Why business modeling is crucial in the development of eHealth technologies.

The impact and uptake of information and communication technologies that support health care are rather low. Current frameworks for eHealth development suffer from a lack of fitting infrastructures, inability to find funding, complications with scalability, and uncertainties regarding effectiveness and sustainability. These issues can be addressed by defining a better implementation strategy early in the development of eHealth technologies. A business model, and thus business modeling, help to determine such an implementation strategy by involving all important stakeholders in a value-driven dialogue on what the technology should accomplish. This idea also seems promising to eHealth, as it can contribute to the whole development of eHealth technology. We therefore suggest that business modeling can be used as an effective approach to supporting holistic development of eHealth technologies. The contribution of business modeling is elaborated in this paper through a literature review that covers the latest business model research, concepts from the latest eHealth and persuasive technology research, evaluation and insights from our prior eHealth research, as well as the review conducted in the first paper of this series. Business modeling focuses on generating a collaborative effort of value cocreation in which all stakeholders reflect on the value needs of the others. The resulting business model acts as the basis for implementation. The development of eHealth technology should focus more on the context by emphasizing what this technology should contribute in practice to the needs of all involved stakeholders. Incorporating the idea of business modeling helps to cocreate and formulate a set of critical success factors that will influence the sustainability and effectiveness of eHealth technology.

A holistic framework to improve the uptake and impact of eHealth technologies.

BACKGROUND: Many eHealth technologies are not successful in realizing sustainable innovations in health care practices. One of the reasons for this is that the current development of eHealth technology often disregards the interdependencies between technology, human characteristics, and the socioeconomic environment, resulting in technology that has a low impact in health care practices. To overcome the hurdles with eHealth design and implementation, a new, holistic approach to the development of eHealth technologies is needed, one that takes into account the complexity of health care and the rituals and habits of patients and other stakeholders. OBJECTIVE: The aim of this viewpoint paper is to improve the uptake and impact of eHealth technologies by advocating a holistic approach toward their development and eventual integration in the health sector. METHODS: To identify the potential and limitations of current eHealth frameworks (1999-2009), we carried out a literature search in the following electronic databases: PubMed, ScienceDirect, Web of Knowledge, PiCarta, and Google Scholar. Of the 60 papers that were identified, 44 were selected for full review. We excluded those papers that did not describe hands-on guidelines or quality criteria for the design, implementation, and evaluation of eHealth technologies (28 papers). From the results retrieved, we identified 16 eHealth frameworks that matched the inclusion criteria. The outcomes were used to posit strategies and principles for a holistic approach toward the development of eHealth technologies; these principles underpin our holistic eHealth framework. RESULTS: A total of 16 frameworks qualified for a final analysis, based on their theoretical backgrounds and visions on eHealth, and the strategies and conditions for the research and development of eHealth technologies. Despite their potential, the relationship between the visions on eHealth, proposed strategies, and research methods is obscure, perhaps due to a rather conceptual approach that focuses on the rationale behind the frameworks rather than on practical guidelines. In addition, the Web 2.0 technologies that call for a more stakeholder-driven approach are beyond the scope of current frameworks. To overcome these limitations, we composed a holistic framework based on a participatory development approach, persuasive design techniques, and business modeling. CONCLUSIONS: To demonstrate the impact of eHealth technologies more effectively, a fresh way of thinking is required about how technology can be used to innovate health care. It also requires new concepts and instruments to develop and implement technologies in practice. The proposed framework serves as an evidence-based roadmap.

Factors influencing the use of a Web-based application for supporting the self-care of patients with type 2 diabetes: a longitudinal study.

BACKGROUND: The take-up of eHealth applications in general is still rather low and user attrition is often high. Only limited information is available about the use of eHealth technologies among specific patient groups. OBJECTIVE: The aim of this study was to explore the factors that influence the initial and long-term use of a Web-based application (DiabetesCoach) for supporting the self-care of patients with type 2 diabetes. METHODS: A mixed-methods research design was used for a process analysis of the actual usage of the Web application over a 2-year period and to identify user profiles. Research instruments included log files, interviews, usability tests, and a survey. RESULTS: The DiabetesCoach was predominantly used for interactive features like online monitoring, personal data, and patient-nurse email contact. It was the continuous, personal feedback that particularly appealed to the patients; they felt more closely monitored by their nurse and encouraged to play a more active role in self-managing their disease. Despite the positive outcomes, usage of the Web application was hindered by low enrollment and nonusage attrition. The main barrier to enrollment had to do with a lack of access to the Internet (146/226, 65%). Although 68% (34/50) of the enrollees were continuous users, of whom 32% (16/50) could be defined as hardcore users (highly active), the remaining 32% (16/50) did not continue using the Web application for the full duration of the study period. Barriers to long-term use were primarily due to poor user-friendliness of the Web application (the absence of "push" factors or reminders) and selection of the "wrong" users; the well-regulated patients were not the ones who could benefit the most from system use because of a ceiling effect. Patients with a greater need for care seemed to be more engaged in long-term use; highly active users were significantly more often medication users than low/inactive users (P = .005) and had a longer diabetes duration (P = .03). CONCLUSION: Innovations in health care will diffuse more rapidly when technology is employed that is simple to use and has applicable components for interactivity. This would foresee the patients' need for continuous and personalized feedback, in particular for patients with a greater need for care. From this study several factors appear to influence increased use of eHealth technologies: (1) avoiding selective enrollment, (2) making use of participatory design methods, and (3) developing push factors for persistence. Further research should focus on the causal relationship between using the system's features and actual usage, as such a view would provide important evidence on how specific technology features can engage and captivate users.

Effectiveness of a Web-based intervention aimed at healthy dietary and physical activity behavior: a randomized controlled trial about users and usage.

BACKGROUND: Recent studies have shown the potential of Web-based interventions for changing dietary and physical activity (PA) behavior. However, the pathways of these changes are not clear. In addition, nonusage poses a threat to these interventions. Little is known of characteristics of participants that predict usage. OBJECTIVE: In this study we investigated the users and effect of the Healthy Weight Assistant (HWA), a Web-based intervention aimed at healthy dietary and PA behavior. We investigated the value of a proposed framework (including social and economic factors, condition-related factors, patient-related factors, reasons for use, and satisfaction) to predict which participants are users and which participants are nonusers. Additionally, we investigated the effectiveness of the HWA on the primary outcomes, self-reported dietary and physical activity behavior. METHODS: Our design was a two-armed randomized controlled trial that compared the HWA with a waiting list control condition. A total of 150 participants were allocated to the waiting list group, and 147 participants were allocated to the intervention group. Online questionnaires were filled out before the intervention period started and after the intervention period of 12 weeks. After the intervention period, respondents in the waiting list group could use the intervention. Objective usage data was obtained from the application itself. RESULTS: In the intervention group, 64% (81/147) of respondents used the HWA at least once and were categorized as "users." Of these, 49% (40/81) used the application only once. Increased age and not having a chronic condition increased the odds of having used the HWA (age: beta = 0.04, P = .02; chronic condition: beta = 2.24, P = .003). Within the intervention group, users scored better on dietary behavior and on knowledge about healthy behavior than nonusers (self-reported diet: χ²2 = 8.4, P = .02; knowledge: F1,125 = 4.194, P = .04). Furthermore, users underestimated their behavior more often than nonusers, and nonusers overestimated their behavior more often than users (insight into dietary behavior: χ²2 = 8.2, P = .02). Intention-to-treat analyses showed no meaningful significant effects of the intervention. Exploratory analyses of differences between pretest and posttest scores of users, nonusers, and the control group showed that on dietary behavior only the nonusers significantly improved (effect size r = -.23, P = .03), while on physical activity behavior only the users significantly improved (effect size r = -.17, P = .03). CONCLUSIONS: Respondents did not use the application as intended. From the proposed framework, a social and economic factor (age) and a condition-related factor (chronic condition) predicted usage. Moreover, users were healthier and more knowledgeable about healthy behavior than nonusers. We found no apparent effects of the intervention, although exploratory analyses showed that choosing to use or not to use the intervention led to different outcomes. Combined with the differences between groups at baseline, this seems to imply that these groups are truly different and should be treated as separate entities. TRIAL REGISTRATION: Trial ID number: ISRCTN42687923; http://www.controlled-trials.com/ISRCTN42687923/ (Archived by WebCite at http://www.webcitation.org/5xnGmvQ9Y).

Asynchronous and synchronous teleconsultation for diabetes care: a systematic literature review.

AIM: A systematic literature review, covering publications from 1994 to 2009, was carried out to determine the effects of teleconsultation regarding clinical, behavioral, and care coordination outcomes of diabetes care compared to usual care. Two types of teleconsultation were distinguished: (1) asynchronous teleconsultation for monitoring and delivering feedback via email and cell phone, automated messaging systems, or other equipment without face-to-face contact; and (2) synchronous teleconsultation that involves real-time, face-to-face contact (image and voice) via videoconferencing equipment (television, digital camera, webcam, videophone, etc.) to connect caregivers and one or more patients simultaneously, e.g., for the purpose of education. METHODS: Electronic databases were searched for relevant publications about asynchronous and synchronous tele-consultation [Medline, Picarta, Psychinfo, ScienceDirect, Telemedicine Information Exchange, Institute for Scientific Information Web of Science, Google Scholar]. Reference lists of identified publications were hand searched. The contribution to diabetes care was examined for clinical outcomes [e.g., hemoglobin A1c (HbA1c), dietary values, blood pressure, quality of life], for behavioral outcomes (patient-caregiver interaction, self-care), and for care coordination outcomes (usability of technology, cost-effectiveness, transparency of guidelines, equity of access to care). Randomized controlled trials with HbA1c as an outcome were pooled using standard meta-analytical methods. RESULTS: Of 2060 publications identified, 90 met inclusion criteria for electronic communication between (groups of) caregivers and patients with type 1 and 2 or gestational diabetes. Studies that evaluated teleconsultation not particularly aimed at diabetes were excluded, as were those that described interventions aimed solely at clinical improvements (e.g., HbA1c or lipid profiles). In 63 of 90 interventions, the interaction had an asynchronous teleconsultation character, in 18 cases interaction was synchronously (videoconferencing), and 9 involved a combination of synchronous with asynchronous interaction. Most of the reported improvements concerned clinical values (n = 49), self-care (n = 46), and satisfaction with technology (n = 43). A minority of studies demonstrated improvements in patient-caregiver interactions (n = 28) and cost reductions (n = 27). Only a few studies reported enhanced quality of life (n = 12), transparency of health care (n = 7), and improved equity in care delivery (n = 4). Asynchronous and synchronous applications appeared to differ in the type of contribution they made to diabetes care compared to usual care: asynchronous applications were more successful in improving clinical values and self-care, whereas synchronous applications led to relatively high usability of technology and cost reduction in terms of lower travel costs for both patients and care providers and reduced unscheduled visits compared to usual care. The combined applications (n = 9) scored best according to quality of life (22.2%). No differences between synchronous and asynchronous teleconsultation could be observed regarding the positive effect of technology on the quality of patient-provider interaction. Both types of applications resulted in intensified contact and increased frequency of transmission of clinical values with respect to usual care. Fifteen of the studies contained HbA1c data that permitted pooling. There was significant statistical heterogeneity among the pooled randomized controlled trials (chi(2) = 96.46, P < 0.001). The pooled reduction in HbA1c was not statically significant (weighted mean difference -0.10; 95% confidence interval -0.39 to 0.18). CONCLUSION: The included studies suggest that both synchronous and asynchronous teleconsultations for diabetes care are feasible, cost-effective, and reliable. However, it should be noted that many of the included studies showed no significant differences between control (usual care) and intervention groups. This might be due to the diversity and lack of quality in study designs (e.g., inaccurate or incompletely reported sample size calculations). Future research needs quasi-experimental study designs and a holistic approach that focuses on multilevel determinants (clinical, behavioral, and care coordination) to promote self-care and proactive collaborations between health care professionals and patients to manage diabetes care. Also, a participatory design approach is needed in which target users are involved in the development of cost-effective and personalized interventions. Currently, too often technology is developed within the scope of the existing structures of the health care system. Including patients as part of the design team stimulates and enables designers to think differently, unconventionally, or from a new perspective, leading to applications that are better tailored to patients' needs.

Patient use and compliance with medical advice delivered by a web-based triage system in primary care.

We studied a web-based triage system which was accessible to the general public in the Netherlands. In a retrospective analysis we investigated the type of complaints that were submitted and the kind of advice provided. Over a period of 15 months, 13,133 different people began using the web-based triage system and 3812 patients went right through the triage process to the end. The most frequent complaints were common cold symptoms, such as cough and a sore throat (22%), itch problems (13%), urinary complaints (12%), diarrhoea (10%), headache (8%) and lower back pain (8%). Most commonly, the system generated the advice to contact a doctor (85%) and in 15% of the cases the system provided fully automated, problem-tailored, self-care advice. A total of 192 patients participated in a prospective study and completed an online survey immediately after the delivery of advice. A follow-up questionnaire on actual compliance was completed by 35 patients. Among these, 20 (57%) had actually complied with the advice provided by the system. A regression analysis revealed that intention to comply was strongly related to actual compliance. In turn, intention to comply was strongly related to attitude towards the advice (P < 0.001). Web-based triage can contribute to a more efficient primary care system, because it facilitates the gatekeeper function.

Increasing the use of e-consultation in primary care: results of an online survey among non-users of e-consultation.

OBJECTIVE: To identify factors that can enhance the use of e-consultation in primary care. We investigated the barriers, demands and motivations regarding e-consultation among patients with no e-consultation experience (non-users). METHODS: We used an online survey to gather data. Via online banners on 26 different websites of patient organizations we recruited primary care patients with chronic complaints, an important target group for e-consultation. A regression analysis was performed to identify the main drivers for e-consultation use among patients with no e-consultation experience. RESULTS: In total, 1706 patients started to fill out the survey. Of these patients 90% had no prior e-consultation experience. The most prominent reasons for non-use of e-consultation use were: not being aware of the existence of the service, the preference to see a doctor and e-consultation not being provided by a GP. Patients were motivated to use e-consultation, because e-consultation makes it possible to contact a GP at any time and because it enabled patients to ask additional questions after a visit to the doctor. The use of a Web-based triage application for computer-generated advice was popular among patients desiring to determine the need to see a doctor and for purposes of self-care. The patients' motivations to use e-consultation strongly depended on demands being satisfied such as getting a quick response. When looking at socio-demographic and health-related characteristics it turned out that certain patient groups - the elderly, the less-educated individuals, the chronic medication users and the frequent GP visitors - were more motivated than other patient groups to use e-consultation services, but were also more demanding. The less-educated patients, for example, more strongly demanded instructions regarding e-consultation use than the highly educated patients. CONCLUSION: In order to foster the use of e-consultation in primary care both GPs and non-users must be informed about the possibilities and consequences of e-consultation through tailored education and instruction. We must also take into account patient profiles and their specific demands regarding e-consultation. Special attention should be paid to patients who can benefit the most from e-consultation while also facing the greatest chance of being excluded from the service. As health care continues to evolve towards a more patient-centred approach, we expect that patient expectations and demands will be a major force in driving the adoption of e-consultation.

Evaluation of internet-based technology for supporting self-care: problems encountered by patients and caregivers when using self-care applications.

BACKGROUND: Prior studies have shown that many patients are interested in Internet-based technology that enables them to control their own care. As a result, innovative eHealth services are evolving rapidly, including self-assessment tools and secure patient-caregiver email communication. It is interesting to explore how these technologies can be used for supporting self-care. OBJECTIVE: The aim of this study was to determine user-centered criteria for successful application of Internet-based technology used in primary care for supporting self-care. METHODS: We conducted scenario-based tests combined with in-depth interviews among 14 caregivers and 14 patients/consumers to describe the use of various self-care applications and the accompanying user problems. We focused on the user-friendliness of the applications, the quality of care provided by the applications, and the implementation of the applications in practice. RESULTS: Problems with the user-friendliness of the self-care applications concerned inadequate navigation structures and search options and lack of feedback features. Patients want to retrieve health information with as little effort as possible; however, the navigation and search functionalities of the applications appeared incapable of handling patients' health complaints efficiently. Among caregivers, the lack of feedback and documentation possibilities caused inconvenience. Caregivers wanted to know how patients acted on their advice, but the applications did not offer an adequate feedback feature. Quality of care problems were mainly related to insufficient tailoring of information to patients' needs and to efficiency problems. Patients expected personalized advice to control their state of health, but the applications failed to deliver this. Language (semantics) also appeared as an obstacle to providing appropriate and useful self-care advice. Caregivers doubted the reliability of the computer-generated information and the efficiency and effectiveness of secure email consultation. Legal or ethical issues with respect to possible misuse of email consultation also caused concerns. Implementation problems were mainly experienced by caregivers due to unclear policy on email consultation and the lack of training for email consultations. CONCLUSIONS: Patients' and caregivers' expectations did not correspond with their experiences of the use of the Internet-based applications for self-care. Patients thought that the applications would support them in solving their health problems. Caregivers were more reserved about the applications because of medico-legal concerns about misuse. However, the applications failed to support self-care because eHealth is more than just a technological intervention. The design of the applications should include a way of thinking about how to deliver health care with the aid of technology. The most powerful application for self-care was secure email consultation, combined with a suitable triage mechanism to empower patients' self-awareness. Future research should focus on the effectiveness of such Web-based triage mechanisms for medical complaints and on the development of interactive features to enhance patients' self-care.

The contribution of teleconsultation and videoconferencing to diabetes care: a systematic literature review.

BACKGROUND: A systematic literature review was carried out to study the benefits of teleconsultation and videoconferencing on the multifaceted process of diabetes care. Previous reviews focused primarily on usability of technology and considered mainly one-sided interventions. OBJECTIVE: The objective was to determine the benefits and deficiencies of teleconsultation and videoconferencing regarding clinical, behavioral, and care coordination outcomes of diabetes care. METHODS: Electronic databases (Medline, PiCarta, PsycINFO, ScienceDirect, Telemedicine Information Exchange, ISI Web of Science, Google Scholar) were searched for relevant publications. The contribution to diabetes care was examined for clinical outcomes (eg, HbA(1c), blood pressure, quality of life), behavioral outcomes (patient-caregiver interaction, self-care), and care coordination outcomes (usability of technology, cost-effectiveness, transparency of guidelines, equity of care access). Randomized controlled trials (RCTs) with HbA(1c) as an outcome were pooled using standard meta-analytical methods. RESULTS: Of 852 publications identified, 39 met the inclusion criteria for electronic communication between (groups of) caregivers and patients with type 1, type 2, or gestational diabetes. Studies that evaluated teleconsultation or videoconferencing not particularly aimed at diabetes were excluded, as were those that described interventions aimed solely at clinical improvements (eg, HbA(1c)). There were 22 interventions related to teleconsultation, 13 to videoconferencing, and 4 to combined teleconsultation and videoconferencing. The heterogeneous nature of the identified videoconferencing studies did not permit a formal meta-analysis. Pooled results from the six RCTs of the identified teleconsultation studies did not show a significant reduction in HbA(1c) (0.03%, 95% CI = - 0.31% to 0.24%) compared to usual care. There was no significant statistical heterogeneity among the pooled RCTs (chi(2) (7)= 7.99, P = .33). It can be concluded that in the period under review (1994-2006) 39 studies had a scope broader than clinical outcomes and involved interventions allowing patient-caregiver interaction. Most of the reported improvements concerned satisfaction with technology (26/39 studies), improved metabolic control (21/39), and cost reductions (16/39). Improvements in quality of life (6/39 studies), transparency (5/39), and better access to care (4/39) were hardly observed. Teleconsultation programs involving daily monitoring of clinical data, education, and personal feedback proved to be most successful in realizing behavioral change and reducing costs. The benefits of videoconferencing were mainly related to its effects on socioeconomic factors such as education and cost reduction, but also on monitoring disease. Additionally, videoconferencing seemed to maintain quality of care while producing cost savings. CONCLUSIONS: The selected studies suggest that both teleconsultation and videoconferencing are practical, cost-effective, and reliable ways of delivering a worthwhile health care service to diabetics. However, the diversity in study design and reported findings makes a strong conclusion premature. To further the contribution of technology to diabetes care, interactive systems should be developed that integrate monitoring and personalized feedback functions.