Review Article

Healthc Inform Res. 2014 January;20(1):3-10.

http://dx.doi.org/10.4258/hir.2014.20.1.3
pISSN 2093-3681 • eISSN 2093-369X

Health Informatics in Developing Countries: Going

beyond Pilot Practices to Sustainable Implementations:
A Review of the Current Challenges
Daniel Luna, MD, MSc, Alfredo Almerares, MD, John Charles Mayan III, MD,
Fernán González Bernaldo de Quirós, MD, Carlos Otero, MD
Department of Health Informatics, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina

Objectives: Information technology is an essential tool to improve patient safety and the quality of care, and to reduce health-
care costs. There is a scarcity of large sustainable implementations in developing countries. The objective of this paper is to
review the challenges faced by developing countries to achieve sustainable implementations in health informatics and possible
ways to address them. Methods: In this non-systematic review of the literature, articles were searched using the keywords medi-
cal informatics, developing countries, implementation, and challenges in PubMed, LILACS, CINAHL, Scopus, and EMBASE. The
authors, after reading the literature, reached a consensus to classify the challenges into six broad categories. Results: The authors
describe the problems faced by developing countries arising from the lack of adequate infrastructure and the ways these can
be bypassed; the fundamental need to develop nationwide e-Health agendas to achieve sustainable implementations; ways to
overcome public uncertainty with respect to privacy and security; the difficulties shared with developed countries in achieving
interoperability; the need for a trained workforce in health informatics and existing initiatives for its development; and strategies
to achieve regional integration. Conclusions: Central to the success of any implementation in health informatics is knowledge of
the challenges to be faced. This is even more important in developing countries, where uncertainty and instability are common.
The authors hope this article will assist policy makers, healthcare managers, and project leaders to successfully plan their imple-
mentations and make them sustainable, avoiding unexpected barriers and making better use of their resources.

Keywords: Medical Informatics, Developing Countries, Public Health Informatics, Health Planning, Health Manpower

Submitted: November 6, 2013 I. Introduction

Revised: January 15, 2014
Accepted: January 15, 2014 In the last decade, the field of health informatics (HI) has
grown worldwide [1]. The Institute of Medicine in the
Corresponding Author
Daniel Luna, MD, MSc
United States has declared that information technology (IT)
Chief Information Officer, Hospital Italiano de Buenos Aires, Pte. Perón is an essential tool to improve healthcare costs, patient safety
4190, C1181ACH, Buenos Aires, Argentina. Tel: +54-1149590507, Fax: and the quality and equity of care [2-4]. These benefits make
+54-1149590507, E-mail: daniel.luna@hospitalitaliano.org.ar.
HI particularly relevant for developing countries, where
This is an Open Access article distributed under the terms of the Creative Com- common difficulties faced by most of them, such as poor
mons Attribution Non-Commercial License (http://creativecommons.org/licenses/by- economics, political uncertainty, and the lack of cutting edge
nc/3.0/) which permits unrestricted non-commercial use, distribution, and reproduc-
tion in any medium, provided the original work is properly cited. infrastructure, have hampered the quality of healthcare.
ⓒ 2014 The Korean Society of Medical Informatics It has been shown that it is feasible to implement a broad
spectrum of IT solutions in developing countries [5,6]. Al-
Daniel Luna et al

though success has been achieved in implementing pilots III. Results

or isolated programs (mostly in mobile health or local Elec-
tronic Medical Records), large sustainable implementations 1. Resource and Infrastructure Limitations
at a country or regional level are less common [7-10]. There are many financial and structural hurdles that de-
This lack of sustainability and scalability prevents improve- veloping countries face when implementing sustainable e-
ments in quality, efficiency, and equity outcomes. Thus, the Health programs. The infrastructure needed to support this
potential benefits and the ultimate goal to achieve quality of kind of implementation is scarce and irregularly distributed.
care improvements through IT are not met, making sustain- Examples of these difficulties are the lack of reliable elec-
ability a primary factor for its success [11]. tricity [14] and low-quality, expensive Internet access [15].
According to Madani and Aronsky [12], when address- The situation is not the same in all developing countries.
ing the application of IT in healthcare, sustainability can Disparities between different regions of the same country
be analyzed through the following factors: 1) effectiveness, are common, and infrastructure can be very different when
measured by outcome variables, such as mortality, morbid- comparing private or public initiatives. These problems are
ity, safety, or quality of medical decision-making; 2) effi- most relevant in rural areas [16,17].
ciency, including factors that affect resource allocation for Developing countries have considerable structural deficits
the development and maintenance of systems, such as user in their physical networks, due to high costs, geographic
training; 3) financial viability, including cost-effectiveness of dispersion, and high percentages of the people living in ru-
applications and return-on-investment in the long-term; 4) ral areas. The possibility of using wireless networks and the
reproducibility, such as integration and application in a vari- widespread adoption of mobile phones help to ameliorate
ety of different settings; and 5) portability, measured by the this issue. The penetration rates of mobile phones are in-
ease of implementing and adapting concepts and approaches creasing year after year in developing countries [7], provid-
to other environments. ing opportunities to implement systems that require less re-
The benefits of achieving major sustainable implementa- sources in new and imaginative ways [18]. For these reasons,
tions in HI have been hampered by several challenges com- mobile health (part of a broader field known as telemedi-
mon to most developing countries [13]. As the field matures cine) is proving to be useful to avoid the lack of an adequate
and health information systems (HIS) become more relevant infrastructure [19]. Nevertheless, these solutions create new
for healthcare, a review of the various factors affecting sus- problems, such as fragmented information, and difficulties
tainability is needed [12]. with project scalability.
Hardware acquisition is another difficult issue. Luckily,
II. Methods given the accuracy of Moore’s law prediction [20], hardware
costs are constantly falling; giving developing countries ac-
Based on this reality, we conducted a non-systematic review cess to technologies that were previously unattainable. In
of the literature. Articles were searched using the keywords addition, some governments are implementing initiatives in-
medical informatics, developing countries, implementation tended to reduce the digital divide, through the distribution
and challenges in PubMed, LILACS, CINAHL, Scopus, and of low-cost, portable computers to children. Examples of
EMBASE. these initiatives are the “Ceibal” program in Uruguay, which
The retrieved articles were classified by consensus rounds has recently distributed its millionth computer [21]; and
into six broad categories related to the challenges in achiev- the “Conectar Igualdad” program in Argentina, with more
ing sustainable implementations in HI: 1) resource and infra- than 3,500,000 netbooks already distributed [22]. In Africa,
structure limitations; 2) development of health IT agendas; 3) Rwanda is the country with the largest number of laptops
overcoming uncertainty, ethics, and legal considerations; 4) distributed to children, with 210,000 computers distributed
lack of use of common interoperability standards; 5) lack of by the end of 2012 [23].
a skillfully trained workforce; and 6) regional integration. In terms of software, the rise of the open-source movement
This review article describes experiences published on the is helping resource limited countries to implement HIS. Two
challenges and barriers faced by developing countries with well-known examples are PostgreSQL, a powerful open-
possible ways to address them, in the hope of assisting policy source object-relational database system, with more than 15
makers, healthcare managers, and project leaders to antici- years of experience, and a strong reputation for reliability,
pate the challenges they will face and help them overcome and OpenMRS, a software platform based on the data model
them early in their implementations. of the Regenstrief Institute, which enables the design of

4 www.e-hir.org http://dx.doi.org/10.4258/hir.2014.20.1.3
 HI in Developing Countries

customized Electronic Health Records (EHRs) with no pro- cieties could advance the generation of regional or national
gramming experience [24,25]. OpenMRS has been imple- agendas that enable or facilitate the implementation of HI
mented in many developing countries in Africa, Asia, and programs through economic incentives and professional
Central and Latin America [9,26]. training programs.
It is noteworthy that the direct costs of HI implementations
can be large, which makes long-term commitments neces- 3. Overcoming Uncertainty, Ethics and Legal Considerations
sary to maintain them. It is common for these programs to Overcoming uncertainty represents a challenge in every new
rely on donor funding for the pilot stages [11], and when implementation. In the process of implementing an EHR,
looking for opportunities to scale up, alternative sources of explicit and broad legal regulation is needed. Otherwise, re-
financing are needed. These can be difficult to obtain in re- sistance to adoption may be a barrier to overcome [35].
source constrained countries, where an e-Health agenda has Ethical considerations must also be acknowledged at an
to compete with more basic needs, like food, healthcare and early stage [36,37]. Patients enrolled in healthcare systems
education [7]. These infrastructure limitations in networks, must trust those invested with the responsibility to safeguard
hardware, and software must be considered before planning their personal information [38,39]. These challenges are
an e-Health project in developing countries [27]. similar worldwide, but their consequences are less serious
in developed countries, because their legal frameworks have
2. Development of Health IT Agendas better support for digital agendas [33].
A comprehensive nationwide e-Health agenda that con- Furthermore, security issues and legal accountability might
templates most of the challenges we address in this review represent a significant obstacle in the implementation process
is vital [9]. The development of health IT agendas has been [40,41]. The high levels of legal uncertainty present in most
attracting increasing interest in recent years. The need for developing countries could act in two antagonistic modes. On
health IT application frameworks to better develop and sus- one side, the lack of legalization in the field could be an incen-
tain IT projects has been advocated by the United Nations, tive to work more freely. On the other side, the lack of needed
the World Health Organization (WHO), and other interna- laws could delay the start of implementations, while countries
tional organizations [28]. wait for a framework to organize such programs. Still, in one
Worldwide, large amounts of health data are electronically way or another, the number of initiatives is lower than expect-
collected, but information is scattered and is not useful for ed when compared to developed countries.
high-quality decision-making. Further development in HI To manage these challenges, local health personnel need
will require the implementation of clear data standards in to acquire knowledge of legal frameworks and medical eth-
order to be of optimal value, and this situation demands a ics. There is an urgent need to enhance the teaching of the
clear framework for understanding and moving forward on discipline at both the undergraduate and postgraduate levels
e-Health [29]. [42]. This teaching must accompany any efforts being made
Many developed countries have advanced in the develop- towards a sustainable implementation [43].
ment of e-Health agendas: Canada, Australia, and Denmark
among others [30-32]. In 2010, the Economic Commission 4. Lack of Use of Common Interoperability Standards
for Latin America and the Caribbean (ECLAC), described the It is common for HIS to be fragmented, incomplete, inac-
advances made and the difficulties encountered by five devel- curate, and isolated, and this problem is even more explicit
oped countries (Belgium, Sweden, Spain, United Kingdom, in developing countries. This leads to information silos, and
and Denmark) while implementing e-Health actions [33]. the information contained inside them cannot be used for
e-Health agendas have suffered from a lack of sufficient patient care or data analysis [44].
focus and targeted priorities in developing countries. Few To overcome this problem, the effective use of standards is
of them have sufficiently strong and effective HIS to meet of cardinal importance [45]. The ability to exchange and use
all their diverse needs. However, since 2008, more than 20 information between different systems (interoperability) is a
developing countries have been working on health informa- fundamental requirement to accomplish healthcare goals [46];
tion strategic plans, supported by the WHO’s Health Metrics the most important consequence of the lack of interoperability
Network, a global partnership created in 2005, dedicated to is the loss of the continuity of care among practitioners.
assessing and strengthening national HIS [34]. The WHO asked its member countries to adopt standards
In this sense, private initiatives could generate a positive for effective information exchange between healthcare actors
impact in the disclosure of these programs. International so- and e-Health implementations through a resolution in its

Vol. 20 • No. 1 • January 2014 www.e-hir.org 5

Daniel Luna et al

66th World Assembly [47]. ships between United States and international academic pro-
Some of the aspects that need to be addressed to achieve grams to expand informatics training in India, Latin Ameri-
effective interoperability are the correct and unambiguous ca, and Africa [53] as well as the AMIA’s Global Partnership
identification of patients, improved cooperation among Program, funded by the Bill and Melinda Gates Foundation,
stakeholders to ensure the consistent application of stan- with the goals of promoting project-centric approaches to
dards across different domains, the use of data interchange training in developing countries to expand the local capacity
standards to ensure syntactic interoperability, the application to continue programs in the future [54].
of semantic interoperability with the use of standard termi- Another approach to this problem is the use of telemedi-
nologies, and the use of quality measures to assure that data cine and mobile devices to connect trained resources with
is accurate and relevant [45]. the population in need. This is especially useful in rural areas
Most of the standards needed to create interoperable sys- located far from urban centers where the specialized work-
tems exist today, and are the same as those required in devel- force tends to live. One example is the experience in India of
oped countries. The problem is that different groups select using mobile tools for the screening of retinopathy [55].
different standards for the same purposes. Governments All of these actions are recognized as essential for advanc-
and stakeholders must be aware of these issues and advance ing educational programs and implementing systems in ways
methods of reaching consensus on the common and consis- that are compatible with local culture and healthcare needs,
tent use of standards. International initiatives showing the and should be coordinated with current efforts being made
benefits of defined standards could improve and accelerate by the International Medical Informatics Association (IMIA)
the process to define these standards in developing regions. through education working groups [56].
In the same way, international standard societies should
help these countries in the process of implementing these 6. Regional Integration
interoperability programs by disseminating its standards and The US Office of the National Coordinator for Health Infor-
training staff. mation Technology and the Institute of Medicine, recogniz-
ing the importance of integrating and sharing experiences,
5. Lack of a Trained Workforce are committed to helping organizations share approaches
There is widespread agreement that an appropriately trained to improve their likelihood of success. The flow of informa-
workforce is a critical dimension if sustained progress is to tion needs to be nurtured to allow for the dissemination of
be achieved. There are too few well-trained medical infor- potential patient safety issues, such as those involved in the
maticians, and they have an inadequate geographic distribu- implementation of HIS.
tion to meet the needs and expertise necessary for health IT The communication of existing projects, as well as of past
implementations [42,48]. experiences has proven to be a challenge in developing
The general model to train the workforce needed emerged countries [57]. Critical to the transition from a pilot project
from the e-Capacity meeting in Bellagio in 2008, during to a sustainable implementation is the sharing of resources,
which components of the educational strategy to train clini- experiences, and lessons learned from other projects [16,27].
cal informaticians and improve the level of informatics Traditionally, the communication of medical knowledge,
knowledge, skills, and attitudes in both formally and infor- research, and advances has been achieved by the publication
mally trained health workers were described [49]. of articles in scientific journals. Yet, this task also represents
Educational programs are emerging around the world. Dif- an obstacle in developing countries, and HI is not excluded.
ferent degrees of specialization are needed, from graduate Publication and retrieval of HI scientific material can be fa-
education to shorter courses. One example is the American cilitated quickly with relatively little expenditure when com-
Medical Informatics Association’s (AMIA’s) 10 × 10 initia- pared with other investments needed [58]. For example, the
tive, a program that aimed to train 10,000 professionals in open-access approach to publishing helps authors in under-
HI by 2010 [50]. Since its introduction, AMIA has been developed regions share information [57].
working alongside local institutions in developing countries, The IMIA, through its working group for development, has
such as Argentina and Singapore, to create an international focused on this challenge, creating a global repository for
version adapted to local needs [51,52]. all ongoing projects related to health IT, with the hope that
Other initiatives include the Informatics Training for Glob- it will fulfill the final goal of connecting all the actors work-
al Health Program of the Fogarty International Center, US ing in HI solutions for developing countries. The site is still
National Institutes of Health, that maintains eight partner- relatively new as it was introduced in July 2013, and manag-

6 www.e-hir.org http://dx.doi.org/10.4258/hir.2014.20.1.3
 HI in Developing Countries

Table 1. Recommendations for developing countries

Resource and infrastructure limi- Use wireless networks and mobile phones, adopt open source software, and create programs
tations to diminish the digital divide
Development of health IT agendas Generate regional or national agendas that facilitate the implementation of informatization
programs through economic incentives and professional training programs
Overcoming uncertainty, ethics Create explicit and broad legal regulation to overcome resistance to adoption
and legal considerations Enhance the teaching of medical ethics at both undergraduate and postgraduate level
Lack of use of common interoper- Advance methods for reaching consensus for the common and consistent use of standards
ability standards International standard societies should help in the process
Lack of a trained workforce Implement educational programs or use partnerships with trusted institutions
Use telemedicine and mobile devices to connect the trained resources with the population
in need
Regional integration Communicate successful programs in the region, and share experiences on implementing
programs and teaching resources

ing the input of data by project leaders has proven difficult Although the challenges described in this article could be
mostly due to lack of knowledge of the tool [59]. Efforts common to all the countries in this group, it is possible that
to communicate successful programs in the region and to they are not the only ones to be considered. Moreover, these
share experiences in implementing programs and teaching challenges are discussed in relation to developing countries,
resources could have a big impact on the dissemination of where implementers must be aware of common barriers and
these initiatives. difficulties that can strain efforts in all IT implementations.
We hope this article will assist policy makers, healthcare
IV. Conclusions managers, and project leaders to successfully plan their
implementations and make them sustainable, to avoid unex-
Knowing the challenges to be faced is important for the suc- pected barriers as much as possible, and to make better use
cess of any implementation in HI. This is especially relevant of their resources.
in developing countries where uncertainty and instability are
very common. Conflict of Interest
We have reviewed the problems faced by developing coun-
tries arising from the lack of adequate infrastructure, and the No potential conflict of interest relevant to this article was
ways these problems can be bypassed. The issues that must reported.
be addressed include: the fundamental need to develop na-
tionwide e-Health agendas to achieve sustainable implemen- References
tations; ways to overcome public uncertainty with respect to
privacy and security; the difficulties shared with developed 1. World Health Organization Global Observatory for
countries to achieve interoperability; the need for a trained eHealth. Building foundations for eHealth : progress of
workforce in HI and existing initiatives for its development; member states : report of the WHO Global Observatory
and strategies for achieving regional integration (see Table 1 for eHealth. Geneva, Switzerland: World Health Organi-
for a summary of recommendations). zation; 2006.
Even while this review has some limitations, such as the 2. Dick RS, Steen EB, Detmer DE; Committee on Improving
fact that it is not a systematic review, and difficulty in finding the Patient Record, Institute of Medicine. The computer-
published papers related to the topic for all the countries in based patient record: an essential technology for health
this group; the challenges and barriers seem to be common care. Washington (DC): National Academy Press; 1997.
to most of them. More resources towards integration of the 3. Kohn LT, Corrigan JM, Donaldson MS. To err is hu-
region may be necessary as well as programs to help incipi- man: building a safer health system. Washington (DC):
ent implementations through the sharing of experiences and National Academy Press; 2000.
workforce. 4. Institute of Medicine, Committee on Quality of Health

Vol. 20 • No. 1 • January 2014 www.e-hir.org 7

Daniel Luna et al

Care in America. Crossing the quality chasm: a new 17. Fraser HS, Jazayeri D, Nevil P, Karacaoglu Y, Farmer
health system for the 21st century. Washington (DC): PE, Lyon E, et al. An information system and medical
National Academy Press; 2001. record to support HIV treatment in rural Haiti. BMJ
5. Douglas GP, Deula RA, Connor SE. The Lilongwe Cen- 2004;329(7475):1142-6.
tral Hospital Patient Management Information System: a 18. Barclay E. Text messages could hasten tuberculosis drug
success in computer-based order entry where one might compliance. Lancet 2009;373(9657):15-6.
least expect it. AMIA Annu Symp Proc 2003;2003:833. 19. Asangansi I, Braa K. The emergence of mobile-support-
6. Rotich JK, Hannan TJ, Smith FE, Bii J, Odero WW, Vu ed national health information systems in developing
N, et al. Installing and implementing a computer-based countries. Stud Health Technol Inform 2010;160(Pt
patient record system in sub-Saharan Africa: the Moso- 1):540-4.
riot Medical Record System. J Am Med Inform Assoc 20. Moore GE. Progress in digital integrated electronics.
2003;10(4):295-303. IEEE Solid-State Circuits Newsl 2006;20(3):36-7.
7. Lewis T, Synowiec C, Lagomarsino G, Schweitzer J. E- 21. Plan Ceibal entrega la computadora 1 millón [Inter-
health in low- and middle-income countries: findings net]. Montevideo, Uruguay: Ceibal; c2013 [cited at
from the Center for Health Market Innovations. Bull 2014 Jan 2]. Available from: http://www.ceibal.org.
World Health Organ 2012;90(5):332-40. uy/index.php?option=com_content&view=article
8. Williams F, Boren SA. The role of the electronic medical &id=1025:iplan-ceibal-entrega-la-computadora-1-
record (EMR) in care delivery development in develop- millon&catid=63:noticias-slider-home.
ing countries: a systematic review. Inform Prim Care 22. Conectar Igualdad [Internet]. Buenos Aires, Argentina:
2008;16(2):139-45. National Social Security Administration; c2013 [cited at
9. Gerber T, Olazabal V, Brown K, Pablos-Mendez A. An 2014 Jan 2]. Available from: http://www.conectarigual-
agenda for action on global e-health. Health Aff (Mill- dad.gob.ar/.
wood) 2010;29(2):233-6. 23. OLPC Rwanda [Internet]. [place unknown: publisher
10. Littlejohns P, Wyatt JC, Garvican L. Evaluating comput- unknown]; c2013 [cited at 2014 Jan 2]. Available from:
erised health information systems: hard lessons still to http://wiki.laptop.org/go/Rwanda.
be learnt. BMJ 2003;326(7394):860-3. 24. PostgreSQL: About [Internet]. [place unknown]: The
11. Gordon AN, Hinson RE. Towards a sustainable frame- PostgreSQL Global Development Group; c2013 [cited at
work for computer based health information systems 2014 Jan 2]. Available from: http://www.postgresql.org/
(CHIS) for least developed countries (LDCs). Int J about/.
Health Care Qual Assur 2007;20(6):532-44. 25. Mamlin BW, Biondich PG, Wolfe BA, Fraser H, Jaza-
12. Madani S, Aronsky D. Factors affecting the sustainabili- yeri D, Allen C, et al. Cooking up an open source
ty of information technology applications in health care. EMR for developing countries: OpenMRS – a recipe
AMIA Annu Symp Proc 2003;2003:922. for successful collaboration. AMIA Annu Symp Proc
13. Blaya JA, Fraser HS, Holt B. E-health technologies show 2006;2006:529-33.
promise in developing countries. Health Aff (Millwood) 26. Mohammed-Rajput NA, Smith DC, Mamlin B, Biondich
2010;29(2):244-51. P, Doebbeling BN; Open MRS Collaborative Investiga-
14. Latourette MT, Siebert JE, Barto RJ Jr, Marable KL, tors. OpenMRS, a global medical records system collab-
Muyepa A, Hammond CA, et al. Magnetic resonance orative: factors influencing successful implementation.
imaging research in sub-Saharan Africa: challenges and AMIA Annu Symp Proc 2011;2011:960-8.
satellite-based networking implementation. J Digit Im- 27. Fraser HS, Biondich P, Moodley D, Choi S, Mamlin BW,
aging 2011;24(4):729-38. Szolovits P. Implementing electronic medical record
15. Shiferaw F, Zolfo M. The role of information communi- systems in developing countries. Inform Prim Care
cation technology (ICT) towards universal health cover- 2005;13(2):83-95.
age: the first steps of a telemedicine project in Ethiopia. 28. World Bank. 2006 world information and communications
Glob Health Action 2012;5:1-8. for development report: trends and policies for the infor-
16. Simba DO, Mwangu M. Application of ICT in strength- mation society. Washington (DC): World Bank; 2006.
ening health information systems in developing 29. World Health Organization; International Telecom-
countries in the wake of globalisation. Afr Health Sci munication Union. National eHealth strategy toolkit.
2004;4(3):194-8. Geneva, Switzerland: World health Organization; 2012.

8 www.e-hir.org http://dx.doi.org/10.4258/hir.2014.20.1.3
 HI in Developing Countries

30. Canada Health Infoway. Pan-Canadian Electronic 44. Glaser J. Interoperability: the key to breaking down in-
Health Record: executive summary. Toronto: Canada formation silos in health care. Healthc Financ Manag
Health Infoway; 2005. 2011;65(11):44-6, 48, 50.
31. National e-Health and Information Principal Commit- 45. Hammond WE, Bailey C, Boucher P, Spohr M, Whitak-
tee. National e-Health strategy. London: Deloitte Touche er P. Connecting information to improve health. Health
Tohmatsu Limited; 2008. Aff (Millwood) 2010;29(2):284-8.
32. Connected Digital Health in Denmark. National strat- 46. Sass M, Feko A. The emergence of telemedicine and e-
egy for digitalisation of the Danish healthcare service health in Hungary. Telemed J E Health 2011;17(5):388-95.
2008-2012. Copenhagen: Connected Digital Health in 47. World Health Organization. eHealth standardization
Denmark; 2007. and interoperability [Internet]. Geneva, Switzerland:
33. Carnicero J, Rojas D. Application of information and World Health Organization; 2013 [cited at 2014 Jan 2].
communication technologies for health systems in Bel- Available from: http://apps.who.int/gb/ebwha/pdf_files/
gium, Denmark, Spain, the United Kingdom and Swe- EB132/B132_R8-en.pdf.
den. Santiago, Chile: CEPAL; 2010. 48. Hersh W, Margolis A, Quiros F, Otero P. Building a
34. Health Metrics Network; World Health Organization. health informatics workforce in developing countries.
Country health information systems: a review of the Health Aff (Millwood) 2010;29(2):274-7.
current situation and trends. Geneva, Switzerland: 49. The Rockefeller Foundation. From silos to systems: an
World Health Organization; 2011. overview of eHealth’s transformative power. New York
35. Ajami S, Arab-Chadegani R. Barriers to implement (NY): The Rockefeller Foundation; 2010.
Electronic Health Records (EHRs). Mater Sociomed 50. Hersh W, Williamson J. Educating 10,000 informaticians
2013;25(3):213-5. by 2010: the AMIA 10x10 program. Int J Med Inform
36. Were MC, Meslin EM. Ethics of implementing Elec- 2007;76(5-6):377-82.
tronic Health Records in developing countries: points to 51. Otero P, Hersh W, Luna D, Lopez Osornio A, Gonzalez
consider. AMIA Annu Symp Proc 2011;2011:1499-505. Bernaldo de Quiros F. Translation, implementation and
37. Amatayakul MK. Electronic Health Records: a practical evaluation of a medical informatics distance learning
guide for professionals and organizations. 2nd ed. Chi- course for Latin America. In: Proceedings of the 12th
cago (IL): American Health Information Management World Congress on Health (Medical) Informatics; 2007
Association; 2004. Aug 20-24; Brisbane, Australia. p. 421-2.
38. Campbell AV. The ethical challenges of genetic data- 52. Margolis A, Joglar F, de Quiros FG, Baum A, Fernandez
bases: safeguarding altruism and trust. Kings Law J A, Garcia S, et al. 10x10 comes full circle: Spanish ver-
2007;18(2):227-45. sion back to United States in Puerto Rico. Stud Health
39. Chalmers D, Nicol D. Commercialisation of biotech- Technol Inform 2013;192:1134.
nology: public trust and research. Int J Biotechnol 53. US National Institute of Health, Fogarty International
2004;6(2-3):116-33. Center. Informatics Training for Global Health (ITGH)
40. Meslin EM. Shifting paradigms in health services re- [Internet]. Bethesda (MD): National Institute of Health;
search ethics. Consent, privacy, and the challenges for c2013 [cited at 2014 Jan 3]. Available from: http://www.
IRBs. J Gen Intern Med 2006;21(3):279-80. fic.nih.gov/programs/pages/informatics.aspx.
41. Institute of Medicine, Committee on the Role of Institu- 54. American Medical Informatics Association. AMIA
tional Review Boards in Health Services Research Data global programs (GHIP) [Internet]. Bethesda (MD):
Privacy Protection. Protecting data privacy in health American Medical Informatics Association; c2013 [cited
services research. Washington (DC): National Academy at 2014 Jan 3]. Available from: http://www.amia.org/
Press; 2000. programs/global-programs-ghip.
42. Detmer DE. Capacity building in e-health and health 55. Murthy KR, Murthy PR, Kapur A, Owens DR. Mobile
informatics: a review of the global vision and informat- diabetes eye care: experience in developing countries.
ics educational initiatives of the American Medical In- Diabetes Res Clin Pract 2012;97(3):343-9.
formatics Association. Yearb Med Inform 2010:101-5. 56. Mars M, Holmes JH, Richards J, Otero P, Marcelo AB,
43. Fadare JO, Desalu OO, Jemilohun AC, Babatunde OA. Luberti AA. Informatics capacity building in the de-
Knowledge of medical ethics among Nigerian medical veloping world-working towards an international edu-
doctors. Niger Med J 2012;53(4):226-30. cational model and curriculum. Stud Health Technol

Vol. 20 • No. 1 • January 2014 www.e-hir.org 9

Daniel Luna et al

Inform 2013;192:1250. 59. International Medical Informatics Association Work-

57. Paton C, Househ M, Malik M. The challenges of pub- ing Group on Health Informatics for Development
lishing on health informatics in developing countries. (IMIA HI4Dev) [Internet]. [place unknown: publisher
Appl Clin Inform 2013;4(3):428-33. unknown]; c2013 [cited at 2014 Jan 3]. Available from:
58. Vose PB, Cervellini A. Problems of scientific research in http://imia-wg4dev.org/.
developing countries. IAEA Bull 1983;25(2):37-40.

10 www.e-hir.org http://dx.doi.org/10.4258/hir.2014.20.1.3