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Ethical health research and privacy protections both provide valuable benefits to society. Health research is vital to improving human health and health care. Protecting patients involved in research from harm and preserving their rights is essential to ethical research. The primary justification for protecting personal privacy is to protect the interests of individuals. In contrast, the primary justification for collecting personally identifiable health information for health research is to benefit society. But it is important to stress that privacy also has value at the societal level, because it permits complex activities, including research and public health activities to be carried out in ways that protect individuals’ dignity. At the same time, health research can benefit individuals, for example, when it facilitates access to new therapies, improved diagnostics, and more effective ways to prevent illness and deliver care.The intent of this chapter1is to define privacy and to delineate its importance to individuals and society as a whole. The value and importance of health research will be addressed in Chapter 3.Go to:CONCEPTS AND VALUE OF PRIVACYDefinitionsPrivacy has deep historical roots (reviewed by Pritts, 2008; Westin, 1967), but because of its complexity, privacy has proven difficult to define and has been the subject of extensive, and often heated, debate by philosophers, sociologists, and legal scholars. The term “privacy” is used frequently, yet there is no universally accepted definition of the term, and confusion persists over the meaning, value, and scope of the concept of privacy. At its core, privacy is experienced on a personal level and often means different things to different people (reviewed by Lowrance, 1997; Pritts, 2008). In modern society, the term is used to denote different, but overlapping, concepts such as the right to bodily integrity or to be free from intrusive searches or surveillance. The concept of privacy is also context specific, and acquires a different meaning depending on the stated reasons for the information being gathered, the intentions of the parties involved, as well as the politics, convention and cultural expectations (Nissenbaum, 2004; NRC, 2007b).Our report, and the Privacy Rule itself, are concerned with health informational privacy. In the context of personal information, concepts of privacy are closely intertwined with those of confidentiality and security. However, although privacy is often used interchangeably with the terms “confidentiality” and “security,” they have distinct meanings. Privacy addresses the question of who has access to personal information and under what conditions. Privacy is concerned with the collection, storage, and use of personal information, and examines whether data can be collected in the first place, as well as the justifications, if any, under which data collected for one purpose can be used for another (secondary)2purpose. An important issue in privacy analysis is whether the individual has authorized particular uses of his or her personal information (Westin, 1967).Confidentiality safeguards information that is gathered in the context of an intimate relationship. It addresses the issue of how to keep information exchanged in that relationship from being disclosed to third parties (Westin, 1976). Confidentiality, for example, prevents physicians from disclosing information shared with them by a patient in the course of a physician–patient relationship. Unauthorized or inadvertent disclosures of data gained as part of an intimate relationship are breaches of confidentiality (Gostin and Hodge, 2002; NBAC, 2001).Security can be defined as “the procedural and technical measures required (a) to prevent unauthorized access, modification, use, and dissemination of data stored or processed in a computer system, (b) to prevent any deliberate denial of service, and (c) to protect the system in its entirety from physical harm” (Turn and Ware, 1976). Security helps keep health records safe from unauthorized use. When someone hacks into a computer system, there is a breach of security (and also potentially, a breach of confidentiality). No security measure, however, can prevent invasion of privacy by those who have authority to access the record (Gostin, 1995).The Importance of PrivacyThere are a variety of reasons for placing a high value on protecting the privacy, confidentiality, and security of health information (reviewed by Pritts, 2008). Some theorists depict privacy as a basic human good or right with intrinsic value (Fried, 1968; Moore, 2005; NRC, 2007a; Terry and Francis, 2007). They see privacy as being objectively valuable in itself, as an essential component of human well-being. They believe that respecting privacy (and autonomy) is a form of recognition of the attributes that give humans their moral uniqueness.The more common view is that privacy is valuable because it facilitates or promotes other fundamental values, including ideals of personhood (Bloustein, 1967; Gavison, 1980; Post, 2001; Solove, 2006; Taylor, 1989; Westin, 1966) such as:Personal autonomy (the ability to make personal decisions)IndividualityRespectDignity and worth as human beingsThe bioethics principle nonmaleficence3requires safeguarding personal privacy. Breaches of privacy and confidentiality not only may affect a person’s dignity, but can cause harm. When personally identifiable health information, for example, is disclosed to an employer, insurer, or family member, it can result in stigma, embarrassment, and discrimination. Thus, without some assurance of privacy, people may be reluctant to provide candid and complete disclosures of sensitive information even to their physicians. Ensuring privacy can promote more effective communication between physician and patient, which is essential for quality of care, enhanced autonomy, and preventing economic harm, embarrassment, and discrimination (Gostin, 2001; NBAC, 1999; Pritts, 2002). However, it should also be noted that perceptions of privacy vary among individuals and various groups. Data that are considered intensely private by one person may not be by others (Lowrance, 2002).But privacy has value even in the absence of any embarrassment or tangible harm. Privacy is also required for developing interpersonal relationships with others. Although some emphasize the need for privacy to establish intimate relationships (Allen, 1997), others take a broader view of privacy as being necessary to maintain a variety of social relationships (Rachels, 1975). By giving us the ability to control who knows what about us and who has access to us, privacy allows us to alter our behavior with different people so that we may maintain and control our various social relationships (Rachels, 1975). For example, people may share different information with their boss than they would with their doctor.Most discussions on the value of privacy focus on its importance to the individual. Privacy can be seen, however, as also having value to society as a whole (Regan, 1995). Privacy furthers the existence of a free society (Gavison, 1980). For example, preserving privacy from widespread surveillance can be seen as protecting not only the individual’s private sphere, but also society as a whole: Privacy contributes to the maintenance of the type of society in which we want to live (Gavison, 1980; Regan, 1995).Privacy can foster socially beneficial activities like health research. Individuals are more likely to participate in and support research if they believe their privacy is being protected. Protecting privacy is also seen by some as enhancing data quality for research and quality improvement initiatives. When individuals avoid health care or engage in other privacy-protective behaviors, such as withholding information, inaccurate and incomplete data are entered into the health care system. These data, which are subsequently used for research, public health reporting, and outcomes analysis, carry with them the same vulnerabilities (Goldman, 1998).The bioethics principle of respect for persons also places importance on individual autonomy, which allows individuals to make decisions for themselves, free from coercion, about matters that are important to their own well-being. U.S. society also places a high value on individual autonomy, and one way to respect persons and enhance individual autonomy is to ensure that people can make the choice about when, and whether, personal information (particularly sensitive information) can be shared with others.Public Views of Health Information PrivacyAmerican society places a high value on individual rights, personal choice, and a private sphere protected from intrusion. Medical records can include some of the most intimate details about a person’s life. They document a patient’s physical and mental health, and can include information on social behaviors, personal relationships, and financial status (Gostin and Hodge, 2002). Accordingly, surveys show that medical privacy is a major concern for many Americans, as outlined below (reviewed by Pritts, 2008; Westin, 2007). As noted in Chapter 1, however, there are some limits to what can be learned from surveys (Tourangeau et al., 2000; Wentland, 1993; Westin, 2007). For example, how the questions and responses are worded and framed can significantly influence the results and their interpretation. Also, responses are biased when respondents self-report measures of attitudes, behavior, and feelings in such a way as to represent themselves favorably.In a 1999 survey of consumer attitudes toward health privacy, three out of four people reported that they had significant concerns about the privacy and confidentiality of their medical records (Forrester Research, 1999). In a more recent survey, conducted in 2005 after the implementation of the Health Insurance Portability and Accountability Act (HIPAA) Privacy Rule, 67 percent of respondents still said they were concerned about the privacy of their medical records, suggesting that the Privacy Rule had not effectively alleviated public concern about health privacy. Ethnic and racial minorities showed the greatest concern among the respondents. Moreover, the survey showed that many consumers were unfamiliar with the HIPAA privacy protections. Only 59 percent of respondents recalled receiving a HIPAA privacy notice, and only 27 percent believed they had more rights than they had before receiving the notice (Forrester Research, 2005). One out of eight respondents also admitted to engaging in behaviors intended to protect their privacy, even at the expense of risking dangerous health effects. These behaviors included lying to their doctors about symptoms or behaviors, refusing to provide information or providing inaccurate information, paying out of pocket for care that is covered by insurance, and avoiding care altogether (Forrester Research, 2005).A series of polls conducted by Harris Interactive suggest, however, that the privacy of health information has improved since implementation of the Privacy Rule. Prior to its creation, a 1993 survey by Harris Interactive showed that 27 percent of Americans believed their personal medical information had been released improperly in the past 3 years. In contrast, 14 percent and 12 percent of respondents believed this had happened to them in 2005 and 2007, respectively (Harris Interactive, 2005 Harris Interactive, 2007). In the 2005 survey, about two-thirds of respondents reported having received a HIPAA privacy notice, and of these people, 67 percent said the privacy notice increased their confidence that their medical information is being handled properly (Harris Interactive, 2005).Responses to other questions on recent public opinion polls conducted by Harris Interactive only partially corroborate these findings. In one survey, 70 percent of respondents indicated that they are generally satisfied with how their personal health information is handled with regard to privacy protections and security. Nearly 60 percent of the respondents reported that they believe the existing federal and state health privacy pro tection laws provide a reasonable level of privacy protection for their health information (Harris Interactive, 2005). Nonetheless, half of the respondents also believed that “[P]atients have lost all control today over how their medical records are obtained and used by organizations outside the direct patient health care such as life insurers, employers, and government health agencies.” In another survey, 83 percent of respondents reported that they trust health care providers to protect the privacy and confidentiality of their personal medical records and health information (Westin, 2007). However, in that survey, 58 percent of respondents believed the privacy of personal medical records and health information is not protected well enough today by federal and state laws and organizational practices.A number of studies suggest that the relative strength of privacy, confidentiality, and security protections can play an important role in people’s concerns about privacy (reviewed by Pritts, 2008). When presented with the possibility that there would be a nationwide system of electronic medical records, one survey found 70 percent of respondents were concerned that sensitive personal medical record information might be leaked because of weak data security, 69 percent expressed concern that there could be more sharing of medical information without the patient’s knowledge, and 69 percent were concerned that strong enough data security will not be installed in the new computer system.Confidentiality is particularly important to adolescents who seek health care. When adolescents perceive that health services are not confidential, they report that they are less likely to seek care, particularly for reproductive health matters or substance abuse (Weddle and Kokotailo, 2005). In addition, the willingness of a person to make self-disclosures necessary to mental health and substance abuse treatment may decrease as the perceived negative consequences of a breach of confidentiality increase (Petrila, 1999; Roback and Shelton, 1995; Taube and Elwork, 1990). These studies show that protecting the privacy of health information is important for ensuring that individuals seek and obtain quality care.The potential for economic harm resulting from discrimination in health insurance and employment is also a concern for many people (reviewed by Pritts, 2008). Polls consistently show that people are most concerned about insurers and employers accessing their health information without their permission (Forrester Research, 2005; PSRA, 1999). This concern arises from fears about employer and insurer discrimination. Concerns about employer discrimination based on health information, in particular, increased 16 percent between 1999 and 2005, with 52 percent of respondents in the later survey expressing concern that their information might be seen by an employer and used to limit job opportunities (Forrester Research, 2005; PSRA, 1999). Reports alleging that major employers such as Wal-Mart base some of their hiring decisions on the health of applicants suggest that these concerns may be justified (Greenhouse and Barbaro, 2005).Studies show that individuals are especially concerned about genetic information being used inappropriately by their insurers and employers (reviewed by Pritts, 2008). Even health care providers appear to be affected by these concerns. In a survey of cancer-genetics specialists, more than half indicated that they would pay out of pocket rather than bill their insurance companies for genetic testing, for fear of genetic discrimination (Hudson, 2007). Although surveys do not reveal a significant percentage of individuals who have experienced such discrimination, geneticists have reported that approximately 550 individuals were refused employment, fired, or denied life insurance based on their genetic constitution (NBAC, 1999). In addition, a study in the United Kingdom suggested that life insurers in that country do not have a full grasp on the meaning of genetic information and do not assess or act in accord with the actuarial risks presented by the information (Low et al., 1998). There is, therefore, some legitimate basis to individuals’ concerns about potential economic harm and the need to protect the privacy of their genetic information. Recent passage of the Genetic Information Nondiscrimination Act in the United States will hopefully begin to address some of these concerns.4Patient Attitudes About Privacy in Health ResearchIdeally, there would be empirical evidence regarding the privacy value of all the specific Privacy Rule provisions that impact researchers, but there are only limited data on this topic from the consumer/patient perspective. A few studies have attempted to examine the public’s attitudes about the use of health information in research. However, few have attempted to do so with respect to the intricacies of the protections afforded by the Privacy Rule or the Common Rule,5which are likely not well known to the public.A review by Westin of 43 national surveys with health privacy questions fielded between 1993 and September 2007 identified 9 surveys6with one or more questions about health research and privacy (Westin, 2007). In some, the majority of respondents were not comfortable with their health information being provided for health research except with notice and express consent. But in others, a majority of respondents were willing to forgo notice and consent if various safeguards and specific types of research were offered. For example, a recent Harris Poll found that 63 percent of respondents would give general consent to the use of their medical records for research, as long as there were guarantees that no personally identifiable health information would be released from such studies (Harris Interactive, 2007). This is similar to the percentage of people willing to participate in a “clinical research study” (Research!America, 2007; Woolley and Propst, 2005) (see also Chapter 3). A 2006 British survey also found strong support for the use of personally identifiable information without consent for public health research and surveillance, via the National Cancer Registry (Barrett et al., 2007).Westin noted that opinions varied in the surveys according to developments on the health care scene and with consumer privacy trends. He concluded from this review that the majority of consumers are positive about health research, and if asked in general terms, support their medical information being made available for research. However, he also noted that most of these surveys presented the choice in ways that did not articulate the key permission process, and that there was much ambiguity in who “researchers” are, what kind of “health research” is involved, and how the promised protection of personal identities would be ensured (Westin, 2007).Reviewing the handful of detailed studies examining patient views of the use of their medical information in research through surveys, structured interviews, or focus groups, Pritts determined that a number of common themes emerge (reviewed by Pritts, 2008):Patients were generally very supportive of research provided safeguards are established to protect the privacy and security of their medical information (Damschroder et al., 2007; Kass et al., 2003; Robling et al., 2004; Westin, 2007; Willison et al., 2007).Patients were much more comfortable with the use of anonymized data (e.g., where obvious identifiers have been removed) than fully identifiable data for research (Damschroder et al., 2007; Kass et al., 2003; Robling et al., 2004; Whiddett et al., 2006).Patients were less comfortable with sharing information about “sensitive” conditions such as mental health with researchers (Damschroder et al., 2007; Robling et al., 2004).In studies where patients were able to provide unstructured comments, they expressed concern about the potential that anonymized data would be reidentified. They were also concerned that insurers or employers or others who could discriminate against subjects could potentially access informa tion maintained by researchers (Damschroder et al., 2007; Kass et al., 2003; Robling et al., 2004). Some feared that researchers would sell information to drug companies or other third parties (Damschroder et al., 2007).Although supportive of research, the majority of patients in these studies expressed a desire to be consulted before their information was released for research (Damschroder et al., 2007; Kass et al., 2003; Robling et al., 2004; Westin, 2007; Whiddett et al., 2006; Willison et al., 2007). Some surveys also show that even if researchers would receive no directly identifying information (e.g., name, address, and health insurance number), the majority of respondents still wanted to have some input before their medical records were disclosed (Damschroder et al., 2007; Robling et al., 2004; Willison et al., 2007). For example, in a 2005 Australian survey, 67 percent of respondents indicated they would be willing to allow their deidentified health records to be used for medical research purposes, but 81 percent wanted to be asked first (Flannery and Tokley, 2005).Studies indicate that public support for research and willingness to share health information can vary with the purpose or type of activity being conducted (reviewed by Pritts, 2008). Studies have found there was less support for activities that were primarily for a commercial purpose, or that might be used in a manner that would not help patients (Damschroder et al., 2007; Willison et al., 2007). Some participants expressed concern that some researchers were motivated by monetary rewards and that decision makers would act out of self-interest (Damschroder et al., 2007).One recent study suggests that the biggest predictor of whether patients are willing to share their medical records with researchers is the patients’ trust that their information will be kept private and confidential (Damschroder et al., 2007). In this study, the patients who most trusted the Veterans Affairs system to keep their medical records private were more likely to accept less stringent requirements for informed consent. Thirty-four percent of veterans who participated in intensive focus groups using deliberative democracy were willing to allow researchers associated with the Veterans Health Administration to use their medical records without any procedures for patient input, subject to Institutional Review Board (IRB) approval, and another 17 percent reported that patients should have to ask for their medical records to be excluded from research studies (opt-out).But participants in focus groups also have expressed a desire to be informed of how their health information was used for research. This desire was tied to a sense of altruism—they wanted to know that their information was useful and that they may have contributed to helping others by allowing their medical records to be used for research (Damschroder et al., 2007; Robling et al., 2004). The veterans also recommended methods to give research participants more control over how their medical records are used in research. These recommendations included requiring that participants are fully informed about how their medical records are being used in research; providing assurances that the research being conducted will benefit fellow veterans; updating research participants about findings and ongoing research; and setting out clear and consistent consequences for anyone who violates a patient’s privacy (Damschroder et al., 2007).The recent Harris poll7commissioned by the Institute of Medicine (IOM) committee for this study found that 8 percent of respondents had been asked to have their medical information used in research, but declined. When asked why, 30 percent indicated they were concerned about the privacy and confidentiality of their personal information, but many other reasons were also commonly cited (ranging from 5 to 24 percent of respondents), including worry that participation would be risky, painful, or unpleasant; lack of trust in the researchers; or belief that it would not help their condition or their family (Westin, 2007).Some studies also suggest that individuals’ attitudes toward the use of their medical records in research may be influenced by a person’s state of health. Although the commissioned Harris Poll found that people who are in only fair health, who have a disability, or who had taken a genetic test were slightly more concerned than the public about health researchers seeing their medical records (55 percent versus 50 percent), other data suggest that people with health concerns may be more supportive of using medical records in research. For example, qualitative market research by the National Health Council showed that individuals with chronic conditions have a very favorable attitude toward the implementation of electronic personal health records (EPHRs). During the focus group discussions, participants noted that EPHRs could be very advantageous in medical research and were supportive of this use even though many had expressed concern about the privacy and confidentiality of EPHRs (Balch et al., 2005 , 2006). Although the Council did not specifically ask about attitudes toward health research and privacy, these results suggest that individuals with chronic conditions may be more likely to grant researchers access to their medical records, and to place less emphasis on protecting privacy than members of the general population.Also, a Johns Hopkins University survey of patients having, or at risk for, serious medical conditions examined these patients’ attitudes about the use of their medical records in research, and compared those results to polls from the general population. Thirty-one percent of respondents stated that medical researchers should have access to their medical records without their permission if it would help to advance medical knowledge.In contrast, the recent Harris poll of the public found that 19 percent of respondents would be willing to forgo consent to use personal medical and health information, as long as the study never revealed their identity and it was supervised by an IRB (Westin, 2007). An additional 8 percent indicated they would be willing to give general consent in advance to have personally identifiable medical or health information used in future research projects without the researchers having to contact them, and 1 percent said researchers should be free to use their personal medical and health information without their consent at all. Thus, 28 percent of respondents would be willing to grant researchers access to their medical records without giving specific consent for each research project. Thirty-eight percent believed they should be asked to consent to each research study seeking to use their personally identifiable medical or health information, and 13 percent did not want researchers to contact them or to use their personal or health information under any circumstances. However, those who preferred not to be contacted at all were actually less likely than those who would grant conditional permission to have declined participating in a research study. Notably, 20 percent of respondents were unsure how to respond to the question about notice and consent for research.Among the 38 percent who said they wanted notice and consent, 80 percent indicated that they would want to know the purpose of the research, and 46 percent wanted to know specifically whether the research could help their health condition or those of family members. Sixty-two percent indicated that knowing about the specific research study and who would be running it would allow the respondent to decide whether to trust the researchers. A little more than half of the respondents (54 percent) said they would be worried that their personally identifiable information may be disclosed outside the study. Among those 54 percent, three-quarters agreed with the statement “I would feel violated and my trust in the researchers betrayed.” Between 39 and 67 percent were concerned about discrimination in a government program, by an employer, or in obtaining life or health insurance (Westin, 2007).However, about 70 percent of all respondents indicated that they trusted health researchers to protect the privacy and confidentiality of the medical records and health information they obtain about research participants. Furthermore, among respondents who had participated in health research, only 2 percent reported that any of their personally identifiable medical information used in a study was given to anyone outside the research staff, and half of those disclosures were actually made to other researchers or research institutions (Westin, 2007).In summary, very limited data are available to assess the privacy value of the Privacy Rule provisions that impact researchers. Surveys indicate that the public is deeply concerned about the privacy and security of personal health information, and that the HIPAA Privacy Rule has perhaps reduced—but not eliminated—those concerns. Patients were generally very supportive of research, provided safeguards were established to protect the privacy and security of their medical information, although some surveys indicate that a significant portion of the public would still prefer to control access to their medical records via consent, even if the information is anonymized. Studies indicate that public support for research and willingness to share health information varies with health status and the type of research conducted, and depends on the patients’ trust that their information will be kept private and confidential. An understanding the public’s attitude toward privacy is important throughout the rest of this report, because many of the IOM committee’s recommendations affect the nature of the privacy protections afforded by the federal health research regulations.Go to:HISTORICAL DEVELOPMENT OF LEGAL PROTECTIONS OF HEALTH INFORMATION PRIVACYThe medical community has long recognized the importance of protecting privacy in maintaining public trust in doctors and researchers, and codes of medical ethics reflect a desire to increase this public trust. Since the time of Hippocrates, physicians have pledged to keep information about their patients private and confidential (Feld and Feld, 2005). The Hippocratic Oath states, “What I may see or hear in the course of the treatment or even outside of the treatment in regard to the life of men, which on no account one must spread abroad, I will keep to myself….” This pledge to privacy has been included in the code of ethics of nearly all health care professionals in the United States. For example, the first Code of Ethics of the American Medical Association in 1847 included the concept of confidentiality (OTA, 1993).The value of health information privacy has also been recognized by affording it protection under the law (reviewed by Pritts, 2008). The rules for protecting the privacy of health information in the clinical care and health research contexts developed along fairly distinct paths until the promulgation of the federal privacy regulations under HIPAA.8Prior to HIPAA, health information in the clinical setting was protected primarily under a combination of federal and state constitutional law, as well as state common law and statutory protections

Health information technology (HIT) is information technology applied to health and health care. It supports health information management across computerized systems and the secure exchange of health information between consumers, providers, payers, and quality monitors. Based on an often-cited 2008 report on a small series of studies conducted at four sites that provide ambulatory care – three U.S. medical centers and one in the Netherlands – the use of electronic health records (EHRs) was viewed as the most promising tool for improving the overall quality, safety and efficiency of the health delivery system.According to a 2006 report by the Agency for Healthcare Research and Quality, broad and consistent utilization of HIT will:[not specific enough to verify]Improve health care quality or effectiveness:Increase health care productivity or efficiency;Prevent medical errors and increase health care accuracy and procedural correctness;Reduce health care costs;Increase administrative efficiencies and healthcare work processes;Decrease paperwork and unproductive or idle work time;Extend real-time communications of health informatics among health care professionals; andExpand access to affordable care.Risk-based regulatory framework for health IT September 4, 2013 the Health IT Policy Committee (HITPC) accepted and approved recommendations from the Food and Drug Administration Safety and Innovation Act (FDASIA) working group for a risk-based regulatory framework for health information technology.The Food and Drug Administration (FDA), the Office of the National Coordinator for Health IT (ONC), and Federal Communications Commission (FCC) kicked off the FDASIA workgroup of the HITPC to provide stakeholder input into a report on a risk-based regulatory framework that promotes safety and innovation and reduces regulatory duplication, consistent with section 618 of FDASIA. This provision permitted the Secretary of Health and Human Services (HHS) to form a workgroup in order to obtain broad stakeholder input from across the health care, IT, patients and innovation spectrum. The FDA, ONC, and FCC actively participated in these discussions with stakeholders from across the health care, IT, patients and innovation spectrum.HIMSS Good Informatics Practices-GIP is aligned with FDA risk-based regulatory framework for health information technology.GIP development began in 2004 developing risk-based IT technical guidance.Today the GIP peer-review and published modules are widely used as a tool for educating Health IT professionals.Interoperable HIT will improve individual patient care, but it will also bring many public health benefits including:Early detection of infectious disease outbreaks around the country;Improved tracking of chronic disease management;Evaluation of health care based on value enabled by the collection of de-identified price and quality information that can be compared.According to an article published in the International Journal of Medical Informatics, health information sharing between patients and providers helps to improve diagnosis, promotes self care, and patients also know more information about their health. The use of electronic medical records (EMRs) is still scarce now but is increasing in Canada, American and British primary care. Healthcare information in EMRs are important sources for clinical, research, and policy questions. Health information privacy (HIP) and security has been a big concern for patients and providers. Studies in Europe evaluating electronic health information poses a threat to electronic medical records and exchange of personal information.]Moreover, software's traceability features allow the hospitals to collect detailed information about the preparations dispensed, creating a database of every treatment that can be used for research purposes.ContentsConcepts and definitions[edit]Health information technology(HIT) is "the application of information processing involving both computer hardware and software that deals with the storage, retrieval, sharing, and use of health care information, data, and knowledge for communication and decision making".Technology is a broad concept that deals with a species' usage and knowledge of tools and crafts, and how it affects a species' ability to control and adapt to its environment. However, a strict definition is elusive; "technology" can refer to material objects of use to humanity, such as machines, hardware or utensils, but can also encompass broader themes, including systems, methods of organization, and techniques. For HIT, technology represents computers and communications attributes that can be networked to build systems for moving health information. Informatics is yet another integral aspect of HIT.Informatics refers to the science of information, the practice of information processing, and the engineering of information systems. Informatics underlies the academic investigation and practitioner application of computing and communications technology to healthcare, health education, and biomedical research. Health informatics refers to the intersection of information science, computer science, and health care. Health informatics describes the use and sharing of information within the healthcare industry with contributions from computer science, mathematics, and psychology. It deals with the resources, devices, and methods required for optimizing the acquisition, storage, retrieval, and use of information in health and biomedicine. Health informatics tools include not only computers but also clinical guidelines, formal medical terminologies, and information and communication systems. Medical informatics, nursing informatics, public health informatics, pharmacy informatics, and translational bioinformatics are subdisciplines that inform health informatics from different disciplinary perspectives.The processes and people of concern or study are the main variables.Implementation[edit]The Institute of Medicine's (2001) call for the use of electronic prescribing systems in all healthcare organizations by 2010 heightened the urgency to accelerate United States hospitals' adoption of CPOE systems. In 2004, President Bush signed an Executive Order titled the President's Health Information Technology Plan, which established a ten-year plan to develop and implement electronic medical record systems across the US to improve the efficiency and safety of care. According to a study by RAND Health, the US healthcare system could save more than $81 billion annually, reduce adverse healthcare events and improve the quality of care if it were to widely adopt health information technology.The American Recovery and Reinvestment Act, signed into law in 2009 under the Obama Administration, has provided approximately $19 billion in incentives for hospitals to shift from paper to electronic medical records. Meaningful Use, as a part of the 2009 Health Information Technology for Economic and Clinical Health (HITECH) was the incentive that included over $20 billion for the implementation of HIT alone, and provided further indication of the growing consensus regarding the potential salutary effect of HIT. The American Recovery and Reinvestment Act has set aside $2 billion which will go towards programs developed by the National Coordinator and Secretary to help healthcare providers implement HIT and provide technical assistance through various regional centers. The other $17 billion in incentives comes from Medicare and Medicaid funding for those who adopt HIT before 2015. Healthcare providers who implement electronic records can receive up to $44,000 over four years in Medicare funding and $63,750 over six years in Medicaid funding. The sooner that healthcare providers adopt the system, the more funding they receive. Those who do not adopt electronic health record systems before 2015 do not receive any federal funding.While electronic health records have potentially many advantages in terms of providing efficient and safe care, recent reports have brought to light some challenges with implementing electronic health records. The most immediate barriers for widespread adoption of this technology have been the high initial cost of implementing the new technology and the time required for doctors to train and adapt to the new system. There have also been suspected cases of fraudulent billing, where hospitals inflate their billings to Medicare. Given that healthcare providers have not reached the deadline (2015) for adopting electronic health records, it is unclear what effects this policy will have long term.One approach to reducing the costs and promoting wider use is to develop open standards related to EHRs. In 2014 there was widespread interest in a new HL7 draft standard, Fast Healthcare Interoperability Resources (FHIR), which is designed to be open, extensible, and easier to implement, benefiting from modern web technologies.Types of technology[edit]In a 2008 study about the adoption of technology in the United States, Furukawa, and colleagues classified applications for prescribing to include electronic medical records (EMR), clinical decision support (CDS), and computerized physician order entry (CPOE).They further defined applications for dispensing to include bar-coding at medication dispensing (BarD), robot for medication dispensing (ROBOT), and automated dispensing machines (ADM). They defined applications for administration to include electronic medication administration records (eMAR) and bar-coding at medication administration (BarA or BCMA).Electronic health record (EHR)[edit]US medical groups' adoption of EHR (2005)Main article: Electronic health recordAlthough the electronic health record (EHR), previously known as the electronic medical record (EMR), is frequently cited in the literature, there is no consensus about the definition.However, there is consensus that EMRs can reduce several types of errors, including those related to prescription drugs, to preventive care, and to tests and procedures.Recurring alerts remind clinicians of intervals for preventive care and track referrals and test results. Clinical guidelines for disease management have a demonstrated benefit when accessible within the electronic record during the process of treating the patient.Advances in health informatics and widespread adoption of interoperable electronic health records promise access to a patient's records at any health care site. A 2005 report noted that medical practices in the United States are encountering barriers to adopting an EHR system, such as training, costs and complexity, but the adoption rate continues to rise (see chart to right).Since 2002, the National Health Service of the United Kingdom has placed emphasis on introducing computers into healthcare. As of 2005, one of the largest projects for a national EHR is by the National Health Service (NHS) in the United Kingdom. The goal of the NHS is to have 60,000,000 patients with a centralized electronic health record by 2010. The plan involves a gradual roll-out commencing May 2006, providing general practices in England access to the National Programme for IT (NPfIT), the NHS component of which is known as the "Connecting for Health Programme".However, recent surveys have shown physicians' deficiencies in understanding the patient safety features of the NPfIT-approved software.A main problem in HIT adoption is mainly seen by physicians, an important stakeholder to the process of EHR. The Thorn et al. article, elicited that emergency physicians noticed that health information exchangedisrupted workflow and was less desirable to use, even though the main goal of EHR is improving coordination of care. The problem was seen that exchanges did not address the needs of end users, e.g. simplicity, user-friendly interface, and speed of systems.The same finding was seen in an earlier article with the focus on CPOE and physician resistance to its use, Bhattacherjee et al.Clinical point of care technology[edit]Computerized provider (physician) order entry[edit]Main article: Computerized physician order entryPrescribing errors are the largest identified source of preventable errors in hospitals. A 2006 report by the Institute of Medicine estimated that a hospitalized patient is exposed to a medication error each day of his or her stay.Computerized provider order entry (CPOE), also called computerized physician order entry, can reduce total medication error rates by 80%, and adverse (serious with harm to patient) errors by 55%.A 2004 survey by found that 16% of US clinics, hospitals and medical practices are expected to be utilizing CPOE within 2 years.In addition to electronic prescribing, a standardized bar code system for dispensing drugs could prevent a quarter of drug errors.Consumer information about the risks of the drugs and improved drug packaging (clear labels, avoiding similar drug names and dosage reminders) are other error-proofing measures. Despite ample evidence of the potential to reduce medication errors, competing systems of barcoding and electronic prescribing have slowed adoption of this technology by doctors and hospitals in the United States, due to concern with interoperability and compliance with future national standards.Such concerns are not inconsequential; standards for electronic prescribing for Medicare Part D conflict with regulations in many US states.And, aside from regulatory concerns, for the small-practice physician, utilizing CPOE requires a major change in practice work flow and an additional investment of time. Many physicians are not full-time hospital staff; entering orders for their hospitalized patients means taking time away from scheduled patients.Technological innovations, opportunities, and challenges[edit]One of the rapidly growing areas of health care innovation lies in the advanced use of data science and machine learning. The key opportunities here are:Health Monitoring and Diagnosis;Medical Treatment and Patient Care;Pharmaceutical Research and Development;Clinic Performance Optimization.[28]Handwritten reports or notes, manual order entry, non-standard abbreviations and poor legibility lead to substantial errors and injuries, according to the Institute of Medicine (2000) report. The follow-up IOM (2004) report, Crossing the quality chasm: A new health system for the 21st century, advised rapid adoption of electronic patient records, electronic medication ordering, with computer- and internet-based information systems to support clinical decisions.However, many system implementations have experienced costly failures.Furthermore, there is evidence that CPOE may actually contribute to some types of adverse events and other medical errors.For example, the period immediately following CPOE implementation resulted in significant increases in reported adverse drug events in at least one study,and evidence of other errors have been reported.Collectively, these reported adverse events describe phenomena related to the disruption of the complex adaptive system resulting from poorly implemented or inadequately planned technological innovation.Technological iatrogenesis[edit]Technology may introduce new sources of error.Technologically induced errors are significant and increasingly more evident in care delivery systems. Terms to describe this new area of error production include the label technological iatrogenesisfor the process and e-iatrogenicfor the individual error. The sources for these errors include:Prescriber and staff inexperience may lead to a false sense of security; that when technology suggests a course of action, errors are avoided.Shortcut or default selections can override non-standard medication regimens for elderly or underweight patients, resulting in toxic doses.CPOE and automated drug dispensing were identified as a cause of error by 84% of over 500 health care facilities participating in a surveillance system by the United States Pharmacopoeia.[39]Irrelevant or frequent warnings can interrupt work flow.Healthcare information technology can also result in iatrogenesis if design and engineering are substandard, as illustrated in a 14-part detailed analysis done at the University of Sydney.Revenue Cycle HIT[edit]The HIMSS Revenue Cycle Improvement Task Force was formed to prepare for the IT changes in the U.S. (e.g. the American Recovery and Reinvestment Act of 2009 (HITECH), Affordable Care Act, 5010 (electronic exchanges), ICD-10). An important change to the revenue cycle is the international classification of diseases (ICD) codes from 9 to 10. ICD-9 codes are set up to use three to five alphanumeric codes that represent 4,000 different types of procedures, while ICD-10 uses three to seven alphanumeric codes increasing procedural codes to 70,000. ICD-9 was outdated because there were more codes than procedures available, and to document for procedures without an ICD-9 code, unspecified codes were utilized which did not fully capture the procedures or the work involved in turn affecting reimbursement. Hence, ICD-10 was introduced to simplify the procedures with unknown codes and unify the standards closer to world standards (ICD-11). One of the main parts of Revenue Cycle HIT is charge capture, it utilizes codes to capture costs for reimbursements from different payers, such as CMS.International comparisons through HIT[edit]International health system performance comparisons are important for understanding health system complexities and finding better opportunities, which can be done through health information technology. It gives policy makers the chance to compare and contrast the systems through established indicators from health information technology, as inaccurate comparisons can lead to adverse policies.

Yes confirming it has significantly undermined all the efforts that yielded a strong Nobel Prize peace accord generating and creating a entire stability across Colombia. Venezuela is the most dangerous country in the world including Afghanistan and Syria.Colombia’s welcoming response has been laudable, the societal and economic shocks accompanying this unprecedented migration inflow, now these 1,9 Million legal and illegal Venezuelans in 2019 combined with Colombia’s own internal pressures, created another important crisis that threaten to destabilize the entire country back into another war.Venezuela’s dire economic and political situation has prompted an estimated over five million citizens to flee the country in 2019. The worsening domestic crisis has prompted to another level this migrant crisis, one that has largely been discounted, but that has many significant implications. Given the politics of international intervention into the region, the influx of migration into neighboring countries, Colombia, Peru, and Ecuador, have created important international security, diplomatic, and humanitarian concerns. With the amount of migrants fleeing Venezuela increasing yearly, and the economic crisis deepening, this crisis cannot afford to be ignored, it is one of the most severe of our time and the involvement of the international community can play a great factor in alleviating the burden on these neighboring nations, but also in alleviating the severity of the conditions on the borders of Venezuela and these nations, like Colombia where the humanitarian crisis is at its worst and continuing and ongoing fast pace since 2016.While these Venezuelan migrants are not considered refugees across all of the neighboring countries that receive them, the 5 million plus that are expected to leave Venezuela or have done so in Nov 2019…as a consequence of the political, economic, and humanitarian crisis. The burden of assisting migrants from Venezuela has largely been on the governments of neighboring countries, most heavily Colombia, countries that already lack the policies, infrastructure, and resources to assist migrants (or more accurately, refugees) since the exodus of Venezuelans began to skyrocket in 2013.Out of all Venezuelans who have fled since 2015, less than half have received formal status in any form. Even still, rather than expand their efforts, several recipient countries have attempted to curb migration altogether by establishing limitations on border entry or access to temporary visas,. These policies are detrimental for the integration of migrants and refugees, as they fuel xenophobic sentiment and leave those without adequate documentation in a vulnerable position of statelessness.The crisis of Venezuelan migrants has caused irreversible damage to the Colombian region, with those who received the most migrants being hardest hit. The once-booming economies of the Colombian-Venezuelan border towns, known as centers of commerce for citizens of both nations have become the most severely impacted. The economic crisis caused by the situation of Venezuela can best be reflected in Cúcuta, Colombia, the largest city on the Colombian-Venezuelan border, and the 6th largest city in Colombia. Cúcuta was known as an important commercial center, it was the center of billion-dollar companies all over the city, as evidenced by its luxurious shopping centers and lifestyle. Its vibrant and booming economy encouraged the use of the bolivar, the main form of Venezuelan currency until it experienced rapid devaluation.The current economy at the border, particularly in Cúcuta, Colombia is emblematic of the devastation of the migrant crisis. The booming economies of border-towns in Colombia of Maicao-Paraguachon La Guajira where are some of the very poor areas and that Venezuela have contributed and deteriorated, as the Colombian economy struggles to account for more “informal” workers, workers whose income is not included in the GDP and who are best known as street vendors, etc., it is failing Colombian citizens.The economic downturn of Cúcuta is reflected in its current 40% poverty rate, a previously inconceivable notion given the wealthy history of the city. Maicao, Paraguachon La Guajira are in the same bad shape as no trade is done between the Colombia Paraguachon La Guajira border and into Zulia Venezuela. Worst the Wayuu largest indigenous population of Colombia and Zulia Venezuela are dying of hunger at such a rate over 5,000 have died in the last two years besides having 700 of the Indigen leaders and social workers killed since 2016. This type of violence and murder epecifically to Indigenous leaders is more typical to Venezuela crime rate, rather than in Colombia.The most striking images that help depict the graveness of the migrant crisis for receiving countries and their need to adapt to these unprecedented waves of migrants are the images of the newly established tents on Colombia’s border. The newly established tents are attempts at providing Venezuelan migrants with a lifeline to help sustain them as they flee from political and economic crisis. The creation of these migrant reception tents and centers in spite of the Colombian government’s refusal to establish refugee centers at the border highlight the severity of the living conditions of these displaced Venezuelans. It is evident that the sanctioning of Venezuela and other political tactics has failed to address the humanitarian crisis, of which many scholars, including Harvard Government Professor Steven Levitsky have stated is just as severe of the Syrian refugee crisis in Europe, and has had disastrous humanitarian impacts on the migrants and the citizens of these neighboring countries.While Visa passes for Venezuelans are generally renewable after expiration, they work with an assumption that the driving factor behind the displacement is a temporary one that can be resolved in a matter of 1-2 years. Unfortunately, even if there were a democratic transition tomorrow, it would likely be years until migration stopped—and even still, there is no guarantee that those who have left will necessarily return. According to a recent study by UNHCR, only 19 percent of Venezuelans actually have intentions to return to Venezuela, with the vast majority hoping to settle elsewhere.There are 232 Illegal border crossing dirt roads called trochas on the Venezuela-Colombia border. (Las trochas -pasos ilegales que normalmente utilizan los grupos criminales dedicados al contrabando y el narcotráfico.)Reportable public health surveillance events among Venezuelans increased from 182 in 2015 to 865 in the first half of 2018. Nearly 20 percent were from groups that traditionally have high health needs, including 50,729 children younger than five years (11.5 percent), 16,812 with chronic health conditions (3.8 percent), 15,705 pregnant and lactating women (3.5 percent), and 468 with infectious diseases (0.1 percent). Of the latter, 202 had tuberculosis and 21 HIV/AIDS. The departments in the border areas had the highest concentration of Venezuelans, with the largest number in North Santander (n = 82,286, 18.6 percent) followed by La Guajira (n = 74,874, 16.9 percent) (RAMV 2018).In 2018, the most common reported events included gender-based and intrafamiliar violence (17 percent), malaria (15 percent), and acute malnutrition in children <5 years (9 percent).transmission of vector-borne illnesses, HIV, and tuberculosis; and outbreaks of vaccine-preventable diseasesThere were 14 measles cases reported between January and June 2018 (compared to none in the previous years), the majority associated with migration from Venezuela.Thirty-six cases of maternal morbidity and two cases of maternal mortality among Venezuelans were observed in the first half of 2018 (compared to three cases of maternal morbidity and no maternal deaths in 2015). Low-birth-weight Venezuelan births rose from three in 2015 to 34 in 2017.Between January 2017 and June 2018, emergency medical attention was provided to 19,108 Venezuelans in government health facilities.The Venezuelan economic, political, and health crisis has triggered an exodus of Venezuelans to countries throughout the region. Hyperinflation in Venezuela is the highest in the world, at 1.37 million percent in 2018, with projections for 2019 in excess of 10 million percent (Reuters 2018). Hyperinflation, coupled with shortages of food, medicine, and healthcare, have contributed to increased humanitarian needs that are not being adequately addressed due to the government’s lack of acknowledgment of the crisis and refusal to accept humanitarian aid (Fraser and Willer 2016; Bello et al. 2017). The deteriorating public health infrastructure has resulted in rising infant and maternal mortality; increased transmission of vector-borne illnesses, HIV, and tuberculosis; and outbreaks of vaccine-preventable diseases (García, Correa, and Rousset 2019; Grillet et al. 2019; Page et al. 2019; Torres and Castro 2019). The number of Venezuelans fleeing the country has dramatically increased in recent years. As of late 2018, the International Organization for Migration (IOM) estimated that 3.4 million Venezuelans had fled the country, and the United Nations High Commissioner for Refugees (UNHCR) reports a 2000 percent increase in Venezuelan asylum applications in 2018 (UNHCR 2018a; UNCHR/IOM 2019).The increase in measles cases is likely attributable to an ongoing outbreak in Venezuela with 7,233 cases reported from 2017 to mid-2018. Emergence of measles in Colombia began in March 2018. In the early stages of the outbreak, through July 2018, 58 percent of cases were imported and 40 percent were imported-related (PAHO/WHO 2018b). Of the 212 measles cases reported in Colombia in 2018, 103 required hospitalization, and none resulted in deaths. In early 2019, the outbreak was still ongoing with cases under investigation in North Santander and other areas of the country (PAHO/WHO 2019). One of the efforts to combat the border health crisis is provision of vaccinations; in 2017 and the first half of 2018, respectively, 58,580 and 86,536 vaccinations were provided at three North Santander border crossings (in addition to lower numbers elsewhere) to vulnerable groups, the majority of which are Venezuelan (Colombian MoH 2017).Erasmo Meoz University Hospital in Cúcuta is the only tertiary hospital in North Santander, and it receives most Venezuelan patients. The Venezuelan case load increased by 248 percent from the first quarter of 2017 to the first quarter of 2018. The hospital treated 9,875 Venezuelan patients in the first five months of 2018, which accounts for approximately 60 percent of Venezuelan cases seen at all public facilities in North Santander. Of Venezuelans who attended in the first five months of 2018, 65 percent were categorized as hospitalizations, 18 percent as emergency care, 12 percent as deliveries, and 5 percent as outpatient consultations (Figure 4b) (Hospital Universitario 2018). Access to non-emergency care remains a critical gap when neither government nor nonprofit clinics are able to attend to more complex cases such as HIV/AIDS, diabetes, cancer, and other noncommunicable conditions. Similarly, access to medicines remains financially out of reach for most Venezuelans, although medications for a small number of infectious diseases (e.g., malaria and TB) and immunizations are provided free of charge via government-supported public health programs.Colombia has reacted proactively and has allocated important resources to serve both migrants and the population living in the receiving areas. However, the extent of this migration requires a greater commitment from the international community.According to a study conducted by researchers of the Universidad del Rosario and presented at the meeting, the migrant population coming from Venezuela does not indicate particularly high educational levels.Colombia hosts the largest number of Venezuelan migrants (1.9 million), 26% of whom are nationals who are returning to their home country. In absolute terms, Bogotá is the city with the largest number of migrants. However, in relative terms, the border areas (Norte de Santander, Arauca and Guajira) are the most affected, with the migrants representing between 4.5% and 5.5% of the population. These regions have development economy lags, which limits their ability to absorb migrants.The distinction between Colombians and Venezuelans is often unclear due to dual-nationality households and documentation issues. Surveillance and health service provision statistics described in the following sections are reported by nationality, and thus under representing the full scale of the migration crisis because they do not include Colombian returnees.One of the main factors of concern to institutions, such as the Office of the Ombudsman or Migración Colombia, in 2019 is that many Venezuelan immigrants are being recruited by criminal gangs operating in different cities throughout the country, and consequently, increasing insecurity.They have increased the crime rate from the day they arrived.United Nations Agency for Refugees (UNHCR) and the International Organization for Migration (IOM). According to the report, only 40% of the migrant children are in school, and the migrant population is twice as likely to be unemployed than the local population. The cost of additional public services caused by migration including education, health, water and sanitation, early care, housing support, employment services and institutional strengthening lies between 0.23% and 0.41% of Colombia’s GDP.Regarding labor, the same 2019 study reveals that 67.32 percent of the immigrants who arrived in Colombia more than 2 years ago, and less than 5, are working. The percentage of those who arrived less than two years ago is 10 percent lower (57.2%); hence, increasing the unemployment rate in our country by 1 5.7%.Peace efforts in the country have ended 50 years of intense conflict. Now, scientists are studying former fighters and victims as they attempt to heal.The accord's reincorporation council continues to determine protocols and institutional arrangements for reincorporation of ex-combatants. The Agency for Reincorporation and Normalization (ARN), formerly the Colombian Reintegration Agency (ACR), is the implementing arm of this process. Delays in implementing the program, caused by the refusal of FARC leadership some now living in Venezuela with influence not to permit members to actively and effectively participate, increased the prospects that some ex-combatants could and or would return to engaging in criminal activities as they do daily in Venezuela.Colombia is a South American country with a frightening reputation for drug wars and kidnappings, but it is emerging on the scene as a favorite destination for adventure travelers.From the Caribbean coast to the friendly people and charming culture, in 2019 -4 millions travelers are flocking to see Colombia before it becomes a tourist hotspot – and here's why you should do it too.Colombia was in the process of overcoming most of the domestic problems after the best International world wide war experts negotiated for years in Cuba a peace accord that yielded real peace and the Nobel Prize in 2016 to then President Manuel Santos. A referendum was held on a date having a hurricane day on the Caribbean- Atlantic coast and this accord was defeated by less than 1 %. From this point the new President of Colombia was capable to get a slightly revised accord approved.The FARC rendered a extremely high % of their arms under the United Nation supervision experts. The EX- FARCS where settled in 26 new resettlement small cities in selected areas of all over Colombia. They are in restrained communities with small houses, School, Libraries, and most of Colombia services are within these compounds that they cannot leave without supervision and authorisation. Most of them are like from another planet and never had a bed nor a bathroom something they now all have. They have also many incentive programs to allow them start a micro business ,studying and raising some kids. Plus they can engage in a Political party defending their cause. There has being some failures, breaches and difficulties thru these 26 camps but something in the low % rates…The disarmament and rehabilitation campaign is run by Colombia’s Reincorporation and Normalization Agency (ARN) in Bogotá. The ARN had been established years earlier, and it has since facilitated the reintegration of some 20,000 paramilitaries and guerrillas who left the conflict independently or as part of a separate peace agreement.The 26 transit zones that former fighters are entering offer amenities such as education and health care, and help to provide at least a measure of protection for the ex-combatants, who are regularly targeted by former enemies, FARC dissidents and civilians. After completing a programme, ex-combatants can receive ID cards that allow them to live and work legally in the country. The prospect of their return doesn’t thrill some local residents all over Colombia .The 26 mall cities with ex-combattant located in Colombia areas.Under the agreement, thousands of former FARC combatants are entering 26 designated ‘transit zones’ throughout the country — known officially as territorial spaces for training and reincorporation (ETCRs). Here, they will prepare to re-enter Colombian society. But several guerrilla groups continue to fight, including 1,000 FARC ‘dissidents’ who have refused to sign on to the accord.But after studying more than 600 combatants, we begun to grasp the complexity of their experiences. “I realized not all of them are sociopaths. I realized most of them are also victims.”The effort, which is politically controversial and expected to cost 129.5 trillion Colombian pesos (US$46 billion), faces overwhelming odds. But it grants scientists a unique opportunity to understand a population that has both inflicted and suffered the horrors of war. Most research into the psychological roots of violence and trauma has been performed with veterans from wealthy countries who fought in conflicts far from home. Most of Colombia’s ex-combatants, by contrast, have little education and are trying to re-enter the same society they once terrorized. There, they face enormous stigma and resentment, which makes it difficult for them to find work and form relationships with others.Colombia’s government is currently engaged in one of the largest peace efforts in history. As part of a 2016 treaty with the left-wing guerrilla group known as the Revolutionary Armed Forces of Colombia (FARC), the government will grant amnesty to fighters who leave the conflict and complete a re-incorporation programme, provided they have not committed serious crimes. Around 11,800 FARC fighter are in the radar program.In 2017, Colombia conducted more than 400 security trainings for thousands of non-Colombian individuals on citizen security, crime prevention and monitoring, military and police capacity building, anti-kidnapping, anti-extortion, hostage negotiation, and cyber-security.Now on the negative side is the Venezuela crisis with the 1,9 millions Venezuelans legals and illegals in Colombia that caused numerous difficulties that today are gaining a strong criminal pace in some hard Terrorist areas as The Department of Cagueta, Cauca, Narino, Catatumbo region, La Guajira representing what is left, including Venezuelans of the long bloody border conflict that had gripped Colombia for more than 50 years.Colombia: 700 indigenous social leaders killed. AL JAZEERA NEWSFive indigenous leaders were killed last Tuesday in the latest attack on native communities in southwest Colombia. / by Hanna Wallis 3 Nov 2019 .President Ivan Duque made an emergency trip to the Cauca on Wednesday, and ordered 2,400 soldiers to be deployed in the region to strengthen security.Tacueyo, Cauca, a town in southwest Colombia, thousands on Saturday to mourn the death of indigenous governor Cristina Bautista, Bautista was an internationally recognised leader, who had represented indigenous women at the UN, who was killed last week along with four volunteer community guards in a massacre that has become a searing emblem of the state's unrelenting violence.The number of hundred of indigenous people killed in the area has risen sharply as armed groups seek to seize control of the power vacuum left by the Revolutionary Armed Forces of Colombia (FARC) after they demobilised as part of the 2016 peace deal.Areas in Colombia, the social and Indigenous leaders where killed.The UN has documented 52 murders of indigenous people in the northern part of Cauca this year alone.The country faces a national epidemic of social leader assassinations. In 2016, Colombia's homicide rate dropped to its lowest in four decades, at some 12,000 cases. And yet the number of social leaders and human rights defenders killed has been on the rise.Dozens of indigenous and social leaders have been killed in the aftermath of Colombia’s historic 2016 peace accord as illegal armed groups and dissidents seek to exert control over for former rebel territory and lucrative drug routes. Among those killed were 14 members of tribes in Cauca state, where Tuesday’s massacre took place. It is one of Colombia’s fastest-growing areas for cocaine production, responsible for about 10% of all illegal crops produced across the country last year, according to the United Nations.“This is a historical battle for territory,” said Sen. Feliciano Valencia, who represents Colombia’s indigenous community in Congress. “While the armed groups fight for control of illicit crops and drug routes, we are defending our territory and autonomy.”The nearly 2 million Colombians belonging to 115 indigenous groups carry less political and economic weight than their brethren in neighboring countries like Ecuador or Peru and are largely relegated to poverty-stricken areas traditionally neglected by the state and where alternatives to growing illicit crops are hard to come by.According to data from the Bogota-based conflict research organisation, INDEPAZ, between the beginning of 2016 and May this year, more than 700 indigenous leaders - 150 of whom were from Cauca - have been killed.( 627 personas líderes sociales y defensores de Derechos Humanos han sido asesinados. 21 en el año 2016, 208 en el año 2017, 282 en el año 2018 y 116 en el año 2019. 92 eran mujeres y 535 eran hombres. 142 indigenas, 55 afro descendientes y 245 campesinos ambientalistas comunales o impulsores PNIS.)The complex power struggle between guerrilla insurgents, the government, paramilitary groups and drug traffickers had killed hundreds of thousands of people and displaced millions. Now in November 2019 / 5 millions plus peoples have left Venezuela, the majority of them in Colombia. Many in Colombia are hard criminals from the Venezuela highest crime rate areas in the world from around Venezuela, and Caracas.In Venezuela there is no governance at all, nor any form of logical commander or police system. The military are engaged in every aspect of any form of illegal trade , from Gas, Oil, Drugs, Food, Gold,Silver, stolen cars and stolen merchandise and controlling most of the drug flights out of Venezuela.Venezuela world largest HUB for shipping drugs worldwideEPL/ “Pelusos” activity (January 1 to June 30, 2018)The EPL, or “Pelusos” as authorities call them, is a dissident faction of the guerrilla group that demobilized in 1991. The EPL has been at war with the ELN in the Catatumbo region since 2018, and is allegedly deeply involved in drug trafficking to Venezuela.The Catatumbo Area is now largest new coca growing area bordering Venezuela. Once inside Venezuela, the drugs are then whisked through military checkpoints and escorted or waved on by the army, allege US and regional officials and several Venezuelan army defectors.A defector from the Venezuelan border patrol told CNN that it was once his task to pick out trucks carrying traffickers' cocaine and ensure they passed through the 232 illegal border dirt road swiftly. He said this happened as often as three times a week, during the five-year period he served in the border region.In Red areas are the hard narco trafficking areas mostly dealing and exporting to Venezuela the world largest hub for Shipping drugs worldwide . Many of the Venezuelan controlling these drug shipments are no living in Colombia.The peace accord is extremely fragile with close to 2 million Venezuelan now in Colombia bringing with them all their high crime rate expertize.1-Informe líderes y defensores de DDHH asesinados al 26 de julio de 20192-Las trochas, único vínculo entre Venezuela y Colombia por cierre de frontera | ELESPECTADOR.COM3-https://repositorio.uptc.edu.co/bitstream/001/2340/1/TGT_990.pdf4-Las preocupantes cifras de Indepaz sobre asesinatos a líderes sociales5-Impact of immigration from Venezuela to Colombia - Universidad Externado de Colombia6-Veranstaltungskalender online - Georg-August-Universität Göttingen7-Despite Challenges, Venezuelan Migration into Colombia can Boost its Growth8-https://www.oecd.org/economy/surveys/Colombia-migration-shock-note-english-2019.pdf9-Venezuelan Migration and the Border Health Crisis in Colombia and Brazil - Shannon Doocy, Kathleen R. Page, Fernando de la Hoz, Paul Spiegel, Chris Beyrer, 201910-Venezuela’s Dangers Spill across the Colombian Border11https://www.addisonlibrary.org/sites/default/files/The%20Collapse%20of%20Venezuela.pdf12-New Research: The Venezuelan Migration Crisis in Colombia14-The Role of Neighboring Countries in the Venezuelan Migrant Crisis15-WOLA Report: Responding to Venezuela's Migration Crisis