GLOBAL INTELLIGENT NETWORK AND HEALTH Executive Summary The Global Information Infrastructure is enabling telehealth applications which are creating opportunities for improving health at the local, national, and international levels. In addition to addressing present day health problems, the establishment of the Health Information Infrastructure on a global scale greatly increases the likelihood that the macro health challenges of the early to mid 21 Century -- such as overpopulation, environmental degradation, and social crisis -- will be addressed early on, while providing opportunities for bettering individual and community health and human prosperity globally. Without the systematic creation and implementation of the health information infrastructure on a global scale, there is a danger of expanding disease trends and social crises that could potentially lead to catastrophic decreases in human populations before the middle of the 21st Century. The task at hand is to build a comprehensive health information infrastructure and health communications tool sets that improve the outcomes of national and international health systems, as well as prevent and manage the social crises associated with global change. Introduction Never before in history have greater numbers of humans enjoyed a longer life, enabled by a rapidly expanding functional life capacity, less encumbered by disease. For example, the naturally occurring incidence of polio has disappeared from the Western hemisphere. Smallpox has been wiped from the face of the earth. Most infectious diseases are in steep decline in the Northern Hemisphere. In developed nations, progress is being made in addressing the problems of chronic illness. In terms of functional life capacity, tens of millions of our contemporaries will travel many times as much as Marco Polo and write more than William Shakespeare. Technology is allowing us to communicate globally with great flexibility. For those wearing personal status monitors [a device worn on the body that monitors vital signs and uses a GPS [global positioning system)], health status can be checked and location can be identified within a nine meter radius anywhere in the world. Tens of millions, enabled by rapid access to knowledge, cognitive tools, and organizational support, are now actualizing their human potentials at levels of health and human prosperity only achieved by a handful of elite, historically. This trend has the potential for being maintained and rapidly expanded to a broader set of countries and subpopulations. Unfortunately, hidden behind the splendors of advancing development enjoyed by so many today, there is also an unprecedented level of human suffering and the potential for social crisis and catastrophic declines in human health. The symptoms and manifestations of these problems and potential catastrophes are already apparent in the inner cities of the most developed countries as well as throughout the most underdeveloped nations in the world today. Humankind will be faced with immense and complex challenges (e.g., overpopulation, environmental degradation, poverty, social crisis) in the coming decades, which will require transformative methods and tools to resolve. For example, it took all history until roughly 1800 A.D. to reach 1 billion people on the earth. At present trends, almost 1 billion more people will be added every decade, when averaged over the next five decades. Already, the world grain reserves of the past few decades are gone. Over a billion and a half people -- and almost 40% of the worldís children -- live in poverty, hunger, and disease today. Without systematic intervention, these problems will unquestionably worsen at an accelerating pace. There are serious considerations regarding whether these trends are sustainable over more than a few decades. Increasing numbers of scientists, politicians, health practitioners, and other professionals are raising concerns regarding mounting social crises and the possibility of die-offs of billions of people associated with extending beyond global carrying capacity (the ability of the earth to sustain human numbers) before the middle of the 21st Century. Addressing these macro challenges will necessitate innovation and transformative strategies deployable globally on a massive scale across four dimensions of human activity: 1) science; 2) information technologies; 3) policy; and 4) the consciousness of the public and the communities they live in. The global intelligent network is one of our most important transformative tools in the process of shifting toward forms of sustainable development and sustainable security that will protect health and expand human prosperity in this time of increasingly turbulent change. The Global Intelligent Network or Global Information Infrastructure (GII) can be thought of as a human/machine network, which today resembles in many ways a nascent planetary nervous system. The GII is already present in 82 countries. In the form of the internet alone, it is used by more than 36 million people internationally and is expanding at an exponential rate in most sectors of the world today. The health component of the GII, which is often referred to as the Health Information Infrastructure (HII) can enable and dramatically improve: 1) the practice of knowledge-enhanced telehealth and medicine; 2) the constructive reengineering of national and international health systems; 3) the creation of local, national, and global markets for the exchange of health products and services; 4) a continual iterative decentralized improvement of health and human prosperity; 5) the protection of the biodiversity of ecosystems; as well as 6) the prevention and management of social crises. Well placed efforts -- such as those of the GII Commission -- could further reinforce these potentials by increasing the speed and likelihood of broad diffusion of these health benefits from the GII. The Gutenberg press led to the Renaissance, which contributed to vast improvements in health and quality of life enjoyed in highly developed communities and societies today as a result of an order of magnitude increase in literacy and educational accomplishment. The Global Intelligent Network offers us the potential for another quantum leap in health, quality of life, and functional life capacity. These benefits of the GII, however, will only be realized and sustained if the Global Intelligent Network is designed to simultaneously address the impending macro challenges we must now collectively face on a global basis. The Emerging Health Information Infrastructure The Global Intelligent Network is already supporting a great number of telehealth and medical applications. In addition, it is beginning to aid in the monitoring, prevention, and management of the socio-ecological factors that are involved in determining the publicís health. The term, "social ecology" is used here to refer to the complex web of social interaction, environment, and infrastructure which heavily influences the well-being and productivity of societies and their inhabitants as related to such concerns as jobs, societal vision, economic market development, communication patterns, services, individual and community aspirations, personal and political relationships, and diffusion of technology. Socioecological factors -- more so than medical care or public health -- determine the health differences observable between countries (e.g., Japan, the Sudan and the United States). Through the use of advanced computing and communications as well as the emerging methodologies of the sciences of complexity, a broader set of professionals, policy makers, and the public are beginning to understand how we can intervene on these socio-ecological factors as major determinants of health and disease. As a result, "telehealth" (the extension of health services through the use of advanced computing and communications) includes, yet augments traditional medical approaches with a broader set of interventions. These seven levels of telehealth applications are also sometimes referred to as the elements of the health component of the GII, or in other words, the Health Information Infrastructure (HII). Below are listed the most commonly referred to elements of the HII:
These seven elements of telehealth are built upon work done in the international medical informatics community. This framework draws heavily from the 1992 and 1993 National Health Information Infrastructure Plenaries, the National Academy of Science task force on the National Health Information Infrastructure, the White House Task Force on Health Care Reform, the Health Information Infrastructure Consortium, the work of the International Medical Informatics Association, and several other U.S. and international efforts. An abbreviated description of the health information infrastructure is discussed below. Administrative Information Systems Administrative information systems enable the exchange of electronic unified claims form and other forms of electronic data interchange and electronic transaction services for health care administrative transactions and inventorying. Many billions of dollars are already beginning to be saved in the United States and Europe through the adoption of these systems. Clinical Information Systems Systems for accessing, storing, and transmitting medical information allow patient records to be accessed instantaneously anywhere in the world by authorized personnel. Clinical practice and decision-making is already beginning to be greatly enhanced with improvements in clinical information systems. Broadly available, interoperable clinical information systems would be a major contribution to improving quality of care, while reducing cost. Telemedicine Telemedicine in the form of telementoring and teleconsultation greatly enhances inter-health facility consultation and resource sharing. Over time as the infrastructure bottlenecks diminish, the great benefits of these services will be achieved in medical underserved areas. Telemedicine is already allowing, for example, rural practitioners to more effectively treat patients that would otherwise have to be transferred to urban medical centers where there is a greater aggregation of expertise and technology in the rural areas. This capability is also being extended to the workers of multinational corporations engaged in business in countries with less developed health systems. For example, some of the best expertise and technologies of the Harvard-based medical centers are being deployed by multinational oil companies in the remote deserts of Northern Africa. Even greater benefits will be achieved in the longer run from home-based telemedicine. Home-based telemedicine allows health professionals to monitor and interact with patients remotely via a system that merges the computer, video and telephone. This often includes telemetry (devices to monitor physiological functions remotely), network functionality, two-way video applications, and data aggregation and analysis. There are already strong indications that these home-based telemedicine services will have a significant impact on the reduction in clinical visits and hospital stays and their associated costs. Personal Health Information Systems Interactive systems are beginning to make personalized health information available to Americans 24 hours a day, 7 days a week. This is enabling the public to make better decisions about their health. These systems support functions such as self-triage, self-care, health risk assessment, personal health records, prevention, and health promotion accessible directly by the public via multimedia. Managed care organizations are adopting these personal health information systems to lower costs through demand management by directing beneficiaries to more appropriate, less costly services. Savings result from (1) reductions in unnecessary professional care; and (2) increases in health promotion and disease prevention, which reduce the total burden of illness. Disease management approaches are also adopted to help those with chronic illnesses (e.g., asthma, diabetes, heart disease) to improve outcomes by augmenting traditional medical care with information and upstream and downstream interventions (health services performed before clinical manifestations appear, as well as self care and alternative care provided in association with medical care). Over the next decade, these measures are collectively projected to hundreds of billions of dollars in the delivery of medical services. As a result, resources can be freed up to better address other types of health-related problems that are so important to health on the international level. Population Health Interventions and System Coordination These elements of the HII are enabling researchers to instantaneously, reliably and systematically aggregate data -- without personal identifiers -- from medical records and personal health information systems with protection of privacy and confidentiality. The resulting improvements in population sampling and data accuracy is already beginning to enhance outcomes research and surveillance of epidemics and endemic disease patterns in Europe and the Americas. The World Health Organization is working diligently to distribute population- based systems to address the needs of all nations, but especially those at highest risk and in most need of health solutions. Use of these types of systems to better prevent and control of diseases, as well as coordinate the provision of prevention efforts and medical care has been explored at the WHO- sponsored Helena Conference in regards to the needs of Africa. Already a handful of interventions have started in Africa. For example, the internet and low earth orbiting satellites are being used to track incidence of onchoscerciasis (river blindness) and the proliferation of black fly populations (the carrier of the disease). Interventions are planned, which kill the black flies in the environment before they ever infect humans, based upon satellite imaging of water levels in rivers and surrounding ground areas. The Centers for Disease Control are also deeply involved in the use of population data for disease surveillance. They are disseminating tools, methods, and information globally through their INPHO and CDC Wonder programs via the internet. These types of efforts will over time provide a fairly accurate definition of health and disease status and health service delivery in many parts of the world with decentralized analysis extending down to the neighborhood level and up to the city, region, national, and global levels. The development of the Healthy Cities Communications Toolbox will be particularly important in disseminating low cost mechanisms for disseminating population health approaches world-wide. Community Networks Community Networks will play a crucial role in the design, implementation, and evaluation of health services and health systems internationally. They enable the discussion of broader issues of public access and participation in improving community conditions impacting health and human prosperity. All aspects of the health information infrastructure will benefit from strong local infrastructure and participation. Community networks, more than any other element of the health information infrastructure, will help involve the public, professionals, and policy-makers in issues of social ecology and management of the local, regional, and global commons. Greater emphasis must be made on establishing a common core minimal datasets and common principles of interoperability and interconnectivity, so that data can be collected at the local level and be aggregated and disaggregated from the neighborhood to the city, the city to the national level, and the national level to a global level. As a result, data-rich geographic information systems and simulation systems embedded in the world- wide web can be developed to monitor and avert social and health crises in vulnerable communities and regional areas. The Healthy Cities Movement, which started in 1985 and now is 2500 cities strong world-wide, provides a useful mechanism for the growth of health commuications hubs based upon health communications toolsets globally. One of the challenges we presently face in properly building out the full manifestation of the health information infrastructure and telehealth is that many people are only proposing to use of the new information technologies to provide old medical approaches more efficiently. Whereas, the greatest contributions of telehealth are likely to be in health applications that could never have been conceived of, let alone be implemented, without advanced information technologies. Personal health information systems, population health, system coordination applications, and community networks hold extraordinary promise of helping us address the underlying factors determining health and disease that today remain largely unaccounted for. It is probably in these newer, more transformative elements of the health information infrastructure that we will find the greatest contributions to preventing and managing the macro health challenges of the early 21st century. Shifts in Social Ecology The social and ecological factors contributing to health status are complicated and have defied most attempts by 20th century science to accurately measure, define, and intervene upon them. In the past, when people accepted the great uncertainties of life and health, it was not assumed that these factors were controllable except through divine intervention. Today, however, citizens of developed nations have come to expect good health and reasonably reliable means of preventing and treating illness. In relatively stable conditions, social and ecological conditions are often ignored. In times of rapid change, significant subpopulations often have difficulty coping with changing conditions and, as a result, their health is compromised. Two major shifts in social ecology (i.e., the shift from the Industrial Age to the Information Age and the approach of global carrying capacity as human population goes from 5.5 billion to an expected 11 billion) as well as an increasing number of social crises (e.g., Los Angeles riots, the former Soviet Union, Somalia, Bosnia, Rwanda, Haiti, Cuba) are waking ever greater numbers out of their complacency regarding the importance of social and ecological conditions. The massive anticipated shifts in social ecology, likely to take place over the next few decades, will have a dramatic impact on health. The transition to the Information Age has already impacted the lives of tens of millions. The approaching counterpressures of global carrying capacity have begun to foreshadow health crises for billions of people alive today. These enormous challenges -- which pose both opportunities and threats to health -- are still largely going unaddressed. The role of socio-ecological interventions will still take many years to build into health systems internationally. However, the process has begun. The Global Intelligent Network has become a major catalyzing force in our efforts to deal with the issues of social ecology as major determinants of health status. New GII tools are rapidly emerging to define, monitor, assess, and successfully intervene to change the key socio-ecological conditions that pose the major threats to continued expansion of improved health in the 21st century. The next section on advanced informational interventions will describe some of the emerging GII tools in the context of the a global network of community health communications hubs. Advanced Informational Interventions There is a need for focused international efforts to explore and engage the potentials of the emerging sciences of complexity and information technologies to ensure the reaping of crucial opportunities to better understand and intervene upon the social and ecological determinants of health. The new approaches of the sciences of complexity and community health communications hubs embedded as nested subsystems of a global intelligent network -- which model health and human prosperity in real time -- are critical to addressing the key macro challenges of the early to mid 21st century. The nature of the global intelligent network, its probable evolution, the structure of its components, telecognition (i.e., network-enhanced cognition and collaborative decision making), and the values embedded within the seeds of telecognition must be explored with far greater intensity in light of their potential impact on improving health as well as preventing and managing social crises on the local, national, regional, and global levels. The community health communication hub, is one type of strategic development which may provide significant new avenues for addressing socio-ecological problems and crises by:
Community health communications hubs, built upon health communications toolsets, are beginning to emerge in pilots, often facilitated by the Healthy Cities movement. The underlying toolsets are still in a nascent form. However, early designs for globally scalable community health communications hubs seem to indicate a likelihood that the following modular tools and software engines might be included in an interoperable health communications toolset: intelligent agents; core datasets; community assessment; geographic information systems; object-based interdisciplinary data warehouses; browsers; search engines; heuristic engines, community knowledge bases; simulation; groupware; and multidirectional interactive communications. Several groups are now rising to the challenge of designing, testing, and integrating these toolsets within an interoperable infrastructure. Policy Implications Over the past two and a half years, the Health Information Infrastructure (HII) Consortium (a group made up of 110 U.S. based and multinational institutions) has identified approximately 25 policy and marketplace development factors crucial to the fully enabled health information infrastructure. The factors established as being most catalytic for the United States during the 1996 and 1997 time frame are as follows:
These catalytic policy issues are similar but not identical to HII policies being considered in advanced information-rich economies throughout Europe, Asia, and Pacifica. However, when considering health concerns arising at the global level, there is a need to build policies and elements of the health information infrastructure that extend beyond the health informatics marketplaces of the developed and rapidly developing world. For example, a community health communications hubs can be built to map and manage the social and ecological determinants of health in any village, town, or city in the world. If implemented widely, a network of these health communications hubs would revolutionize health systems and elevate the stature of population-based health approaches, such as the Healthy Cities / Healthy Communities movement in the coordination of health systems from the neighborhood to the global level. A fully integrated system of community health communications hubs, running on the global intelligent network, if used to its fullest, would provide the basis for linking health needs with the most efficient methods of addressing needs on local, national, regional and global bases. This is technically feasible within a few years. However, the policy barriers on the international level and the lack of, or ill-defined, knowledge-based markets and information infrastructures presently inhibit effective growth of the Health Information Infrastructure in many developing and underdeveloped nations. These nations tend to have the most devastating health problems and are often at the highest risk for social crisis. The problem of addressing social and ecological factors contributing to ill health (e.g., circumventing increases of disease and death rates within sub- populations as a result of a shift into information-based economy or from global change) must be dealt with through a constellation of socio-ecological interventions initiated from both the public and private sectors. Reorganizing national and international health systems in order to improve socio-ecological conditions, will require concerted effort in four areas:
1) improve the science base -- employing the sciences of complexity -- to help prevent and manage the public health effects of massive shifts in the social ecology; 2) establish an intelligent network, with an open architecture and clear mechanisms to drive toward broad access, conducive to improving the social and economic conditions upon which health is dependent; 3) change the nature and process of the polis (the political domain) so that health challenges requiring preemptive action can be appropriately evaluated, prioritized, and dynamically and iteratively addressed -- before any significant negative impact on health is apparent; 4) elevate the cognitive and sentient capabilities of the public and communities, while improving their ability to participate in adaptive and proactive approaches to improve the health-enhancing attributes of their social ecology. A health communications toolbox can be designed to elevate these issues within the public agenda and provide mechanisms for bringing them to the political agenda in conjunction with more traditional means. Conclusion Today, there is no shortage of problems facing the turbulent cities, sprawling suburban housing tracks, and poverty-rife shanty towns of the late 20th century. Unfortunately, most of the frightening challenges we presently face in cities, such as Mexico City, Monrovia, Bombay, Amsterdam, New York, Los Angeles, Nairobi, or even Salt Lake City, Utah, will grow more complex over the coming decades if exploding population growth, stifled economies, and decrepit or nonexisting social infrastructures continue to diminish health and human prosperity. This complexity, if managed globally at the community level to improve health and the human condition, could lead to a fruitful blossoming of human potential. Not dealing effectively with this complexity world-wide could lead to disastrous, if not cataclysmic, conditions. An integrated system of community health communications hubs -- built upon the global intelligent network -- shows great promise for addressing health problems resulting from massive shifts in social ecology. These hubs will provide a context within which new health interventions can emerge, based upon the sciences of complexity, information technologies, and the emerging capabilities of intelligent network users. WIth the help of telehealth and community health communications hubs, those saddled with the daunting responsibiilties of reengineering health systems to address the macro health challenges of the early 21st Century will gain new insights and be able to provide a new set of tools and methods with which to fight disease and build health-enhancing social ecologies globally.
|