Revitalising Primary Healthcare in the Information Age : Joan Dzenowagis, Diana Zandi, Misha Kay eHealth Unit, World Health Organisation

The Internet and World Wide Web have evolved from an information highway, to an enormous virtual library, to a platform for global enterprise and well beyond. ICT has changed the way we communicate, seek information, conduct business and commerce, share data and build knowledge.

Technology is changing the rules

At the time of Alma Ata when the World Health Organisation called for a global commitment to Health for All, the world was on the brink of the information revolution. In the 30 years since then the rapid growth and broad diffusion of information and communication technologies (ICT) have had a profound impact on society and the lives of people in all countries. The world has come to rely on connectivity and increasingly sophisticated software to support its financial networks, just-in-time food supply chains, news and information services, and connected global transport systems. The Internet and World Wide Web have evolved from an information highway, to an enormous virtual library, to a platform for global enterprise and well beyond. ICT has changed the way we communicate, seek information, conduct business and commerce, share data and build knowledge. By changing the means and ease of sharing knowledge and information these technologies have transformed the world in ways never imagined in 1978.

The impetus for the rapid diffusion and uptake of ICT around the world is clear. Catalysed by government incentives and businesses opportunities, investment in ICT reflects a belief in the potential of markets to drive development. Technology is becoming more readily available, access to information is possible and affordable, and consumers are embracing mobile phones, online social networks, and similar tools of the information society. Their expectations and behaviour, such as online purchasing, information seeking and sharing are changing the rules and the relationships between consumers, professionals, industry and government. This is happening in all sectors, including healthcare. However, there are many left behind, as the “digital divide” remains a reality within and between countries. What impact can these technologies have on health, and on primary healthcare in particular? And given the reality of the digital divide, what can be done to ensure that everyone benefits?

The primary healthcare approach

Revitalising primary healthcare calls first and foremost for a renewal of the principles and values, which underpin it. At its core, primary healthcare is a commitment to equitable and affordable care for all people, ensuring citizen-centred services needed to live a healthy and productive life. The World Health Organisation considers primary healthcare as “an approach to organising health systems.” And in the information age, ICT must be central to this.

Highlights of the primary healthcare approach:

  • Reaching all people, enabling care for everyone, where ever they live.
  • Reform of health services towards citizen-centred care, involving people in their health.
  • Engaging all sectors, recognising the role of others in supporting health.
  • Leadership and effective, responsive government.

Care for everyone

Reaching all people is a fundamental element of primary healthcare. Yet some countries, chronically burdened across the spectrum of government obligations, have a diminished ability to provide even basic health services. In particular, countries in conflict and transition or those affected by natural or man-made disasters require external aid and technical assistance. Strategic use of ICT can help governments coordinate aid, reach out to citizens and put in place measures to support displaced persons by anticipating needs and facilitating planning for personnel, equipment and supplies. The extensive use of ICT in coordinating the global response to the Asian tsunami in 2004, and the China earthquake in 2008 provide important lessons in this respect. For example, ICT was used to relay updates on health conditions, facilitate delivery of water, food, supplies and medicines, and to connect to experts for remote consultation. Whether for immediate assistance or follow-up care, ICT provided critical support for reaching those in need with the basics of care.

Improving healthcare delivery

Telemedicine and related terms refer to a spectrum of ICT applications with the potential to improve access to care by linking patients and professionals where distances may be great and local expertise limited. Many of the early technological problems of telemedicine have been resolved and the bandwidth and infrastructure situation continue to improve. Today the main obstacles to realising the potential of telemedicine have more to do with the policies, training and business models that will facilitate its integration into existing primary care services and its responsible, sustainable use. Challenges in ensuring this include financing initial equipment purchase and ongoing operating costs, establishing policies to protect patient privacy and confidentiality, and resolving questions of data ownership, liability for care delivered, and payment-for-service models.

The European Union has transformed the concept of “access to care” to include the right of its citizens to receive care in any country in Europe. A landmark Directive, issued in July 2008 stipulates, “provision of cross-border healthcare does not necessarily require either the patient or the professional to physically change countries, but may be provided through information and communication technologies”. In establishing the legal and policy basis for doing so, they have opened the door to using ICT to improve access to care in Europe. The world will be watching how this unfolds and will be taking careful note of its impact on healthcare, including the effect on cost, safety and patient satisfaction.

Towards citizen-centred care

Early uses of ICT in health facilities focused primarily on the efficiencies to be gained in areas such as administration, finance and supply chain management. To be sure, these applications are fundamental to containing costs, ensuring adequate supplies and managing the day-to-day facility operations. But the use of ICT in primary care extends well beyond these fundamentals.

Relationships between professionals and patients are changing as patients become more informed, and begin to experiment with using ICT to manage and monitor their chronic conditions. No longer considered the sole authoritative source of information, health  professionals increasingly act as “infomediaries” in interpreting  information and guiding patients to online resources.

Every health centre and health professional needs information to act and to communicate effectively, in order to do their job well. This also applies to individuals, who need to be informed and active in their own healthcare. As technology based health services continue to be introduced, user expectation grows accordingly. There are a myriad of ways in which ICT can be used in primary care. Whether sending text messages to patients to remind them to take their medications, allowing online scheduling of appointments, monitoring chronic diseases at home, or sending test results to specialists for interpretation, technology can make health services more efficient, personalised and reliable.

Health professionals are adapting to new roles shaped by ICT. Relationships between professionals and patients are changing as patients become more informed, and begin to experiment with using ICT to manage and monitor their chronic conditions. No longer considered the sole authoritative source of information, health professionals increasingly act as “infomediaries” in interpreting information and guiding patients to online resources. They are using technology to monitor patients at home, consult via eMail, and receive automatic alerts when laboratory results are out of the expected range. In this age of social networking, professionals are sometimes bypassed completely as patients connect with online communities and resources for self-diagnosis and self-prescribing of medications. A revitalised approach to primary care recognises the greater role that patients play, and will use ICT to enhance this role by providing information and guidance, thereby treating the patient as a full partner in their own care.

Examples of ICT in health
ICT in public health practice ICT in healthcare and laboratory practice
Identify disease and risk factor trends Track and provide patient information
Model diseases in populations Enable communication between patients and professionals; deliver training
Analyse demographic and social data Deliver services despite distance and time barriers via telemedicine
Access research, publications and databases Standardise ordering and delivery of drugs and supplies
Monitor and communicate potential threats to health Monitor care, quality and safety in all settings, including the home
Adapted from: Dzenowagis J (2005). Connecting for Health: Global Vision, Local Insight. Report for the World Summit on the Information Society; WHO, Geneva.

ICT is also changing primary care through its impact on professional and research communities. The adoption of facility-based tools such as electronic medical records and e-prescribing enables more responsive, integrated and safer care. Professional tools such as decision support systems, resources such as journals and databases, and the possibility to be connected to a network of professionals further support the delivery of care. And in the same vein, large-scale computing initiatives such as “grid” are bringing the power of supercomputing to solve long-standing challenges in health, towards improving diagnostics and better targeting therapies and drugs. This ultimately leads to more personalised care and more effective patient management in primary care services.

Engaging all sectors

The interdependence of the sectors and thus the need to engage others in supporting health has never been more evident or more realisable. The uses of ICT are common to all sectors: gathering, analysing, managing and exchanging information; expanding knowledge, linking systems, enabling research, improving capabilities, communicating and coordinating. As the World Summit for the Information Society began in 2003, the then-United Nations Secretary General Kofi Annan said this about the transformative potential of information and communication technologies:

  • “From trade to telemedicine, from education to environmental protection, we have in our hands, on our desktops and in the skies above, the ability to improve standards of living for millions upon millions of people”
  • To realise this potential requires that the health sector engage fully with the technology sectors telecommunications and information technology to bring the power of communications to every single health centre, healthcare provider, and citizen.

Leadership and effective, responsive government

As eGovernment initiatives around the world have shown, ICT supports transformation and revitalisation. Where the strategic objective is that governments are well managed, accountable, and resources are allocated to achieve results, different functions are aligned towards ensuring that government acts as one. Information “interoperates” rather than resting in silos. Practices, approaches and tools are shared. There is clear accountability, efficiency and relevance to meeting people’s needs.

In the same way, citizens interacting with their modern health services should be able to receive consistent, reliable information and services. In using technology to achieve this goal many stakeholders benefit: citizens have ease of access, transparency and seamless service; management is effective, efficient and focused; employees have pride and job satisfaction; officials can better use tax money, improving public trust; successful government initiatives depend on social consensus on major actions, which means that citizens need to be included in the debate on values, goals and approaches. ICT enables citizens to be informed, to participate, and to speak from a common knowledge base.

Ensuring solutions equal to the challenges

The WHO eHealth Strategy, approved by 192 Member States at the World Health Assembly in 2005, has citizen-centred care at its core. It represents a recognition of the growing contribution of ICT and a willingness on the part of governments to facilitate the adoption of these technologies in health services and systems. Countries all around the world are faced with prioritising investments, providing safe, cost-effective care and ensuring the education, deployment and management of personnel. As they strive to take advantage of ICT in health they face a number of issues, which parallel those faced years ago with the incorporation of ICT into systems such as banking. Chief among them, for example, is to ensure that regulatory and legislative systems support consumer protection, privacy and confidentiality, while enabling information sharing where needed. This requires foresight and action.

In addition, the global nature of ICT means that there are shared challenges worldwide. Agreeing on mechanisms to improve health Internet quality and cooperating on protection measures against Internet fraud are but a few. Left unresolved, these and related issues will not only hinder effective implementation of primary healthcare. They will also limit the true potential of primary healthcare to take advantage of the opportunities offered by the information age.


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