The number of IT applications concerning health and health care is rising swiftly. E-Health is a broad term used for many different things, e.g. sharing of electronic health records, accessing health information on the internet, telemedicine, online appointment systems, online consultations, mobile health or m-health and also self measuring devices from which the collected data can be shared through the internet. Which impact will these developments have on the way we practice medicine? Will it significantly alter the patient-physician relationship? How can we use e-Health to the best advantage of both patient and physician? Do you know of any articles studying these questions?
Definitely ehealth is already cahnging medical practice and the doctor-patient relationship. It has changed the way doctors structure their attention to patients. the interaction between patients and doctors and it could also influence the quality of care, efficiency of doctors' consultation and moreover clinical outcomes. There are possitive aspects and also some negative.
It depends on what you are exactly looking for, but there is some literature on this topic, some older and some more recent, likethe following examples: E-health:transforming the physician/patient relationship. Marion J.Ball, Jennifer Lillis; Untangling the web-the impact of internet use on health care and the physiscian-patient relationship.Hedy S. Wald. catherine E. Dube, David C. Anthony; haematology patients and the internet- the use of on-line health information and the impact on the patient-doctor relationship. Tom Rider, Muzaffar Malik, Timothy Chevassut.
I believe it already has. As in other fields, prosumers have come to the fore to take responsibility, educate themseleves and (not always desirably) question or reject professional expertise. Buying a car today, for example, is much different than before the Internet. When you go to the dealer you already probably know more about the car you want than the salesperson. Some people take this same attitude to the doctor and believe that by browsing their condition on the Internet they will have reached the status of prosumer, even throwing statistics and experimental procedures at the doctor. It has and will continue to have positive (mobility, universal health records owned by patients) and negative implications (self-medication, varyig levels of satisfaction), but that's the thing about a paradigm shift, you never know where it is going to lead. Some articles:
Salzer, M. S. (1997). Consumer empowerment in mental health organizations: Concept, benefits, and impediments. Administration and Policy in Mental Health and Mental Health Services Research, 24(5), 425–434. doi:10.1007/BF02042724
http://www.healthy.net/Health/Article/The_Rise_of_the_Medical_Prosumer/1039
The Wisdom of Patients: Health Care Meets Online Social Media - CHCF.org. (2008). Retrieved from http://www.chcf.org/publications/2008/04/the-wisdom-of-patients-health-care-meets-online-social-media
Chapko, A., Gräßle, M., Emrich, A., Werth, D., Laum, N., Lerche, C., … Weber, A. (2011). User-generated mobile services for health and fitness. Presented at the IEEE International Conference on Emerging Technologies and Factory Automation, ETFA. doi:10.1109/ETFA.2011.6059232
Sundstrom, B. (2013). (Re)Writing the body: A prosumption analysis of pregnancy. Journal of Social Marketing, 3(2), 127–143. doi:10.1108/JSOCM-08-2011-0044
Some years ago it would have been strange to think that we were going to communicate with our doctor using the e-mail, but now it is not so uncommon.Nowadays patients are frequently informed about their possible diagnosis before visiting the doctor, health literacy is improving in some groups of patients. This is leading to a shift of the power from doctors to patients who can participate actively and much more involved in the decisions with regards their conditions. The so called patient empowerment is a natural growing trend due to internet. Doctors should see this shift of power as an opportunity to establish a trust relationship with their patients.This will increase the efficiency of the visits and could improve the quality of health care as other ehealth elements (EMR, telemedicine..). Some of the negative aspects are related to inaccurate information found in some websites. For that reason, doctors should provide patients with additional reliable sites and additional information that will make informed consent have real meaning. Better informed patients, especially for those having chronic conditions can have a positive influence in their disease management, leading to better self-management and less visits to the doctor that could potentially have an economic impact in the health care system.
Thank you for your answers! I certainly agree that the internet can empower patients and improve the way we use the EMR. On the other hand, it brings along more responsibilities for the patient. Is there a risk of putting too much pressure on a patient with a chronic disease if you ask him or her to manage it on their own? It will also be necessary to have research on how you can reach the most vulnerable patients: can it improve health illiteracy, or will ehealth create other/more differences? There is an ehealth monitor in The Netherlands, which is an interesting project (www.nictiz.nl). Many studies/articles concerning ehealth look at a very specific disease, group of patients or application. I think it is also interesting to look at the phenomenon of ehealth from a broader point of view. I have found the ehealth IMPACT study (European Commission); it tends to concentrate on the economic impact.
I also agree that e-health is contributing to a paradigm shift.
This creates challenges both for the healthcare providers as well as the patients. I doubt that we will ever be asking a patient with a chronic disease to manage their condition on their own. Rather we need these patients to be actively involved in their disease management which also requires that they are able to enage with the appropriate online portals.
This shift is also refelected into the burgeoning lietrature on this topic for example the Journal of Medical Internet Research-
http://www.jmir.org/
Yes it can be expected that a paradigm shift will come, eventually, but it really depends on the country and how E-Health is being used. In some developing countries, there are many challenges in delivering basic health care and many E-Health initiatives have not been implemented successfully while for others there are several aspects of E-Health which are already in place bringing many benefits to both patients and care providers. So it really depends on the country, usage patterns, user acceptability, benefits vs challenges... E-Health is a broad term and as different countries have implemented aspects of E-Health at different levels, it may be difficult to predict the outcome and effects of it .. although general expectation would be that it will eventually bring about a paradigm shift
A huge question, and huge literature (inc. International Journal of Medical Informatics, Methods of Information in Medicine, and many papers in other journals). It is rather like asking in earlier decades how the motor car, then the telephone, would change health care - it is what becomes deeply embedded that will matter most, but there will not be a standard answer.
We have to be aware that a top down, imposed approach, is often counter-productive. Also, projects do have a value but it has to be seen as limited, because of the special investment and the Hawthorne Effect.
Two things are important. One is taking an evidence-based approach, with scientific evaluation as the main source of evidence, as with any other health intervention. See e.g. Rigby M et al: Evidence Based Health Informatics: 10 Years of Efforts to Promote the Principle - Joint Contribution of IMIA WG EVAL and EFMI WG EVAL; in Sérousi B, Jaulent M-C, Lehmann CU (eds.). Evidence-based Health Informatics – IMIA Yearbook of Medical Informatics 2013; 34-46, Schattauer, Stuttgart, 2013.
The second is not to create new health inequalities, through expectations that everyone will be e-literate and connected. See e.g. Showell C, Turner P: The PLU problem: are we designing personal ehealth for people like us?Stud Health Technol Inform. 2013;183:276-80.
No e-Health will not change health care. The principle of health care is an individual having an ilness or care needs and requiring health care. I see no progress in eliminating diseases and care needs. I see a society changing however, and applying more and more technology. And of course such technology is been taken up in health care. That process started somewhere in the fifties of last century, so we have about 60 years of experiences. The medical informatics did change the way the subprocess of information processing in health care is managed. And the telemedicine made it possible to exchange information via a distance. And video conferencing made it possible to communicate with each other using these distance bridging tools.
But e-health? What is is anyway? Some buzzword....changing the paradigms?
Let me align myself with those who answered YES. From my view point, eHealth could expand or improve ACCESS to QUALITY healthcare in under-served areas. For example, we are implementing a system that would allow 'experienced caregiver' in big cities to have access to patients' information in remote villages without necessarily traveling to those areas. A key advantage of this project would be access/improved quality of healthcare for the rural patients.
Secondary, so many people like me visit websites such as www.babycenter.com etc to study and understand issues with children and pregnancy, that way you are able to learn from the experiences of other people. Again, ACCESS to medical information is key to managing healthcare needs.
Finally, caregivers would be more professional and proactive if they have direct access to patient's historic data in a user-friendly format rather than flipping through a couple of case notes documented in a paper-based folder. Access to patient historic medical information.
I may personally have issues with regulations and standards especially in developing countries like Nigeria.
Dear all,
access to quality care has been a requirement since thousands of years. And of course access to information as well. I support the comments that this is important today, and yes the tools available make it easier. But the question was if it is a paradigm shift in health care. I insist it is not changing health care fundamentally. It is gradually making some aspects better in particular in which communication and information play a role. It makes information easier to use, better accessible, quicker available, of higher quality and so on. But a paradigm shift does in my eyes implies a change in what we did before, and what we do now. I still have not seen that happening after 25 years plus of study, research and implementations in e-health (health informatics).
Should we continue to work with e-health? Definitely!
Should we pray haleluja everything changed based on e-health? Lets keep a scientific approach please!
There are some major changes looming. The increased computational power combined with technology is going to facilitate prescision medicine-ie the tailoring of treatments (particularly therapeuitic agents) based on an understanding of individual patients genetics.
In addition remote delivery of services to rural regions will be facilitated by using the tools effectively (think telemedicine, of the use of hand held devices for taking images of skin lesions for example, which can be relayed via a secure portal to a dermatologist in another location). Plus some care will be delivered via being able to monitor patients in the community (via tracking, type sensor devices).
When looking at the Netherlands, eHealth it already having its impact. This is a logical result of an increasingly elderly population that stresses the capacity of healthcare, rapid developments in eHealth techonology (such as Infection Manager apps for nurses, diagnostic tools, prevention apps, discussion platforms) and the decreasing price of electronics. This combination of factors creates a fertile ground for eHealth. How this will develop in the future is hard to predict however and personal contact will always be necessary. Nevertheless, economical / capacity reasons will make eHealth a viable option.
Dear Melle,
I definitely agree that eHealth is viable. I know that for 30 years now, and have been trying to break down hurdles all this time. However, the question was is it a paradigm shift. I have not heard / read any argument that it is fundamentally changing health care.
William
According to Thomas Kuhn, (The Structure of Scientific Revolutions,1962), a paradigm shift is a fundamental change in the ruling theory of science or the underlying scientific principles. The term has also since been applied to other non hard science concepts to indicate a radical change in thinking eg in complex systems or organisations. I think it is debatable that healthcare could be considered a hard science. I suggest it is an applied science, which is dependent on a foundation of many disciplines within the hard sciences.
Thus while eHealth or health informatics may not have changed the underlying principle of healthcare ie to improve the health of individuals through care interventions, it has contributed to a fundamental shift in the structure and organisation of healthcare systems. The paradigm shift relates to how services are provided and more importantly to the empowering of the individual to participate in their own health management and in shared decision making. It also empowers clinicians, who choose so, to move from a more heuristic decision making process to a more fully evidence based system where the power of data is used to inform decision making more consistently.
Paradigm shifts may be triggered during times of instability. They are not likely to be a sudden or rapid change, but can take years to fully transform, following considerable debate and conversion of the proponents of the earlier theory to the new paradigm, eg theory of evolution, theory of relativity.
Thus disruptive events occurring in healthcare now, such as economic pressures to curb the escalating costs of care, increased chronic disease, the integration of information technologies everyday life, changes in the standard of care demanded by patients as well as the increased information available to them may be contributing to this paradigm shift which, understandably is likely to be a slow process considering the extent and complexity of the healthcare system. So just because eHealth has been around for 30 years does not mean that a paradigm shift is not occurring, it may just be taking a little time.
Here is an interesting article discussing moving eHealth from pilot projects to embedded process in Australia.
http://www.transformingthenation.com.au/2014/10/brave-new-world-health-communications/
Dear Susan,
Wauw, well written. I think we are moving to the real points of discussion; fundamental changes in health care delivery systems. Here I agree in particular about slowly moving to evidence based, shared care models that empower the individuals in their relationship with the institutions. I am working on a personal data store in which the sharing data, sharing responsibilities, lifetime records, and data exchange, transaction control by individual are based on a privacy by design approach. And there I see a pattern arising which leads to a fundamental shift. Thank you for a well thought contribution.
I agree on the analysis by Susan Smith. I do think it is an interesting question whether the informatics or ehealth in health care will cause fundamental changes or not. The shared EMR takes up a much more significant role in health care processes and patient-physician interactions. How will this evolve? Data collection is rapidly changing and expanding with every individual patient registering various parameters. How will this Big Data be processed individually and on a societal level? What kind of impact will this have on a person's everyday life? Will the care for our health take up more space and time? To which extent will the notion of privacy be adjusted by these developments? I think ehealth can be an instrument to empower the patient and the physician, but it also holds several risks. It seems quite difficult to me to find research answering those more philosophical questions.
Dear Tania,
Thank you for the question. My interest in this area stems from working within the NHS in UK when the National Project for IT was rolled out. I then had the privilege to further train in Health Informatics with the CHIME unit at University College London.
There has been much literature in this area. However, it has remain elusive to show conclusively that the application of Health Informatics can positively impact both the delivery and experience of health care in the front lines.
My personal view is that we have now reached a point of convergence of hardware, software and affordable wireless networking capabilities worldwide that allows Health Informatics to play a significant role in national health care systems.
However, whether this will be of benefit and to who remains to be determined. Too often, the clinicians in the front lines are not involved enough. This leads to the development of "systems" without the direct input and/or feedback from the end users. The outcome is often not satisfactory when this happens (e.g. Choose and Book Project)
On the other hand, it is difficult to engage the front-line clinicians, who may see the huge costs involved in national IT projects (11 Billion Pounds for NPfIT from 2002 to 2011: National Audit Office, 11th May 2011) as an unjustified source of drain on an already rapidly diminishing pool of funding for healthcare.
Also, there is a need to be clear on the purpose of implementing IT in healthcare. Health Informatics can improve the delivery of care. However, it cannot lead to better outcomes if the process of care is not already in place, or if the clinical input has not been able to achieve it's clinical targets in the first instance.
For example, The Whole System Demonstrator study showed that Telehealth may reduce hospital admission and mortality rates in a select group of patients and General Practitioners over a 12 moth period. However, the mechanism for this was unclear in the original paper (BMJ 2012;344:e3874). It is thought that the implementation of Telehealth in itself may have influenced the process of care among the study population, which would have had an important impact on the outcome of the study.
There is much work to be done (i.e. Knowledge Management at the Point of Care, Clinical Informatics, How to Prevent Failure in Health Informatics Systems, etc).
For the "Paradigm Shift" to occur, more of us in the front line needs to be involved at all stages of the development and implementation of Health Informatics Systems.
I share with you the results of an on-going online survey on the relationship between Clinicians and Health Informatics that I am conducting. The survey and the whole website is meant as an Open Source project. Feel free to use the data. Hope it may be of some use to you.
The links are:
http://hiicp.org/info_clinical/hiicp_few_questions.html
The survey can be accessed here:
https://qtrial2010.az1.qualtrics.com/SE/?SID=SV_8idLachOjexYgXa
The public reports can be found here:
https://qtrial2010.az1.qualtrics.com/CP/Report.php?RP=RP_9TDMnHVXhOq23BP
We have modified the survey form to include all non-medical clinical staff based on feedback tonight, so the results will be reset tonight.
Thank you.
Dear William, thank you for considering both sides of the topic! Privacy is one of the great stumbling blocks in eHealth - good luck with your valuable work.
another article that discusses the effects of eHealth in transforming care - from the UK - is attached Discussing many of these themes.
Tania, there is an increasing recognition of the risks that HIT may have in healthcare and that this is in fact just as for any other healthcare intervention. I agree that it is difficult to find specific research on the philosophical aspects you mention, certainly there is a growing literature regarding the technical risks and socio technical issues. Some other issues include the changes in practice resulting from clinical performance monitoring eg as occurred in New York when Cardiac Surgeons were publically monitored. There was an decrease in operations on 'risky' patients, with a concomitant increase in neighbouring states - the patients had to travel further or missed out on potentially life saving surgery. It took some time to work out the best strategy to monitor outcomes for improvement, avoiding unexpected consequences.
I also worry a little that medicine may lose some appeal for high achievers who may not see the effort as worth the personal reward - as specialists may perceive that they lose their sense of status, power and autonomy which is very attractive to high achievers. Do you think this is a valid concern? It is certainly likely to alter the power structure....
http://www.theguardian.com/healthcare-network/2014/sep/17/health-social-care-digital-revolution-barriers-solutions?commentpage=1
https://www.researchgate.net/publication/276121947_Mobile_Health_Services_A_New_Paradigm_for_Health_Care_Systems?ev=prf_pub
Article Mobile Health Services: A New Paradigm for Health Care Systems
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