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AND DEVELOPMENT
This is the first book to provide a comprehensive overview of the social
and technological context from which eHealth applications have arisen, the
psychological principles on which they are based, and the key development and
evaluation issues relevant to their successful intervention.
Integrating how eHealth applications can be used for both mental and physical
health issues, it presents a complete guide to what eHealth means in theory, as
well as how it can be used in practice. Inspired by the principles and structure
of the CeHRes Roadmap, a multidisciplinary framework that combines and uses
aspects from approaches such as human-centred design, persuasive technology
and business modelling, the book first examines the theoretical foundations of
eHealth and then assesses its practical application and assessment.
Including case studies, a glossary of key terms, and end of chapter summaries,
this groundbreaking book provides a holistic overview of one of the most important
recent developments in healthcare. It will be essential reading for students,
researchers and professionals across the fields of health psychology, public health
and design technology.
Dr. Saskia M. Kelders is Assistant Professor at the Centre for eHealth and
Wellbeing Research of the University of Twente, The Netherlands and Extraordinary
Professor at the Optentia research focus area of the North-West University, South
Africa.
Hanneke Kip is a PhD student at the Centre for eHealth and Wellbeing Research
of the University of Twente, The Netherlands, with a background in psychology
and an interest in behaviour change and improvement of mental healthcare via
technology. Her current research focuses on the development, implementation and
evaluation of eHealth technologies in forensic mental healthcare.
and by Routledge
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CONTENTS
Preface vii
List of contributors xv
PART 1
Underpinnings of eHealth 1
1 Introducing eHealth 3
Lisette (J.E.W.C.) van Gemert-Pijnen, Hanneke Kip,
Saskia M. Kelders and Robbert Sanderman
PART 2
eHealth development, implementation and evaluation 129
Glossary 330
Index 344
PREFACE
• explain the relationship between technology, psychology and health, and con-
nect them to this book’s vision of eHealth.
• state several areas of application of eHealth and provide accompanying examples.
• name several benefits and barriers of eHealth in development, implementa-
tion, evaluation and use in practice.
• explain what a holistic vision of eHealth entails and why it is required to over-
come the barriers and achieve the benefits.
• name and explain the importance of the five pillars of holistic eHealth
development.
• explain the advantages of technology for health and know what possibilities of
technology induce these advantages.
• discuss the evolution of technology, in particular, technologies relating to
eHealth.
• discuss different examples of technologies and their opportunities for health
and well-being.
• explain the basics of common building blocks of technology, namely, machine
learning, natural language processing, image recognition and neural networks.
• name and explain different software design models.
• elucidate what eHealth is intended to deliver, by showing how eHealth can help
us realize the full potential of the health system in sustaining human health.
• decide if an application of eHealth will be of value to humans and supportive
of their health.
• intervene in the health system more effectively by both understanding and
taking advantage of the characteristics of complex systems, and by seeing
these characteristics to be of value rather than just problems.
• explain why and in what way the contextual inquiry is essential for the eHealth
development process.
• provide concrete examples from practice to illustrate the relevance of conduct-
ing a good contextual inquiry for the development of good eHealth development.
• name and explain the relevance of multiple research methods that are used in
the contextual inquiry.
• explain the identification, analysis and added value of stakeholders during the
contextual inquiry, and connect this to the entire eHealth development process.
• connect the contextual inquiry to holistic development using the terms user,
context and technology.
xii Preface
• describe that eHealth technologies are resources for business to create value
propositions for their customers within the context of a business value network.
• analyze the business value networks using graphs to identify flow of products
and services on one hand and the flow of payments on the other hand.
• translate added value as perceived by key stakeholders into value propositions
delivered by business to their customers.
• explain what relationships, channels and revenue models are needed to deliver
the value propositions to the customers.
• describe what activities, resources and partners are needed to create these
value propositions.
• explain how to develop feasible business value networks with business using
viable business models.
Acknowledgements
First, we would like to thank all authors for their valuable contributions. Their con-
tinuous efforts have resulted in a comprehensive and coherent book that offers
multiple perspectives on the important topic of technology for health and well-
being. Also a very special thanks to our student reviewers whose feedback assisted
us in writing a book that is valuable to students from different disciplines and back-
grounds: Felix Smoletz, Femke van de Lagemaat, Gulsen Öcal, Kaija Troost, Kamila
Skolik, Lida David, Marcel Hoeve, Marileen Kouijzer, Mariska ter Horst, Stefan Perk,
Stina Nagelmann and Talin Yakob. We would also like to thank Russell George and
Alex Howard from Taylor & Francis for giving us the opportunity to create this
book and for their assistance during the whole process. Furthermore, we would
like to thank our colleagues at the Centre for eHealth and Wellbeing Research of
the University of Twente for their enduring support. Finally, a very big thank you to
Roberto Cruz Martinez for all of his hard work in setting up the student reviews, the
great Excel sheets, and getting the book ready to be published.
CONTRIBUTORS
Editors
Dr. Saskia M. Kelders received her PhD in 2012. Her dissertation focused on
keeping people engaged with (mental) health interventions using persuasive
technology. She is now Assistant Professor at the Centre for eHealth and Wellbeing
Research of the University of Twente and Extraordinary Professor at the Optentia
research focus area of the North-West University, South Africa. Her research
interests are positive psychology, persuasive technology and digital interventions.
Ongoing research projects are focused on using individual engagement to
personalize eHealth interventions. Methods used are, for example, analysis of
log data, experimental studies and randomized controlled trials. Examples of
interventions Saskia works on are web-based gamified interventions and mobile
apps to increase well-being.
Hanneke Kip is a PhD student who works at the Centre for eHealth and Wellbeing
Research of the University of Twente. She also teaches in psychology and health
sciences. Her PhD project takes place at Transfore, a forensic hospital with both
inpatients and outpatients. Her research focuses on the development, implementation
and evaluation of eHealth technologies in forensic mental healthcare. Her research
interests include participatory development, monitoring biopsychosocial factors via
technology, virtual reality, behaviour change theories and data-driven coaching of
aggression.
xvi Contributors
Prof. Dr. Robbert Sanderman was trained as a clinical psychologist and is
Professor in Health Psychology (since 1999) – both at the University of Groningen
and at the University of Twente, The Netherlands. His research is in the area of
psychological and social adaptive processes in patients with a chronic somatic
disease, in which he focuses on the development over time of quality of life and
psychological mechanisms in adjustment. In addition, he is involved in studies
testing the efficacy of psychosocial interventions to improve quality of life among
patients, and more recently also got involved in research on eHealth. He has
supervised over 50 PhD students and has been President of the European Health
Psychology Society.
Chapter authors
Dr. Nienke Beerlage-de Jong received her PhD in 2016. Her dissertation focused
on how persuasive eHealth technology that is developed from a socio-technical
perspective can contribute to infection prevention and to the fight against
antimicrobial resistance. Her research interests mainly lie in persuasive design,
participatory development, gamification and decision support. She now works as a
postdoctoral researcher at the Department of Psychology, Health and Technology
at the University of Twente. Currently, she is involved in research projects aiming
to develop technologies to support risk communication and crisis communication
among healthcare professionals during outbreaks of zoonotic infections.
Christina Bode is psychologist and is Associate Professor and Director of the Self-
management & Health Assessment Lab at the Department of Psychology, Health
and Technology at the University of Twente. Her research and teaching is dedicated
to the question of the conditions under which people with chronic illnesses can
live a vital and meaningful life and how this aim can be facilitated and achieved
with technology such as innovative measuring and monitoring of patient-reported
outcomes and by self-management interventions.
Dr. Matthew Howard received his PhD in Biological Sciences in 2002 from Imperial
College London and has subsequently held roles across Start-Up Biotech, Big
Pharma, Life Science Consulting and Technology Leadership. He is now Director
of Artificial Intelligence at Deloitte UK and focused on cross-sector and healthcare
applications of AI. Prior to Deloitte, Matthew was the European Lead for IBM
Watson Health, working with leading cognitive AI platforms in the field of clinical
decision support in genomics and oncology.
Julia Keizer, MSc. is a PhD candidate at the University of Twente, where she received
both her bachelor’s and master’s degrees in Health Sciences cum laude. Complex
healthcare-related issues form the base of her research, in which cooperation
with healthcare workers and bridging theory and practice are crucial. Previous
research focused on improving proactive palliative care for oncology patients and
on decision-making processes of healthcare workers for surgeries in frail elderly
cancer patients. Her current research focuses on supporting healthcare workers in
limiting antibiotic resistance and infections in hospitals.
Nadine Köhle, PhD, received her PhD in 2016. Her PhD thesis describes the
participatory development and mixed-methods evaluation of a Web-based self-help
intervention for partners of cancer patients. Her general research interests include
supporting partners of cancer patients and informal caregivers in general, positive
psychology (such as Acceptance and Commitment Therapy, mindfulness and self-
compassion), eHealth, and participatory design. She now is Assistant Professor at
the Department of Psychology, Health & Technology at the University of Twente.
Eimear Morrissey (BA, MSc.) is a PhD candidate and Irish Research Council Scholar
at the School of Psychology in NUI, Galway. Her research is based around digital
interventions for adherence to medication and self-management guidelines in a
hypertensive population.
Rosalie van der Vaart is a member of the Health, Medical & Neuropsychology
Unit, Institute of Psychology at Leiden University in The Netherlands. She is a
researcher and teacher in health and medical psychology at Leiden University
and specializes in eHealth and chronic diseases. The main aim in her work regards
the development, evaluation and implementation of online self-management
interventions, taking into account the needs, wishes and skills of stakeholders and
the facilitators and barriers in clinical practice.
Jane Walsh (PhD) is the Director of the mHealth Research Group and a lecturer in
Health Psychology at the National University of Ireland (NUI), Galway. Her research
interests are underpinned by the theme ‘Health Behaviour for Healthy Ageing’.
Her research mainly involves developing optimum digital interventions for health
behaviour change to enhance health and well-being.
Dr. Jobke Wentzel received her PhD in 2015. She researched and developed
eHealth technology to support healthcare professionals to prevent and combat
antimicrobial resistance. In addition, she has worked on research projects focused on
the development, evaluation or implementation of eHealth, eMental health and
accessible multimodal technology. Jobke’s research focuses on human-centred
design, participatory development, persuasive technology and accessibility.
PART 1
Underpinnings of eHealth
1 Introducing eHealth
Lisette (J.E.W.C.) van Gemert-Pijnen,
Hanneke Kip, Saskia M. Kelders and
Robbert Sanderman
In this chapter, we introduce eHealth and describe its emergence, the visions on
eHealth in improving health and well-being and making healthcare more efficient
and effective. We describe in what ways eHealth has been used in practice and
what the added value of eHealth can be, showing observed benefits and barri-
ers. Furthermore, the chapter introduces a participatory development approach,
a holistic approach to guide the development, implementation and evaluation of
eHealth technologies and interventions. The chapter ends with an outline of the
book. After completing this chapter, you will be able to:
• explain the relationship between technology, psychology and health, and con-
nect them to this book’s vision of eHealth.
• state several areas of application of eHealth and provide accompanying
examples.
4 Lisette (J.E.W.C.) van Gemert-Pijnen et al.
Why eHealth?
The essence of healthcare is to provide the best care possible that meets the
needs of patients and their caregivers. However, due to declines in birth rates
and longer life expectancies, the number and proportion of older people in
our developed society is growing. An ageing population implies an increase
in the chances of age-related illnesses like coronary heart disease, diabetes,
and/or lung diseases. These chronic diseases cannot be cured, but they can be
self-managed to maintain an acceptable quality of life. Older people may have
more than one of these conditions (called ‘multi-morbidity’), which makes
the demand for successful care even more complex. It is important to support
these older people so that they can manage their own chronic disease(s) as
best as possible.
At the same time, fewer working-age adults are available to support the increas-
ing number of older people. Preserving high standards of patient-centred care will,
therefore, be a challenge in the near future. Not surprisingly, all this leads to the
concern that a healthcare system with an acceptable quality of care will become
too expensive to sustain. In most countries, the delivery of the necessary care with
fewer resources is considered to be a major political challenge. The healthcare
system is in great need of innovation.
Introducing eHealth 5
A particular trend in the world today is that patients and their ‘informal caregiv-
ers’ (such as family members) are more in the lead of their own healthcare. This
is in contrast to the traditional model, in which a professional caregiver is in the
lead and makes most of the decisions. This enhanced status and empowerment
of patients and their informal caregivers increases the involvement of patients
in the management and treatment of their health and well-being. A cooperative
model of healthcare encourages and expects active involvement of all the parties
involved – the patient, caregivers and healthcare professionals alike. This concept
of ‘participatory health’ is also applicable to prevention, physical fitness, nutrition,
mental health, end-of-life care, homecare and other fields related to an individual’s
health. This increasing importance of participatory health requires innovative ways
of support.
Researchers and policy makers from all over the world are looking for these
innovative solutions, and many have been thought of and tried out in practice. Seri-
ous future options include: de-hospitalization, organizing healthcare into regional
networks, adequate homecare, and the concentration of highly specialized, com-
plex care in one location. Since a large proportion of the population has access to
and uses the Internet in their daily lives (via, for example, a PC, tablet, wearables
and/or smartphone; see Figure 1.2), the role of technology is emphasized in such
solutions, both within and outside of healthcare.
What this shows is that the field of eHealth is very broad and, more importantly,
that eHealth has an impact on many aspects related to healthcare and well-
being. We have seen that the Internet created new opportunities for exchange
of information and for interactions among patients and between patients and
caregivers. These opportunities empowered patients because they have become
more active participants in management of their health and well-being, and this
has impacted the healthcare infrastructure, for example, by providing care that
is affordable and accessible everywhere and anytime, and by sharing knowledge
to everyone who has access to the Internet. As Eysenbach already stated in
2001, eHealth is more than just introducing technology in healthcare (Eysen-
bach, 2001):
eHealth: psychology
eHealth aims to improve health and well-being, using technologies. Often, a change
in people’s cognitions and behaviours is required to achieve this, but changing behav-
iour via interventions has proven to be very difficult. Merely using a well-functioning
and nice-looking technology doesn’t suffice: theories and approaches from psychol-
ogy should be used to create technologies that can enable behaviour change.
Research has shown that eHealth interventions that use psychological behaviour
change theories are more effective in changing behaviour than those that do not
(Webb, Joseph, Yardley, & Michie, 2010). Consequently, approaches such as behav-
iour change techniques (Michie et al., 2013) or persuasive features (Oinas-Kukkonen
& Harjumaa, 2009) should be used in eHealth interventions. Behaviour change tech-
niques are derived from abstract psychological theories and can be used in interven-
tions (see Chapter 2). Persuasive technology aims to persuade users in a positive
way to make better choices for their health and well-being. It does this by using
Introducing eHealth 9
the characteristics and possibilities of technology, such as cues for communication
(text, speech, video, graphics), anonymity, or its possibility to access situations in
which human persuaders are not allowed (see Chapter 11). The use of these kinds of
approaches in a design increases the chances of effective behaviour change.
Furthermore, eHealth technologies have to be used by people, so they should fit
their perspective. Merely using theory doesn’t account for this important aspect.
When theory-based interventions are created behind a desk, without talking to
actual people, chances are that they don’t appeal to or fit the user, since the devel-
opers can be mirroring themselves and are thus implicitly designing for them-
selves. Designing for your target group requires knowledge of how people think
and behave. Psychological theories and methods can be used to get a grasp of this,
since psychology pays a lot of attention to analyzing and explaining human behav-
iour via research methods such as interviews, observations and questionnaires.
Figure 1.3 Technology can influence our cognitions, and our cognitions influence
the way we view and use technology
Source: © Image used under license from Shutterstock.com
10 Lisette (J.E.W.C.) van Gemert-Pijnen et al.
interrelationship. However, in many cases, the content of an intervention is
developed by social scientists, and the technology is created separately, by
engineers or technology designers. Understandably, both groups speak differ-
ent languages, often causing a lack of collaboration or project management.
For example, a team of psychologists might have a certain design in mind to
deliver the content for an intervention. They communicate this to designers
who have to ‘translate’ the delivered content into a technology that fulfils the
need of content experts. Unfortunately, this often proves to be challenging
because of misunderstandings or differences in preferences and experiences.
Consequently, content and technology are often developed independently
from each other, which often causes the perspectives of the user and stake-
holder to be forgotten along the way. To prevent this, collaboration is key.
Content and technology developers not only should closely communicate with
each other but should also be in frequent touch with users and other stake-
holders to ensure that an eHealth intervention is an integrated whole that fits
all stakeholders’ needs as closely as possible.
Benefits of eHealth
The first part of this chapter has given a high-level idea of why eHealth is neces-
sary. In this section, we will discuss in more detail why eHealth can be of added
value. eHealth can have different advantages in different contexts and for different
people. Therefore, an exhaustive list of all the possible eHealth benefits is impos-
sible to compile. Also, not all benefits will always be true for every eHealth technol-
ogy. Again, this is because the technology’s added value will be different depending
on the context and the people. The benefits below are provided to give an idea of
some of eHealth’s advantages for healthcare and people in general. They refer to
the access to care that eHealth can enhance, the empowerment of patients and
healthy people via eHealth, its possibilities for innovating healthcare and the way
we look at health and well-being, and its potential for improving quality of care.
Access to care
Via eHealth, healthcare can become available independent of time and place
because people can access it whenever and wherever they need it. An example
is someone who has a busy working schedule and trouble making appointments
with his or her diabetes nurse. eHealth provides a way for him or her to have some
of her consultations occur online, through secured email contact. Furthermore,
someone living in a remote area might, instead of driving for an hour, use Skype to
contact his or her general practitioner.
eHealth can also create a lower threshold to access healthcare, which entails
that more people have a possibility to access healthcare (WHO, 2016). With easier
access, healthcare becomes more equally distributed among people, allowing for
an improvement in healthcare equity. For example, online support groups enable
social networking and emotional support of isolated individuals. However, a pre-
condition for the actualization of this benefit is online access and a satisfactory
Introducing eHealth 11
amount of (computer) skills. eHealth can also remove thresholds to healthcare like
stigmatization. An example of this is the provision of anonymous online consulta-
tions or anonymous peer-to-peer online communication. An HIV patient who may
be uncomfortable finding help in person might be more willing to talk with peers
online.
Empowerment
Technology may empower people by giving them the opportunity to take more
control of their own healthcare. Technology can enable people to choose when
and where they want to access healthcare. In this way, they are more in control of
their own health and care process. Furthermore, people can be empowered when
they are educated about their health and more aware of their own health data.
For example, technology can give people access to their own health data, which
increases people’s knowledge about their own health, through personal health
records or via self-generated data via monitoring technologies such as wearables.
Patient-centredness is another important advantage. Technology can enable
people to choose when and where they want to access healthcare. Also, the infor-
mation people can collect can make it easier for them to make their own informed
health decisions, or to have more equal discussions with their doctors, since
patients are becoming experts on their own health.
Finally, care professionals can be empowered as well. Technology can provide
tailored support on medical decision making, among other things, via data-driven
diagnosis support and artificial intelligence. Watson (see Chapter 3) is a question-
answering technology that uses natural language and has the computational
power to facilitate informed decision making using big data. Quick diagnoses and
precise and personalized medicine is made possible by such systems, and this leads
to more transparent healthcare decisions because it is known on what grounds
decisions have been made.
Innovation
New technologies and new applications of technologies open up a whole range
of possibilities for healthcare (see Chapter 4). The mere use of technology will
not automatically result in long-lasting and positive change, but it can provide
the groundwork for sustainable change in healthcare by supporting important
movements within the domain such as patient-centred care and integrated care.
A straightforward example of this is the opportunities that technology can cre-
ate for easy communication, audio and video, between different healthcare
professionals.
The possibilities that eHealth offers can be seen as a catalyst for innovation in
healthcare. Technology has the ability to change the way healthcare is delivered
by stimulating all involved stakeholders to critically think about how they deliver
or receive care. This opens up new ways of thinking, which can in turn stimulate
innovation. For example, think of a wearable that monitors the movement of COPD
patients 24/7, this information can be extremely valuable to doctors since it might
be used to predict exacerbations.
12 Lisette (J.E.W.C.) van Gemert-Pijnen et al.
Quality of care
The quality of healthcare can be improved via highly efficient, innovative systems
and by effective interventions that lower costs and increase safety by reducing
human errors. eHealth technologies can incorporate medical guidelines and quality
standards for healthcare, for example, via an app that supports nurses in prescrib-
ing antibiotics to patients at their bedsides. This makes following guidelines or
standards independent of individual care providers’ skills and knowledge and an
integral part of the regular process. Information systems can even monitor real-
time compliance with guidelines to support safety at work.
Effectiveness can also be improved by using the possibilities of technology to
improve traditional interventions and treatments. For instance, think of an inter-
vention for stimulating activity and monitoring stress levels in depressive patients,
where wearables can track a person’s activities during the entire day. The collected
data can be used to provide tailored advice, something that current traditional
interventions and therapists cannot do.
Efficiency is an important benefit as well, since eHealth can require fewer
resources to achieve the same quality of care and effects on health and well-being.
Teledermatology – the use of audio and video communication in the assessment
and treatment of skin conditions and tumours – can decrease the number of doctor
visits, saving costs and time.
eHealth: in practice
eHealth is increasingly being used in practice. In this section, we will provide sev-
eral examples to give you an idea of what eHealth can look like and to see how the
benefits may be achieved. Within the field, there is not one categorization that is
perfect and always applicable, mainly because of the continuously evolving pos-
sibilities of technology. We use a categorization below that is based on the level of
involvement of specific stakeholders: self-care and prevention, supportive care and
societal health.
Figure 1.4 An example of how technology, in this case a smartwatch that monitors
physical states and an app, can be used to self-manage health
Source: © Image used under license from Shutterstock.com
not only information but also an opportunity to interact with the system. These
decision aids are a way to allow the user to interact with the information. For
example, they can be simple question-and-answer systems that help health con-
sumers or patients make a decision on what to do with a certain health com-
plaint or disease. Decision aids can help you to decide whether you need to
visit a doctor, or assist you in choosing the type of therapy that best suits you,
for example, whether or not to have surgery for carpal tunnel syndrome. Ide-
ally, these systems are based on medical protocols. In addition, technology can
support interaction with others in multiple ways. There are technologies that
support interaction between people with similar health issues, like discussion
forums. Technology can also support interaction with care providers, for exam-
ple, through moderated discussion forums or e-consultation. In the latter case,
these systems should enable safe and secure communication and account for
privacy rules.
Another form of self-care and prevention can be found in technologies that
support (self)-monitoring of health-related information. For example, the quanti-
fied self-movement is enabled by industrial companies providing wearables like
14 Lisette (J.E.W.C.) van Gemert-Pijnen et al.
smartwatches that track, trace and trigger behaviours and moods to support
healthier lifestyles or to reduce medical issues. Activity and sleep trackers have
become more popular and mainstream in recent years and have inspired many
individuals to monitor many aspects of their daily life through technology. These
devices can help you gain insight into how healthy you actually are. Some examples
are the Misfit, the Apple watch, and the Fitbit. Also, these wearable technologies
are more and more used in medical settings, using wearable sensors (e.g. EEG and
ECG) generating real-time data about health-related variables (heart rate, blood
pressure, glucose levels, etc.).
The last example of self-care and prevention in eHealth technologies are online
(self-help) treatments. These exist for many lifestyle areas, such as physical activ-
ity, diet and smoking, but also for mental health. Many online treatments can be
followed without support from a therapist, such as for depressive complaints, but
there are also online treatments available with therapist support, open to anyone,
even without a prescription from a healthcare provider. Also, these online interven-
tions are being increasingly used in combination with face-to-face therapies, called
blended care (Wentzel, van der Vaart, Bohlmeijer, & van Gemert-Pijnen, 2016).
Ideally, online treatments are based on evidence-based protocols and grounded
in theories like Cognitive-Behavioural Therapy or Acceptance and Commitment
Therapy. They often use a fixed structure of lessons. For example, every lesson
starts with an explanation of the purpose of the lesson, followed by assignments,
exercises and useful information provided by experts.
Supportive care
This domain is characterized by more involvement of the healthcare professionals
and, ideally, healthcare professionals and patients work together to manage or
improve the health of the patient or client. In this domain, the care process is often
more complex than in self-care and prevention, as caregivers are involved for a lon-
ger period of time, or multiple caregivers are involved, as is visualized in Figure 1.5.
The care of patients with a chronic disease such as diabetes is an example of this.
eHealth can play an important role in supportive care. For instance, it can improve
the information exchange across professionals or between professionals and their
patients, as well as provide online self-management support, and monitor the per-
formance of disease management programmes.
An example of the role of eHealth in supportive care is telemedicine. In 1995,
teledermatology, a form of telemedicine, became one of the first examples of
eHealth among healthcare professionals. In teledermatology, telecommunication
is used to exchange long-distance medical information, for example, by means
of video conferencing. This can enable one dermatologist to ask for another col-
league’s opinion about skin conditions based on actual images. As compared to
just a text message or phone call, images can help dermatologists give more reli-
able advice. This case shows eHealth as a valuable tool to support care decision
making.
Electronic personal health records (PHRs) are another example of promising
eHealth technology for supportive care and chronic disease management. A PHR is
Introducing eHealth 15
an electronic application through which individuals can access, manage and share
their health information and that of others for whom they are authorized, in a
private, secure and confidential environment. Recently, many PHRs have added
functionalities in order to support disease management. Besides sharing clinical
and personal data (e.g. disease history, test results, treatment plans and appoint-
ments) between patients and care providers, these systems often include functions
to support self-management like working on health-related goals while being sup-
ported by a care provider and/or the system, and patient-care provider communi-
cation, which allows patients to keep in touch with their care provider or make new
appointments.
Societal health
In this domain, patients and healthcare professionals are both involved, but the
lead is at a higher, societal level. Societal health focuses on broad health-related
issues that might affect individuals. However, societal health issues can never be
solved by the behaviour of just one individual (like self-care) or by a small group of
people (like supportive care). Societal health issues demand that governments play
a vital role in creating policies and regulations. In turn, healthcare inspectorates
must implement and maintain these policies and regulations. Examples of such
broad societal health issues are the prevention, spread and control of diseases and
infections as well as access to healthcare for everyone. As you can imagine, due
16 Lisette (J.E.W.C.) van Gemert-Pijnen et al.
to its large reach, interactivity and ability to provide easy access to information,
eHealth is often seen as a way to improve the health and well-being of individuals
on a large scale. Since eHealth can help to change people’s attitudes and behaviour,
it can be used to address societal health issues or gain information about them.
First, eHealth can influence the attitude or awareness of individuals about soci-
etal health issues. An example of this is the CDC (the U.S. Centers for Disease Con-
trol and Prevention) ‘Solve the Outbreak’ game. In this game, you become a disease
detective trying to fight an outbreak before it can spread any further. The goal of
this app is for the general public to learn about diseases, their outbreaks and the
complexity of managing those outbreaks.
Second, it can be used to support behaviour that is compliant with guidelines
that are required to manage broad health-related issues. Technology can help
healthcare professionals follow policies or guidelines in a care environment, for
example, in managing their use of antibiotics in order to decrease the spread of
resistant bacteria. This is a societal health issue, where, for example, the govern-
ment plays an important role in creating the policies on how to deal with this chal-
lenge. Technology can assist in translating such policies into action.
Finally, technology can support communication between health professionals
about societal health issues. An example of this is the risk communication, deci-
sion making and education of healthcare professionals about zoonoses. Zoonoses
are infectious diseases of animals that can be naturally transmitted to humans,
like Lyme disease and MRSA. A technology such as a serious game can be used to
support this.
eHealth barriers
Multiple (potential) benefits of eHealth were described earlier. However, in practice,
eHealth technologies are often not as successful as expected: not all potential ben-
efits are reached. There are multiple barriers that cause this gap between the cur-
rent situation and the potential. Some of the most important ones are described
below. Attention will be paid to barriers with regard to the implementation of an
eHealth technology in practice, (potential) ethical barriers and barriers on evi-
dence and research on eHealth technologies.
Implementation barriers
Implementation of eHealth refers not only to its introduction in a specific context
but also to its dissemination and long-term use. A successful eHealth intervention
should be embedded in practice and used as was intended, but multiple factors
can negatively influence its uptake in practice (Greenhalgh et al., 2017, also see
Chapter 12).
First of all, a lack of incentives to use technology can result in a resistance to
use it. For eHealth to be used it should be financially feasible, but often there are no
obvious financial benefits, and it is not clear enough who pays for what. For exam-
ple, e-Consultation failed because the reimbursement for using it in a general prac-
titioners practice was lower than face-to-face visits. Incentives can also be related
Introducing eHealth 17
to perceived benefits for people’s health and well-being. Self-management portals
to support patients with chronic care, although proven effective, are often not used
because patients feel they are not benefitting enough. This could happen because
of the distinct ‘feeling’ caused by the lack of human support in self-management
portals. When people’s needs are not acknowledged and thought through during
the development process, the eHealth technology can lack commitment and sup-
port because people do not perceive enough financial or personal benefits.
Also, a lack of eSkills can hinder the uptake of eHealth technologies. Merely using
the Internet is not a guarantee people have the capacities and skills to manage
their own health with technology. Digital health literacy is often assumed, although
many people are not educated or trained to use technologies or to understand self-
management data visualized via graphs or tables. This lack of familiarity with tech-
nology can have a negative impact on the reach of health technologies, since highly
educated people often benefit more than people with a lower education level.
Furthermore, there often is a lack of motivation to start or continue using an
eHealth technology among users and other stakeholders. eHealth technologies
touch the lives and work of many people. When the interests of these people are
not acknowledged and thought through, the new eHealth technology can lack sup-
port. Think of nurses who have been told to start using an app that they haven’t
agreed to use in the first place and which may not fit into their individual work
routines. Once people have accepted a technology, motivation can still be an issue:
many people stop using a technology prematurely or do not use all of the available
opportunities. This issue is called non-adherence and indicates that eHealth inter-
ventions are not always motivating enough to use in the long term, which hampers
effectiveness.
Lack of confidence in technology is another barrier. People might fear that they
will be substituted by technology, for example, in the case of robots. Also, a well-
known problem in practice is the fear that a technology might decrease the quality
of treatment: a psychologist might fear that the use of technology in treatment
will negatively impact the therapeutic relationship with his or her client. Creating
confidence and showing how technology can have added value for people should
be part of the introduction and implementation strategies to innovate healthcare.
Technologies are developed using different software and hardware elements,
with the frequent result of systems not being interoperable. This makes it difficult
or even impossible to communicate information from one system to another. In
other words, interoperability is low. For example, wearables to monitor behaviour
are sometimes not compatible with other apps on a smartphone. Or data gener-
ated by systems that track activities, mood and food intake are not interoperable
with platforms to translate the data into personalized coaching strategies.
Finally, unclear regulations can hinder successful use of eHealth technologies
in practice. Often there is lack of clarity about legal issues. Think about who is
ultimately responsible for an online diagnostic system. What happens if a moni-
toring and coaching system does not refer a patient to a hospital when it actually
should have done so? Who is responsible when a wrong suggestion is made? More
attention should be paid to legislation issues on a national level and within health
institutions.
18 Lisette (J.E.W.C.) van Gemert-Pijnen et al.
It is clear that issues that might hinder implementation need to be identified
in advance so that they can be accounted for before the technology is fully devel-
oped: a good development process increases the chances of good implementation
(see Chapter 12). In a good development process, attention is paid to the values
of the users and other stakeholders, the characteristics and nature of the context
in which the technology will be used and the design of the technology itself (see
Chapter 7).
Ethical barriers
The barrier of regulations touches upon the topic of ethics and its importance for
eHealth. Of course, ethics is not a new phenomenon with respect to health infor-
mation, but the use of technology in healthcare raises many new ethical issues that
have to be accounted for. The process of storing and sharing health data becomes
beyond peoples’ ability to directly control. This impacts multiple factors that should
be addressed to increase the chances of eHealth’s success in the long term.
Privacy and security are obstacles people perceive when using technologies to
share health or medical information. Who is the owner of the information? And
how do we know who has access to the information? Companies might sell per-
sonal health information or can use this information to make decisions about peo-
ples’ health conditions. For example, companies provide technologies to monitor
physical activity, sleeping and eating behaviours with monitoring devices such as
smartwatches. These devices collect data that can be analyzed using algorithms to
personalize health and provide tailored feedback to people on how to reach their
goals. These data provide much insight into people’s health and might be misused
by, for example, health insurance companies to increase their premiums for people
with an unhealthy lifestyle.
The lack of transparency is not a new phenomenon per se compared to tradi-
tional care, but the difference is that the ‘clinical eye’ of a caregiver is missing.
For example, people receive tailored feedback on their behaviour but often do not
have any idea what decision rules ground the personalized feedback. Technology
provided by industrial companies requires clear policy and rules about the trans-
parency of data.
The quality of information is another ethical aspect. To what extent can we trust
the information that is provided by the Internet? Think of Wikipedia pages that can
provide unreliable and incorrect information about symptoms or treatments, or a
system that provides wrong feedback about the amount and intensity of physical
activity for an obese person. Credibility of information can be guaranteed by com-
panies that check the information using certain standards or by providing medi-
cal approvals by appropriate regulatory agencies, such as the U.S. Food and Drug
Administration or the U.K. Medicines Control Agency.
People use technology for self-regulation, like devices for self-testing health.
An issue is how this impacts the autonomy and trustworthiness of healthcare. For
example, self-regulation is possible by using sensors for monitoring and automated
coaching. However, these monitoring devices are not ‘tested’ following medical
standards, using clinical trials. People adopt self-regulation devices rapidly, and
Introducing eHealth 19
infiltration with medical practices is ongoing. This can put medical professionals
under pressure: how should we cope with information from data that is not based
on medical standards? How should we respect patients’ self-judgements? How
should we use self-test information in clinical consultations?
It becomes clear that these ethical issues are pivotal to eHealth’s success to
ensure that negative consequences are avoided. We should study these ethical
issues in depth. Stakeholders such as software developers, caregivers, patients and
equipment suppliers should participate in ethical discussions to ensure that we are
proactive in the ongoing path of innovations.
Evidence barriers
A critique on eHealth interventions is the limited large-scale -evidence of the cost-
effectiveness of eHealth interventions and the little information on long-term effects
on health and healthcare. More good, long-term evidence is needed: the more we
know about what works, why and for whom, the more we can optimize eHealth.
The main barrier regarding evidence can be found in the study designs that
are used to evaluate many eHealth interventions, as they don’t always address
the full picture. In general, the effects of web-based interventions are measured
with the golden standards for clinical interventions (Randomized Controlled Trials;
RCTs). These experimental or sometimes quasi-experimental studies use cut-off
measurements at fixed points in time to determine if an eHealth intervention was
successful in improving predetermined outcomes. An example would be whether
an intervention was successful in reducing depressive complaints or increasing
physical activity. However, these conventional pre-post comparisons do not help
us understand what elements of the intervention contributed to outcomes. Factors
such as costs, usage of the technology and other outcome variables should be
measured continuously since they are also really important processes. The need
for this type of evidence requires other evaluation methods.
Another barrier to evidence is related to this main issue: we do not have enough
knowledge on the process of adherence, which refers to the question of whether
the technology is used as was intended by the developers. We know that many
people are not adherent: they stop using the technology prematurely, or do not use
all of its different possibilities, which might have a negative influence on the inter-
vention’s impact. More knowledge is required on what impact this non-adherence
has on effectiveness and what factors can predict or even influence adherence to
eHealth interventions.
Furthermore, as was mentioned before, mere information on effectiveness on
specific outcome measures doesn’t suffice for eHealth. Since it is always used
within specific contexts and can influence the way healthcare is delivered, infor-
mation on eHealth’s impact on these contexts is required as well. Consequently,
we need information on the reach of eHealth to, for example, find out which share
of the target group actually accessed an intervention. Matters such as adoption –
answering questions about when and how people started using the technology –
and the implementation process should be studied as well to get a holistic view of
the impact of the eHealth technology.
20 Lisette (J.E.W.C.) van Gemert-Pijnen et al.
Another issue that has to be addressed to ensure that the quality of eHealth evi-
dence increases is related to the way evaluation studies are reported. Many studies
have a rather myopic view on technology and evaluation, meaning that they do
not provide enough information about matters that need to be reported to ensure
replicability of studies and interventions. For example, in most cases it is unclear
which software functionalities and development methods have been used to create
the technology. Studies do not report why and how a certain technology was used,
developed and implemented: evaluation is merely outcome driven and little to no
attention is paid to the quality of the evaluated technology. As a consequence, it is
impossible to identify what specific features of technology could have contributed
to the effects of the eHealth interventions, and replication is hardly possible. To
overcome this problem, a CONSORT checklist was developed to guide how ‘eHealth
and mHealth trials should be reported, in particular related to reporting sufficient
details of the intervention to allow replication and theory-building’ (Boutron, Alt-
man, Moher, Schulz, & Ravaud, 2017).
Finally, eHealth technology is not fixed: it can be tailored to different user profiles,
and can be constantly updated and adapted by developers or users. In controlled,
experimental studies with only a few measurements, these changes in technology
are often not considered as subject for research, though they are important. A flex-
ible intervention requires a flexible evaluation approach, which can be provided by
agile science. In agile science, development and evaluation occur in parallel, itera-
tively, until the eHealth technology has been optimized to fit the complex context in
which behaviour occurs. Advanced methods such as time series and log data can be
used to provide ongoing information about the use of technology and its impact on
the context and people. This kind of information is necessary to take eHealth evalu-
ation to the next level and overcome evidence barriers.
It is important to overcome these evidence barriers to increase the added value
of eHealth in practice. We need not only more evidence on effectiveness but also
more insight into the working elements of eHealth interventions. This requires
both applied and fundamental research. Applied research focuses on matters such
as good design, implementation, use of in practice and effectiveness of an inter-
vention, all within specific contexts. Fundamental research aims to make generic
claims about constructs such as adherence, behaviour change theories, persua-
sive elements or tailoring. It is needed to empirically ground eHealth in theories
on, for example, behaviour change and well-being. The results of experiments and
empirical studies can be used to validate abstract theory-driven behaviour change
models or to develop new models to predict reach, usage and adherence. These
models are useful for applied research in which they can be used to, for example,
optimize interventions.
Summary
This first chapter introduced the domain of eHealth and described the relation-
ship between technology, psychology and healthcare. It provided an overview of
current visions of eHealth. The chapter made clear that changes in healthcare,
society, technology and the behavioural sciences are all related to eHealth, directly
or indirectly. This results in many advantages of eHealth, but in practice, barriers
are still experienced. In order to overcome these barriers and achieve the benefits,
a holistic, multidisciplinary approach is advocated. Such a development approach
will likely result in an eHealth technology that fits the people and their environ-
ments. The take-home messages for this chapter are:
• eHealth has many actual and potential advantages for health, well-being and
healthcare and can be divided into self-care and prevention; supportive care
and societal health.
• In practice, many barriers of eHealth are experienced with regard to imple-
mentation in practice, ethics and evidence.
• A holistic vision of eHealth is advocated: the technology, people and their con-
texts are all intertwined.
• A holistic development, design, implementation and evaluation process can
create eHealth technologies that overcome the barriers and achieve the
benefits.
• The CeHRes Roadmap can support holistic eHealth development and is based
on approaches such as participatory development, human-centred design,
business modelling and persuasive design.
Introducing eHealth 25
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