Many nations have some form of eHealth policy, but commonality remains limited. Policymakers face numerous challenges in thinking beyond local representation needs in a global context. (3) The potential of eHealth to meet both national and global health objectives has not been fully developed and requires strong leadership. (14)

Global eHealth policy and governance development and implementation is an iterative and ongoing process. Enormous advances have been made in medical knowledge, technology, and training of health care professionals, but eHealth application based on standard methodologies is significantly lagging because of policy gaps. Policymakers generally react to specific problems and crises leading to gaps in the overall national and global polices. Nations around the world struggle to effect eHealth policy models that can build on evidence-based practices and measures. Some sporadic, focused efforts have occurred before and since the meeting in Bellagio 2008 (Exhibit 1). However, to date, no global, sustained collaborative effort has been established towards developing global eHealth policy and governance guidelines. Collaborative investments in global policy and governance development are needed to usher in the promise of eHealth. (15)

Health in all countries could benefit from the development of a coordinated global eHealth policy to support national legislation development for effective use of eHealth resources.

A unified voice for eHealth policy development is absent. (16) Often, Ministries of Health do not fully understand the benefits that eHealth can bring to national public health programs. Numerous fragmented pilot efforts continue to reinvent the wheel and consume resources. Informatics tools to guide on-the-ground baseline assessment, implementation, scaling, and evaluation of information systems are needed, using substantial resources already in existence such as the HMN tools. (9) Exhibit 2 summarizes the Track 1 discussion. (Exhibit 2)

Bringing organizations together, building consensus, and developing a roadmap are complex propositions that present great opportunities and challenges and require momentum. (17) A logical next step would be to build a collaborative environment for convening sustainable effort. Track participants developed a 5-year national eHealth framework approach that could be used to lay the foundations for national policy development efforts (Exhibit 3).

Collaboration among diverse stakeholders to share knowledge and expertise is a fundamental factor for public health practice. Knowledge management systems are critical tools to bring people, processes, information, and technology together. A 2005 Association of State and Territorial Health Officials (ASTHO) report provided perspectives for public health knowledge management,(18) and Liebowitz has summarized selected international efforts in this domain. (19)

Overall, there is an increasing trend in the application of knowledge management and collaboration principles and methods to the health enterprise to develop sustainable global partnerships. However, there have been few implementations that are inclusive of low-resource settings. Some eHealth specialties, such as mobile health (mHealth),(20) extensively leverage collaborative methodologies and knowledge management practices; however, eHealth in general has not yet widely adopted these informatics best practices. Additionally, training and practice in these domains are still quite limited in the global health setting.

The participants highlighted existing knowledge management systems and collaborative methodologies, and recognized that Web 2.0 applications and mobile technologies (21) have provided tremendous opportunities for knowledge sharing and collaboration. Experience has demonstrated that collaborating to share data, information and knowledge empowers us to increase transparency, improve research and education, support better decision making, help deliver care, and save lives. (22)

Many public health information systems are functionally isolated from other systems because they are not based on informatics standards nor on sustainment models. Planning generally lacks collaboration and systems thinking; therefore, systems are not interoperable. Additionally, collaborative projects across multiple governments and organizations face policy and sociocultural barriers, in addition to lack of resources and skills, that are often bigger than technical challenges.

Resources need to be better coordinated at all levels to optimize efficiency and efficacy. Collaborative projects should be encouraged to use international informatics standards and promote free access to international standards, thus enabling interoperability, while sharing innovation and best practices. Formation of a working group to facilitate the development of the domain of global public health knowledge management and collaboration is necessary to identify strategic goals, align priorities among stakeholders, create an inventory of standards, and promote sharing of best practices. (Exhibit 4)

Strengthening informatics workforce capacity positively affects public health by promoting quality of care and increasing the ability to monitor health trends. Sustainable changes require long-term planning and investment. Global health spending currently exhibits a trend toward long-term programmatic commitment, which suggests that a stable level of funding for global health initiatives will exist in the long-term. (23) Sustainable national informatics capacity will ensure continuity of informatics applications, which will promote continued improved outcomes when external funding eventually expires.

Externally funded development initiatives provide support to resource-constrained countries, offering immediate relief for pressing health concerns. However, such efforts rarely include a strategic plan for creating long-term change in local information management infrastructure and workforce capacity.

A robust informatics workforce supports local care delivery and public health practice. A strong local workforce provides independence from external funding and supports expertise for information management activities over the long term.

Local informatics capacity building is limited in several ways. Stakeholders with varying priorities provide funding to health-promoting programs. (24) However, strategies to develop in-country information management capacity are not typically a focus of these programs. When informatics is included as a fundable activity in such programs, the goal is to provide local systems for the life of a project instead of developing capacity that will serve future efforts as well. Lack of informatics training is a major barrier to ICT implementation in resource-constrained environments. (25) Training programs, when present as part of an externally-funded program, are often focused on the use of a specific system for a finite purpose instead of basic computer literacy and information management principles. As a result, learners are rushed into information system usage without acquiring foundational skills. As there are few professional paths for health informaticians in these settings, there is little incentive for local technology talent to seek work in public health programs.

The participants advocated in-country health programs should create actionable plans to bolster local informatics capacity. Externally funded programs should contribute to local capacity while concurrently fulfilling their health intervention missions. A neutral entity must develop a framework for local informatics capacity building. The framework should build off of existing efforts to standardize capacity development,(15) and focus on sharing core training materials and curricula. Adherence to standards for capacity development should be an integral part of every public health intervention and include building off of local innovations to support viable economic development, fostering government ownership to enable eHealth benefits and knowledge transfer through portable accreditation programs. (Exhibit 5)

In today’s resource-constrained global economy, globally reusable resources are useful for developing sustainable eHealth infrastructures and systems essential to a health enterprise. Their use allows the development of community solutions, professional networks for data sharing, and open access to health information. (26, 27) Existing evidence indicates that dedication to developing globally reusable resources can lead to production of agile, efficient health systems, which can result in timely and more accurate responses to public health events. (28–30)

Many standards-based free and open source software (FOSS) products, especially m-Health applications, are available online. (31) A number of these open source applications have achieved worldwide impact—notably, the Linux operating system and the Apache web server, which dominate the market. However, FOSS business models vary and may not always work across a global context. Additionally, total cost of ownership involving FOSS components must account for implementation and operational support as well as software update costs. The incentive model for private-sector companies must be modified to support reuse of ICT resources. Capacity building of the workforce should not be underestimated; standardized tools find success primarily through user adoption. Most mainstream public health information systems are not yet developed with reusable resources. In the health care domain, VistA — based on open source components — has the largest market share for comprehensive hospital information systems in the US,(14) and has been adopted in many international settings as well.

The primary benefits are cost reduction and interoperability by avoiding duplication of effort and following standards. Quality of generated information can improve if organizations use well-tested and validated components for systems development. Cloud computing (Software as a Service – SaaS model) provides significant cost savings. (32) The main savings are in the resources required to support ICT infrastructure; shared services have cost and workflow efficiencies when resources are reused across a virtual organization. (28)

Challenges to building the global health infrastructure using standards-based reusable resources such as tools and services are threefold. First, basic computer science skills required to shift from the current model of siloed or isolated databases into distributed systems are limited. Second, there is a lack of policy and legal regulations in support of open access to information across the global context. (33) Finally, standardizing medical concept definitions is time consuming, making data inconsistent between systems and slowing the process of developing systems. (34)

Translating the benefits of reusable resources to resource-poor environments can be challenging. Reliable Internet access is rare in rural areas, though mobile phone networks are improving. Many projects need to manage local databases, though some are able to synchronize the data to a central server when connectivity is available. Electricity availability represents a challenge in many rural and even urban locations, but solar power, low-power devices and better batteries, and generators offer options to address outages.

Policy and governance development for the oversight of shared reusable resources is a global responsibility. (35) Certification for quality assurance may ensure high system quality and interoperability, leading to improved user satisfaction while easing data management burdens. Readiness assessments that measure economic and human capacity realities should be required. Assistance could be provided by a global community of practice to low-resource countries as required, to ensure that response and remediation to global health challenges are addressed quickly and efficiently. The next logical step is to make health informatics standards, especially those developed using public funds, available in the public domain. (Exhibit 6)

Due to limited funding for this activity, only participants of the 2011 Public Health Informatics Conference were able to attend the workshop. Thus, there was under-representation from many low-resource countries. An attempt was made to overcome this limitation by ensuring that the participants selected from the online registrants list brought a diverse experience of supporting the under-represented areas.

Following the 2008 Meeting in Bellagio, Gerber et al identified the need for “an international public-private sector framework for understanding and moving forward on eHealth”(15). The 2011 global health workshop was an important step towards addressing this need and bridging a gap in the global health informatics domain. The workshop discussions created a rich environment to examine the evidence base and the participants’ experience for the current status; compelling and potential benefits; challenges, barriers, and gaps; and recommendations for the key domains of informatics as applied to global health.

The strength of the workshop lay in the unique blend of participants who represented 15 countries and a diverse stakeholder landscape of governmental organizations, private sector companies, academia, and non-governmental organizations. In addition to their regular jobs, the participants provide voluntary support to various informatics and eHealth technical workgroups around the world and thus also represented those collaborative virtual organizations.

The participants recommended that effective policies and governance mechanisms must be in place prior to global crises response so that global health events do not overwhelm public health response capacity. The development of an infrastructure to support global health information exchange must address legal, technical, political and economic barriers. Establishment of priorities to guide economic investments in informatics research and innovation should support patient care, global health goals, public access to data and knowledge sharing among countries across both international and regional boundaries.

The health informatics community needs to collaboratively focus on addressing global health problems and challenges by leveraging existing infrastructure, harmonizing global policy and governance efforts, and advocating effectively. (36) For such a diverse community to coalesce and collaborate, appropriate resources must be acquired and allocated optimally to provide sustainable virtual and physical organizational support. Such a global community can drive rapid development of knowledge management mechanisms and systems that facilitate the identification of global health priorities; create, manage, share, and disseminate information; and facilitate decision making for evolving global health challenges, policies and events.

In resource-constrained environments, building informatics capacity allows for clinical delivery organizations and national Ministries of Health to continue to benefit from standards-based information management practices beyond the duration of externally-funded interventions or programs. When building informatics capacity, stakeholders must examine methods to train, maintain and retain a workforce at the local level with skills to design, develop, implement and sustain the deployment of health information systems for eHealth initiatives.

Reusable ICT resources play a critical role in support of global health. (37) Primary drivers of adoption are economic because of reducing duplicate efforts; interoperability by building solutions on common technology standards;(38) developing partnerships with mutual benefits; pooling of experience and knowledge; and instituting a two-way information and knowledge flow between developed and developing countries. Low-threshold access to more resources than any single health system could afford individually can facilitate country participation in the global health information exchange projects while concurrently strengthening national infrastructure. (39)

Many countries have developed national eHealth strategies and initiatives to enhance the implementation of ICT in health. However, few have realized that developing eHealth national strategies while focusing only on the domestic needs has the potential to technically isolate their country from the rest of the world at times when there is need for relevant information sharing across borders. Examples of such use cases include reporting cases of public health emergencies of international concern by complying with the 2005 International Health Regulations (IHRs) (40), or when their residents visit other countries and health providers in the international location need to access the visitors’ previous health information to provide care. (41) Following the informatics recommendations of standards-based implementation of eHealth will ensure that countries get prepared for participation in regional and global networks in support of use cases such as global health surveillance and global access to health care, with minimal additional effort required for each emerging event. The 2011 global health workshop recommendations pave the way for establishing an overarching global informatics strategy, following which will help countries stay technically synchronized with countries outside their borders. Because of the myriad of ongoing activities in the eHealth domain, individual countries would benefit from the informatics agenda for global health by acquiring guidance for developing and enhancing their individual and regional agendas.

Roadmap development activities on a global scale require commitment and funding support from global health funding organizations. The 2011 workshop was supported by limited funds from a few organizations; travel funds were not available for more key stakeholders to be included and thus the workshop lacked more global representation among the participants. Additionally, more funding would have enabled us to develop a longer and more comprehensive plan for the workshop. The large number of participants representing a diverse stakeholder group who acquired their organizations’ support to attend the workshop clearly highlights the value of this activity. This report provides evidence that more investment in this domain is required. We anticipate that major global health donors will consider supporting the next phase of this activity.

In summary, the participants highlighted the importance of developing and implementing good informatics policy and governance guidelines in support of global health. They recognized the importance of global health stakeholders to focus on transparency, equity and technological interoperability as local needs change in response to domestic and global health events. To improve knowledge management and collaboration, stakeholders highlighted the need to explore methods for identifying, collating and sharing best practices, and for the adoption of social networking technologies to foster rich collaborations. Local informatics workforce capacity development was recognized as a key foundation-stone for long term sustainability of eHealth initiatives. In the use and creation of health information resources, stakeholders must ensure that the products are adaptable, adoptable, and reusable by the global health community. Attention to these issues can lead to measurable improvements in health equity, individual health outcomes, and positive impact on global public health.