projects in the field of ICT for Health and Wellbeing (e-Heath) 21

3. e-Pulse (e-Nabız)............................................................................................................... 28

3.1 e-Pulse (e-Nabız)............................................................................................................... 28

3.2 Features and Functionalities of e-Pulse (e-Nabız) ....................................................... 29

3.3 Future Functionalities of e-Pulse (e-Nabız) ................................................................... 30

3.4 Security and Privacy related with e-Pulse (e-Nabız) .................................................... 30

3.5 Legal Case related with e-Pulse (e-Nabız) .................................................................... 31

3.6 Infrastructure of e-Pulse (e-Nabız) ................................................................................ 32

3.7 Integration of e-Pulse (e-Nabız) with Other Systems ................................................. 32



4. Comparing epSOS (EU), NHS (England), HealtheVet (USA), HealthHub (Singapore),

and e-Pulse (Turkey) ................................................................................................................ 34

4.1 epSOS (EU) ........................................................................................................................ 34

4.2 NHS (England) ................................................................................................................... 35

4.3 HealtheVet (USA) .............................................................................................................. 36

4.4 HealthHub (Singapore) .................................................................................................... 41

4.5 Results of Comparison regarding epSOS (EU), NHS (England), HealtheVet (USA),

HealthHub (Singapore), and e-Pulse (Turkey) ..................................................................... 42

5. Future Works ..................................................................................................................... 47



List of Tables

Table 1 - Comparative Statistics regarding Health (Health Workforce and Infrastructure

& Technologies) ................................................................................................... 18

Table 2 - Comparative Statistics regarding Health (Total Expenditure on Health and

General Government Expenditure on Health) .......................................................... 18

Table 3 - Health Metrics ........................................................................................ 19

Table 4 - Systems Integrated with e-Pulse (e-Nabız) and Rationales for Integration ... 32

Table 5 - Results of Comparison regarding epSOS (EU), NHS (England), HealtheVet

(USA), HealthHub (Singapore), and e-Pulse (Turkey) with respect to General

Characteristic ....................................................................................................... 42

Table 6 - Results of Comparison regarding epSOS (EU), NHS (England), HealtheVet

(USA), HealthHub (Singapore), and e-Pulse (Turkey) with respect to Functionalities .. 43



List of Figures

Figure 1 - e-Health Journey ................................................................................... 11

Figure 2 - e-Pulse (e-Nabız) Web Page ................................................................... 28

Figure 3 - e-Pulse (e-Nabız) Application.................................................................. 28



1. Introduction

1.1 Scope

This report gives information about

e-Health [Definition of e-Health, Main Players in the Field of e-Health, Success

Factors for e-Health Projects, The 10 e’s in e-Heath, Current e-Health Projects or

Services of Turkey, Statistics Regarding the Health and e-Health Industries of

Turkey, EU Citizen’s Use of e-Health Services, Comparative Statistics regarding

Health, Metrics related with Health and e-Health, and European Funded Projects

in the field of ICT for Health and Wellbeing (e-Heath)],

e-Pulse (e-Nabız) [e-Pulse (e-Nabız), Features and Functionalities of e-Pulse (e-

Nabız), Future Functionalities of e-Pulse (e-Nabız), Security and Privacy related

with e-Pulse (e-Nabız), Legal Case related with e-Pulse (e-Nabız), Infrastructure

of e-Pulse (e-Nabız), and Integration of e-Pulse (e-Nabız) with Other Systems],

Comparing epSOS (EU), NHS (England), HealtheVet (USA), HealthHub

(Singapore), and e-Pulse (Turkey) [epSOS (EU), NHS (England), HealtheVet

(USA), HealthHub (Singapore), Results of Comparison regarding epSOS (EU),

NHS (England), HealtheVet (USA), HealthHub (Singapore), and e-Pulse

(Turkey)], and

Future Works.

1.2 Definitions and Abbreviations

€ Euro

CHRMS Core Health Resources Management System

CT Computed Tomography

DoD Department of Defense

ECHO Echocardiogram

EHIC Integration of the European Health Insurance Card

epSOS European Patients - Smart Open Services

EU European Union



EUROSTAT European Statistics Office

FMIS Family Medicine Information System

GP General Practitioner

ICS Integrated Care Services

IT Information Technology

ICT Information and Communication Technologies

MoH Ministry of Health

MRI Magnetic Resonance Imaging

N No

NHS National Health Services

No. Number

NY Not Yet

OECD Organization for Economic Co-operation and Development

PHR Personal Health Record

SCR Summary Care Record

SMS Short Message Service

USD United States Dollar

VA Veteran Affairs

VA CCD VA Continuity of Care Document



WHO World Health Organization

Y Yes

1.3 References

Akdağ, R.

Health Transformation Program in Turkey September 2010

PROGRESS REPORT, Republic of Turkey, Ministry of Health

Publication No: 807 ISBN: 978-975-590-336-1

Altınok, R. Turkey’s e-Health Activities, 2013.

http://css.escwa.org.lb/ictd/2094/2.pdf

Andreassen, H.

K., Bujnowska-

Fedak, M. M.,

Chronaki, C. E,

Dumitru, R. C.,

Pudule, I,

Santana, S., Voss,

H., and Wynn, R.

European citizens’ use of E-health services: A study of seven

countries, BMC Public Health, 7-53, 2007.

epSOS About epSOS, No Date. http://www.epsos.eu/home/aboutepsos.

Html

epSOS Frequently Asked Questions (FAQ), No Date.

http://www.epsos.eu/faqglossary/faq.html#c91

Erciyas, S. S. and

Geçgil, T. A.

Turkish citizens to manage their own health data, eHealth Law &

Policy, 2-5, 2015.

European

Commission

eHealth projects - Research and Innovation in the field of ICT for

Health and Wellbeing: An overview, EUROPEAN COMMISSION

Directorate-General for Communications Networks, Content and

Technology, 2014.

Eysenbach, G. What is e-health?, Journal of Medical Internet Research

2001;3(2):e20. doi:10.2196/jmir.3.2.e20

HealthHub HealthHub, No Date. http://www.healthhub.sg/

HealthHub HealthHub, About Us, No Date. http://www.healthhub.sg/aboutus



Maurice Mars

eHealth Economics: The Need For Standardized Metrics and

Frameworks. 2011.

https://www.medetel.eu/download/2011/parallel_sessions/

presentation/day2/eHealth_Economics.pdf

Müezzinoğlu, M.

2016 YILI BÜTÇE SUNUMU 10 Şubat 2016 TBMM Plan ve Bütçe

Komisyonu, 2016. http://www.saglik.gov.tr/TR/dosya/1-

101400/h/tbmm.pdf

The College for

Behavioral Health

Leadership

Health Metrics. No Date.

http://www.change4health.org/technologies/consumer-e-health-

and-health-metrics/frameworks/

The NHS in

England

Your health, your choices - Your health and care records, 2016.

http://www.nhs.uk/NHSEngland/thenhs/records/

healthrecords/Pages/overview.aspx

T.C. Danıştay 15.

Daire

2015-2900. http://www.ttb.org.tr/images/stories/haberler/

file/danistay_10_daire_2015_karar.pdf

T.C. Sağlık

Bakanlığı

T.C. Sağlık Bakanlığı Sağlık İstatistikleri Yıllığı – 2014, Ankara,

Turkey, 2015. http://www.saglik.gov.tr/TR/belge/1-2952/istatistik-

yilliklari.html

T.C. Sağlık

Bakanlığı eNabız

Portalı

e-Nabız, no date. https://enabiz.gov.tr/Yardim.html

T.C. Sağlık

Bakanlığı Sağlık

Bilgi Sistemleri

Genel Müdürlüğü

Kişisel Sağlık Sistemi Platformu “e-Nabız” Tanıtım Dokümanı, 2015,

https://enabiz.gov.tr/klavuz-magazine/

T.C. Sağlık

Bakanlığı Sağlık

Bilgi Sistemleri

Genel Müdürlüğü

Sağlık.NET Hakkında. No Date. http://www.e-saglik.gov.tr/belge/1-

33811/sagliknet-hakkinda.html

Türk Tabipleri

Birliği

e-Nabız Projesinin yürütmesi durduruldu, 2016.

http://www.ttb.org.tr/index.php/Haberler/e-nabiz-5957.html

Türkiye İstatistik

Kurumu

Temel İstatistikler, 2015.

http://www.tuik.gov.tr/UstMenu.do?metod=temelist



U.S. Department

of Veterans

Affairs

My HealtheVet The Gateway to Veteran Health and Wellness, 2014. https://www.myhealth.va.gov/index.html

U.S. Department

of Veterans

Affairs

My HealtheVet Account Types, 2014.

https://www.myhealthevet.va.gov/mhv-portal- web/anonymous.portal?_nfpb=true&_nfto=false

&_pageLabel=spotlightArchive&contentPage= ipa/mhv_account_status-definitions.html

WHO Trade, foreign policy, diplomacy and health, EHealth, No Date.

http://www.who.int/trade/glossary/story021/en/

WHO World Health Statistics 2015. 2015.

http://apps.who.int/iris/bitstream/10665/

170250/1/9789240694439_eng.pdf?ua=1&ua=1



2. e-Health

2.1 Definition of e-Health

E-health is still another popular application area of e-transformation and management.

The World Health Organization (WHO) defines e-health as the transfer of health resources

and health care by electronic means. It encompasses three main areas:

The conveyance of health information, for health professionals and health

consumers, by means of the Internet and telecommunications.

Using the power of information technology (IT) and e-commerce to improve

public health services, e.g. through the education and training of health workers.

The use of e-commerce and e-business practices in health systems management.

For a while but particularly in recent times, e-health concept and applications is a

developing field in the juncture of medical informatics, public health and business,

referring to health services and information delivered and/or improved through the

Internet and/or related technologies.

In a broader sense, the term of e-health 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 (ICT).

Unquestionably, the term e-health, referring to all digital health-related information, is

exceedingly all-purpose as it covers:

Products, like instruments to ensure the constant monitoring of blood pressure

in ambulatory patients,

Systems, like computer-assisted surgery systems, and

Services, like:

o Operating surgical and intensive care units, with interconnected

instruments and surveillance services ensuring continuous patient

monitoring;

o Computer-assisted prescription services, where the software checks for

incompatible drugs, contraindications and dosage levels;

o Information services for patients and consumers, including individual

electronic health records.

Furthermore, e-health can be defined as the introduction of information technologies in

the field of health on the internet for effective and efficient provision of healthcare

services, ensuring rapid access and sustainability of data exchange among all relevant

stakeholders.

In today’s settings, generally, e-health products, systems and services are mostly location

independent, in that they can be used locally (doctors’ surgeries, hospitals) or remotely,

as is inherent in the term “tele” (tele-dermatology, tele-surgery, tele-diagnosis, tele-

medicine, and etc.).

E-health has a very definitive journey for nearly all countries. The e-health journey can

be figured as in Figure 1.



Figure 1 - e-Health Journey

In this context, specifically for Turkey, the e-Health vision of the Ministry of Health of

Turkey is to establish a national health information system, which may be accessed only

by the authorized persons and institutions, in which all persons can access their own

health data, which complies with international standards and is supported by decision

support systems, which has large band width and covers the whole country; and which

is based on the utilization of technologies such as tele-medicine and tele-health in

practice.

2.2 Main Players in the Field of e-Health

In contradiction of the old-fashioned health sectors, e-health solutions firmly necessitate

coordination with dissimilar players whose philosophies, purposes and backgrounds are

to a certain extent miscellaneous.

These players can be enumerated as:

United Nations agencies and other international bodies dealing with health,

telecommunications, and trade,

Government authorities, health and telecommunication decision-makers at the

national and regional levels, as well as the regional bodies to which they belong,

Academic and research institutions,

Local health professionals, and their associations,

Consumers, patients, and their associations,

Donors,



Relevant non-governmental organizations,

The private sector, including foundations and industries related to health and

ICTs, and

The media.

For sure, each of these groups has a dissimilar scholastic experience and convention, as

well as by some means contradictory responsibilities and constraints. Nevertheless, all of

these have to be well analyzed, respected, mobilized, and coordinated to achieve the

success.

2.3 Success Factors for e-Health Projects

To be legitimately effective and successful regarding the e-health, the implementation

efforts related with e-health settings must be based on a clear appreciation of the

country’s current and future public health and healthcare issues and opportunities, with

a characterization of the corresponding national priorities, and on a medium- to long-

term accomplishment plans for the use of e-health technologies to meet healthcare

priorities, with fragmentary renovation and restoration of the health systems themselves.

For better accomplishment, the related strategy must:

bring together players from the public sector, not-for-profit organizations and the

private sector,

be structured in the form of a business plan, approved by the stakeholders,

be sponsored by a strong commitment on the part of all players, and

include a comprehensive plan for ongoing education and communication with the

partners.

2.4 The 10 e’s in e-Heath

Intended for an effective and efficient e-health content and context, there must be 10 e’s

attained and sustained. Each of these 10 e’s is elaborated below:

1. Efficiency

e-health must be efficient.

One of the aptitudes of e-health is to increase efficiency in health care, thereby decreasing costs. One conceivable way of decreasing costs would be by avoiding duplicative or

unnecessary diagnostic or therapeutic interventions, by dint of enhanced communication

possibilities among health care establishments, and through patient involvement.

2. Enhancing

e-Health should be enhancing quality of care.

Specifically, increasing efficiency involves not only reducing costs, but at the same time improving quality. E-health may enhance the quality of health care for example by



allowing comparisons between different providers, involving consumers as additional

power for quality assurance, and directing patient streams to the best quality providers.

3. Evidence-based

e-Health ought to be evidence based.

That is to say, e-health interventions should be evidence-based in a sense that their effectiveness and efficiency should not be assumed but proven by rigorous scientific

evaluation.

4. Empowering

e-Health must be empowering.

e-Health should lead to empowerment of consumers and patients by means of making

the knowledge bases of medicine and personal electronic records accessible to consumers over the Internet, e-health opens new avenues for patient-centered medicine, and

enables evidence-based patient choice.

5. Encouraging

e-Health should be encouraging.

Specifically, encouragement of a new relationship between the patient and health

professional, towards a true partnership, where decisions are made in a shared manner.

6. Education

e-Health ought to be provided with education.

Education should be provided and repeated as required regarding e-health. It consists of education of physicians through online sources (continuing medical education) and

consumers (health education, tailored preventive information for consumers).

7. Enabling

e-Health must be an enabler.

It should enable information exchange and communication in a standardized way

between health care establishments.

8. Extending

e-Health should have an extending attribution.

E-health ought to extend the scope of health care beyond its conventional boundaries. This is meant in both a geographical sense as well as in a conceptual sense. e-health

enables consumers to easily obtain health services online from global providers. These

services can range from simple advice to more complex interventions or products such as pharmaceuticals.



9. Ethics

e-Health should be blended with ethical concerns.

Ethics should be achieved and sustained as e-health involves new forms of patient-doctor interaction and poses new challenges and threats to ethical issues such as online

professional practice, informed consent, privacy, and/or equity issues.

10. Equity

e-Health ought to be providing equity.

Equity should be ensured to make health care more equitable is one of the promises of

e-health, but at the same time there is a considerable threat that e-health may deepen the gap between the “haves” and “have-nots”. People, who do not have the money, skills,

and access to computers and networks, cannot use computers effectively. As a result, these patient populations (which would actually benefit the most from health information)

are those who are the least likely to benefit from advances in information technology, unless political measures ensure equitable access for all. The digital divide currently runs

between rural vs. urban populations, rich vs. poor, young vs. old, male vs. female people,

and between neglected/rare vs. common diseases.

2.5 Current e-Health Projects or Services of Turkey

Turkey’s Ministry of Health (MoH) executes fairly large projects in the e-health domain.

Each of these projects are exceedingly funded and rigorously managed. These projects

are: Health-NET, Family Medicine Information System, Core Health Resources

Management System, Green Card Information System, Tele-Medicine Project, Decision

Support System, e-Pulse (e-Nabız), e-Training, and Other Projects.

Brief information for each of these major and fundamental projects executed by Turkey’s

MoH are given below.

1. Health-NET

Health-NET is an integrated, safe, fast and expandable information system which aims to

improve efficiency and quality of health services by collecting all kinds of data produced

in the health institutions in line with the standards and generating information adequate

for all stakeholders out of the collected data.

2. Family Medicine Information System

Family Medicine practice, initiated under the Health Transformation Program, has

introduced innovations both in terms of healthcare service provision and primary health

care data collection discipline of Turkey’s MoH. The most important innovation in this

context is the Family Medicine Information System (FMIS).



3. Core Health Resources Management System

This project, realized by the Central Organization of the MoH and 81 Provincial Health

Directorates has ensured the provision of accurate and updated information support to

managers of all levels in order for the human, material and financial resources to be

monitored and directed as required. Core Health Resources Management System

(CHRMS) is integrated with other projects and implementations and has become

indispensable for the Ministry with its database.

4. Green Card Information System

Through the Green Card Information System, green card entitlement of the citizens

holding green cards is monitored and this information is shared with other stakeholders

through web service.

5. Tele-Medicine Project

Through the Tele-medicine Project, distant reporting service was introduced in the field

of imaging with the use of information and communication technologies; and a total of

68 hospitals, consisting of 58 sender and 10 receiver hospitals, have been integrated in

the field of tele-radiology, tele-pathology and the roll-out works are continuing.

6. Decision Support System

Decision Support System, which provides analysis, reporting and statistics support for the

Health Policy makers, planners and decision makers was put into service. This way, it will

be possible to carry out epidemiologic and demographic analysis about the burden of

disease.

7. e-Pulse (e-Nabız)

e-Pulse (e-Nabız) is a personal health records system that allows users to manage all

health information and to access to the health history from a single point, regardless of

where the examinations and treatments are completed. Further details are given in

Section 3 of this report.

8. e-Training

E-training portal has been devised in order to support graduate in-service training of MoH

personnel and to provide them training at any place and time they wish. The project was

initiated in May 2009 and Microsoft Office 2007 and Information Safety Training have

been provided to around 2500 health personnel by way of distant training.



9. Other Projects

Through the MoH Tender Information System, it is possible to see the tender results for

the procurement of medicines, devices, materials and services in all MoH Provincial Health

Directorates, all hospitals, and Hygiene Regional Directorates.

Moreover, Pharmaceutical and International Classification of Diseases codes started to be

implemented. Within the framework of health informatics, National Health Data Dictionary

and Healthcare Minimum Data Sets were prepared for the first time and Health Coding

Reference Server was put into service.

Again for the first time, Organ Transplantation and Tissue Data Bank were established in

order to find the most suitable organ for the citizens waiting for organ transplantation;

and to prevent illicit organ transplantation. Through the Physician Data Bank, the diploma

and the specialty information of all physicians in the Republic Period are fettered into

records.

2.6 Statistics Regarding the Health and e-Health Industries

of Turkey

In order to understand and appreciate the size and promise of the related market with

respect to heath and e-health industries of Turkey, some statistics were gathered. These

numbers clearly show that health and e-health industries in Turkey are really promising

and they have high potential.

Collected statistics: Number of mobile phone subscriptions in Turkey: 72,174,826 [June, 2015]

(Turkish Statistical Institute)

Number of Internet subscriptions in Turkey: 44,395,360 [June, 2015] (Turkish

Statistical Institute)

Computer usage in households and individuals in Turkey: 54.8% [2015] (Turkish


Internet usage in households and individuals in Turkey: 55.9% [2015] (Turkish


Households with access to the Internet in Turkey: 69.5% [2015] (Turkish


Number of physicians in Turkey: 135,616 [2014] (Turkish Statistical Institute)

Number of persons per physician in Turkey: 573 [2014] (Turkish Statistical

Institute)

Number of patient hospital visits per physician in Turkey: 4648 [2014] (Turkish


Total number of visits to physicians in all healthcare facilities in Turkey:

643,992,030 [2014] (MoH, Republic of Turkey)

Total number of visits to physicians in hospitals in Turkey: 396,577,644 [2014]

(MoH, Republic of Turkey)



Number of hospitals in Turkey: 1528 [2014] (MoH, Republic of Turkey)

Number of public hospitals in Turkey: 866 [2014] (MoH, Republic of Turkey)

Number of private hospitals in Turkey: 556 [2014] (MoH, Republic of Turkey)

Number of university hospitals in Turkey: 69 [2014] (MoH, Republic of Turkey)

Number of other hospitals in Turkey: 37 [2014] (MoH, Republic of Turkey)

Number of MRI devices in Turkey: 757 [2014] (MoH, Republic of Turkey)

Number of CT devices in Turkey: 1071 [2014] (MoH, Republic of Turkey)

Number of ultrasound devices in Turkey: 5286 [2014] (MoH, Republic of Turkey)

Number of Doppler ultrasonography devices in Turkey: 3151 [2014] (MoH,

Republic of Turkey)

Number of ECHO devices in Turkey: 1793 [2014] (MoH, Republic of Turkey)

Number of mammography devices in Turkey: 903 [2014] (MoH, Republic of

Turkey)

Number of MRI devices in private hospitals in Turkey: 403 [2014] (MoH, Republic

of Turkey)

Number of CT devices in private hospitals in Turkey: 484 [2014] (MoH, Republic

of Turkey)

Number of ultrasound devices in private hospitals in Turkey: 1865 [2014] (MoH,

Republic of Turkey)

Number of Doppler ultrasonography devices in private hospitals in Turkey: 666

[2014] (MoH, Republic of Turkey)

Number of ECHO devices in private hospitals in Turkey: 666 [2014] (MoH,

Republic of Turkey)

Number of mammography devices in private hospitals in Turkey: 517 [2014]

(MoH, Republic of Turkey)

Current health expenditure in Turkey: USD 72,456 M [2013] (MoH, Republic of

Turkey)

Health investment expenditure in Turkey: USD 4262 M [2013] (MoH, Republic of

Turkey)

2.7 Comparative Statistics regarding Health

In order to understand the whole-picture in the context of health and pertinent practices

in the related field, it is a must to have a look at the comparative statistics regarding the

health.

Table 1 gives the comparative statistics regarding health (health workforce and

infrastructure & technologies). Table 2 gives the comparative statistics regarding health

(total expenditure on health as %).

Table 1 highlights that, when compared with United Kingdom, United States of America,

Singapore, and France; Turkey needs to improve its health workforce and health

infrastructure and technologies.

Additionally, Table 2 reveals that, when compared with United Kingdom, United States of

America, and France; Turkey needs to improve its total expenditure on health as % of

gross domestic product and general government expenditure on health as % of total

government expenditure.



Table 1 - Comparative Statistics regarding Health (Health Workforce and Infrastructure & Technologies)

Country

Density of health workforce

(per 10,000 population)

Density of health

infrastructure and

technologies

Physicians

Nursing and

midwifery

personnel a

Hospitals

(per

100,000)

Psychiatric

beds (per

100,000)

Turkey 17.1 24.0 1.5 9.3

United Kingdom 28.1 88.0 No Data 34.1

United States of

America 24.5 No Data No Data 50.2

Singapore 19.5 57.6 0.5 44.3

France 31.9 93.0 No Data 89.6

Table 2 - Comparative Statistics regarding Health (Total Expenditure on Health and General Government Expenditure on Health)

Country

Total expenditure on health

as % of gross domestic

product

General government

expenditure on health as % of

total government expenditure

2000 2012 2000 2012

Turkey 4.9 5.4 9.8 10.7

United Kingdom 6.9 9.3 15.1 16.2

United States of

America 13.1 17.0 16.8 20.0

Singapore 2.7 4.2 7.1 11.1

France 10.1 11.6 15.5 15.8

2.8 Metrics related with Health and e-Health

Table 3 shows the generic metrics for the context of health.



Table 3 - Health Metrics



Additionally, for the context of e-health, following evaluation methods can be used to

monitor and control process and/performance: Cost analysis

Marginal net present value calculation

Cost effectiveness analysis

Total absorption costing

Cost minimization

Cost minimization analysis

Payback period and breakeven point

Cost consequence analysis

Affordability gap analysis

Cost benefit analysis

Utilization review

Cost utility analysis

Cost utility analysis

Value chain analysis

Willingness to pay

eHealth utilization

Contingent valuation method

Activity based costing

On the other hand, both of these approached should be agreed on related parties for

employment.

Organizations need to blend these two category of metrics and methods to monitor and

fine-tune their efforts and practices related with health practices. Health metrics and e-

health metrics are determined by related organizations to evaluate the effectiveness and

efficiencies of related systems.

2.9 EU Citizen’s Use of e-Health Services

There is a study that investigated patterns of health-related Internet use, its

consequences, and citizens’ expectations about their doctors’ provision of e-health

services (Andreassen, Bujnowska-Fedak, Chronaki, Dumitru, Pudule, Santana, Voss, and

Wynn, 2007).

In the subject study, representative samples were obtained from the general populations

in Norway, Denmark, Germany, Greece, Poland, Portugal and Latvia. The total sample

consisted of 7934 respondents. Interviews were conducted by telephone.

44% of the total sample, 71% of the Internet users, had used the Internet for health

purposes.

Factors that positively affected the use of Internet for health purposes were youth, higher

education, white-collar or no paid job, visits to the GP during the past year, long-term

illness or disabilities, and a subjective assessment of one’s own health as good.

Women were the most active health users among those who were online. One in four of

the respondents used the Internet to prepare for or follow up doctors’ appointments.



Feeling reassured after using the Internet for health purposes was twice as common as

experiencing anxieties. When choosing a new doctor, more than a third of the sample

rated the provision of e-health services as important.

As a result of the subject study, it is concluded that the users of Internet health services

differ from the general population when it comes to health and demographic variables.

The most common way to use the Internet in health matters is to read information,

second comes using the net to decide whether to see a doctor and to prepare for and

follow up on doctors’ appointments.

Henceforth, health-related use of the Internet does affect patients’ use of other health

services, but it would appear to supplement rather than to replace other health services.

2.10 European Funded Projects in the field of ICT for Health

and Wellbeing (e-Heath)

In this part of the report, an overview of some of the most current (on-going or recently

finished) European funded projects in the field of ICT for health and wellbeing (e-Health)

are provided.

These are provided to reflect the current project examples in the e-health in the European

zone.

1. eHealthMonitor

Development of a platform for individualized personal healthcare services, design of

knowledge sharing methods which consider privacy protection requirements, and include

all stakeholders in the decision making process.

More information is available at the following webpage: www.ehealthmonitor.eu

Duration: 2011-2014

2. Mobiguide

The aim of the MobiGuide project (www.mobiguide-project.eu) is to develop an intelligent

decision support system for patients with chronic illnesses. The system accompanies the

patients wherever they go and helps them and their care providers in managing their

illness, whether they are at home, at work, out and about or travelling abroad on holiday

or for business. The MobiGuide tool analyses bio signals from body-worn sensors and

gives advice 24/7.

Duration: 2011-2015

3. MyHealth Avatar

Digital representation of patient health status.

More information is available at the following webpage: www.myhealthavatar.eu

Duration: 2013-2016



4. p-Medicine

p-Medicine (‘Personalised Medicine’) is working on an infrastructure that will facilitate the

translation from current practice to personalized medicine.

More information is available at the following webpage: www.p-medicine.eu

Duration: 2011-2015

5. DAPHNE

With DAPHNE, researchers and businesses join forces to help people manage their weight

and increase physical exercise using emerging technologies and information systems. The

project will use a new generation of sensors to detect how much energy a person expends

– including how much time they have been sitting still, walking, standing, doing

housework, etc. - and can monitor their overall fitness.

More information is available at the following webpage: www.daphne-fp7.eu

Duration: 2013-2016

6. BeatHealth

Better at sports while listening to music? BeatHealth wants to exploit this link between

music and movement for boosting individual performance and enhancing health and

wellness. It aims to create an intelligent portable tool and IT network for rhythmical

stimulation adapted to the individual’s skills. The beneficial effects of BeatHealth will be

evaluated both in patients with movement disorders (i.e., Parkinson’s disease), and in

healthy citizens of various ages with moderate physical activity.

More information is available at the following webpage: www.euromov.eu/beathealth

Duration: 2013-2016

7. PEGASO Fit for Future

Promoting healthy lifestyles and food awareness among teenagers through games and

technology - this is the goal of the "PEGASO Fit for Future" project.

More information is available at the following webpage: www.pegasof4f.eu

Duration: 2013-2017

8. SPLENDID

This project will develop hi-tech sensors aiming to prevent obesity: By measuring food

intake and activity these sensors can assess obesity risks. In the fight against obesity,

SPLENDID also developed special programs for guiding both school children and adults.

More information is available at the following webpage: splendid-program.eu

Duration: 2013-2016



9. PRECIOUS

To maintain a healthy lifestyle, PRECIOUS aims to improve motivation using a

combination of motivational interview and gamification principles, as well as creating a

personalized system that adapts to the users’ goals and preferences. The system will

measure food intake, physical activity, stress levels and sleep patterns.

More information is available at the following webpage: www.thepreciousproject.eu

Duration: 2013-2016

10. SEMEOTICONS

The central idea of SEMEOTICONS (SEMEiotic Oriented Technology for Individual’s

CardiOmetabolic risk self-assessmeNt and Self-monitoring), is to exploit the face as a

major indicator of individual’s wellbeing by tracing traits of physical and expressive status.

To map and assess these face signs, SEMEOTICONS will design and construct a multi-

sensory system integrated into a hardware platform having the exterior aspect of a

mirror: the so-called "Wize Mirror". This will easily fit into users’ home or other sites of

their daily life.

More information is available at the following webpage: www.semeoticons.eu

Duration: 2013-2016

11. eHealth Innovation

This thematic network wants to develop a European roadmap for sustained eHealth

innovation. The focus is on personalized health services and a supportive eHealth

infrastructure. Special emphasis will be put on chronic disease management for an ageing

population. The network involves 22 partners: 20 from 10 Member States and 2 from

Switzerland representing a broad range of stakeholders: national and regional authorities,

industry (ICT and pharma), national solution providers, researchers and users (health

professionals, patients, healthcare providers and insurers/third party payers), European

and national associations.

More information is available at the following webpage: www.ehealth-innovation.eu

Duration: 2011-2013

12. CLEAR

This project proposed the implementation of a "Tele-rehabilitation service" in four

Member States of the European Union. The ambition was to convert the project, after its

completion, to a European platform for Tele-rehabilitation, and to contribute to the

harmonization of eHealth services in the EU. CLEAR was a fundamental step in helping

doctors treating patients who seek health treatment in a comfortable environment,

including home, under supervision of a specialized team.

More information is available at the following webpage: www.habiliseurope.eu

Duration: 2008-2012



13. CommonWell

The CommonWell project (commonwell.eu) delivered integrated telecare and telehealth

services among social care providers and hospitals on open platforms. The developed

services were targeted mainly for patients suffering from chronic diseases and

professionals dealing with these conditions. The system collects and makes sure health

parameters are monitored and health care providers receive up-to-date information about

patients. The main advantage with this ICT solution is that it prevents unnecessary

admissions to hospitals and patients can go on living actively and independently.

The project implemented a platform which tested 4 different services in the pilot sites:

Telecare integration for better emergency care;

Managed hospital admission for care providers;

Early intervention and telehealth for patients;

Integrated support for heart failure patients.

The project ended in early 2012 and integrated services are now in real-life operation at

the four pilot sites established in Spain, Germany, England and the Netherlands.

Duration: 2008-2012

14. MOMENTUM

A European telemedicine "Blueprint" to mainstream telemedicine into daily practice and

make it sustainable.

More information is available at the following webpage: www.telemedicine-

momentum.eu

Duration: 2012-2014

15. NEXES

The NEXES project (www.nexeshealth.eu) moved the focus from hospital care to primary

and home care using ICT support. To this end, the project assessed deployment of 4

innovative Integrated Care Services (ICS) for chronic patients (respiratory, cardiac and

type II diabetes mellitus) including well standardized patient-centered interventions:

home-based wellness and exercise-training; enhanced care for frail patients; home

hospitalization and early discharge and remote support to primary care for diagnosis and

therapy. The pilot was carried out in three different sites – Spain, Greece and Norway –

where it developed insights into local structural and operational barriers which have to

be overcome for further development of Integrated Care Services.

Specific achievements of the project have been:

Development of Integrated Care Services for chronic patients with enhanced

effectiveness and reduced costs,

Consolidation of an open source modular Health Information Sharing Platform

supporting organizational interoperability among actors and clinical decision

support systems, and

Strategies for scalability of the ICT services at regional level.

Duration: 2008-2012



16. RenewingHealth

This project has sought to deliver telemedicine and personal health services (PHS) to the

many people suffering from Chronic Obstructive Pulmonary Diseases (COPD), diabetes

and cardiovascular diseases.

The project has implemented large scale real-life pilots to validate and evaluate innovative

patient-centered personal health systems and telemedicine services.

The ultimate goal is to demonstrate what PHS and telemedicine services can deliver:

More effective and efficient care and

Improving of the quality of life and enhancing patients’ involvement and

empowerment.

More information is available at the following webpage: www.renewinghealth.eu

Duration: 2010-2013

17. United4Health

The United4Health project aims to exploit and further deploy innovative telemedicine

services implemented and trialed under the Renewing Health project. All included service

solutions adopt a patient centered approach, and involve the telemonitoring and the

treatment of chronic patients with diabetes, COPD or CVD diseases.

More information is available at the following webpage: www.united4health.eu and

ec.europa.eu

Duration: 2013-2015

18. THALEA

Through the THALEA project, five hospitals from Germany, Netherlands, Spain, Belgium

and Finland will initiate a joint Pre-Commercial Procurement (PCP) focusing on getting a

highly interoperable telemedicine and tele monitoring platform (a central ‘monitoring

cockpit’) for improving the care of acutely live threatened patients at intensive care units.

THALEA intends to launch a European wide published PCP call for tender for the value of

around €1,55M.

More information is available at the following webpage: www.thalea-pcp.eu and THALEA

factsheet

Duration: 2013 - 2016

19. INSPIRE

An EU-network to bring together experts and procurers interested in developing and

implementing innovative procurements in the eHealth, Active Aging and Independent

Living areas.

More information is available at the following webpage: www.nhg.fi

Duration: 2013 – 2015



20. CARRE

To help patients manage their chronic heart and kidney disease, CARRE will develop

personalized alerting, planning and educational services. This will empower patients, and

both professionals and patients will be able to make shared informed decisions on the

disease. The CARRE consortium consists of 6 partners from 4 countries (Greece, United

Kingdom, Lithuania and Poland) and is coordinated by the Democritus University of

Thrace in Alexandroupoli, Greece.

More information is available at the following webpage: www.carre-project.eu

Duration: 2013 – 2016

21. MovingLife

MovingLife ("MObile eHealth for the VINdication of Global LIFEstyle change and disease

management solutions") has delivered a set of roadmaps for mHealth ("mobile health").

These include technology and application research and innovation, implementation

practice and policy support. The roadmaps are supposed to accelerate the establishment,

acceptance and wide use of mHealth solutions at a global scale.

More information is available at the following webpage: www.moving-life.eu

Duration: 2011-2013

22. DECIPHER PCP

DECIPHER PCP (www.decipherpcp.eu) deals with mHealth procurement. It is developing

a mobile solution which enables secure cross-border access to existing patient healthcare

portals.

Duration: 2012-2016

23. UNWIRED Health

UNWIRED Health also deals with mHealth procurement for the transformation of

healthcare services. In this case, the Pre-Commercial Procurement (PCP) focuses on apps

offering services: to improve vaccination coverage and adherence and to coach patients

with heart failures enabling education, motivation, remote monitoring and other

functionalities, integrating and coordinating care provided by a hospital and the primary

care physician.

Both of these apps will be innovative, fully integrating the apps in the regional public

health systems and can be prescribed by GPs. These services will be implemented in open

platform infrastructures that will make the apps platform-agnostic, suitable to any

smartphone and any participating operator. The consortium consists of three procurers

introducing the innovation into their territories in Catalonia, Scotland and Southern

Denmark and three vendor independent non-profit associations that will act as catalyst

to foster the development of open platforms and interoperable solutions.

Duration: 2014-2016



24. PALANTE

PALANTE (www.palante-project.eu) focusses on patient empowerment: Maximize the

potential of ICT technologies in health care by validating pilots that address mechanisms

involved in patient empowerment. Currently there are 9 ongoing pilots: in Andalusia

(Spain), Lombardy (Italy), Turkey, Norway, Austria, Czech Republic, Basque Country

(Spain), France, Denmark. All of these pilots address the issue of patient’s secure access

to their own health information.

Duration: 2012-2015

25. SUSTAINS

To empower patients, SUSTAINS ("Support User Access to Information and Services")

comprises a basket of services based on giving citizens online access to their Electronic

Health Records (EHR). The services proposed have been distilled from the experience of

regions which have already pioneered such access. The regions of the SUSTAINS

Consortium share their experiences and achievements to speed up the implementation

of the SUSTAINS outcomes.

More information is available at the following webpage: sustainsproject.eu

Duration: 2012-2014

26. epSOS

epSOS (www.epsos.eu) is short for European Patient Smart Open Services.

This large scale project provides:

Patient Summary: a digital summary of medical status to make abroad care better

and more efficient, especially helpful in an emergency situation.

ePrescription: a digital drug prescription, so users can pick up medication in a

participating pharmacy abroad.

Duration: 2008-2014

27. Trillium Bridge

What if someone, while visiting the US, need urgent medical help and the doctor doesn’t

know medical history? The Trillium Bridge project wants to align the use of standards

between the EU and the US to share basic patient data between EU and US health

professionals. Of course only when the patient has given his consent.

By helping to create a transatlantic interoperability bridge for health data, Trillium Bridge

is implementing the EU-US Roadmap on eHealth.

More information is available at the following webpage: www.trilliumbridge.eu

Duration: 2013-2015



3. e-Pulse (e-Nabız)

3.1 e-Pulse (e-Nabız)

e-Pulse (e-Nabız) is a personal health records system that allows users to manage all

health information and to access to the health history from a single point, regardless of

where the examinations and treatments are completed. e-Pulse (e-Nabız) can be

accessed via a web-page (Figure 2) or devoted mobile applications (Figure 3) available

for mobile devices.

Figure 2 - e-Pulse (e-Nabız) Web Page

Figure 3 - e-Pulse (e-Nabız) Application



According to the Minister of Health of Turkey, Dr. Mehmet Müezzinoğlu, in less than one-

year period, since the introduction of the e-Pulse (e-Nabız), the number of users reached

to 3-million, and it is estimated that this number will be about 25-million in next five

years.

e-Pulse (e-Nabız) is the world’s largest and most comprehensive health informatics

infrastructure which can be securely accessed on the internet.

e-Pulse (e-Nabız) provides

health records are reviewed by the doctors to the extents that are allowed by

users,

enhancements in the quality and speed of diagnosis and treatment process as

previous records are accessible, and

a powerful communications line between patients and doctors.

3.2 Features and Functionalities of e-Pulse (e-Nabız)

Functions of the e-Pulse (e-Nabız) can be listed as:

Users can view the details about health facilities they visited with branch, time,

receipts, doctor details, and medicines information.

Users can record and update side effects information about the medicines that

they used.

Users can view test results, reports, and medical images with their reports.

Users are able to record and update medicine allergies and other allergies that

they have, if any.

Users are able to make appointments by using the e-Pulse (e-Nabız) as the

system is integrated to the central hospital appointment system.

It is possible users to add notes to their appointments.

There is an integrated calendar in the e-Pulse (e-Nabız), and users may use this

to track their appointments.

Users can share their records with others or doctors as they wish with the

conditions they set.

Users can track when the records that they shared are accessed with related

people.

In the system, there is a messaging capability that users can use to communicate

with the contact networks that they created.

Users can evaluate and rate on the health services that they take and comment

on these.

By using the adding data module, users are able to either manually or

automatically add, modify, and delete their blood pressure, blood sugar, pulse,

and weight data.

Mobile application of the e-Pulse (e-Nabız) sends reminders to the patients

regarding their medicines to take.

By using the 112 emergency button, users can call emergency services with the

exact location that is shared by the application.

Users are the only ones to control their records on the e-Pulse (e-Nabız) and they

can delete or share the records of their own, or they can pause or completely

terminate/remove their accounts on the e-Pulse (e-Nabız) system.



Smart-wristbands that measure steps, pulses, and calories, blood pressure and blood

sugar monitoring devices with Bluetooth capabilities, and certain mobile devices and

applications can be integrated to the e-Pulse (e-Nabız) profile and all health records can

be stored in a single place via the e-Pulse (e-Nabız).

Users can use the e-Pulse (e-Nabız) to access the details of their all examinations and

treatments. Users can update their profile information by using the profile section and

review last activities, last access details, and health facility visits of the related account

by using the notifications section. Users can either manually add their blood pressure,

blood sugar, and weight information to the system or authorize their devices to

automatically send these data to the system.

Regardless of in which health facilities they are completed, all test results and medical

images with their reports are recorded in the e-Pulse (e-Nabız) system. As long as these

are shared with the doctor by the patient, there is no need to repeat all these.

e-Pulse (e-Nabız) does not share any of the records without the consents of the users,

unless these are requested or required by laws or courts. e-Pulse (e-Nabız) uses

encryption for all records to protect them.

There is a SMS verification system for all update and delete operations. The system sends

a verification code to the users to complete the update and delete operations.

3.3 Future Functionalities of e-Pulse (e-Nabız)

In the future, following functionalities are planned to be integrated to the system:

All notifications and reminders regarding pregnancy monitoring will be available

with the e-Pulse (e-Nabız).

Users will be able to see their children’s vaccine follow-ups and growth curves.

Patients with chronic diseases will be able to track their doctor visits and they will

be reminded by the e-Pulse (e-Nabız) as their appointments approach.

Deaf citizens will be able to ask for ambulances by using the 122 emergency

button.

3.4 Security and Privacy related with e-Pulse (e-Nabız)

It is seen that confidentiality is an important component of the e-Pulse (e-Nabız) and the

MoH has duly set an encrypted platform on the website. In the system, only people

owning the data and authorized physicians can access the related data; the authorization

can be withdrawn at any time. These systems of electronic access have so far proved a

success in terms of the security of access.

Nevertheless, particularly for mobile signatures or one-time codes sent to GSM numbers,

loss or theft of mobile devices may lead to compromised security for the individual.

However, in terms of system infrastructure the e-government and electronic signature

systems have proven to be reliable in terms of addressing security concerns.



As this system (e-Pulse/e-Nabız) involves a separate website and access by authorized

individuals other than the owner of the health data, we will need to wait and see the

system in action in order to weigh whether the security risks are adequately addressed.

Critically though, Turkey currently does not have a finalized data protection law.

Accordingly, data protection is regulated in a piecemeal fashion by a combination of the

Turkish Constitution and the Turkish Criminal Code.

The Turkish Criminal Code has criminalized unauthorized access to and use of personal

data, therefore if any personal data is accessed or used outside the intended scope of

the e-Pulse (e-Nabız), those identified as the offenders would be sued under the Turkish

Criminal Code.

Nonetheless, as Turkey does not have a data protection law, there are also no separate

provisions defining sensitive data, such as race, ethnicity, sexual orientation or health. As

the data that will be stored within the scope of the e-Pulse (e-Project) will be mostly

regarded as sensitive data, Turkish citizens will not have the additional safeguards that

are afforded to such data in places like the European Union. This, in turn, may lead to

such data being insufficiently safeguarded.

Except for the above facts, in the conditions of use of the platform, the MoH noted that

some data may be used in national or international health research or analysis conducted

for Decision Support Systems but that only authorized MoH personnel will be able to

access the data and that the data itself will be anonymized. This means that there might

be exceptions to the authorized access to personal data.

Finally and disappointingly, the MoH claims a non-liability clause for missing information,

errors or delays in the data, software viruses etc. The MoH notes that the service and

application is provided by the MoH but the data is the responsibility of the institutions,

their personnel and people who update their own data. Such a non-liability clause may

cause problems in the application and implemented infrastructure of the system.

Additionally, coupled with the fact that Turkey does not have a data protection regime,

such a non-liability clause may limit the right of redress of those whose data is affected

by any such incident.

3.5 Legal Case related with e-Pulse (e-Nabız)

The Turkish Medical Association applied to the State Council and filed a lawsuit for the

cancellation of the MoH’s Communiqué, claiming that collecting personal health data with

patient names and identity numbers is against the general terms of data privacy.



The Association supported its claims through a precedent decision of the Constitutional

Court on the cancellation of the provisions of Decree Law no. 663, which authorized the

MoH to collect personal health data.

The State Council made a decision to cancel the Communiqué of MoH of Republic of

Turkey on that as there is no existing pertinent legal structure, particularly considering

the lack of a national law protecting personal data in Turkey.

Current situation is that all related data can be collected and maintained if and only if the

patients clearly permit to do so before any recording and maintenance.

Most probably this issue is to be evaluated when finalizing the Turkish national law

protecting personal data.

3.6 Infrastructure of e-Pulse (e-Nabız)

The e-Pulse (e-Nabız) uses the infrastructure of the Health.NET (Sağlık.NET). Certain

characteristics of the Health.NET are:

An infrastructure based on web technology that transfer standards data from the

first, second, and third step independent software.

A decision support system taking role in decision mechanisms which provides

related information from the center.

A reporting system which provides an ability to track indicators requested from

international organizations, like WHO, EUROSTAT, and OECD.

An infrastructure which enables lawful international data exchange.

Providing citizens ability to let them access and manage their records.

Applications to support national surveillance systems to reach data by using early-

warning systems.

3.7 Integration of e-Pulse (e-Nabız) with Other Systems

Systems integrated with e-Pulse (e-Nabız) and rationales for the pertinent integrations

are given in Table 4.

Table 4 - Systems Integrated with e-Pulse (e-Nabız) and Rationales for Integration

Integrated System Rationale for Integration

Central Doctors Appointment

Systems

To let users make appointments by using the e-

Pulse (e-Nabız).

Tele-medicine and Tele-radiology To let users access radiological images and

reports.



Integrated System Rationale for Integration

Central Census Management

System To access citizens’ specific data and information.

Health Management System

(Health-NET)

To facilitate the collection of data collected in

health facilities.

e-Government Website To provide user authentication to the e-Pulse (e-

Nabız).

Family Medicine Information

System

To access data collected in related health

facilities.

Core Health Resources

Management System

To access data related with doctors and health

facilities.



4. Comparing epSOS (EU), NHS (England), HealtheVet

(USA), HealthHub (Singapore), and e-Pulse (Turkey)

4.1 epSOS (EU)

epSOS is aimed to design, build and evaluate a service infrastructure that demonstrates

cross-border interoperability between electronic health record systems in Europe.

epSOS attempts to offer seamless healthcare to European citizens. Key goals are to

improve the quality and safety of healthcare for citizens when travelling to another

European country. Moreover, it concentrates on developing a practical eHealth framework

and ICT infrastructure that enables secure access to patient health information among

different European healthcare systems. epSOS can make a significant contribution to

patient safety by reducing the frequency of medical errors and by providing quick access

to documentation as well as by increasing accessibility of ones prescribed medicine also

abroad. In emergency situations, this documentation provides the medical personnel with

life-saving information and reduces the (sometimes needless) repetition of diagnostic

procedures.

The goal of the epSOS Large Scale Pilot project is to develop and test (“pilot”) services

that

enable patients to receive medication (ePrescriptions) when they are in another

European country. The medication must initially be prescribed in one of the

epSOS health professional in the patient's home country.

permit health professionals to receive the relevant, translated clinical information

stored in the patient’s home country (“Patient Summary”). This is only possible

in the case of consultation and when the patient gives his/her consent.

epSOS Services are ePrescription

Patient Summary

Integration of emergency services

Integration of the European Health Insurance Card (EHIC)

Patient access to data

The project partners in cooperation with the eHealth Governance Initiative and other

Large Scale Pilots will disseminate the results to all European member states as well as

non-EU countries. Everyone interested will be able to access the results free of charge.

The epSOS pilot project is open to all citizens, physicians, hospitals, healthcare centers

or pharmacists that are living/located in those European countries participating in the

pilot project.



4.2 NHS (England)

Wherever someone visits an NHS service in England a record is created. This means

medical information can be held in various places, including GP practice, any hospital

where someone has had treatment, dentist practice, and so on. At times, this can delay

information sharing which can affect decision making and slow down treatment.

To help improve the sharing of important information about someone, the NHS in England

is using an electronic record called the Summary Care Record (SCR). Since April 2015 all

GPs should offer their patients online access to summary information of their GP records.

A health record (sometimes referred to as medical record) should contain all the clinical

information about the care received. This is important so every healthcare professional

involved at different stages of care has access to medical history, such as allergies,

operations or tests. Based on this information, healthcare professionals can make

judgements about the care going forward.

Health records should include everything to do with care, including x-rays or discharge

notes. The data in records can include:

treatments received or ongoing

information about allergies

medicines

any reactions to medications in the past

any known long-term conditions, such as diabetes or asthma

medical test results such as blood tests, allergy tests and other screenings

any clinically relevant lifestyle information, such as smoking, alcohol or weight

personal data, such as age, name and address

consultation notes, which doctor takes during an appointment

hospital admission records, including the reason admitted to hospital

hospital discharge records, which will include the results of treatment and

whether any follow-up appointments or care are required

X-rays

photographs and image slides, such as magnetic resonance imaging (MRI) or

computerized tomography (CT) scans

If someone is registered with a GP practice in England, she/he will have a Summary Care

Record (SCR) unless she/he have chosen not to have one. SCR contains the following

basic information:

the medicines

allergies

bad reactions to certain medicines



It also includes name, address, date of birth and unique NHS Number which helps to

identify person correctly.

An SCR is used in a number of healthcare settings and will provide healthcare

professionals with any information they wouldn't otherwise have. For example, when

someone is visiting an urgent care center or being admitted to a hospital, staff could view

her/his SCR and discover if someone is on a particular medication or has allergies.

Users can choose to add any information to their SCR that they think will help improve

their care. This can be of particular benefit to patients with detailed and complex health

problems.

If users are a parent or guardian of a child under 16 and feel that their child is able to

understand this information they should show it to them. They can then support them in

the decision to maintain an SCR and whether to include additional information.

Only authorized healthcare professionals directly involved in users’ care can access their

SCR. SCR will not be used for any other purposes. The person viewing SCR:

Needs to have an NHS Smartcard with a chip and passcode,

Will only see the information they need to do their job, and

Will have their details recorded every time they look at record.

In addition, the healthcare professional must seek user’s permission if they need to look

at SCR. If they cannot ask users because they are unconscious or otherwise unable to

communicate, they may decide to look at record because doing so is in best interest. This

access is recorded and checked by the Privacy Officer of the organization to ensure it is

appropriate. Users can choose to opt out of having an SCR at any time. If someone do

opt out, she/he need to let her/his GP practice know by filling in an opt-out form.

4.3 HealtheVet (USA)

Using My HealtheVet can help users gain a better understanding of their health status. It

allows users to explore different ways they can monitor and improve their health.

When users use the tools on My HealtheVet, they become a more active partner with

their health care team. Working hand in hand with health care team and sharing

information may help them better understand personal healthcare needs.

The great benefit is that users can easily access their personal health information in their

My HealtheVet account - anytime and anywhere they have Internet access. Their

information is available to them at their convenience, 24/7.



My HealtheVet is VA’s online personal health record. It was designed for Veterans, active

duty Service members, their dependents and caregivers. My HealtheVet helps users

partner with their health care team. It provides opportunities and tools to make informed

decisions and manage health care

Specific features in My HealtheVet are available to users based on their account type. All

users who have a Basic account are able to view their self-entered information. If user is

a VA patient, she/he can upgrade account to Advanced or Premium.

Among the newest features available to Veterans with a Premium Account include VA

Notes. These are clinical notes that health care team records during appointments or

hospital stays. Also available are VA Immunization records, more detailed lab reports and

a list of current medical issues. These features are in addition to prescription refills, VA

Appointments and Secure Messaging.

My HealtheVet’s Blue Button feature allows users to view, print, or download and store

information from their personal health record (PHR). Then everything is all in one place

and viewable whenever they need.

By organizing and accessing medical records, the VA Blue Button helps users better

manage their health care needs and communicate with health care team. With the Blue

Button, users can download PHR and share it with VA and non-VA providers. This helps

them get the big picture of health and inform them how doing in reaching treatment

goals. Users can download record either as a PDF, text file or customizable Blue Button

file. Users can select the date range and the categories of information they wish to

include.

Users can start building their PHR by self-entering personal information, such as their

health history, emergency contacts and medications. They can monitor vital signs and

use the journals to track their diet and physical activity.

Then when users click the VA Blue Button, they can view all the data. If user is a Veteran

who receives care from VA, she/he can set preferences so that some VA and/or DoD

records feed into VA Blue Button copy of PHR, such as military service information.

Downloadable PHR can show:

Information for emergency contacts, health care teams and insurance providers,

Over-the-counter medications, allergies, military health history, medical events

and lab tests,

Daily records in diet and physical activity (exercise) journals, and

Recorded Vitals & Readings (blood pressure, blood sugar, cholesterol, heart rate,

body temperature, weight, pain level, etc.).



My HealtheVet users who are registered as a ‘VA Patient’ can also see:

Military service information from VA and/or DoD records and

Prescription history.

Users can make their PHR even more beneficial by upgrading to a Premium Account. This

level gives them full access to My HealtheVet features, including Secure Messaging with

VA health care team. When users download their data with the VA Blue Button, they can

also view information that VA/DoD has added into health record, such as:

VA Chemistry/Hematology/Microbiology Lab results – the results from lab tests

Information on VA Appointments– the details of recent and future appointments

at VA medical centers

VA Immunizations – a history of the immunizations received through VA

VA Problem List – a list of active health conditions and symptoms

VA Notes – the clinical notes that health care team records during appointments

or hospital stays

VA Admissions and Discharges including discharge summaries-a list of admissions

and discharges plus the detailed summary documented by health care provider

when discharged from the hospital

A number of smartphone apps are also available through a variety of non-VA sources.

While VA doesn’t endorse specific apps, there are now creative, secure and easy-to-use

ways of viewing Blue Button data. Search for “Blue Button” in smartphone apps library to

learn more.

My HealtheVet offers three account types:

Basic

Advanced

Premium

Basic Account - Anyone who registers on My HealtheVet starts with a Basic Account. This

account does not require that users have their identity Authenticated. A Basic Account

provides limited access to features in My HealtheVet that users self-enter. Users may use

the journals and other tools to track their health measures. However, users cannot see

their personal information located in VA or DoD systems.

With a Basic Account users may use My HealtheVet to:

Add information to a personal health journal about over-the-counter medications,

allergies, military health history, medical events, tests and allergies

Record and track personal information such as contact information, emergency

contacts, health care doctors and providers, and health insurance information

Record and track personal health measurements (blood pressure, blood sugar,

cholesterol, heart rate, body temperature, weight, pain level, etc.) in Vitals &

Readings



Print a wallet ID card with the personal information entered into the personal

health record

Set personal goals. My Goals makes it easy for users to set Goals, identify their

Strengths and Tasks, to overcome Obstacles, and track their progress. My Goals

can be used to help user’s health care team understand what is important to

them.

Users can use the VA Blue Button (Download My Data) to view, save, print or

download and save self-entered information; then share this with caregiver, non-

VA provider or others they trust. Self-entered information may include:

o Activity Journal, Self Reported

o Allergies, Self Reported

o Family Health History, Self Reported

o Food Journal, Self Reported

o Health Care Providers, Self Reported

o Health Insurance, Self Reported

o Immunizations, Self Reported

o Labs and Tests, Self Reported

o Medical Events, Self Reported

o Medications and Supplements, Self Reported

o Military Health History, Self Reported

o My Goals: Current Goals, Self Reported

o My Goals: Completed Goals, Self Reported

o Treatment Facility, Self Reported

o Vitals and Readings, Self Reported

Advanced Account - This account is only for Veterans and/or VA Patients. It is a higher

level of access to features offered in My HealtheVet. It provides users the ability to view

some information in VA and/or DoD records. This account does not require that users

have their identity authenticated. However, when users register as a VA Patient, their

profile information is linked to VA/DoD records. When this happens, users are given an

Advanced Account. If users are a VA patient, this type of account lets users refill their VA

prescriptions online using My HealtheVet.

Premium Account - This account is only for Veterans and/or VA Patients. It gives users

the highest level of access to My HealtheVet features. To get this type of account users

need to go through authentication and have their My HealtheVet profile information (full

name, Social Security Number (SSN), date of birth (DOB) and gender) linked to VA/DoD

records. After users register, users’ account type will be displayed in the Member Login

box. Those with a Premium Account will have Premium Account Icon after their name.

With a Premium Account users may use My HealtheVet to view key portions of VA health

record, such as:



VA Admissions and Discharges (including discharge summaries) - Discharge

Summaries are available 3 calendar days after they are completed.

VA Allergies

VA Appointments (future)

VA Appointments (limited to past 2 years)

VA Demographics, VA Electrocardiogram, and VA Immunizations

VA Laboratory Results: Chemistry/Hematology/Microbiology - VA Laboratory

Results

VA Medication History

VA Notes - VA Notes written from January 1, 2013 forward are available 3

calendar days after they have been completed and signed by all required

members of VA health care team.

VA Pathology Report: Surgical Pathology/Cytology/Electron Microscopy. VA

Pathology Reports are available 14 calendar days after they have been

completed. Some studies done at a non-VA facility may not be available or they

may not necessarily include an interpretation.

VA Problem List - VA Problem List contains active health problems VA providers

are helping to manage. This information is available 3 calendar days after it has

been entered. It may not contain active problems managed by non-VA health

care providers.

VA Radiology - Report is available 3 calendar days after it has been verified by

members of the VA health care team

VA Vitals and Readings and VA Wellness Reminders

VA electronic health record information such as VA Continuity of Care Document

(VA CCD) and other information as it becomes available

Department of Defense (DoD) Military Service Information

In addition users may be able to:

Use the VA Blue Button to view, save download and/or print VA health and DoD

Military Service Information. Users can also share this with their caregiver, non-

VA provider or others they trust.

Download user’s VA Continuity of Care Document (VA CCD). This is a standard

electronic exchange document, used for sharing patient information. The VA

CCD will be a summary of important health information from the Veterans VA

Electronic Health Record.

Use Secure Messaging to communicate online with VA health care team. Users

may send messages to request or cancel VA appointments. Use it to ask about

lab results or find out about a medication or health issue. Or simply to discuss

other general health matters.



4.4 HealthHub (Singapore)

HealthHub is a one-stop portal and mobile app for Singaporeans to access a wide range

of health content, deals, rewards and e-services.

HealthHub designed to empower Singaporeans to take greater ownership of their health

and wellness through the online access of personalized health records, better health

literacy and adoption of healthy lifestyle practices.

HealthHub is an initiative by the Ministry of Health, and Health Promotion Board,

supported by Ministry of Health Holdings, Integrated Health Information Systems and

public healthcare institutions including:

Agency for Integrated Care

Alexandra Health System

Eastern Health Alliance

Health Science Authority

Jurong Health Services

National Healthcare Group

National University Health System

Singapore Health Services

HealthHub allows users to access their health records, and the health records of their

children's information. Apart from viewing their screening and lab test results, users can

view their children’s school health and immunization records.

HealthHub provides:

Immunizations records

Health screening

Lab test results

Discharge information

Medical appointments

School health assessments

HealthHub lets users look up the health information they need. A-Z takes users to the

glossary displaying information on local health topics. Users can locate nearby healthcare

and lifestyle facilities, providers and suppliers in Singapore with the Directory.

HealthHub provides users to discover interesting and useful health information for the

stage of life they are in. HealthHub pulls together articles and features about health

concerns relevant to user’s age, gender, and role. Users can check out current events

and news with What’s On. HealthHub Deals brings together deals for activities, health

equipment, meals, exercise facilities, and classes.



4.5 Results of Comparison regarding epSOS (EU), NHS

(England), HealtheVet (USA), HealthHub (Singapore),

and e-Pulse (Turkey)

Regarding epSOS (EU), NHS (England), HealtheVet (USA), HealthHub (Singapore), and

e-Pulse (Turkey), specific features and function of each are listed in detail in above

sections. However, Table 5 provides the overall comparison results of these. Additionally,

Table 6 provides the comparison results of these with respect to functionalities.

Table 5 - Results of Comparison regarding epSOS (EU), NHS (England), HealtheVet (USA), HealthHub (Singapore), and e-Pulse (Turkey) with respect to General Characteristic

Dimension epSOS NHS Healthe

Vet

Health

Hub

e-Pulse

Free of charge Y Y Y Y Y

In full operation NY Y Y Y Y

Users can view

and manage

records

Y Y Y Y Y

Users can

manually enter

records

Y Y Y Y Y

Users can delete

records

Y N Y N Y

Mobile application

is available

N N Y Y Y

Privacy and

security

addressed

Y Y Y Y Y

Integration with

other health

services

NY Y Y Y Y



Dimension epSOS NHS Healthe

Vet

Health

Hub

e-Pulse

Owned and

maintained by

government

NY Y Y Y Y

Conforms a

relevant Data

Protection Act

N Y Y Y NY

Offers different

account types for

users (patients)

N N Y N N

Provides opt-out

option

Y Y Y Y Y

Integration with

sport, fitness, and

health devices

N N N N Y

Table 6 - Results of Comparison regarding epSOS (EU), NHS (England), HealtheVet (USA), HealthHub (Singapore), and e-Pulse (Turkey) with respect to Functionalities

Functionality epSOS NHS Healthe

Vet

Health

Hub

e-Pulse

View the details

about health

facilities visited

with branch, time,

receipts, doctor

details, and

medicines

information

+ + + + +

Record and

update side

effects

information about

the medicines

+ + + + +




Vet

Health

Hub

e-Pulse

View test results,

reports, and

medical images

with their reports

+ + + + +

Record and

update medicine

allergies and

other allergies

+ + + + +

Make

appointments

- - + + +

Add notes to their

appointments.

+ - + - +

Integrated

calendar

+ + + + +

Share records

with others or

doctors with the

conditions set

- - + - +

Track when the

records that

shared are

accessed with

related people

- - - - +

Messaging

capability that

users can use to

communicate

- - - - +

Evaluate and rate

on the health

services and

comment on

these.

- - - - +




Vet

Health

Hub

e-Pulse

Either manually or

automatically add,

modify, and

delete their blood

pressure, blood

sugar, pulse, and

weight data.

- - + + +

Sends reminders

to the patients

regarding

medicines to take

- - - - +

Emergency button - - + - +

Pause or

completely

terminate/remove

accounts

+ + + + +

Certain mobile

devices and

applications can

be integrated

- - + - +

Encryption for all

records to protect

+ + + + +

SMS verification

system for

operations

- - - - +

ePrescription + + + + +

Patient Summary + + + + +

Integration of

emergency

services

- - + - +




Vet

Health

Hub

e-Pulse

Integration of the

European Health

Insurance Card

(EHIC)

+ + - - -

Set personal goals - - + - -

School health

assessments

- - - + -

Articles and

features about

health

- - - + -



5. Future Works

Following works can be done in the future in the direction of improving the information

and knowledge distilled and presented in this report:

Searching for the international standards and regulations, and evaluating the

related systems (epSOS, NHS, HealtheVet, HealthHub, and e-Pulse) with respect

to clauses covered in the related standards and/or regulations.

Searching for the data protection laws in the context of health data and

information of certain countries, and comparing and contrasting them.

Gathering statistics about the usage and benefits of the related systems (epSOS,

NHS, HealtheVet, HealthHub, and e-Pulse), and comparing and contrasting them.

Searching for an inclusive answer for the question of how different countries find

solutions regarding the privacy and confidentiality of the systems in the context

of e-health.

Searching for security breaches in healthcare and theoretically testing these for

related systems (epSOS, NHS, HealtheVet, HealthHub, and e-Pulse), and

comparing and discussing results.

mustafa degerli - 2016 - e-health and e-pulse - report

Health & Medicine