Worldwide availability and implementation of eHealth is an important step in the pursuit of good health for all human beings. The Internet is a perfect platform for the gathering of health-related information and the dissemination of health supporting programmes. eHealth therefore can become the best method for the delivery of education, pre-treatment, treatment, post-treatment and rehabilitation to people who are at risk of needing or who are in actual need of healthcare. Because of the promising scaling opportunities, eHealth has caught the eye of local, regional, and national governments. Unfortunately eHealth has yet to fully deliver on its promise.
Until now, most national eHealth funds were directed almost solely towards proving the clinical effectiveness of eHealth, while little attention was given to the way in which eHealth is implemented and the conditions that support its use. For eHealth to become a successful component, the focus must be widened: the current emphasis on the development and provision of evidence-based clinical programmes or technical solutions for their dissemination is too narrow. Instead, attention must be given to how eHealth interventions can best be integrated within conventional healthcare services.
It’s essential to adopt an integrated strategy, not only horizontally (at user level) but also vertically (across all divisions of policymaking, technology and service users). By bringing together clinical expertise, system expertise, user expertise and the NHS, opportunities will open up to improve the dissemination and implementation of eHealth in society and reduce unnecessary healthcare costs.
The staggered implementation of eHealth
National authorities have recognised eHealth’s potential and have been allocating impressive sums of money to develop state of the art eHealth programmes with proven clinical effectiveness.
Currently, many evidence-based eHealth programmes are available for the treatment of the more common disorders – depression and anxiety disorders, or diabetes and cardiovascular disorders – but their implementation is lagging behind expectations. While health professionals make extensive use of Internet-based learning (i.e. to widen their knowledge of state-of-the-art clinical standards, care pathways or to consult other experts), they are hesitant when it comes to incorporating eHealth in the treatment of their patients. Proven clinical effectiveness is only one factor that contributes to the implementation of eHealth, and it’s not necessarily the one that makes the difference.
There are other obstacles that inhibit the optimal implementation of eHealth in clinical practice.
Firstly, a strategic framework that enables the major players across science, policymaking and clinical health practice to share knowledge, cooperate, and work towards a common goal is lacking. Holistic, cross-discipline knowledge sharing will drive innovation in evidence-based eHealth programmes, as well as the production of scientific material about the dissemination of eHealth amongst healthcare professionals and eHealth’s successful implementation into clinical practice.
Secondly, a lack of resources for clinicians and relevant IT companies hinders the effective implementation of eHealth. Clinicians often cannot proceed with incorporating eHealth because they lack the skills, time or money. This represents a capacity failure that national governments and local authorities must tackle. Examples include the funding of in-depth postgraduate training, the acquisition of eHealth programmes, or encouraging the public to use eHealth services by providing computers in the waiting rooms of GP surgeries or other practice buildings. However, due to the lack of a strategic framework, national resourcing institutes often fail to notice the struggles taking place in clinical practice.
In addition to resources, there needs to be an ongoing focus on providing incentives for the service user. The current knowledge gap between the parties involved makes them lose sight of each other’s perspectives. It’s important to look into why clinicians adopt and incorporate eHealth, because without the right incentives the implementation of eHealth will be limited to a few techie doctors, whereas the aim is that the majority of clinicians will embrace it. In order to create a sustainable eHealth culture we need to approach its dissemination and implementation as part of an actionable learning programme that has the support from all major stakeholders representing the interests of greater societal relevance, including those in health and social policy and funding.
Improving the implementation of eHealth
The following definition of eHealth was formulated more than fifteen years ago, but supports our arguments:
eHealth is an emerging field in the intersection of medical informatics, public health and business, referring to health services and information delivered or enhanced through the Internet and related technologies. In a broader sense, the term characterizes not only a technical development, but also a state‐of‐mind, a way of thinking, an attitude, and a commitment for networked, global thinking, to improve health care locally, regionally, and worldwide by using information and communication technology (Eysenbach, 2001).
Eysenbach’s definition shows that eHealth’s promise has been in waiting for almost two decades. The second half of the definition makes clear that eHealth can’t be introduced with a laissez-faire approach. eHealth is about an ongoing commitment (a state of mind) to improve healthcare by means of information and communication technology. It’s about joining forces to build an IT infrastructure that supports the continuous improvement of healthcare services. Embedding technology into the care process must be linked to face-to-face contact to deliver real added value to the service user. This is the minimum requirement for making eHealth services sustainable.
History has shown that the dissemination and implementation of eHealth is a complex enterprise. Implementing technology into healthcare services is a dynamic process. Often, unexpected situations require an on-the-spot solution and it’s therefore essential to connect researchers, clinicians, technicians and service users for a strategic approach. Depending on the developmental phases of the service, these parties must be able to gather information on the obstacles preventing eHealth’s successful adoption and be available for consultation in order to solve problems promptly.
Additionally, it is necessary to have visibility of when and how clinicians add eHealth to the care process and how well the service user reacts, while the programme is running. As eHealth is rolled out, we learn more about specific, context-related and general prerequisites necessary for a successful implementation process. This knowledge is essential for ensuring that eHealth continues being used properly and that service users adhere to the programme. This is what we mean by an actionable-learning programme.
As argued, the successful launch of eHealth into service delivery settings needs the joint efforts of research-oriented content developers, clinicians, service users and Internet technicians. In order to do this, interdisciplinary platforms must be created, without limiting their ambitions to the utilisation of eHealth. They should include knowledge and understanding of how eHealth is adopted by the healthcare system and the larger public, especially service users who are facing a health risk.
For society to reap the benefits, one of the main goals of eHealth evaluation should be to gain insight into the adoption process. In addition to understanding how eHealth is included in the healthcare process, we must also find out how it can be scaled up for the benefit of a larger public.
Governments, local authorities and other involved parties must take into account the complex dynamic of exchange, interaction and co-creation of knowledge between stakeholders. Until recently, innovations in service delivery were developed independently without strong evidence for, or even consensus on, best practices for accomplishing this task. The successful implementation of eHealth requires an evidence-based explanation of how each factor influences each interaction between the various stakeholders within the health infrastructure.
Blended care as a bridge between traditional care and eHealth
One of the apparent reasons that eHealth services fail to be included into the healthcare process is because eHealth providers often present clinicians with fixed care programmes. As a ‘standalone programme’, such eHealth initiatives assign no role to the clinician and are therefore often judged as being of limited clinical value.
What further influences the risk of non-implementation is that it’s difficult for clinicians to decide when and how to introduce these standalone eHealth programmes into the regular care process, even when they are considered clinically relevant. Struggling with unclear concepts and goals, clinicians find it hard to exercise their clinical expertise especially in a digitalised context in which expertise is assigned a different role. The Internet makes it possible for service users to gather and compare health information from a large number of sites, which puts clinicians in a different, less controlling role than they are used to. And role ambiguity is not something clinicians are looking forward to. Stand-alone programmes deprive clinicians from the level of control they are used to. As a result, eHealth remains absent from care processes where it could make a valuable contribution to the health of service users.
To make eHealth work for clinicians, it has to be part of a care format that leaves plenty of room for the clinician to share expertise whenever this is necessary in his or her view. This can be achieved by a blended care format that keeps clinicians in the controlling seat, while making use of eHealth. Blended care shows clinicians on the job how to cut back on time spent on healthcare services that are better suited to be managed and controlled by the service user. This way, clinicians are able to let go of unnecessary, unsatisfactory and ineffective control and transform the healthcare process from within.
Blended care opens the way to Personalised Mental Healthcare. With the inclusion of eHealth, treatment can be easily adapted to the idiosyncratic characteristics of the patient. With the introduction of protocol-based treatment strategies the patient was put in a somewhat dubious role. While therapy lost its personal touch, clinicians also lost contact with the specific needs of the patient and the ways in which healthcare contributes to their overall health status.
Personalised Mental Healthcare brings back into the mental health process the idiosyncratic characteristics of the patient in the broadest sense: their physical and mental abilities and shortcomings, their needs and demands, their values and goals in life etc. For many service users, especially within mental health services, ignoring these deeply personal characteristics will foster not only user dissatisfaction, but also lagging health results. Personalised mental healthcare adds to effective treatment, but can also add to healthcare costs. To counter this, eHealth modules that target highly personal needs can be added to the mental healthcare pathway. Executed with the right approach personalised blended care can be a satisfying and cost saving process.
One of the promising eHealth characteristics is its patient empowering quality. eHealth helps service users to manage their own health, that is, to take better care of themselves in every possible way. Autonomy and self-management are two key goals for every human being and should be respected by every social system, including the healthcare system. Easy access to reliable health-related psycho-education and tools for self-management can hand control over their lives and the opportunity for self-management to patients. Combining personalised mental healthcare and technology makes it possible to exercise self-management and autonomy. With blended care, service users are better prepared to take responsibility for their role in the healthcare process, with better outcomes for the healthcare process.
Blended care is primarily a healthcare format that can teach us a lot about the application of eHealth in clinical practice. With blended care, a programme of actionable learning will feed back to clinicians the ways in which patients are using eHealth services. At a micro level they will learn why a patient is motivated to use eHealth, how they use eHealth services and how they learn from it. With this information it is possible to develop eHealth inspired pathways, i.e. blended care pathways that are of most value to the service user.
We consider blended care necessary for (1) helping clinicians embrace eHealth; (2) promoting personalised mental healthcare and supporting service users with adhering to mental healthcare pathways; (3) contributing to patient empowerment, quality of care and the reduction of healthcare costs; (4) learning about the ways in which eHealth can contribute to an affordable personalised healthcare system.
Cost saving blended care
Healthcare providers, government and other stakeholders grapple with balancing healthcare demands and costs. Cost analyses should be made on all levels and in all contexts (national, regional, local, individual, policy, professional, service user) since the dynamics at NHS level are different from those at provider or service user level. In this instance, individual-level cost analyses are too restrictive; it is also important to look at interrelated levels of cost analysis. Experience shows that if not all levels and contexts are considered integrally, chances are that while costs are relieved on one level or in one context, they increase on another level or in another context.
Identifying the appropriate focus for the cost analysis of blended care is crucial. It is often assumed that healthcare professionals are not interested (enough) in how to reduce healthcare costs. But that is too simplistic: clinicians, more than any other stakeholder group, are confronted daily with service users who have become victims of rising healthcare costs and longer waiting lists. As they are trained to consider healthcare from a patient’s point of view, it almost feels unethical to put costs ahead of effective treatment. Over the past decade, discussions have taken place whether to explicitly focus on the welfare of the individual or to also consider other social issues affecting the welfare of all beings. It has encouraged health professionals to adjust their views and roles and has fostered the understanding that everyone has an ethical responsibility towards managing healthcare costs.
It’s important for everyone to reach a consensus about how to reduce healthcare costs. Consensus does not primarily require changing healthcare priorities or objectives. It asks for an enhanced and sensitive in-depth understanding of the characteristics of the playing field, the stakeholders and their sometimes-conflicting roles, and last but not least, how the dynamics within healthcare are changing. We stand to gain from a holistic view of the healthcare process, the dynamics affecting supply and demand, and the opportunities that exist to reduce costs - without sacrificing quality of care.