TABLE OF CONTENTS Executive Summary... 3 Introduction Country overview and demographics... 5 Public Health Informatics... 8

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1 TABLE OF CONTENTS Executive Summary... 3 Introduction Country overview and demographics Public Health Informatics Morbidity and mortality pattern Use of cell phones and handheld devices The structure of the national health information system Past and current efforts regarding promoting IT application for health Past and current challenges and approaches Future plans and prospects to strengthen public health informatics References The Path to Interoperability How healthcare providers and consumers communicate in predominant world languages Technology and/or e-health standards to facilitate interoperability The biggest interoperability challenges, the country has faced The success in interoperability Key standards considerations related to electronic health systems interoperability: References Access to information Access to information by the general population Health information system and information technology structure How do researchers and providers use information and communication technology to access health information (research, journals, databases, etc) today Key challenges to the use of information and communication technology to access health information References E-health capacity building MOH policy on IT application Where do hospitals and government currently turn for technical support? What infrastructure and training in health informatics exists currently in the country? Are there masters/phd degrees in health or biomedical informatics available? What are the current programs for training healthcare workers in ICT and informatics? What has worked well, and what hasn t? Challenges and solution (6) : References: Electronic health records Implementing EHR system in Vietnam Challenges Actions References Mobile ehealth The situation of Vietnamese communication

2 6.2 The plan for communication development Real situation of mobile informatics system in Vietnam The situation of applying mobile informatics system into health care Unlocking the market for e-health Private sector IT and e-health companies that offer products and services in the target country: achieving the goals and profitable Have any IT or e-health companies left the market? Why? MOH strategies related to private IT company What are the challenges that private e-health companies would face if they try to enter this market? National ehealth Policies Annex Annex 1. Details tables and diagrams Annex 2. Country data Annex 3. Profile 1: Health management information system (HMIS) Annex 4. Profile 2: Application of MEDISOFT in hospital management LIST OF TABLES AND FIGURES Figure 1: Trend of communes with CHC and CHC has medical doctor... 6 Figure 2: Trends in distribution of cases by causes over time... 8 Figure 3: Trends in the distribution of causes of death over time... 8 Figure 4. Growth diagram of telephone subscriber by year Figure 5. Market share for mobile phone subscribers in Figure 6: A complete model of epidemiological surveillance for communicable diseases. 30 Figure 7: A model of collecting, reporting, and feedback of epidemiological surveillance data for communicable diseases Figure 8: Structure of health system in Vietnam Figure 9: System of organizations and institutions responsible for making health statistic reports Figure 10: Flow of raw surveillance data Table 1: Distribution of health workers in state sector in Vietnam... 6 Table 2: Approaches to challenges of health IT development and application

3 EXECUTIVE SUMMARY Vietnam, the 12 th largest country in the world by population, has an area of 331,689 km 2, located in the Eastern part of the Indochina peninsula, bordering China to the North, Laos and Cambodia to the West, facing the South China Sea and the Pacific to the East and the South. The country has a total length of 1,650 km from the northernmost point to the southernmost point. Its width, stretching from the Eastern coast to the Western border, is 500 km at the widest part and 50 km at the narrowest part. Since 1986, Vietnam economy has shifted from the centrally-planned economy to the socialistoriented market economy. National industrialization and modernization were initiated together with the policy of multi-lateralization and diversification of external economic relations, openness and international integration. This led to a strong GDP growth rate which stood at 8.2% in as compared to 3.9% in This rate dropped to 7.5% in due to the impacts of the Asian financial crisis. During , GDP growth rate was at an average level of 7.2%. The rate was estimated as approximately 8.5% in The economic development helped Vietnam rapidly escape hunger and poverty and lay the initial foundation for an industrialized economy. Along with widespread grown in other segments of the economy, such as transportation, energy, manufacturing, banking services, etc., both the healthcare and ICT (information & communication technologies) segments have been systematically advanced. Nationwide efforts have been successful in improving access to healthcare, with 10,293 primary care centers (commune health centers) each providing care to approximately 1,000 families in more than 98% of the nation s communes. The number of physicians has increased by 50% in less than 15 years, from 4.2 to 6.2/10,000 inhabitants (during a time when the population increased by 20%). Since 1995 the number of commune health centers (CHC) with a full time physician has more than tripled, from 19.6% to 69.4% by General economic improvements along with better access to medical care have resulted in a significant change in patterns of morbidity and mortality, with a halving of morbidity from communicable diseases (over 55% in 1976 to less than 25% by 2006). Life expectancy at birth has increased from 68 in 2000 to 71 in 2006, while maternal mortality rate has reduced from 95/100,000 life births in 2000 to 75 in 2006 and infant mortality rate reduced from 37/1.000 life birth (2000) to 16 (2006). However, there has been an increase of morbidity and mortality associated with developed economies, such as transportation accidents and chronic illnesses such as heart disease, diabetes and hypertension. ICT has also significantly improved, with rapidly increasing use of telephony, including increase in land lines and a much greater increase in the use of cell phones. Internet usage, including access to broad band connectivity, has increased throughout the population and even into rural areas and a concentrated national effort has been made to build out advanced ICT infrastructure. Up to now % GDP invested for telecommunication is about ; About 129 people use internet for every 1,000 people; 12,7/1,000 people has personal computers; Percentage of mobile phone subscribers is 115,4 per 1,000 people. It also has been estimated that 20% of schools have connected to Internet; Secure internet servers per 1 million people is 0.143; Internet hosts per 100,000 inhabitants is 1. Vietnam s first communication satellite was launched recently and is in a testing phase. A WiMax demonstration project is underway 3

4 in a rural area to provide internet access where optical cable and end of the line access would be difficult to build. Viet Nam is now ranked 30 th in the world in internet use. As in many countries, the younger age groups have rapidly made use of the internet for communication and knowledge acquisition and have made great advances in computer skills. Since 25% of the population is younger than 15 this increased comfort with and expectation of access to improved ICT will be a major driving force for development in the future. Already the country has seen the development of large, significant and successful Vietnamese IT corporations and significant increases in IT training programs in university departments and private businesses. Key decisions have been made at the ministerial level to lay a foundation for the interoperability of eventual healthcare IT applications, increased usage of health care IT, and eventual adoption of clinical data systems. For example, coding, lexicon, communication and messaging standards, such ICD-10, HL7, SNOMED, DICOM ELINCS, etc., have been approved. National healthcare data reporting systems are already standardized using ICD-10 and use a software program, the internally developed Medisoft system, for reporting public health data to the Ministry of Health. Most of the nation s hospitals and clinics are operated directly by the Ministry of Health or through subordinate public health bureaus at the Provincial and District levels. In those facilities all paper forms, including clinical documentation forms, are nationally standardized and centrally approved and, as such, provide an base for standardized and uniform electronic health and medical records. In addition, the country has practical experience with introducing and managing fundamental and large scale change in the healthcare training and delivery systems, critical experience which provides a solid background for managing the enormous changes inherent in the eventual introduction of electronic clinical systems. So far the introduction of healthcare IT systems in hospitals has been limited to business processes and management systems, with very limited or no use of clinical applications such as EHRs, order entry systems, decision support, pharmacy systems, etc. This has been limited by the need to build out infrastructure, develop comprehensive strategic plans, develop or acquire specific healthcare IT and medical informatics expertise, develop or acquire clinical and business applications, and find the funds necessary for development, training and implementation. At the national level, the Ministry of Health, along with support from the Ministry of Education and Training and other ministries, have established goals and broad policies for the development of e-health capacity and capabilities. These goals, among others, include specific targets for the adoption of hospital management systems, internet access in healthcare facilities, website and LAN development, internet connectivity in all health service offices, improved public health databases, and improved internet access and e-learning at medical universities and other healthcare training centers. There is a recognition at all levels of the public health system and in medical universities for the need for increased use of interoperable IT systems to improve clinical care, increase efficiencies and improve public health. Given the country s history of efficient and systematic success in achieving other difficult, large scale and complicated goals it is likely that within the next few decades that Vietnam will have one of Asia s most extensive and effective nationally integrated health care IT systems. 4

5 INTRODUCTION COUNTRY OVERVIEW AND DEMOGRAPHICS Vietnam is the 12 th largest country in the world by population. It has an area of 331,689 km 2, located in the Eastern part of the Indochina peninsula, bordering China to the North, Laos and Cambodia to the West, facing the South China Sea and the Pacific to the East and the South. The country has a total length of 1,650 km from the northernmost point to the southernmost point. Its width, stretching from the Eastern coast to the Western border, is 500 km at the widest part and 50 km at the narrowest part. The country belonged to a region considered as a cradle of human civilization, and one of the earliest agricultural centers practicing wet rice farming, where stone and metallurgical revolutions took place. The first Vietnamese state was established in the 7 th century B.C. In the cause of national building, the Vietnamese also had to cope with foreign aggression. Viet Nam had been dominated since the 2 nd century B.C by different Chinese dynasties for more than a thousand years. Since the 19 th century, the country became a semi-feudal colony of France for nearly 100 years In August 1945, after the collapse of the Japanese occupying forces at the end of WW II, the Vietnamese people successfully launched a general uprising to seize power under the leadership of the Communist Party. With the Proclamation of Independence on 2 nd September 1945, the Democratic Republic of Viet Nam came into being. The country was soon re-occupied by the French colonialists until 1954 and then divided into two parts until Since then, Viet Nam has ushered in a new era of peace, unification and national construction. The estimated population of Viet Nam rose to 84,155,800 people, of whom males account for 49.1% in 2006 [1]. Population density is 252 persons per square kilometer, and the majority (73.0%) of the population lives in the rural areas. The population aged 0-14 accounted for 26.4% of the total population, decreased by 8.6% in comparison with The proportion of those over 64 years increased rapidly, approximately 1.1 % for a five - year period. Viet Nam has 54 different ethnic groups of which the Kinh represents 87% of the total. The ethnic minorities are scattered all over the country. A substantial spontaneous migration has been taking place, with numerous migrations from rural to urban areas. Viet Nam is a socialist republic and one-party state, governed by the Communist Party of Viet Nam. The National Assembly is the highest representative body of the people and is the only organ with constitutional and legislative power. Beyond the central government, the People s Committees in localities are responsible for daily administration at corresponding levels. Mass organizations, such as the Women s Union, Farmers Union and Youth Union, exist to accommodate the interests of the people and to serve as a link between the people and the Party. Since 1986, Vietnam economy has shifted from the centrally-planned economy to the socialist-oriented market economy. National industrialization and modernization were initiated together with the policy of multi-lateralization and diversification of external economic relations, openness and international integration. This led to a strong GDP growth rate which stood at 8.2% in as compared to 3.9% in This rate dropped to 7.5% in due to the impacts of the Asian financial crisis. During 5

6 , GDP growth rate was at an average level of 7.2%. The rate was estimated as approximately 8.5% in 2007 [2]. The economic development helped Vietnam rapidly escape hunger and poverty and lay the initial foundation for an industrialized economy. Table 1: Distribution of health workers in state sector in Vietnam Year Population (million) Total health workers Doctors/10,000 inhabitants Nurses/10,000 inhabitants Nurse/doctor ratio , , , , * Source: (Luu Ngoc Hoat, MD, MSc.Epi, PhD thesis, [Health Statistical Yearbooks, Vietnamese Ministry of Health]) Figure 1: Trend of communes with CHC and CHC has medical doctor Percentage % communes with CHC % CHC has medical doctor * Source: (Luu Ngoc Hoat, MD, MSc.Epi, PhD thesis, [Health Statistical Yearbooks, Vietnamese Ministry of Health]) During the process of economic development, morbidity and mortality in Vietnam have changed. The incidence of communicable diseases (CDs) has fallen in recent decades, with the contribution of CDs in annual numbers of cases and deaths due to all causes decreasing from 55.5% and 53.1% in 1976, to 24.9% and 13.2% in 2006 [3]. The incidence of non-communicable diseases (NCDs) has shown a tendency to increase in the last two decades, with a share in the total morbidity rising from 39.0% in 1986 to 62.4% in 2006, and in the total mortality from 41.1% to 61.6%, respectively. NCDs were the leading causes of death among both young adults and older people. The telecom infrastructure is growing exponentially in Vietnam. By May 2008, Vietnam has 52.5 millions of lines [4]. The fixed lines accounted for only less than one-fourths of the total lines. The teledensity is 60.4 subscribers/100 people, increased by 6.7 times in 6

7 compared with the same figure in Vietnam officially entered into the internet community since By April 2008, the number of internet subscribers reached 5,595,159. The number of internet users is 19,453,791, which account for 23.12% of population. Out of 64 provinces or cities in the whole country, 59 have achieved internet connection to universities, colleges, secondary schools and primary schools. ICT industry has also strongly developed with growth rates of 20%-25% per year. Intersectoral and non-governmental cooperation to promote ICT infrastructure development was implemented in In 2005 a national strategy was issued for ICT development in Vietnam up to 2010, with additional indications for development direction to The master plan for telecommunications and internet development in Vietnam to 2010 was approved in A number of targets have been set for development of ICT infrastructure during period of , including: Telecoms growth rate will reach times the average rate of economic growth; The telephone density will reach 32-42%, including 14-16% for fixed phone subscribers; The internet user rate will be 25-30% of population; 100% of communes will have accessed to public telephone, 70% of communes will have internet access, 100% of districts and almost all communes in key economic regions will be connected with internet broadband. Vietnamese is an official language used in the country. English and French are among the most frequently used foreign languages. Some minority ethic languages are used locally. Language has been considered as a challenge in health education and promotion for ethnic minorities. This challenge remains for development of electronic multicultural health contents. In the health sector, ICT skills courses as a part of university curricula for health sciences students and ICT skills programmes in the ongoing training of health care professionals have been offered since 1994/1995 [5]. Health professionals have had access to online health content through international electronic journals since The general public gained access to health information in electronic format that same year. However, health sciences courses through e-learning for health professionals in training and practice are not yet available. 7

8 1. PUBLIC HEALTH INFORMATICS 1.1 Morbidity and mortality pattern In Vietnam, together with the development of society and the economy, non-communicable diseases are increasing, while communicable diseases are currently showing a downward trend (Figure 2 & 3). However, some infectious disease such as respiratory tract infection and diarrhea are still quite frequent. In addition, in recent years Vietnam has seen several serious communicable diseases such as SARS, avian influenza and dengue fever. In terms of mortality, both communicable and non-communicable diseases are important causes deaths. Pneumonia and injuries of all kinds are the main reasons. The HIV/AIDS epidemic has also become a big challenge. Figure 2: Trends in distribution of cases by causes over time Percentage 70,0 60,0 50,0 40,0 30,0 20,0 10,0 0,0 59,2 62,4 55,5 50,0 42,7 39,0 37,6 24,9 12,4 12,7 1,8 1, Communicable diseases Non-communicable diseases Accident, injury, poisoning Figure 3: Trends in the distribution of causes of death over time Percentage 70,0 60,0 50,0 40,0 30,0 20,0 10,0 0,0 61,6 53,1 52,1 43,7 44,7 41,8 33,1 25,2 2,2 6,1 23,2 13, Communicable diseases Non-communicable diseases Accident, injury, poisoning * Source: (Luu Ngoc Hoat, MD, MSc.Epi, PhD thesis, [Health Statistical Yearbooks, Vietnamese Ministry of Health]) 8

9 Morbidity and mortality data are often collected and reported through one or a combination of several ways - vital registration, census, research reports, household surveys, sample surveys, hospital statistics, epidemiological surveillance, routine health information, etc. Yet diseases are largely monitored or followed up at the hospital level, first from clinical departments including both inpatient and outpatient wards, then reported to the statistical unit of each hospital in order to report to higher hierarchical levels (Huong, Deputy Director of Hanoi Obstetrics Hospital 2008, pers. comm., 13 June). To identify a disease, hospital doctors seek both clinical signs and test results. For hospital morbidity and mortality data reporting there are 312 disease-related groups, coded according to the 10th Revision of the ICD, and categorized by sex and three age- groups (under 15; 15 60; and over 60). Since currently in Vietnam communicable diseases, especially unfamiliar cases (SARs, avian influenza, dengue fever, etc) are among the main threats to the general population, surveillance programs have focused on such diseases. The flow charts 3 and 4 (see Annex) detail how a case of communicable disease is monitored or surveyed and reported through the public health hierarchy. 1.2 Use of cell phones and handheld devices Another way of monitoring diseases is the use of cell phones and handheld devices. The availability and use is at present quite encouraging. Almost all health facilities (health centre, hospitals, institutes at any level commune, district, provincial or central) have mobile or fixed phones. The hand devices are frequently used for disease follow-up as a number of functions such as health information exchange and communication when needed and urgent reporting for emergencies. However, data from this source are often considered as an unofficial source and sometimes not recognized; it is for communication rather than for reporting. In emergencies, handheld devices have two functions: first to declare or report epidemics like SARs, avian influenza, or dengue, etc to higher levels or relevant health facilities like preventive medicine centers in order to control an outbreak and take further steps for prevention, and second use is for contacting the emergency 114 system for urgent or serious cases such as strokes, injuries, accidents, etc., to take patients to a proper health facility. However, the 114 system is mainly based in urban areas such as in large cities (Hanoi, Hochiminh, Danang, Cantho, etc). 1.3 The structure of the national health information system Vietnam is administratively divided into four levels: central, provincial, district and commune. Health information system of the country is also based on this system. Ministry of Health (Department of Planning and Financial) is the highest organization to gather and issue health information. This information based on the reports from provincial levels, prepared and reported by provincial/city health departments. In those provincial health departments, they gathered data from all districts in their local area, while the districts gathered data from community health centers (Dung & Luat 2005). Besides this routine flow of information, all national or international programs/projects also collect information separately with their own forms, standards from provincial, district and commune levels. This leads to the overload and overlap in reporting systems. However, most of the information follows a one-way direction from lower to higher hierarchy, while the feedback system from higher to lower level has not received enough 9

10 attention. Figures 10 and 11 (see Annex) show how information flows in the national health information system. 1.4 Past and current efforts regarding promoting IT application for health Recent efforts in Vietnam regarding IT in the health area are mainly at the level of issuing decrees encouraging the use of IT in health and disease management and raising awareness for key players and actors, but for specific IT applications. Since the promulgation of Ordinance No 58/CT-TW dated 17/10/2000 by the Ministry of Politics on promoting the use of IT in socioeconomic and health sector, the impact has been relatively significant (Hung 2005). The government has spent some fund for computerization projects for administrative management as of The health sector tried to integrate the investment and development of IT application in hospital projects. A Centre for Health Information Technology has been established which plays a key role in providing technical consultancy to health facilities. A number of hospitals have made a great attempt to apply IT in hospital management with fairly high efficacy. There has been several software programs built and applied for management purposes at hospitals, wards, departments, institutes, etc. Hospital IT staff have been trained, though to a limited extent in numbers. The efforts in the health sector have initiated great interest from international organizations about development of IT in the health sector, especially in hospital settings to manage health information (Hung 2005). Overseas study tours and training courses have also been conducted in order to gain experience and acquire skills in applying IT for hospital management. Beside, IT also was introduced in preventive medicine sector. There are some health institutes apply GIS currently. They are National Institute Hygiene Epidemiology, National Institute of Malaria Parasitology & Entomology, and some Provincial Services with supported from some projects as Ha Tay Provincial Service, Bac Ninh Provincial Service, Lai Chau Provincial Service, An Giang Provincial Service, and Tay Ninh Provincial Service. 1.5 Past and current challenges and approaches The main challenges facing the Vietnamese health sector are lack of IT health staff both in quantity and quality, lack of investment resources, including finance and equipment, and the capacity of international integration as well as determination in applying public health informatics (Hung 2005). Lack of a master plan for development of IT and health communication up to 2010 and further may also prevent future development initiatives. Another big challenge is the lack of one comprehensive uniform package of professional software that can be applied to all public health facilities. If such a uniform package is not made available, Vietnam will repeat the experiences of other countries as an example in this regard. To address such barriers, the following approaches have been attempted, though currently to a limited extent, and should be strongly encouraged, plus other further steps or actions. 10

11 Table 2: Approaches to challenges of health IT development and application No Main approaches 1. Policy initiatives 2. Organizational initiatives 3. IT development initiatives 4. Capacity building initiatives 5. Resources mobilization initiatives Detail description Create more legal policies regarding IT development in health. Develop a master plan for health IT development Develop an investment policy for health IT development Build up a network of health information management using IT from national to grassroots level. Employ more IT health workers to take professional responsibility. Develop specific system requirements, criteria, and standards for software applications for the health system. Standardise hardware and infrastructure for health informatics Construct an ehealth database for the whole health system. Strengthen training activities both locally and internationally to increase expertise Conduct outreach and education to raise awareness of health professionals on IT application to health sector. Organize workshops/conferences to raise capacity building and disseminate new knowledge. Visit or study overseas to learn from the experiences of others. Call for the Government for funding Mobilize resources and contributions from community and organizations Develop international cooperation for funding. Key players/actors to involve Government, ministry of Health, institutes, other relevant sectors and organizations, including both public and private sector Government, ministry of Health, institutes, other relevant sectors and organizations, health facilities including hospitals IT professional organizations and companies, health sector and relevant institutions Health workers, IT staff, relevant officers Any individuals, communities, organizations, agencies, donors, etc who have potential to support. * Source: Hung (2005), Hung (2008a) & Hung [(2008b), in-depth interview with a deputy director of the Centre for Health Information Technology (11 June 2008)]. 1.6 Future plans and prospects to strengthen public health informatics To address the current efforts to strengthen public health informatics, possible activities that the MOH should take (Hung 2008b & Cuong 2008, pers, comm., 11 June) include: Set up a coordination mechanism to ensure that information gathered includes both the public and private sectors (since health data from the private sector is currently lacking). Since too many parallel systems are being tested in different health facilities by different agencies, strengthen the capacity to establish an effective common or 11

12 integrated system of IT for health system management, providing appropriate feedback mechanisms, including information sharing, data analysis, use and management of information at various levels of the system. Since the skills of health staff are weak and variable across health levels and health facilities, it is imperative to continue to train staff at various levels in using IT to update, analyze, report and use data. It would also be important to improve the skills of healthinformation staff in data management and analysis, information quality control, report generation and presentation, and computer system maintenance skills. Information feedback and technical assistance from higher to lower levels also needs improvement. References Cuong, N. Q. (Director of Health Strategy and Policy Institute) 2008, Personal Communication (in depth interview), 11 June. Dung, T. V. & Luat, N. D. 2005, Health Organization and Management, Medical Publisher, Hanoi. Hochiminh Pasteur Institute 2003, Supervision, (online), Available at: (accessed 15 June 2008). Hung, N. H. 2005, Strengthening the efficacy of applying informatics technology in management of building up and developing ehealth information database system of Vietnam, Master Thesis, Military Technology Institute, Hanoi, Vietnam. Hung, N. H. 2008a, Some thoughts about strengthening the efficacy of applying informatics technology to assist management of health sector over the period of , Unpublished paper, Centre for Health Information Technology, Ministry of Health. Hung, N. H. (Deputy Director of the Centre for Health Information Technology Ministry of Health) 2008b, Personal communication (indepth interview), 11 June. Huong, T. M. (Deputy Director of Hanoi Obstetrics Hospital) 2008, Personal Communication (indepth interview), 11 June. Representative (anonymous name required) of the National Preventive Medicine Administrative) 2008, Personal Communication (indepth interview), 11 June. Vietnam National Health Survey 2002, General health status in Vietnam National Health Survey , Vietnam Ministry of Health, Medical Publisher, Hanoi, Vietnam, pp Vietnam Health Statistic Yearbook 2006, Ministry of Health, Hanoi, Vietnam. World Bank 2001, Status of and trends in health indicators, in Vietnam: Growing Healthy: A Review of the Health Sector, WB, Hanoi, Vietnam, pp Thu Linh 2006, HT MEDSOFT a Vietnamese Leading Company on Technology, (Online), Available at: (accessed 12 June 2008). Yen, N. T. (representative of Hanoi K Hospital) 2008, Personal Communication (indepth interview), 11 June. 12

13 2. THE PATH TO INTEROPERABILITY In the context of this report, we used the definition mentioned in an example of a country case study for e-health of Rockefeller Foundation. In that paper, interoperability is defined as ability of systems to freely exchange sets of data in an error-free manner with limited or no human interaction. As in many other sectors, the leaders in the health sector also recognized the importance of IT in exchanging data sets in an error-free manner. The application of IT requires a certain level of use of the predominant world language English which is used in almost all computer software programming and documentation. 2.1 How healthcare providers and consumers communicate in predominant world languages Nowadays, in the world of globalization, English is recognized as a predominant world language. It is also the common language for many diplomatic and international activities in Vietnam. It is the same for many technologies. Producers use English in their products such as in the manuals or training books, and in the user interfaces in the software, and so on. However, the English proficiency of Vietnamese people still does not match needs of the changing world. Due to a long period that English was not taught in schools and universities, especially in the North and in rural areas, most adults can not speak or listen to basic English properly. English has received special attention in many sectors. For example, in tourism, English is very essential for staff carrier. However, the number of staff who do not have enough English capacity is very high. A test was organized for more than 1,000 staffs working in 200 hotels (3 to 5 star hotels) and travel agencies showed that, 45% of tour guides and tour managers, 53-87% security staff, and 67-69% of receptionists did not meet the requirements [1]. The universities are also facing the same problem. The Ministry of Education and Training would like to improve the training and education quality and integrate with the international training system. Several courses, in which English is the subject language, are conducted in some famous universities of Vietnam. But the English capacity of both teachers and students became a barrier and limit the learning process. [2] Only a small percentage of people, who had the chance to work with international organizations or who studied abroad for long abroad courses could communicate in English. In the health sector, government staffs are requested to achieve a certain level (level B) of foreign languages, which can be English, French, China, or others. A major number of people select English as their foreign language. However, in reality, only a small group of health staff could communicate well enough in English. They are mainly those who studied in a long course abroad and work in big cities such as Hanoi, Ho Chi Minh or Hue. Other people did not a chance to study English or had learned English, but did not have chance to practice and therefore they could not communicate in English. One of the obstacles for health staff to communication in English is they did not find any chance to regularly practice English, and the official language and day-to-day communication language is Vietnamese. 13

14 2.2 Technology and/or e-health standards to facilitate interoperability Computers and software are considered important instruments for facilitating data exchange in an error-free manner. Therefore, many sectors have been applying it as soon as they could set up enough infrastructure for the system. An obvious example of the application of IT is in banking system. Nowadays, all local banks use computer and software systems for accurate banking activities. Other examples could be the application of IT application in airline ticket sales or communication systems. Recently, the Vietnamese government issued Decision number 64/2007/NĐ-CP dated 10 th of April, 2007, regarding IT applications in government organizations. This Decision requested all ministries and government s organizations to set up information, data in digital form and maintain standard criteria for managing, processing and searching. In Viet Nam s health sector, leaders had recognized the important of health data, which provide evidence for planning, implementation, monitoring, evaluation as well as evidence of success or failure. However, for a long time, the data were collected in traditional ways using printed reports from lower levels. This system causes a lot of bias during the process of making reports, summarizing lower level reports and reporting to higher levels. Therefore, there are a number of complaints about the quality of health information and data. Among many strategies to strengthening health information systems, IT applications play a very important role. In a paper published in Journal of Practical Medicine in 2001, the Vice Minister of Health addressed the urgent need to apply IT in the health sector, and the necessity to improve human resources capacity of the health sector in this area. [3] E-Health standards to facilitate interoperability in Vietnam are in the beginning stages and include electric health records in hospitals and clinics [4], hospital management software [5], and community health management software [6]. However these applications still have limitations. The Ministry of Health issued requirements for a health record and reported data from hospitals and clinics, and other institutions belonging to the MOH. These can be treated as standards for information systems. When IT companies develop software for hospitals or institutions they must take these standards into consideration. However, software application for health records, hospital management and community health management were limited to a small number of institutions, especially with community health management. Some other new e-health technologies have also started to be introduced within the health sector, but not yet implemented, such as the use of smart cards [7]. 2.3 The biggest interoperability challenges, the country has faced The main challenges for interoperability were stated in the MOH report. They are concerning the lack of a comprehensive and effective action plan at ministerial and lower organization levels regarding IT applications; the very limited capacity of human resources in IT for health, and IT application development and implementation becoming a burden in some institutions, especially where there are no staff trained specifically in bioinformatics; and the IT infrastructure is not well set up. [8] 14

15 2.4 The success in interoperability There has not yet been much success in interoperability in Vietnam at the current time. All activities are still in beginning stages and need much more effort to be successful. However, there are a number of advantages that can support success in moving down the health care IT development and application path. First, the government and MOH leaders have given a high priority to IT adoption. Second, people have become more and more interested in IT, especially the young. Third, the ever increasing popularity of the internet and increasing intranet usage is in almost all areas of the country. 2.5 Key standards considerations related to electronic health systems interoperability: Regarding the adoption of standards, MOH has requested all health facilities to use the same format for reports using some standards. For example, hospital report to the MoH uses ICD-10. Another consideration for interoperability is data structure. Viet Nam already has a highly standardized structure, centrally regulated by the MoH, for all paper forms used for clinical documentation within the public health facilities at all levels, including structured and standardized forms for clinical documentation. Therefore, the country s health care system as a whole is accustomed to central standardization of clinical documentation and that lays a very good foundation for the development of standardized electronic clinical documentation systems. References 1. Develop the standard in English for Tourism: Improving the quality and professionalism for human resource. (in Vietnamese) 2. Modern program needs modern teachers. (in Vietnamese) 3. Le Ngoc Trong. IT application in health sector is an urgent need now (in Vietnamese) Journal of Practical Medicine. Vol Hospital information: technical management a series of short reports Scientific Conference on IT application in hospital management in Vietnam. (in Vietnamese) 5. IT Application in hospital management and health care a series of short reports Scientific Conference on IT application in hospital management in Vietnam. (in Vietnamese) 6. Bui The Duc et al. IT application in counseling, community health care Scientific Conference on IT application in hospital management in Vietnam. (in Vietnamese) 7. Le Quang Duc et al. Develop a hospital management system using smart card in nationwide scale Scientific Conference on IT application in hospital management in Vietnam. (in Vietnamese) 8. Plan to apply IT in health sector in the period of Ministry of Health Vietnam 15

16 3. ACCESS TO INFORMATION 3.1 Access to information by the general population. In Vietnam, more than 90% of the population speaks Vietnamese, the national official language. Various other languages are also spoken by the remaining population belonging to several minority groups. Literacy rate is high in Vietnam. The adult literacy rate has risen to 95% for men, and 91% for women (1). The homogeneity of the language and high literacy rate would strongly facilitate increasing access to information by the general population. Furthermore, in recent years, English is becoming more popular as a second language and this also increases the opportunities for those who can use English to access a wealth of international literature. Vietnam has extensive information and communication systems. Vietnam s radio network- Voice of Vietnam (VOV) - has provincial and district radio stations. In addition to the VOV, there are a number of regional and district radio stations run by local authorities. Household radio ownership is 47%. Vietnamese Television (VTV) is state owned, with around 5 main channels broadcast nationally. Household TV ownership in 2003 was 89%. There is increasing use of residential cable TV services, with the availability of international news, educational and entertainment programming. The state-organized telecommunications system reaches nearly all areas of the country, but few villagers own telephones. Telefax machines are generally scarce. Mobile phones are common among high-income earners in cities, but are expensive to use. Many national and provincial state newspapers exist in Vietnam, most of which represent different associations and organizations (2). In 2004, about 17% of households living in urban area had a computer and the corresponding figure for rural area was 1.7% (3). Internet service is generally accessible and affordable for urban people. Vietnam has about 6 million Internet users. Internet cafés can be found throughout major cities, small towns, and even many villages. More and more cafes (actal coffee shops) have WiFi internet access and there is increasing use of laptop computers. The internet cafés, populated primarily with young people playing games and chatting, provide hope for the future of widespread information access. Vietnam is ranked 30th in the world in Internet use, with nearly six million users as of 2005 (4). International news sites are readily available at public internet cafes and through the telecommunication network internet service providers, principally operated by corporations which are in whole or in part owned by the government. (O Donnell, personal observation, ). Apart from that, various internationally funded projects have promoted the idea of an electronic library, and it has caught on quickly, particularly in universities and research institutes. Students and educated professionals in Vietnam have the desire and, largely, if they live in urban areas, the ability and the means to search for information online 3.2 Health information system and information technology structure In general, the focus of the health information system in Viet Nam has been on collecting and transmitting data. Analyzing and using data has not been done in a systematic way. 16

17 The data are produced at all basic health institutions and are usually entered into standardized registries. Vertical national health programs register their data originating in commune health stations in different ways (5). Overall, computer hardware and software are present at most levels of Vietnam s public health system, but only sporadically at local commune levels. Many top-level hospitals in Vietnam have individual health information systems. The quality and daily usage of these systems vary. Most of these systems incorporate in some way Medisoft 2003 software developed by the Ministry of Health for hospitals at all levels to send statistics and reports to the Ministry s Department of Therapy. Provincial hospitals generally have IT networks, as well as some health information systems with linked databases for patient master indices, consultations and emergency, finance, and pharmacy. District and commune health centers tend to have just a few computers with dial-up internet connections. Lowerlevel units derive much of their general medical information from television and newspaper and via training courses. Together with the United Nations Development Program, the Ministry of Health s Department of Financial Planning developed software for district and commune health information system management; however, this software is not yet widely used. 3.3 How do researchers and providers use information and communication technology to access health information (research, journals, databases, etc) today Researchers and health providers usually find medical information in medical books in medical libraries and research reports published in domestic journals. Medical libraries have not been developed in Vietnam. Only in Hanoi or Ho Chi Minh City, are there good development libraries (donor funded) open to the public that collect this information. Domestic journals can be elusive and difficult to access in Vietnam as they are not free and have not been published online. Researchers and providers certainly benefit from having access to information online, and as donors and the government continue the trend to put more online, such as scientific paper project reports, case studies, budgets, laws, etc. Reports and studies from donors, agencies, and NGOs are generally available online from the organization's Web site, and are often available in print free of charge from the local office. For researchers and providers who know English, internet provides access to a wealth of academic literature that was previously unavailable to most people in Vietnam. 3.4 Key challenges to the use of information and communication technology to access health information There are several challenges to the use of ICT to access health information (6) - Skill of information technology technicians: While there is great interest among health workers in Vietnam at all levels of the health system, the majority of the population is unaware of the vast potential of information technology. - Infrastructure and resources: There is a shortage of stable information technology network connections throughout Vietnam, especially in rural areas and in small health 17

18 centers. Although mobile phones are prevalent in cities, they are not as widespread in rural areas; as a result, the use of telemedicine and mobiles phones as key infrastructure for information technology is not yet feasible. - Cost: For a health center, the cost of one computer alone can be prohibitively high, not to mention the cost of a network of computers. Most hospitals and health centers have very limited budgets for information technology operation and maintenance. Software is also expensive, especially the cost of the software s license if copyrighted. - Standards: information technology software is not standardized at each point of care, such as in different clinical departments or ancillary service areas. As a result, some hospitals must enter a patient s information repeatedly in different programs and each program might have a different identifier for the same patient. References (1) (2) (3) (4) (5) (6) United Nations Educational, Scientific and Cultural Organization (UNESCO). Literacy as Freedom Malene Felsing and Nguyen Song Ha. Information access survey.2003 General statistics office. The World Fact book. Vietnam The World Fact book. 4 August The World Health Organization: Review of health information systems (HIS) in selected countries: Pham Thi Mai Huong, Vo Thi Kim Hue. Vietnam HIT Case Study E-HEALTH CAPACITY BUILDING 4.1 MOH policy on IT application The Vietnamese Government paid a special attention in guiding IT application development and implementation in economic and social development. To implement this policy, MoH created early the IT Application Steering Committee to direct this mission. To progressively satisfy the need to improve the quality of medical assessments and treatment of people, the national hospital system must promote modern processes, infrastructure, equipment and management. So the use of IT applications in hospital management is an urgent requirement which will help promote comprehensive hospital IT development. In 2006, national conference on IT applications in hospital management had identified objectives for developing hospital management IT to 2010 and further goals for 2020 as 100% of hospital country-wide applying hospital manage statistics software (Medisoft 2003 (7). Ongoing goals to 2020 include integrated network connections between hospitals country-wide and MoH progressive implementation of telemedicine. 18

19 4.2 Where do hospitals and government currently turn for technical support? As mention in previous section, recognized the importance of IT application in health sector, MoH has established IT Center aimed to provide technical support to other health institutions. However, up to now, this Center play very limited role in training and studying only. Therefore, almost hospitals and institutions, who wished to apply IT in their management and technical work, had hired private IT companies. 4.3 What infrastructure and training in health informatics exists currently in the country? Are there masters/phd degrees in health or biomedical informatics available? The IT infrastructure of health facilities was not the same in all levels. National institutions often received more investment of government, hence, they showed a better IT infrastructure. But it is not so good in provincial and district health institutions, except those situated in big cities or more economic development areas. In 2006, a survey on IT infrastructure of MOH IT steering committee showed that more than 90% offices belonging to the MoH have a LAN, with. The networks having and average of 2.5 servers; the number of offices with a LAN in the Health Service, Hospitals and Province level health office 45.24%; 21.59% and 19.17% respectively. The number of communes having a computer is 8% and the percent of health commune center with an internet connection is 0.05%. A few central health agencies have its own dedicated connection to the internet backbone, 59% of the units use ADSL and 28% connect to the Internet by Dial-up. Almost all provincial health departments have their professional IT staffs. The average is three professional IT staffs in each office, 2.6 among having graduated from college. Each province has 34 IT staffs working in all provincial health sector, and the average is every three institutions have only 2 IT staffs. At the district level, the IT staff makes up 1% of the human resources. The results of the ministerial level research paper Future and developing IT in the Health sector show that there is 54.9% of IT managers have IT certification, and 55.6% of IT staff eit certification. 37% of surveyed units organized IT training courses for their staffs. From their reports, the contents of courses included: basic informatics (59%), advanced informatics (20%), Internet (2%). Among them 4% was evaluated as very good, 67% good, and 22% fair. For higher training level, there are no master or PhD level programs in this area up to now. 4.4 What are the current programs for training healthcare workers in ICT and informatics? What has worked well, and what hasn t? According to the MoH s plan for applying IT in health sector, during the period , the IT capacity building activities will include (5) development of IT managers, development of professional IT staff, and popularize IT application for health workers. In more detail, it combines of recruiting enough IT professional staffs for each level, organizing IT training for leaders, training and refresher training courses for civil servants 19

20 and office holders, organizing advance training for IT professional staff, training for students in IT, and organizing study tours abroad for IT leaders and IT managers. 4.5 Challenges and solution (6) : The challenges that MOH is facing can be finance for health sector is limited so finance for medical informatics is very poor, understanding and knowledge in IT by health staff are very low, even at the manager level, and there is few IT professional staffs in the health sector. MOH has given some solution to overcome these challenges such as develop IT professional staff from central level to grassroots level, have detailed regulations in IT organization, and IT personnel in all health offices, and assure that there is sufficient, predictable and stable money for medical IT development and implementation. References: 1. No 58/CT-TW dated 17/10/2000 by the Ministry of Politics on promoting the application of IT in the health sector 2. Decision No 531/QD-TTG dated 08/08/1996 by the Prime Minister regarding management of national target program using IT 3. Strategic orientations of the Ministry of Health leaders on public administrative and professional management using IT, as well as developing a unanimous database bank for the whole health system or health sector 4. The Result of Surveillance in IT application in health sector of MoH IT application steering committee. 12/ Plan application and development IT in health sector MoH. 10/ Interview representative of Science and Training Department and Therapy Department of MoH 7. Tran Quy Tuong, Vice Director of Therapy Department, MoH. Objectives and solutions for application IT in hospital management ELECTRONIC HEALTH RECORDS Electronic Health Record (EHR) is a longitudinal electronic record of patient health information generated by one or more encounters in any care delivery setting. Included in this information are patient demographics, progress notes, problems, medications, vital signs, past medical history, immunizations, laboratory data and radiology reports. The EHR automates and streamlines the clinician's work flow. The EHR has the ability to generate a complete record of a clinical patient encounter - as well as supporting other 20