Sue Whetton

Consumer e-health: an overview of research evidence and implications for future policy.

Consumer e-health is rapidly becoming a fundamental component of healthcare. However, to date only provisional steps have been taken to increase our understanding of how consumers engage with e-health. This study, an interpretive review, assessed the evidence about consumer use of e-health and identified five categories that encompass consumer e-health: (i) peer-to-peer online support groups; (ii) self-management/self-monitoring applications; (iii) decision aids; (iv) the personal health record; and (v) Internet use. Our findings reveal that e-health offers consumers many possibilities and potential benefits, although there appears to be apprehension concerning the efficacy of some interventions and barriers relating to the trustworthiness of Internet-acquired information. It is imperative that policy initiatives address these issues to ensure that consumer e-health services can be effectively, efficiently, and safely accessed.

Successes and Failures: What are we measuring?

In telemedicine and telehealth, the perception of success is complex, varies according to time and context, and depends on the perspective of the observer. Several reviews of the evaluation literature have been undertaken in recent years. These reviews identify common methodological shortcomings. Telehealth services continue to be funded as short-term projects. While it is essential to address methodology issues, it is important to understand that studies of pilot projects provide only interim findings about the feasibility of such applications, not how well they operate as mature applications. This represents something of a conundrum: evaluation is expected to establish the long-term value of telehealth using criteria which are specific to short-term projects. A useful approach would be to develop frameworks enabling all similar studies (e.g. diabetic home care) to be examined in order to extract commonalities and differences. This would enable us to draw conclusions about where telehealth is effective, as well as what variables demonstrate ‘success’

Exposure to 'exergames' increases older adults' perception of the usefulness of technology for improving health and physical activity: a pilot study

Background High rates of sedentary behaviors in older adults can lead to poor health outcomes. However, new technologies, namely exercise-based videogames (“exergames”), may provide ways of stimulating uptake and ongoing participation in physical activities. Older adults’ perceptions of the use of technology to improve health are not known. Objective The study aimed to determine use and perceptions of technology before and after using a 5-week exergame. Methods Focus groups determined habitual use of technology and the participant’s perceptions of technology to assist with health and physical activity. Surveys were developed to quantitatively measure these perceptions and were administered before and after a 5-week intervention. The intervention was an exergame that focused on postural balance (“Your Shape Fitness Evolved 2012”). Games scores, rates of game participation, and enjoyment were also recorded. Results A total of 24 healthy participants aged between 55 and 82 years (mean 70, SD 6 years) indicated that after the intervention there was an increased awareness that technology (in the form of exergames) can assist with maintaining physical activity (P<.001). High levels of enjoyment (Physical Activity Enjoyment Scale [PACES-8] score mean 53.0, SE 0.7) and participation rates over the whole study (83%-100%) were recorded. Conclusions Older adults’ have low perception of the use of technology for improving health outcomes until after exposure to exergames. Technology, in the form of enjoyable exergames, may be useful for improving participation in physical activity that is relevant for older adults.

Conceptual challenges for advancing the socio-technical underpinnings of health informatics.

This discussion paper considers the adoption of socio-technical perspectives and their theoretical and practical influence within the discipline of health informatics. The paper highlights the paucity of discussion of the philosophy, theory and concepts of socio-technical perspectives within health informatics. Instead of a solid theoretical base from which to describe, study and understand human-information technology interactions we continue to have fragmented, unelaborated understandings. This has resulted in a continuing focus on technical system performance and increasingly managerial outputs to the detriment of social and technical systems analysis. It has also limited critical analyses and the adaptation of socio-technical approaches beyond the immediate environment to the broader social systems of contemporary society, an expansion which is increasingly mandated in today’s complex health environment.

Broadening the socio-technical horizons of health informatics.

This special socio-technical supplement of the Open Medical Informatics Journal showcases a number of innovative and unique research approaches that highlight the current scope of socio-technical perspectives in the health informatics discipline. In just three short decades the discipline of health informatics has evolved from a primary focus on the “application of computers to all fields of medicine – medical care, medical education and medical research” [1] to an increasing focus on socio-technical issues where “people and organizational issues are critical” (page 79) [2]. The incorporation of socio-technical perspectives arose as researchers sought to analyse the reasons behind the limited successes of many early health information management systems. The application of socio-technical analyses demonstrated that effective systems implementation required an appreciation of both technological and organisational factors. While technical elements continue to be core to health informatics knowledge, socio-technical research seeks to further our understanding of the organisational and cultural factors inherent in the introduction of information management systems into the health care environment. Early socio-technical research included reflections both on its role in knowledge development and its application to the practice of health informatics [3-5]. Research and discussion often took the form of a critique of the established technology focussed approaches. However, as Coiera notes, “for the contribution of socio-technical systems thinking to be more than simply a means of critiquing current practices and systems, it needs to also contribute to the process of developing new and more effective systems” (page S98) [6]. The papers in this supplement highlight how many of today’s researchers have adopted a socio-technical focus as an established and credible methodology, not just for critiquing past mistakes, but for developing an understanding of key success factors in the development and implementation of new systems. The papers also show how researchers are using the basic concepts and multi-method socio-technical approaches, and applying these to a range of research situations. Chhanabhai and Holt demonstrate the universal relevance of socio-technical perspectives in their analysis of information and communications technologies in developing countries [7]. The authors present an overview of current methods through which healthcare information is communicated to the public within these countries. Niazkhani applies socio-technical analyses to a clinical environment. This exploratory research draws on socio-technical theories to provide insights into the differences between the perceptions of surgical and non-surgical clinicians in relation to Computerised Provider Order Entry (CPOE) systems [8]. The papers by Scott [9] and Li [10] highlight the increasing interest of today’s researchers in making connections between academic research and the professional environment. Li’s paper seeks to develop a model that will bring together the theory and practice of socio-technical perspectives in health informatics. Scott also investigates this area as a means of constructing an innovative socio-technical assessment tool for health information system implementations. The authors contributing to this special edition also highlight the multi-disciplinary, interrelated character of health informatics. The papers by Borycki and Kushniruk [11], and Cummings and Turner [12] demonstrate how a melding of socio-technical perspectives with other approaches can offer new insights for health informatics practitioners. Borycki and Kushniruk combine socio-technical and cognitive approaches to facilitate a more holistic understanding of the impact of health information systems [11], while Cummings and Turner adopt a multi-disciplinary approach in their critical review of current research and evaluation practices [12]. Contributors to this supplement also expand the focus of socio-technical systems research from interaction between clinicians and their systems to explore ways in which other users interact with information management systems. Cummings and Turner note that users of socio-technical systems are no longer restricted to health professionals and highlight the role of patients (or consumers) as important users in their own right [12]. The increasing emphasis on consumer focussed health care creates new challenges for health informatics as consumers take responsibility for managing their own health and well-being supported by information and communication systems. The contributions to this supplement also point to links between the micro-environment of socio-technical systems and the macro-environment of power, politics and ethics. This is flagged by Chhanabhai and Holt who incorporate concepts of equality and empowerment into their discussion [7], while Borycki and Kushniruk raise the possibility of extending their analysis to incorporate broader social processes and the critical role they play in health information system utilisation, performance and their contribution to patient care [11]. The final paper by Whetton and Georgiou [13] considers the influence of socio-technical perspectives, research and practice within the discipline of health informatics. They note the limited discussion of the philosophy, theory and socio-technical perspectives within health informatics, arguing that instead of a solid theoretical base from which to describe, study and understand human-information technology interactions, we continue to have fragmented, and unelaborated understandings. While socio-technical perspectives within the wider academic research community have begun to explore the interaction between the information system and the broader social environment, the focus in health informatics remains at the level of the immediate environment. In the increasingly complex and interconnected contemporary health care environment, now may be the time to broaden the focus of socio-technical perspectives in health informatics.

Health Informatics and E-health Curriculum for Clinical Health Profession Degrees.

The project reported in this paper models a new approach to making health informatics and e-health education widely available to students in a range of Australian clinical health profession degrees. The development of a Masters level subject uses design-based research to apply educational quality assurance practices which are consistent with university qualification frameworks, and with clinical health profession education standards; at the same time it gives recognition to health informatics as a specialised profession in its own right. The paper presents details of (a) design with reference to the Australian Qualifications Framework and CHIA competencies, (b) peer review within a three-university teaching team, (c) external review by experts from the professions, (d) cross-institutional interprofessional online learning, (e) methods for evaluating student learning experiences and outcomes, and (f) mechanisms for making the curriculum openly available to interested parties. The project has sought and found demand among clinical health professionals for formal health informatics and e-health education that is designed for them. It has helped the educators and organisations involved to understand the need for nuanced and complementary health informatics educational offerings in Australian universities. These insights may aid in further efforts to address substantive and systemic challenges that clinical informatics faces in Australia.

Evaluating educational interventions for health professions in the digital age

As we saw in the previous chapters, various educational interventions have been designed and implemented to prepare health care professionals to practice in the information and Information and Communication Technology (ICT)-rich environment of the twenty-first century. However, for interventions to be effective there is a need for more evidence: we need to know what interventions work best, for what, for whom, and under which conditions. Evaluation is critical for providing this evidence. In this chapter, we will discuss the evaluation of educational interventions in general and of interventions related to challenges of the digital era in particular. We start by defining evaluation and discussing the relationship between evaluation and research, Then, we will describe the three intervention types (simple, complicated, and complex), and the different implications of each. Next, the five attributes of evaluation (reliability, validity, feasibility, acceptability, and educational impact) will be introduced, and the various levels of evaluation discussed with an emphasis on the need to consider cost-effectiveness and the process that learners go through. Subsequently, we will highlight the challenges involved in evaluating educational interventions in general and the specific issues pertaining to informatics-related interventions. Finally, we will use case studies from our own and others research to illustrate these issues.

Response to Catherine Pettiford

References Cebul, R.D., Love, T.E., Jain, A.K. and Hebert, C.J. (2011). Electronic health records and quality of diabetes care. New England Journal of Medicine 365: 825-833. Cripps, H., Standing, C. and Prijatelj, V. (2011). The implementation of electronic health records: a two country comparison. 24th Bled eConference eFuture: Creating solutions for the individual, organisations and society. Bled, Slovenia. Department of Health and Ageing. (2011). Concept of operations: relating to the introduction of a personally controlled electronic health record (PCEHR) system. eHealth Division, Australian Department of Health and Ageing, Canberra. Iezzoni, L.I. (1997). How much are we willing to pay for information about quality of care. Annals of Internal Medicine 126: 391-393. Pearce, C. and Haikerwal, M.C. (2010). E-health in Australia: time to plunge into the 21st century. Medical Journal of Australia 193: 397-398.

Book Review: Human and Organizational Dynamics in e-HealthHuman and Organizational Dynamics in e-HealthBangertDavid C and DoktorRobert, eds. IBSN 1-85775-666-5. pp. 342. £40.00. Abingdon, UK: Radcliffe Publishing, 2005.

It has long been argued that the health-care environment is markedly different from that of business and commerce. Contemporary health systems are typically large and complex, comprising a mixture of clinical and other professions working as public and private providers, and characterized by multiple lines of authority and responsibility. These factors have a significant effect on the extent to which e-health, telemedicine or indeed any health information system is adopted and used. Yet, until now, few books have focused specifically on the role of cultural and organizational issues in the adoption of e-health. The book Human and Organizational Dynamics in e-Health introduces these issues on page one of the preface, and keeps them at centre stage, systematically exploring the dynamics at play in the e-health environment. The book aims to develop our understanding of organizational and individual resistance to e-health. It also offers solutions to overcome this resistance. The book is a collection of articles from experts in diverse fields around the globe. The contributions include research, thought pieces, literature reviews and case studies. They provide a comprehensive picture of healthcare environments, exploring issues ranging from macrolevel cultural and organizational factors to micro-level mental models, networks and alliances. Contributions from around the world enable international and crosscultural comparisons, demonstrating that the issues transcend the local environment, and are applicable in many cultural and organizational contexts. It can be difficult to maintain continuity and interconnectedness in a book comprising such diverse contributions, but this book does so, through the use of a conceptual model based on the layers of an onion. The outer layers of the onion explore the cultural and institutional context of e-health, while the inner layers enable analyses of the micro-factors within these cultural and organizational contexts. The sections of the book represent layers of the onion. Each layer explores a particular aspect of successful telemedicine and e-health innovation, while at the same time experts draw in other layers, thus demonstrating the interconnections. Understanding grows as each layer is peeled away. The first section of the book discusses the use of human factors methods to identify macro-ergonomic issues, user characteristics, and technology issues relevant to the design and successful implementation of a telemedicine system. This provides a framework around which many contributors base their discussion. Section 2 explores the role that culture plays in the adoption and use of e-health. Articles discussing experiences in Tanzania and India emphasize the need to consider the particular cultural contexts in which a system is to be implemented, rather than simply introducing the technology and assuming that it will be adopted. Therefore, the message in this section is the importance of designing implementation strategies to suit particular cultural and organizational environments. This understanding is expanded in Section 3, where the need to understand the effect of new technologies within the cultural context is discussed. Although entitled ‘Technological innovation in e-health’, this section maintains the focus on cultural and organizational issues. Drawing on diverse experiences ranging from the effect of legal and administrative structures on new technologies in Finland, to the implementation of remote access to electronic health records in Australia, this section emphasizes that acceptance and utilization of new technologies is influenced by the extent to which they are consistent with established routines, procedures, understandings and ways of operating. The message is the need to develop implementation strategies that take into account the idiosyncrasies of the health sector generally, and of the particular structures and cultures of individual organizations within that sector. Section 4 turns to the practicalities of change management with the important message that, while there may be broad principles and strategies for managing change, these must be adapted to meet the specific characteristics of the host environment. Contributions from the Netherlands and Oklahoma illustrate the application of widely accepted broad principles to specific cultural and organizational contexts. Section 5 moves towards the micro-level, discussing issues around actors, networks and alliances, described as key ingredients in the successful design and implementation of e-health systems. The contributors in this section explore ways of identifying, understanding and utilizing the motivations and attitudes of actors, and the alliances between actors in networks, to facilitate the utilization of telemedicine. The inclusion of experiences from Sweden, Australia and the USA once again focuses on the cross-cultural applicability of human and organizational dynamics. In Section 6, the core of the onion is reached. These articles explore the role of mental models and clinical perspectives on the successful implementation of telemedicine systems. The message here is the need to consider the different, sometimes contradictory, mental models of all participants, including primary-care providers, specialists and patients. Each group plays a