Boris Horvat, UP PINT, Muzejski trg 2, 6000 Koper, boris.horvat@upr.si
Primož Lukšič, UP PINT, Muzejski trg 2, 6000 Koper, primoz.luksic@upr.si
Lea Jensterle, UP PINT, Muzejski trg 2, 6000 Koper, leajen@gmail.com
Abstract
Health 2.0 is a term that describes web applications aimed at solving problems in the area of health care and medicine by helping patients (and doctors) to gain important information, share data, gain insight of their health state and connect with others with the same issues. We use a similar definition for Environment 2.0 when observing the environment. Even broader definitions of e-health and e-environment are used for describing processes in health care and the environment that are electronically / digitally covered, instead of just being available on the Internet.
The article summarizes the present state and challenges in the area of e-health and eenvironment in Slovenia and worldwide, recognized within project P7 of the competence centre KC CLASS. Also presented are suggestions for new solutions and implementations of several pilot e-health applications using cloud computing concepts.
Keywords cloud computing, e-health, e-environment, health 2.0, mobile applications, sensors
1 Introduction
Project P7 – “Cloud services for supporting health and environment” is one of the projects dealing with cloud computing in Slovenian competence centre KC CLASS. The goal of project P7 is to offer objective results and guidelines for developing novel cloud-based ehealth and e-environment systems by doing experimental research in the fields of cloud computing, e-health and e-environment which follows national guidelines and strategies, combined with study solutions, pilot applications and analyses of these solutions.

The definitions of e-health and e-environment are used for describing processes in health care and environment, which are electronically / digitally covered. When focusing only on web applications aimed at solving problems in the area of health care and medicine we use the term Health 2.0 and similarly Environment 2.0, when observing the environment.
2 Challenges of e-health
In recent years we have witnessed the use of Internet for various health care related reasons from the perspective of end-users, especially patients. The users, who when being ill used to depend only on the doctor and his treatment, now want to actively influence and take control over their health and the healing process. The Web, with the different services it provides and novel mobile technologies, represents a suitable and reliable communication and collaboration channel.
Primary health care demands of users in the context of (their) health are: to get as much information as one can from different aspects about a specific disease; to take more active role in curing the disease; to use the applications and electronic services with which one can simplify the process of healing, etc. These e-services in collaboration with health care institutions, their services and information systems, combined with active role of all participants of health care system, are defined as e-health, which is a part of the global strategy of Health 2.0.
In recent years in the context of global e-health activities, many different applications and services have been developed which serve users in improving their health or getting the information they need. The services can be roughly divided into three groups which enable
1) acquiring information, 2) social inclusion and networking, and 3) informatization and automation of different user scenarios with health care institutions.
Even though Internet offers a great potential in developing services in the area of e-health, huge amounts of data and different fragmented services cause trouble for the users. They have trouble identifying suitable and verified services from the aspect of reliability, safe use and data confidentiality. Due to fragmentation of information, users have to utilize several different applications and services at the same time, which takes more time, especially because of disconnection of some services, which can clearly be associated.
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Because of the dimension of the Internet, users are not even aware of the existence of some services. A potential solution for these troubles lies in the development of a larger collaboration system that will logically connect different services and applications and consequently enable access through one entering point. This is at the same time one of the goals of the project P7 in the context of e-health.
Modern technological solutions have not always been successfully accepted among the healthcare providers and users due to unreliability of the systems and additional bureaucracy. One of the key aspects for successful adoption of a new information system by health care professionals is in helping them to become more effective and obtain control over all dependent sub-systems, which are crucial for providing good quality services (and content that is being served). Hence the quality of the cloud service is necessary for the involvement of professionals and for the existence of the user community.
Because of the sensitivity of the field it is necessary to pay special attention to data acquisition, data security, data storage, collection and processing. It is necessary to ensure the results will be in accordance with all current regulations in Slovenia which concern personal data: Personal Data Protection Act, Electronic Communications Act, Patient’s
Rights Act, Decision – Surveillance of the Location and Health State of the Patients,
Decision – Global Positioning System (GPS) surveillance, etc.
With the review of online health service market, we can conclude that a lot of applications exist to facilitate the planning of a healthy lifestyle and help diagnose and cure diseases, though most of these tools are intended for foreign markets. Particularly, for the Slovenian market there is little quality interactive content dealing with health issues of type Web 2.0.
Based on the list of applications a plan was made to implement several applications to help patients with treatment of their health problems.
3 Situation in Slovenia
In the context of development vision of Slovenia, e-health has an important strategic and national significance and is regulated nationally with various plans and strategies that include health system informatization. In practice, however, we can talk about different levels of informatization when observing different institutions and recent attempts of developing new solutions for end users.
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In Slovenian health care the first steps in basic computer technology education were made relatively recently together with introduction of computer technology equipment, implementation of computerized exchange of business data, establishment of standards and data collections and introduction of health care insurance card system (KZZ). With the latter we achieved a high visibility in Europe, with our experiences being used in similar card projects in other countries.
One of the achieved milestones of the previous period is also the implementation of data reports about hospital admissions for the needs of classification in the diagnosis related groups – DRG; this method is known is Slovenia as SPP – “skupine podobnih primerov”.
At the same time, other applications in health care were developed: electronic discharge letters; data monitoring for risk factors for cardio-vascular diseases; test introduction of digitalization of radiology with PACS implementation; connection of providers of health care services with laboratories; applications for covering emergency health care help in dispatcher service, etc. While developing and introducing these applications, a large knowledge base was formed, based mainly at the Health Insurance Institute of Slovenia
(ZZZS) and with providers of information services for health care practitioners.
Despite that basic informatization of health care organizations in Slovenia was done early, we still don't have a health care information system that can be manageably upgraded or connected to other information (sub-)systems . Many such (sub-)systems were developed for the needs of individual public health care institutions and are meant especially for satisfying their own requirements, but are not inter-operable enough. For the development of an information system for Slovenian health care, we still have to tackle a lot of inadequacies, which strategic plans try to eliminate. The vision of informatization of
Slovenian health care system is:
 effective, adjustable and modern health care informatics to support achieving strategic goals of Slovene health care system for satisfying the needs and interests of citizens, health care professionals, leaderships of health care organizations and health care system managers;
 connecting local information systems which will enable citizens and health care professionals to cross the administrative and organizational boundaries when searching for information, and to communicate directly without temporal or organizational limitations.
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This vision is being realized using the following strategic directions:
 increasing the active role and responsibility of citizens in their care for their health, ensuring the citizens are being properly informed and ensuring the best possible health care;
 enabling health care professionals secure and reliable access to key information in electronic health records and other data collections that they need in their everyday work, with effective electronic communication, better learning and knowledge management;
 easier planning and management of a health care organization or the health care system as a whole on the basis of quality and credible economic, administrative and clinical data;
 improving accessibility of health care services for those patient groups that would be otherwise excluded on the basis of their lower chances, age or other reasons;
 establishing of basic informatization infrastructure and defining basic collection of health and social data for establishing and managing electronic recording of health data of the patients as well as establishing the foundations for electronic recording of this data on a national level;
 connecting health care and social information systems into an integrated system on a national level with special emphasis on the establishment of standardized health care information portal, which will enable secure and reliable data exchange and standardized and schematic informing and connectivity with comparable EU systems to all subjects of health care system;
 effectuation of e-business as a usual way of work in Slovenian health care.
In the long run new solutions in the area of e-health will be needed which will be helpful or beneficial to all the participants, i.e. patients, users of health care services, health care providers, health care system management, health care ministry, and to the health care system as a whole. In the context of the project we are monitoring examples of good practice in Europe as well as all over the world. E-health is a popular subject, addressed by all countries around the world as well as companies, multinational enterprises and web giants (Google, Microsoft, etc.). Despite that in the context of e-health national projects are currently effectuated only in some countries Scandinavian countries: Denmark,
Netherlands and Finland; with another pretty good system being used in Croatia.
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4 Connections between environment and health
Environment, which we live in, directly affects our health and well being. Therefore, research that investigates the connection between health state of individual and the environment that he or she lives in is of key importance for improving the living environment and health of the population. Environment affects the individual in different segments: through pollution, air, water, weather changes, etc. As one of the important factors in health related issues, the emphasis is also on finding a connection between health and the state of the environment, particularly in the quality of air. In the context of eenvironment (within the project P7) we have focused especially on the effect of air quality on development of lung and cardiovascular diseases.
The research in this area has until now been done especially in regions, where there is more air pollution because of various reasons (factories, transportation, etc.). In Slovenia this is especially the region of Primorska (Luka Koper, vicinity of the port in Trieste, logistics, increased traffic due to touristic activities) and Šaleška dolina (industry, power plant, coal mine, etc.). Environment data in Slovenia is being collected by several organizations and offices and disseminated over the Internet. Data can be found on webpages of Statistical Office of the Republic of Slovenia and Slovenian Environment Agency and at other data sources with environmental data in Slovenia managed by faculties, research institutes, local communities, etc. Environmental data for Slovenia is available also on web-pages of European Statistical office of EU (Eurostat) and European
Environment Agency. Slovenian Environment Agency also manages Catalogue Data
Sources, which represents overview of the data, collected on the side of national as well as other institutions. But almost none of those services are using cloud computing concepts.
5 Including sensor data
Institutionalized health care a lot of times drives people away from such services.
According to research approximately one third of people asked would be prepared to pay a small amount of money to have more independency, offered by control tools equipped with intelligent sensors. Among possibilities for sensor tool uses are:
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
Movement sensors that control if the elderly move normally in their homes, and also warn, when there is a suspicion that a person has fallen or has not gotten up from the bed yet.

Movement sensors that people can wear, e.g. tools that help with losing weight where people record the food they have eaten and the system then calculates the difference between used and consumed calories.

Bracelets for measuring blood pressure and glucose meters that send data through mobile devices to patient’s doctor who can then monitor and detect early signs of a disease.

Patients with chronic conditions like arthritis, asthma and diabetes can themselves take care of the stability of their health state and in this way can avoid hospitalization. The solutions for the stability of chronic conditions include monitoring of vital signs
(weight, blood pressure, insulin) and storing the data in a central repository. When the results drop below or raise above the acceptable level, defined individually for every patient, the system automatically informs the competent health care workers that an intervention is needed.

Mobile measurers of environmental pollution that people can wear. In this way we measure the exposure to harmful environmental effects (e.g. passive measurers of ozone exposure). This data can also be used in detailed modeling of pollution expansion.
We can find several foreign applications which already include sensor and other patient data; for example for measuring insulin and blood pressure: CardioSmart (American
College of Cardiology), DiabetesPHR, 20/20 LifeStyles, Aetna Personal Health Record,
ActivePHR (ActiveHealth Management), Epilepsy Diary (Epilepsy Therapy Project and
Irody, Inc.), ApoThera (Drug Regimen Review), etc..
6 Solutions
Expected results of the project in the context of e-health and e-environment are research papers, study solutions, development and implementations, intended for different health aspects of the patients and individuals, interested in environmental problems. Study implementations of a multichannel location-based platform will be developed, which will
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inform the user about some meteorological parameters and pollution data, warn about possible health dangers and raise alerts on important information about prevention and curing of various diseases, especially the ones, connected with pollution.
We are aware that prevention and education are of key importance, therefore, why we will dedicate special attention to informing the public about risks, connected to pollution. We will make sure that information will be adapted to different target groups, and will also be ready to be used in schools.
In recent years there have been more and more web health care services worldwide that offer various services for the patients as well as for doctors, and also serve as a communication tool between both sides. Among the most used services are: portals for general public, body mass index calculators, web tools for healthy diet planning, portals with described diagnoses and responses to users’ questions (from doctors and other medical staff), pages with advice for healthy lifestyle, recreation and diet, etc. The most representative ones are:

Health care portals: MerckEngage; MyFamilyHealth; LifeMojo; HealthcareMagic;
Revolution Health; WebMD; Healthwise ; RememberItNow!; FreeMD.

Health care communities: Daily Strength; Psych Central; TuDiabetes.com;
SpineConnect.com; Sermo; Patients Like Me; TimedRight; eDrugSearch; Organized
Wisdom; MDJunction; HITSphere; WalkingSpree; CareFlash; Medting; CureTogether;
FacetoFaceHealth.

Health care consultancy: Healthgrades; Health Dialog; Health2.Info; CiteHealth.

Financial services in the health care area: First Horizon Msave; Health Equity;
MedBillManager; MyMedicalControl.

Personal (health care) records: Keyose*; SugarStats.com; MedCommons; Tolven
Health; Medic Drive; NoMoreClipboard.

Pages for comparisons in the health care area: Vimo; RateMDS; HealthShoppr;
Intelecare Compliance Solutions; Medziva; InforMed Centers; MyMedLab; eHealthMe.

Other (undefined): Click4Care; biowizard.com; Health wikis; Yahoo Health &
Welness Groups; American Diabetes Association Message Boards; Microsoft Health
Vault; WhoIsSick; Google Health; Keas; SickKids.
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Slovenian portals with health care information: Institute for researching the burnout syndrome and psychotherapy; Viva.si; Med.over.net; Open platform for clinical food
(OPKP); Zdravstvena.info; Zdravjelepota.si; Vizita; SRC infonet; Draagle.
Within the project we will continue to research the trends and challenges in the areas mentioned, and we will deal especially with study implementations of the modules, which will represent an important part of a multichannel platform using location-based services, described below.
Tools which automatically remind the user on repeating events and inform the user of the newest findings in the area that directly affect him . We will develop study implementations of a program library, a web application and a mobile application that will enable registration to the events and setting of events. Examples of such events are: terms of doctor's appointments or appointments in health care institutions, schedules for taking medicines, reminders on approaching vaccinations (for vaccinations that are repeated in intervals), reminders on approaching periodical appointments and optional events associated with the health interest of the patient, etc. With this application a study implementation of the reminding service on the newest findings in the area of patients’ interest will be developed. This service will be intended for patients as well as their personal doctors. Environmental issues will also be addressed by developing study implementations of applications, which warn the user of potential pollutants in the air and propose preventive actions.
Tools for making and coordinating appointments with doctors . A study implementation of a cloud service for making appointments with the doctor will be performed. Data will be stored in a cloud and integration with the reminding system will also be possible.
Tools for patient - doctor communication. A study implementation of the tool for communication between the doctor and the patient, named “MyDoctor”, will be available as a web portal and will represent a social component in the line of e-health tools. In the continuation of the project we will offer support for mobile clients as well.
Support for computationally intensive analytics in the cloud - connection with SaaS .
We will develop a study implementation of the framework, intended for computationally intensive analyses on large amounts of medical data. For acquiring useful information,
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rules and patterns and connections between them we will also make use of data mining principles and techniques. We will try to find connections between individual factors by analyzing medical data. The focus will be on the impacts of the environment (in connection to location), especially the impacts on appearance certain signs of a disease in a selected area.
Tools for data anonymization and usage. We will develop a study implementation of module for data anonymization. We will examine different possibilities of usage of anonymization algorithms, identify the most suitable and on the basis of these, design our module for anonymization of medical data. Phase of prototype implementation will be followed by evaluation, on which we will implement possible needed improvements of program module.
Tools for health care optimization – connection with logistics. A study implementation of the cloud application will be developed, that will include the support for multichannel capture, display and optimization of resources, and time management in the health care system. We will select a few optimization problems, e.g. optimization of waiting queues, schedule problems, optimization of usage of healthcare materials, reservations, time management, and information support to certain processes of the treatment. The implemented study solutions will be able to tackle those problems that users until now have not been able to solve efficiently. Special focus will be given to cloud implementation of clinical pathways, which are an important tool for improving care processes in hospitals.
Educational content and data visualizations – connection to e-learning . In this section we will design multimedia-rich educational content with interactive quizzes, through which the public will be able to inform itself about pollution impact on health. The section will be specifically adjusted for different age groups, where special attention will be paid on groups of people, for which exposure to pollution is especially dangerous. The educational content will be prepared in such a way that could be used on out-door screens and in school settings.
Interactive map with pollution levels . We will make a study implementation of an interactive map of the coast region, on which it will be possible to observe momentary level of pollution using many parameters, check if there is danger for exceeded levels, and check the real time measures and history of pollution for selected area. Where possible, we
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will integrate publicly available data from automatic measuring stations and results from measures in the field with passive measurers. Our aim is to investigate the relationship among location-supported mobile services of monitoring environmental impacts on people’s health.
Prototype integration of cloud services and location-aware mobile devices in the context of e-health and e-environment. We will make study implementations of computer libraries and applications for mobile devices running on iOS and Android operating systems that will support the use-cases stated below.

Calculator of estimated risk for diseases.
The user will enter into his device or computer his general lifestyle. In this way the user will adjust the parameters for simplified automatic generation of risk estimation and environmental impact on health. Wherever possible, mobile device will use data gathered from sensors, especially location-based data and publicly available data from meteorological stations.

Impact of weather on health state/condition . The user will be able to subscribe to the cloud service, which will send the information on impact of weather on health, together with real time weather data and forecasts. Location of the user will be determined automatically.

Meteorological alarm/alert . The study implementation of a cloud service that will send alerts to subscribers when they will be located in the area, where allowed concentration of harmful substances in the air is exceeded. The service will send the user a notice with alert about exceeded concentrations, level of risk and recommendations and directions for preventive measures.

Carbon print.
The user will be able to follow his movement with his device and gain a rough approximation of calculation of CO
2
releases, which have been made in this time. The mobile device will measure the velocity of movement, location, time and from velocity and location make a simplified assessment of users »CO
2 print«.

The nearest doctor.
A study implementation of multichannel application, which will be intended especially for tourists that come to Primorska region in the summer. The users will be able to access data about the nearest hospital,
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community health centre and pharmacy according to where they are currently located.
 Multichannel applications »My Pharmacy« and »My well being«
. A study implementation of multichannel application »My Pharmacy« will be developed, including: a catalogue of medicines for certain diseases, a display of side effects, information about proper medicine storing, reminder for medicine usage and their dosage, a display of home supply, etc. We will also research the possibility of integration of e-prescription, verification of compatibility of various drugs, presents the composition of medicines, and warns about the potential side effects.
The application “My well being” will capture data about the state of the patient
(depression, disease, well being, and satisfaction of the user with health services).
The users will have an option to check their physical and mental state and get personalized instruction for prevention and treatment.

Algorithms for linking the history of the state of the air pollution with the number of occurrence of certain diagnoses . Within the project a research on statistical algorithms will be performed, through which simplified statistical and epidemiological occurrence of certain diagnoses in a certain area regarding the change in pollution will be modeled. In this way we will try to get important data about the impact of pollution on health of the people, and findings about age groups, which are influenced the most by environment. The acquired knowledge will serve as a further development of the tool for health workers, Institute for
Health Protection and other health organizations for planning preventive health care.
7 Conclusion
E-health will be the next step in the development of health services; however, the adoption will depend on the quality, availability and the user experience. In close relation with heath issues is also the impact of the environment pollution on the health of population. The research and resulting services of the project P7 will present a step in the direction of ehealth and e-environment by providing users more reliable health related information quickly and easily.
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8 Literature
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DRudel_Nacionalna%20strategija%20zdravja%20na%20daljavo.pdf

Health 2.0, http://www.health2apps.com/

Wikipedia.org Health2, http://en.wikipedia.org/wiki/Health_2.0

Na dokazih utemeljene smernice za promocijo zdravja starostnikov (Evidence –
Based Guidelines on Health Promotion for Older People), 2008 (Več avtorjev), http://www.healthproelderly.com/pdf/Smernice_za_promocij_zdravja_pri_starostni kih_TISK02_Predogled.pdf

Zdravje EU - Starejši, http://ec.europa.eu/health-eu/my_health/elderly/index_sl.htm

Zakon o varstvu dokumentarnega in arhivskega gradiva ter arhivih (ZVDAGA) , http://zakonodaja.gov.si/rpsi/r04/predpis_ZAKO4284.html
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Wikipedia.org Health2 Companies, http://health20.org/wiki/Health_2.0_Companies

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ARSO, http://gis.arso.gov.si/
 Geodetski inštitit Slovenije, http://www.geod-is.si/

Sermo, http://www.sermo.com

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
Navodilo za uporabo spletne objektne storitve (arso wfs) – PDF dokument, http://gis.arso.gov.si/wfs_web/blobattributesservlet?Grupa=NAVODILA&ImeBlob
=NAVODILASLO

Wikipedia.org Shapefile, http://en.wikipedia.org/wiki/Shapefile
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Wikipedia.org GML, http://en.wikipedia.org/wiki/Geography_Markup_Language#GML_and_KML
 Informacijski pooblaščenec, http://www.ip-rs.si/varstvo-osebnihpodatkov/inspekcijski-nadzor/najbolj-pogoste-krsitve/zdravstveni-podatki
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