Digital Health Information Systems in the Member States of the Commonwealth of Independent States: Status and Prospects

Abstract

This paper examines the status of the development of national digital health information systems (HIS) in Commonwealth of Independent States (CIS) member states. Data for research were collected using a questionnaire adapted from the questionnaire of the WHO’s Third Global Survey on eHealth. The results showed that the digital transformation of HIS was occurring in all seven CIS member states (participating in the study), which were financed by different resources. Laws and regulations on electronic medical records (EMR) use were present in almost all participating CIS member states. Various international standards and classifications were used to support development and the interoperability of digital health information system (d-HIS), including International Classification of Diseases (ICD), Digital Imaging and Communications in Medicine (DICOM), ISO 18308, Logical Observation Identifiers, Names, and Codes (LOINC), Systematized Nomenclature of Medicine Clinical Terms (SNOMED CT), and ISO TC 215. Several CIS member states had adopted a national information security strategy for the safe processing of both personal data and medical confidential information. The digital transformation of healthcare and the Empowerment through Digital Health initiative are taking place in all CIS member states, which are at different stages of introducing electronic medical and health records.

1. Introduction

During the past 20–30 years, we have witnessed the digitalization of the economy [1], bringing innovation and efficiencies for society, but that also created many challenges related to privacy, security, competition, and innovation [2]. The digital transformation involved all spheres, from the media to healthcare, tourism, agriculture, and education.

Healthcare was one of the first spheres where digital transformation occurred [3]. In the late 1980s and early 1990s, information technologies became more available because of affordability and more local area networks, and increased in power and size, resulting in faster and cheaper Internet. These developments made access to medical records easier and initiated the digitalization of healthcare [4,5].

While new digital technologies can engage patients and doctors more efficiently and safely, they have little value without data. As major components of digital health information systems (d-HIS), electronic medical records (EMR), the digital version of a patient’s medical records and the electronic health records (EHR), and the digital record of a patient’s overall health records including EMRs from different healthcare providers play a fundamental role in patient management and effective medical care services [4]. The adoption rate of EMRs in healthcare facilities has become the main index to measure the digitalization of healthcare in different countries [6].

The active deployment of EHRs has spurred the development of several terminologies and their adoption by the clinical community. To exchange information, different digital health systems must have similar standards, activities and semantics to express them [7]. In the USA in 1987, a large intraoperative system, Health Level Seven (HL7), was introduced and is currently being used in 55 countries worldwide [8]. The Systematized Nomenclature of Medicine Clinical Terms (SNOMED CT) and the Logical Observation Identifiers, Names, and Codes (LOINC) have become widely used international standards [9,10]. There are other systems as well, such as RxNorm for clinical drugs and Current Dental Terminology (CDT) codes for dental treatment in the USA, NHS Dictionary of Medicines and Devices in the UK, and Australian Medicines Terminology in Australia [11,12].

In 2005, the World Health Assembly, through its resolution WHA58.28 on eHealth, urged more than 120 member states “to consider establishing and implementing national electronic public-health information systems and to improve, by means of information, the capacity for epidemiological surveillance and rapid response to disease and public-health emergencies” [13]. This triggered a growing recognition of the necessity to integrate telehealth and health informatics applications to provide consistent digital health solutions [14].

The findings from the Global Observatory for eHealth (GOe) 2015 survey showed that supporting the development and delivery of healthcare with strong information systems was becoming mainstream.

All 194 WHO member states were surveyed to determine whether they had established national policies related to digital health. Results from the 125 responses showed that having a digital health strategy is now becoming the norm; well over half of the countries (n = 73; 58%) reported having a digital health strategy in place. Almost all of these strategies (n = 64; 91%) had policy or strategy objectives addressing how digital health could contribute to universal health coverage (UHC) [15].

Later, in March 2019, a consultative process that was endorsed by the seventy-third World Health Assembly (WHA73) resulted in the development of a global strategy on digital health, the vision of which was “to improve health for everyone, everywhere by accelerating the development and adoption of appropriate, accessible, affordable, scalable and sustainable person-centric digital health solutions” [16]. Four guiding principles, aiming to direct the strategy towards the appropriate and sustainable adoption of digital health technologies, were offered in this Assembly. The foruth principle of the strategy among the proposed long-term actions speaks to the establishment of an electronic patient health records system in developing countries [16].

Health information systems (HISs) and digital health are also priority areas of focus identified in the WHO European Programme of Work (EPW) 2020–2025. In fact, the “Empowerment through Digital Health” is one out of four key flagships of EPW and digital health information systems are an important part of this flagship [17].

A challenge for HISs all over the world that exposed the weaknesses of the systems was the coronavirus (COVID-19) pandemic. It also triggered a change in the way people treat and manage their health. Areas of digital health, such as telemedicine, remote patient care, and continuous monitoring of patients, were heavily affected by the pandemic. Comparing the first quarter of 2020 with the same period in 2019, the Centers for Disease Control and Prevention (CDC) observed that the number of telehealth visits increased by 50%, with a 154% increase in visits noted in surveillance week 13 in 2020 [18]. Taking care of patients in their homes can save substantial amounts of money for the countries that typically spend it on the maintenance of large hospitals. Using wearable devices and using health-related mobile applications that track and safely collect data on health are other important parts of the digitalization of healthcare. All these data are analysed using different algorithms, and they help healthcare providers access large amounts of information derived from different studies aiming to improve healthcare services [19,20].

Generating, analysing, and applying healthcare data are particularly challenging tasks for low- and middle-income countries. However, the recent methods to collect, analyse, and apply data (through a big data approach) seem to be the solution for filling the gap between medical services and population health, contributing to the improvement of health outcomes [21]. Many developing countries have programs intended to fight infections such as human immunodeficiency virus (HIV), tuberculosis, or malaria. These programs usually require detailed information that can now be collected by community workers using electronic tools such as mobile phones, tablets, and laptops [22,23,24].

The WHO Regional Office for Europe also continues to work with member states directly and support the strengthening of HIS through many regional and global health information networks that play an important role in catalysing collaboration and building expert knowledge. An example of such a network is the Central Asian Republics Information Network (CARINFONET), which was relaunched in 2014 to support higher quality and more targeted approaches to health information systems, strengthening the central Asian region [25].

The Commonwealth of Independent States (CIS) member states, like many other countries, have embarked on a digital transformation of their economies. Focusing on the development and buildup of digital healthcare is an integral part of the digital transformation of the economy. Moreover, on 25 October 2019, during the discussion on digital healthcare among the CIS member states, the Council of CIS Heads of States decided to approve the Concept of Cooperation of the CIS member states in the area of digital development of society and the plan of priority measures for its implementation [26].

Later, by the decision of the Council of CIS Heads of State on 18 December 2020, the concept for the further development of the CIS and the plan of the main measures for its implementation were approved. In concept, one of the main priority areas was the enhancement of cooperation in the development of the digital economy, including the digitalization of the healthcare system, introduction of end-to-end information technology, development of digital skills, and the building of an integrated digital infrastructure and information security system.

Currently, the member states of the CIS are actively implementing information technology (IT) projects in healthcare. This is enshrined in the Decision of the CIS Heads of State Council of 28 October 2016 to approve the Strategy for Cooperation of the CIS Member States in Developing and Building up the Information Society and the Action Plan for its implementation for the period until 2025 [27].

To implement these strategic documents, the Ministry of Health of the Republic of Belarus came forward with the initiative to integrate the national d-HIS systems of the CIS member states. The CIS Health Cooperation Council supported this initiative, and the Republic of Belarus, with the technical support from the WHO Regional Office for Europe, developed a questionnaire to evaluate the level of implementation of information and communication technologies (ICT) in the healthcare of CIS states. As there is a lack of literature about the experience of CIS states in regard to the establishment of d-HIS, this study aims to compare the details of the implementation of d-HIS in seven CIS member states based on the information obtained through the evaluation questionnaire.

The specific objectives of this study were (a) to describe the current status of d-HIS implementation progress in different CIS countries and (b) to evaluate the possibility of further integration of existing d-HIS in different countries.

2. Materials and Methods

2.1. Study Design and Sample

This was a cross-sectional study conducted in 2020. The information was provided by the Ministries of Health of Armenia, Belarus, Kazakhstan, Moldova, Russia, Tajikistan, and Uzbekistan in the scope of the Concept of Cooperation of the CIS member states in the digital development of society and the plan of priority measures for its implementation.

2.2. Study Setting

The CIS is a regional interstate organization recognized by the international community that provides partnership in the political, economic, humanitarian, and other areas on the basis of true equal rights, and serves as a unique dialogue platform that takes into account the interests of all member states [28]. CIS was founded in 1991 after the dissolution of the Soviet Union. The CIS performs its activities based on the Charter, adopted by the Council of Heads of CIS States on 22 January 1993, which sets the goals and principles of CIS as well as the rights and obligations of the participating states [29].

2.3. Study Instrument and Data Collection

The study instrument (see Supplementary Materials) was adapted based on the questionnaire of the WHO Third Global Survey on eHealth 2015, which was developed by the WHO’s Global Health Observatory in accordance with the information received after discussions with different WHO strategic partners: governments, WHO offices in various countries, professional associations, and international organizations [30,31].

The co-authors and expert groups of the CIS member states provided feedback on the questionnaire, adopted by the authors of the present paper from the Republic of Belarus. After reaching a consensus on the questionnaire, it consisted of 38 questions most of which were closed-ended and single-choice questions. It was divided into four thematic sections, each of which dealt with different aspects of d-HIS implementation in healthcare (

Table 1. Description of the questionnaire for evaluation of ICT implementation in the healthcare systems of the CIS member states.

Section Title	Purpose of the Section
Part 1. Operation of digital health	Obtaining information on the national strategies for development of digital health in the CIS member states.
Part 2. EMR and EHR	Obtaining information on the regulatory framework for the use of EMR and application of the international standards in the development of EMR, as well on the availability of integrated EHR.
Part 3. Ensuring information security when using ICT in healthcare	Obtaining information on the regulatory framework of confidentiality and security in the development of d-HIS and implementation of measures to ensure information security in healthcare.
Part 4. Integration of the national digital health information systems	Obtaining information on the intention to integrate the national d-HIS and the feasibility of this process in the CIS member states from a technical and legal point of view.

).

The first part of the questionnaire focused on important aspects related to national digital health policies/strategies, the existence and development of d-HIS, language support, inter-country interactions, and financing sources.

The second part focused on key aspects related to regulations governing the use and the timeline of EMR and EHR implementation, the utilization of international standards, patient access to their own data, and the existence of future plans for integrated d-HIS.

The third part covered the evaluation of the information security measures in place within the healthcare sector. The questions address the presence of a national information-security strategy, legislation regulating information security, and procedures for compliance verification. Additionally, the section explored aspects such as the protection of personal data, cross-border data transfer procedures, and the management of information-security incidents within the healthcare system.

And finally, Part 4 touched on the integration of national d-HIS of the CIS member states.

The adopted questionnaire was sent to the participating CIS member states for data collection. The experts participating in the survey were the representatives of the Ministries of Health and/or agencies responsible for the development of their national digital Health.

2.4. Data Analysis

Data were analysed descriptively.

2.5. Ethical Aspects

The analyses were exempt from board IRB approval as this research project involved no study participants and thus no risk to anyone.

3. Results

3.1. Part 1—Operation of Digital Health

Analysis of the obtained information showed that the digital transformation of healthcare was taking place in all CIS member states that participated in the study. However, not all member states had a defined and confirmed national digital health strategy. For example, in three out of seven participating countries there was no such document, but still the national d-HIS was being developed and functional.

In 29% of the countries (n = 2), the national HISs were under development; their launches are planned for 2023 and 2024. It should be noted that in four countries (57%) where national d-HIS had been developed, there were no integration plans with the similar systems of other countries. At the same time, one of the countries was interested in integrating its information system with those of the Central Asian countries.

Support for the Russian language was provided or planned to be provided for the national d-HIS in all Commonwealth states that took part in the survey, except one.

The development of digital health was financed from different sources in different countries, e.g., public sources and public-private partnerships, while 14% of them used all sources of financing permitted by the law. In one of the countries, the national d-HIS is developing, inter alia, at the expense of a World Bank loan (

Table 2. Sources of digital health financing in the CIS member states.

	Public	Public–Private Partnership	Donors/Non-Governmental	Private or Commercial
Armenia		+
Belarus	+
Kazakhstan	+
Moldova	+		+
Russia	+	+		+
Tajikistan	+	+	+
Uzbekistan	+	+	+	+

).

In three out of seven countries, the Ministries of Health ensured quality control of care using ICT as well as ICT safety and reliability in healthcare. It was identified that in different countries the responsibility of these functions was distributed among different agencies including the Ministry of Health, Labour and Social Protection, Federal Service for Surveillance in Healthcare, Territorial Compulsory Health Insurance Funds, the Federal Service for Supervision of Communications, Information Technology and Mass Media, the Federal Security Service, and the Federal Service for Technology and Export Control.

3.2. Part 2—EMR and EHR

In almost all CIS member states, laws and regulations govern the use of EMR. These countries introduced EMR in practice during 2014–2019. In one of the countries, certain sections of the EMR had been introduced in the medical information systems since 2005; however, the regulatory legal act governing their use was adopted after 13 years in 2018 [32].

Integrated EHRs were already being used in 57% of the countries (n = 4); in 29% of countries, their implementation was planned for 2023; and in 14% (n = 1), for 2025. In the CIS countries that took part in the survey, the international standards, such as HL7 and Digital Imaging and Communications in Medicine (DICOM), were mainly used when developing EMR and EHR. The EMR architecture standard (ISO 18308) was in use in 29% of countries, the LOINC standard in 29%, the SNOMED CT in 14%, and technical specifications for EMR (ISO TC 215) in 14% of the countries (

Table 3. International standards that were used within the d-HISs of the CIS member states.

	DICOM	HL7	ICD	ISO 18308	ISO TC 215	LOINC	SNOMED CT
Armenia	+	+				+	+
Belarus	+	+	+
Kazakhstan	+	+		+
Moldova	+		+
Russia	+	+	+	+	+	+
Tajikistan			+
Uzbekistan	+	+	+

).

3.3. Part 3—Ensuring Information Security While Using ICT in Healthcare

Among the CIS member states that took part in the survey, a national information security strategy or other legislation regulating these issues was adopted in 71% of the countries (n = 5). In three countries out of seven, information security in healthcare was regulated by the relevant strategies and policies. In one of the countries, most issues in information security were regulated by the regulatory legal acts that specify procedures and rules for the safe processing of both personal data and family, personal, and medical confidential information.

In 43% of the countries (n = 3), the information and telecommunication infrastructures of the healthcare institutions were combined into a single data transmission network. In one of the countries, the development of a single health data transmission network is planned to be completed in 2023.

Procedures for the cross-border transfer of personal data and information related to the health of individuals were established in three countries out of seven.

3.4. Part 4—Integration of National Health Information Systems

All participant countries except one considered the opportunity to integrate the national d-HISs of the CIS member states appropriately. As for the readiness for integration, 43% (n = 3) mentioned that they were ready to work on this direction, while another 43% answered that integration would be possible after upgrading existing systems. Almost all the participants (except for two countries) stated that, from a legislative point of view, the integration was possible but would require the adoption of amendments to the normative legal acts.

4. Discussion

Our study showed that the CIS member states participating in this research (Armenia, Belarus, Kazakhstan, Moldova, Russia, Tajikistan, and Uzbekistan) were in different stages and paths to the implementation of d-HIS in terms of access for patients, sources of financing, and existing regulatory frameworks for digital health. However, d-HISs are a priority for all of them and they had established a national d-HIS or planned to establish one in the upcoming 1–3 years. Also, they had started using EMRs supported with international standards. This is particularly important because it shows that countries are moving towards strengthening and modernizing HIS. Otherwise, the experiences of many countries has shown that having an underdeveloped HIS is an obstacle and a challenge towards reaching the health-related Millennium Development Goals [33,34].

National digital Health policy or strategy was reported to be present in only four countries out of seven. However, the other three countries reported having national HIS without stating the existence of any policy or strategy. The international experience shows that appropriate policies and legislation form the basis of a sound HIS. Policies define priorities and provide a guiding framework within which all stakeholders operate, whereas the legislation enhances access to data wherever and whenever is appropriate from all sources, including the private and non-governmental health institutions [35,36,37]. Studies conducted in different developing countries mentioned limited financial resources, lack of technical infrastructure, limited health information management expertise, as well as challenges related to interoperability, data privacy, and limited user acceptance among the barriers to EHR implementation [38,39,40]. Policies and legislation can also support the mobilization of resources for digital health development.

It was shown that in 57% of the countries (n = 4), patients had the right to access their own data contained in the EMR, which is important since patients become active players in the process of healthcare provision. The literature review shows that many benefits were demonstrated for patients gaining access to their medical records. Additionally, patient-accessible medical records can enhance doctor–patient communication [41].

One of the goals that different CIS states wanted to achieve in terms of EMR and EHR development was to overcome the existing obstacles preventing the free and prompt exchange of medical data by introducing uniform information standards for integration, including classifiers, protocols, and regulations for the exchange of digital medical information. The use of valid international standards by all states was a prerequisite for ensuring maximum compatibility and full interaction for the national d-HIS. In the CIS countries that took part in the survey, different international standards were already used in the process of EMR and EHR establishment, for example, along with DICOM and HL7, which was present almost in all the countries (except for one), EMR architecture standard (ISO 18308), LOINC standard and SNOMET CT, ISO 183 and technical specifications for EMR (ISO TC 215) were used by different countries. However, it is important to note that many of the international standards noted can be cross-mapped to other standards, thus facilitating the smooth flow of data exchange process [42].

The integration of existing EHR systems in developing countries has been a topic of interest to promote interoperability and information exchange. Various studies explored the potential for EHR integration in low- and middle-income countries. To this end, they highlighted the need for standardized health information systems, regulatory frameworks, and technical infrastructure to support integration efforts [43]. This study emphasized the benefits of integration, such as improved coordination of care, continuity of health records, and data-driven decision making. A study focusing on the integration of EHR systems in Sub-Saharan Africa highlighted the challenges faced by the region, including limited resources, fragmented healthcare systems, and lack of interoperability standards. This study also emphasized the importance of building partnerships, capacity development, and leveraging innovative approaches to overcome these challenges and enable the integration of EHR systems in the region [44]. When integrating a national HIS, special attention should be paid to information security since, in the process of care delivery, large volumes of confidential information are being processed; they contain both personal data of the healthcare workers and patients, along with information qualifying for doctor–patient confidentiality. In addition to the legal regulation ensuring the protection of confidential information, integrity, and availability of personal medical data and information assets, organizational and technical measures were instituted to protect the information and monitor the operation of information and computer systems [45].

According to the WHO report “From Innovation to Implementation: eHealth in the WHO European Region,” CARINFONET and CIS member states showed lower adoption levels of legislation to protect individuals’ health-related data privacy in EHR. A stronger focus on legislation regarding health-related data is needed in these countries to keep pace with their digital health development [46].

The experience of the countries of the European Union with HIS integration showed that the process of integration can be challenged by the quality and availability of data and its methods of collection, as well as the differences in legislative frameworks, political structures, healthcare systems, health insurance, and the size of the population [47]. The above-mentioned WHO report also states that among the WHO subregions with legislation on sharing data, CIS and CARINFONET member states had one of the lowest percentages of data sharing among health professionals in their countries, with other countries, and between research entities, which remains a barrier to cross-border health care. In addition to this, these subregions had the lowest percentages of member states with legislation allowing the individuals to access their own EHR data, specify sharing of data, and request inaccurate data to be corrected or deleted [46]. Hence, before discussing the establishment of a single d-HIS of the CIS member states or the integration of the existing information systems, it is necessary to deliver on a number of targets, such as the development and provision of access to common information resources, the development and maintenance of a unified system of regulatory reference information, and the harmonization of the use of existing international standards for generating, processing, storage, and transmission of data. Ensuring the protection of data during possible interstate information interactions through the development and adoption of a proper framework for the protection of personal data in healthcare systems and finding a balance between the secondary uses of data for public health purposes are also important prerequisites for HIS integration [45].

The implementation of activities aimed at national HIS integration will contribute to positive transformations in the health systems of the CIS member states to ensure affordable and high-quality healthcare, regardless of the social status and place of residence of the citizens. It will also lay the foundation for further integration with the health systems of various other countries.

Strengths and Limitations

To the best of our knowledge, this is the first high-level evaluation of the existing situation and the opportunities for the integration of HIS in Commonwealth states using a questionnaire.

The limitation of the study is that an existing questionnaire was adapted. Due to time and other constraints and convenience issues, researchers often apply some kind of adaptation such as rewording items or deleting or adding new questions specific to the new study. Also, the questionnaire was not translated to the local languages and was not validated. For this reason, the researchers cannot ensure that the new questionnaire has the same reliability and validity as the previous version.

5. Conclusions

Our study showed that the digital transformation of health was taking place in all CIS member states. However, different member states were at different stages in terms of the introduction of d-HIS and the use of EHR. Efforts will be made to overcome the legislative, language, and organizational barriers on the way to d-HIS development and integration.

Patient engagement through granting access to medical records emerged as a key aspect, benefiting doctor–patient communication.

The successful integration of national d-HIS holds the potential to transform healthcare systems, ensuring affordable and high-quality care for all citizens in the CIS member states. Further research is necessary to understand what the human and professional barriers were and the ways to overcome them in the implementation of EHR, as well as to understand how to improve the data reporting process in the CIS member states. Also, in the next study(ies), the Technology Acceptance Model (TAM) can serve as a valuable framework for understanding individuals’ acceptance and intention to use technology driven by their perceptions of its usefulness and ease of use. By applying the TAM framework to our findings, we can gain insights into the factors that shaped the operation of digital health systems and the implementation of EHRs across the participating countries.