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E-health - drivers, applications, challenges ahead and strategies: a conceptual framework

A U Jai Ganesh
20,Dharmapura Madam Street,
Nagapattinam, Tamil Nadu, India.
Pin: 611001.
E-mail: au_jaiganesh@yahoo.co.in 

Abstract:
Technological innovations have given health services providers the means to diagnose and treat an increasing number of problems and illnesses. They can used to diagnose and treat illness, prevent disease, maintain patient well being, or facilitate the provision of health services. Integration and coordination of health services could result in optimal use of scarce and expensive resources. By leveraging information and communication technologies to provide better health care services in underserved areas, networked health systems and patients gain access to seamless, coordinated and continuing care. With the advances in modern telecommunications, information processing capability and miniaturization of health diagnostic equipments it is possible to deliver more immediate and effective heath care to the masses. This paper presents a snapshot of various forces driving the e-health applications; challenges for their widespread adoption and attempts to provide a conceptual framework for successful deliverance of e-health services.

Key Words: e-Health, Health applications of electronic communications, Enablers for e-health services.

1. Introduction
Health care is a domain replete with vast and varied knowledge and information relating to health issues, nutrition, sanitation, disease prevention, disease management and cure through medication, change in lifestyle. This knowledge, which is continuously generated, resides in the individual, the physician and the community also known as the pivots of a health care system. To deliver quality healthcare to a greater number of people, providers need to create and operate more cost-effective facilities, reduce operating costs, enhance productivity and increase efficiency through good management of patient flows and optimum utilisation of expensive equipments and manpower. To meet this challenge, governments and private health care providers can make use of advantages, information and communication technologies provide in effective knowledge management, extending the reach through seamless interaction and connectivity between these three vital sources of health information. This needs the adoption of sound policies and strategies that guarantee the provision of high quality, sustained and integrated health care services to the population. In this article, e-health refers to any use of an electronic information and communication technology to promote health or improve health care.

1.1 Drivers of e-health
Health care industry can benefit enormously from the applications of electronic communications. Health care services are characterized by information, communication-intensive set of functions, and diverse stakeholders. The advantages of ubiquitous reach, speed and seamless connectivity provided by e-health can enhance the delivery of health care through maintenance of public health, education of health professionals, facilitate collaboration among health sciences researchers, improve access to quality care and as well reduce its cost by streamlining processes. E-health promises connectivity and clinical care as core capabilities1. Patient's desire for online communication with their health care providers is likely to change the course of both telemedicine and e-health technologies2. To a large extent current growth in e-health is driven by (box 1)

• Consumer preferences

• Technical capabilities

• Health system policy

• Economic considerations

1.2 Health applications of electronic communications
The communication age has brought with it the powerful potential for many applications that will transform the way we work, learn, and live. Healthcare is one specific industry that is witnessing an interesting transformation through the integration of these telecommunications technologies³. The health care industry increasingly views IT as a fundamental asset in providing health-related information services and decision support on demand, as well as in managing rising costs and changing organizational needs, improving the quality of health services and patient care, and fighting illness while promoting wellness⁴. Online support groups exist for almost every disease and condition, and discussion topics within each disease category are limitless⁵. Physicians Gerber and Eiser⁶ postulate that the Internet age offers opportunities to improve the patient-physician relationship by sharing the burden of responsibility for knowledge. Prescription refills, lab results, appointment reminders, insurance questions, and routine follow-up inquiries are well suited to e-mail. It also provides the patient with a convenient way to report home health measurements, such as blood pressure and glucose determinations⁷. In medical education, the web is increasingly used both as a learning tool to support formal programmes and as a means of delivering online learning programmes. Web based learning can be useful to support clinical teaching when learners are geographically dispersed - for example, to learn clinical skills through video demonstrations⁸. E-health applications can be broadly grouped under the following (Box 2)

• Consumer health

• Clinical care

• Financial and administrative transactions

• Public health

• Professional education

• Biomedical research

1.3 Challenges to widespread adoption

In spite of the support for the exciting benefits of e-health, a number of impedimentss continue to stand in the way of its widespread adoption by health organizations and consumers. Most consumers are still not aware that they may access specialist knowledge online⁹. Use of electronic communication in medicine, implicates a variety of legal issues, including a physician's duty of confidentiality, a patient's right to informed consent, the components of a medical record, customary usage and practice standards, state licensing

and product endorsement¹⁰. When clinical information systems interfere with traditional practice routines, they are not likely to be accepted by physicians¹¹. E-health has a number of challenges to overcome before it can be integrated into the overall fabric of health care. They can be broadly (box 3) categorized as 

• Technical

• Knowledge

• Organizational

• Regulatory and policy

• Social

• Economic

The healthcare triangle (fig 1) shows the three interlinked groups that work together to develop, promote and deliver healthcare services. These three key players are labeled on the triangle as patient, practitioner and provider. 

Patient
A patient can be defined as a person who receives medical examination, treatment, guidance or care from a health care professional. The contact between the patient and the health care services initiates the process of care. The patient is therefore the most important party in the health care system. A patient needs knowledge about basic health issues, access to information specifically relevant to his/her condition, awareness of health system and the options available.

Practitioner
The practitioner is any healthcare professional and is distinguished from a provider. The patient gets in touch with the physician (general practitioner or specialist) for consultation, which may include medical investigations, treatment or supervision of the plan of care. In e-health, it is practitioners who are engaged with clients or other practitioners in the delivery of health care. A practitioner needs access to best, up-to-date medical knowledge available pertaining to their patients.

Provider
Include healthcare service providers (hospitals, medical and academic research institutions), diagnostic equipment providers, informatics and computer suppliers, professional associations, health management organizations, insurance companies, the Ministry of Health, Communications (or equivalent) nd pharmaceutical companies. A provider needs expertise to promote and sustain healthy life and social practices among its clientele.

In a triangle, all the three sides are essential to complete the whole. Similarly in healthcare services all the three key players represented in the triangle (see fig 1) are vital. As e-health is the result of convergence of telecommunication, information and health care technologies, technology in general turns out to be the linking factor between these three key players. Successful implementation of e-health requires clear understanding of the roles these three are expected to play. Hence development of certain protocols and strict adherence to them becomes essential (Box 4). 

2. Conceptual framework for successful delivery of e-health services

The impact of e-health on health care structures can be significant and hence needs to be implemented carefully and managed well. This requires the adoption of sound policies and strategic plans that guarantee the provision of high quality sustained and integrated health care services. Health-care planning needs to take e-health into account within the framework of the national health policy with National Ministries of Health and Communications working together towards the introduction of an e-health policy in the context of a national 'health for all' policy. Such a policy or strategy should identify health-care priorities and include consideration of how e-health can be funded, whether by government, by industry, as part of universal service obligations for telecommunication operators, or by other means.

The seven key enablers that can possibly lead to successful delivery of e-health services are as follows.

2.1 Defining e-health needs
The introduction of e-health should be needs driven, not technology-driven. A key part of planning a sustainable e-health program is conducting a needs assessment. Hence it is necessary to identify and express health-care needs and then see how e-health could help meet those needs. In a typical needs assessment, the areas that require consideration go well beyond simply identifying needs¹². For example, Doolittle and Cook's¹³ needs assessment model considers three critical perspectives-clinical, economic and technical. All e-health applications, technology selections, and operational decisions should be made using needs assessment as the basic foundation to improve participation, satisfaction, and system utilization. If you build it and they don't need it, they won't come¹⁴.

2.2 Developing infrastructure requirements
Once the needs have been determined, they must carefully be matched with the available resources. A clear understanding of what technical needs and resources practitioners will require being clinically and technically comfortable is essential. The infrastructure of any e-health program is comprised of three key components: technical, medical and human. The infrastructure should support the health care service structures, rather than the health care service adapting itself to the infrastructure.

Technical 
Telematics infrastructure constitutes an essential link in any e-health application. E-health demands a high degree of telecommunications network security, availability, adequate transmission capacity and reliability. For practical and economic reasons, security and reliability of telecommunications networks is a decisive factor in introducing e-health applications. The technical infrastructure may vary greatly depending on the resources available to any program. Guaranteeing the integrity, confidentiality and security of sensitive patient data is essential if patients and clinicians are to have confidence in the application of IT in health care as a whole, as well as the implementation of EHCR's (Electronic Health Care Records) in particular¹⁵. A major technical problem is communication between medical devices, since manufacturers have developed their commercial devices in isolation and in way that precludes communication both between themselves and with hospital computer and data management systems¹⁶. In order to derive the expected clinical, administrative and research benefits from electronic communications in health care, need for technical standardization and the development of protocols that enable open and structured communication are paramount.

Medical
In any e-health service for providing guidelines, diagnoses, treatment and care both quality and modern monitoring, diagnostic equipment and professional expertise are essential. The most important part of selecting equipment is to make sure it meets a defined need and is easy to use - based on the user community and from a vendor who will provide high quality, reliable service after the sale, help to troubleshoot problems and to train the clinical personnel. Linking physicians and patients is critical. Physicians remain the most trusted source of medical information, advice and care, even in this Internet age. And whether the focus is on content, convenience, customization or connectivity, healthcare organizations must recognize the fundamental nature of the physician-patient relationship and continually reinforce it¹⁷. 

Human
The human component sets up the program and keeps it operational. Education for health care staff in the form of continuing medical education courses, grand rounds and case presentations serves to keep the clinical staff up to date in medical treatments and to help them advance in their professional careers. The training of health professionals in the use of information and communication technologies is a prerequisite to the demystification of e-health and its acceptance by clinicians into their routine methods of practice. Medical curriculum and training programs need to include the topic of use of applications of information and communication technologies in health care and aim at preparing clinicians for the opportunities and challenges offered by these technologies in the field of health care. Consumers need to be informed and made aware of how and when to use these services. Better-informed consumers/patients is a powerful way to create sufficient pull.

2.3 Mobilizing organizational support
Health care organizations cannot increase their commitment to e-health applications without strong leadership and vision. A shared vision of what the organization is trying to accomplish, a clearly articulated mission and institutional leadership are often crucial determinants of successful e-health programs. Stable, well financed, and coordinated efforts in the areas of resource development, technical services, clinical operations, training, and advocacy for a favorable regulatory and policy infrastructure will go long way in establishing any successful e-health projects. If e-health is to be introduced widely then mobilization of organizational support is essential. 

2.4 Planning technically feasible and medically valid applications
Health care needs may change over time, so this must be considered in the planning of the e-health program to provide flexibility. The applications that are developed for the use must be well planned and allow for growth into areas beyond the initial concepts. E-health programs should be flexible to address healthcare delivery needs, provide a wide range of applications, and allow any member organization to connect with another in an open architecture system. Designers often develop systems based on their perceptions of what users want and need. Our findings suggest that a more user-centered design is advantageous, if we want our community health information networks (CHIN's) and other networks to provide functionality and services that are valuable to users¹⁸. A technically feasible, clinically effective, and reimbursable application engenders adoption and usage by physicians. As adoptions and usage increase, the need for systematic organizational support services also increases¹⁹. Ideally, the services should match the health care needs of the target population.

2.5 Conducting pilot projects
It will be useful to undertake pilot projects in order to evaluate the potential benefits and implications of e-health projects. The implementation of basic e-health services could provide the foundation for delivering more specialized services in future. It is better to start with a scaled down program initially, requiring less start up capital, providing fewer and less expensive services at first and then ramping up as recognition of value and patient volume increases. Local commitment and participation in pilot projects is essential if a project is to have a chance of success. Trials are the only way in which rational decisions can ultimately be reached regarding whether scarce resources should be devoted to telemedicine in developing countries, or whether they should be employed in more conventional health care measures whose outcomes are known to be cost-effective²⁰.

2.6 Benchmarking successful delivery models
WHO has proposed a global strategy to design and reconfigure healthcare systems to better meet the needs of people with chronic illnesses^{21, 22} (see box 5). The WHO strategy could serve as a model for delivering comprehensive e-health services. The development of national and international integrated networks requires an effective and efficient organizational structure to develop guidelines, regulations, licensing procedures, as well as security and privacy protection for patients and providers. The WHO has also made a commitment to use telecommunications for health and to partner with the United Nations and other organizations to advance the exchange of health information across geographic, temporal, and social boundaries²³. 

2.7 Promoting partnerships
The healthcare industry is ripe for collaboration with competitors, or "co-opetition," under the right circumstances. Though not always easy to carry out, cooperative initiatives with competitors to develop acceptance of common information (clinical, administrative and financial standards) can benefit all those involved and improve the efficiency and quality of healthcare system wide¹⁷. As implementation and delivery of e-health requires multidisciplinary collaboration, establishing joint ventures in the field of e-health, by inviting local or foreign partners to participate and to take equity stakes in the delivery of e-health services holds the key for success. An e-health strategy should take into account the need to identify appropriate partners, to specify appropriate technology and to find financing. Telematics and e-health experts, suppliers and service providers should be encouraged to work together and leverage strategic alliances and partnerships in order to provide a best in class solution that can meet and grow with evolving healthcare needs. Partnerships between governments, non-governmental organizations resulting in creation of national associations, committees, task forces, with a multidisciplinary composition is necessary to bring together information technology experts, health professionals, lawyers, industry and others to assist in developing effective and sustainable e-health programmes. A consortium approach and the sharing of experience might help to overcome many of the problems and help in the widespread deployment without "reinventing the wheel".

3. Implementing economically viable and sustainable program
A sustainable e-health system can prove its value through improved access to health care, reduced costs, and improved productivity. E-health programs should be based on sound economic framework and deliver significant value for the investment. Shannon et al²⁴ mention about basic attributes of successful models suggested by practitioners and observers. For providers, sustainability relies on reimbursement from payers for clinical services, sufficient volume of clinical usage of the system, demonstrable clinical benefits and cost savings. To be able to claim that an e-health application has been successful, the criteria for success should be previously agreed. For example the program could be expected to result in demonstrable cost and clinical outcomes. Profitability though a crucial parameter, need not be the only criteria for success. For example, a publicly funded project can still be cited as a success if it has enabled more efficient health care delivery. 

4. Summary
Ensuring that the e-health becomes a suitable, ubiquitous medium for delivering health care services is a challenging task. E-health must not only provide connectivity among the participants in clinical care transactions, but it must also ensure that such transactions do occur predictably, efficiently, and without endangering patient safety. The ability of e-health to empower consumers, support dynamic information exchanges among organizations, and "flatten" organizational hierarchies might result in need for new operational strategies, business models, service delivery modes, and management mechanisms. Organizations need to evaluate the potential and implications of e-health, anticipate health care needs and be prepared to adapt to local conditions, while minimizing the risks associated with e-health service delivery. 

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