Ebook: E-Health: Current Status and Future Trends

The concept of e-health introduces new channels of communication and transactions in healthcare and challenges the traditional definitions of patients' and providers' roles. E-health is often viewed as the digital transformation of care delivery and redesign of the business models that prevail in the health care industry. For the purposes of this book, we define e-health as the use of advanced telecommunications such as the Internet, portable and other sophisticated devices, advanced networks and new design approaches aiming to support healthcare delivery and education. Thus, e-health refers to a fundamental redesign of healthcare processes based on the use and integration of electronic communication at all levels. It aims to lead to patient empowerment which describes the transition from a passive role where the patient is the recipient of care services to an active role where the patient is informed, has choices and is involved in the decision making process.

Within the context of e-health, the term “consumer health informatics” is often used to describe the study of behaviors and information seeking patterns of patients in their role as consumers of health related information and managers of their health decisions. Obviously, the Internet has played a great role in enabling consumers to access a wealth of information and exchange knowledge with peers and support groups. However, other advanced technologies have also introduced innovative ways of empowering patients and improving the patient-provider communication. Technological advances such as wearable devices and sensors that capture and automatically transmit vital signs, mobile applications that enhance care delivery and enable disease prevention or early detection and new applications of electronic medical records are emerging. In addition to the evaluation of the impact of such applications on the health status of citizens, we need to address issues related to policy and reimbursement and furthermore, create an ethical framework for the design and implementation of such systems. The ethical issues are also an integral part of research in the era of post-genomic medicine.

E-health has the potential to improve efficiency on a global level when patients cross national boundaries to seek treatment in other countries and to enable medical facilities and services across countries to be linked and accessible to citizens. This book is the result of a two-day conference that took place in February of 2004 in Columbia, Missouri. The conference was sponsored by the European Union Center of the University of Missouri-Columbia and the Department of Health Management and Informatics and examined issues of e-health applications in the United States and Europe. Guest speakers from Europe and the US covered a broad range of e-health issues and carried out a dialogue between researchers, practitioners, vendors and consumers. Discussion topics focused on the use of mobile technologies in health care, “smart home” technologies, telemedicine applications that cross national borders, transatlantic collaborations in bioinformatics and the use of the Internet in health care. Furthermore, legislative efforts and ethical concerns associated with the diffusion of e-health were discussed and policies in the EU and the US were reviewed and compared.

This book reflects the discussion that was fostered by the conference and covers a wide range of topics related to e-health research. The contributors are academic researchers from the European Union and the United States and are presenting current work, future trends and a discussion of challenges that will arise in the coming years.

The concept of telemedicine is obviously an essential component of the e-health era. Hicks and Boles present a model that provides a systematic framework to be used in evaluating the effectiveness, efficiency, and feasibility of telemedicine. Demiris describes telehomecare and smart home applications and provides an overview of an evaluation framework for home-based e-health applications and the associated implementation challenges.

E-health will have a great effect on medical education. Headrick describes the qualities required for future physicians to deliver the care that their patients need and deserve, in the context of e-health. There are professions that might have been traditionally not included in the digital transformation of medicine that can benefit from the use of new technologies. Oliver and Demiris discuss the potential application of e-health tools for social workers. The use of such tools impacts the way health care professionals and researchers conduct their work. Patrick et al address the issue of standards for information retrieval to support decision making in e-health.

Contributors of this book also discuss innovative technologies and new concepts that are being introduced by e-health. Schopp discusses the concept of telework for people with disabilities and provides a comparison of the current status in the United States and Europe. Mitchell explores ways that the Human Genome Project will change health care and she also investigates the ways that e-health systems will be influenced by the genomic data. De Moor and Claerhout highlight the relevance of privacy enhancing techniques in the context of e-health. Chan defines and discusses health captology, the application of persuasive technology to health care, and its potential to leverage proven persuasive techniques to improve clinical outcomes.

Finally, specific projects that are currently being carried out and demonstrate future trends, are being described. Van Halteren et al. describe the MobiHealth system which is based on the concept of a Body Area Network (BAN) allowing high personalization of the monitored signals and thus adaptation to different classes of patients. The system and service have been tested in four European countries. Pinciroli et al provide a description of an audible web-based medical record for emergency patients and in a different chapter discuss service level web monitoring in the field management of emergencies. Pedersen provides an overview of e-health in the Nordic countries and the way the national health care system of a country impacts the diffusion rate of e-health.

I would like to thank all of the contributors of this book. I wish to acknowledge and give special thanks to Dr. James Scott and Dr. Kelly Shaw of the European Union Center at the University of Missouri-Columbia for assisting and supporting me in the organization of the e-health conference and the invitation of guest speakers from different parts of the world. Furthermore, I would like to thank Dr. Gordon Brown, Chair of the Health Management and Informatics Department and Dr. Joyce Mitchell, Director of Informatics and Director of the National Library of Medicine Biomedical and Health Informatics Training Program at the University of Missouri-Columbia for their advice and support, and David Moxley, Associate Director of the Executive Informatics Program, for his valuable assistance in the editorial process.

Increasingly, telecommunications and advanced information technologies are being used for a variety of activities: clinical, administrative, and education/research. These activities are undertaken with the expectation that health care delivery will be improved. To validate this expectation, a number of investigations have been undertaken to assess the effectiveness and efficiency of the activities. Unfortunately, many of these investigations have either been incomplete or have applied inappropriate techniques in the evaluation process. This is especially true in the attempts to evaluate the cost effectiveness of various telecommunication technologies and service delivery. The model presented here provides a systematic framework that can be used in evaluating the effectiveness, efficiency, and feasibility of telemedicine. The model delineates the different aspects and characteristics of an evaluation across three dimensions—focus (cost, quality, access), level (individual, community, society), and activities (clinical, administration, education/research). These dimensions are interrelated, making comprehensive evaluation difficult.

Home based e-health applications use telecommunication and video-conferencing technologies to enable a healthcare provider at the clinical site to communicate with patients at their home. Such an interaction is called a ‘virtual visit’. Numerous applications are utilizing commercially available monitoring devices and the Internet to enable home based disease management and monitoring. The aim to meet older adults' desire to remain independent at home while controlling home health care costs has also led to the development of “smart home” technologies. A smart home is a residence equipped with technology that enhances safety of patients at home and monitors their health conditions. Therefore, the devices and sensors chosen to be installed and maintained in the older adults' residences need to address functional limitations and social and health care needs. This paper provides an overview of home based e-health applications and discusses the challenges of implementing and evaluating e-health applications.

What will the practice of medicine be like when people use publicly-available performance data to choose their physicians, own their own medical records and therefore exercise more control over medical decision making than has ever been seen in the past? What do these changes mean for the preparation of physicians? The Institute of Medicine has set forth six aims for health care in the United States, that it be safe, effective, patient-centered, timely, efficient and equitable. Achieving this requires new rules for our work in health care and new goals for medical education. The University of Missouri-Columbia School of Medicine has identified eight key characteristics of its graduating students and residents. We believe these are the qualities required for future physicians to deliver the care that their patients need and deserve.

Social workers have been using telemedicine technologies since the late 1950's. The use of telemedicine has been most common in mental health practice. Psychotherapy using telephones, interactive video and more recently the Internet have gained in popularity with social workers in these settings. However, the use of e-health tools in medical social work is limited and worthy of further investigation. This paper will report promising projects with medical social workers and discuss the potential application of e-health tools for these practitioners. The purpose of the paper is to advocate for research measuring effectiveness of e-health interventions in social work practice.

Persons with disabilities represent a growing population in both the European Union (EU) and the United States (USA). The ability to work is a key component in achieving independence and full inclusion in society, and employability is increasingly seen as an important outcome variable for studies in health and disability. However, persons with disabilities face considerable challenges in returning to work due to barriers related to transportation, job changes after disability, lack of support services in the workplace, and related barriers. Telework, or work from a distance, may help to mitigate these obstacles, while expanding the range of work options available for persons with disabilities. The EU has made substantial policy progress to support telework, but persons with disabilities have had only limited long-term success in telework initiatives due to lack of work support services. The USA has generally strong support services but lacks telework policy infrastructure. The EU and the USA can benefit from collaborative work to enhance their complementary strengths.

In this chapter we address the issue of standards for information retrieval to support decision making in e-health. Specifically, we consider the issue of evidence-based retrieval in the e-health domains of the consumer, healthcare practitioner, healthcare researcher, and genomics researcher. We present the results of a preliminary study to assess the current state of evidence-based retrieval in e-health. Within this study, we reviewed articles in e-health and telemedicine to determine the extent to which authors provide details of the information retrieval strategies used, as well as evidence of the effectiveness of those strategies. We also examined the extent to which the associated journals require authors of reviews to explicitly provide details of information retrieval strategies that they used, as well as reporting any evidence for the effectiveness of those strategies.

The Human Genome Project (HGP) and e-Health are two fundamental changes that will alter the way we approach human health and life. These two scientific and societal forces will inevitably impact each other. This paper not only explores the ways that the HGP will change health care but also investigates the ways that e-Health systems will be influenced by the genomic data. The Electronic Medical Record (EMR) is discussed at length, including the probable impact on the laboratory, pharmacy, computerized provider order entry (CPOE), and other components. Thirteen points of a possible genomic future involving the EMR are presented. The genomic impact on other e-Health systems includes those at all levels of data: population, disease, patient, tissue and organ banks, cellular and for specific genes. The genomic impact on consumer health systems is explored, including Internet consumer information resources and the movement for direct-to-consumer genetic testing. The paper concludes that technology and trends of e-Health will enable the upcoming revolution caused by the health implications of the research emanating from the Human Genome Project.

This overview highlights the relevance of Privacy Enhancing Techniques (PETs) in the context of e-Health. A number of validated privacy protecting techniques is briefly presented. The implementation of such PETs could provoke, for a number of applications, a shift in paradigm, namely from “Privacy through Security” to “Security through Privacy”.

Professionals in industries such as advertising and sales have used techniques of persuasion to enhance the efficacy of marketing campaigns and sales revenues. In contrast, health care has traditionally relied on the persuasive power of facts and evidence to encourage healthy behavior. The evidence suggests, however, that this current approach is failing. Health care experts and opinion leaders cite overwhelming evidence of an epidemic in diseases such as obesity and diabetes, despite numerous initiatives to educate the public how to prevent morbidity and mortality. Health captology, the application of persuasive technology to health care, attempts to leverage proven persuasive techniques to improve clinical outcomes.

Emergency conditions can inhibit the use of clinical data, even when it has been professionally collected and structured. Our aim is to improve the assessment of patients' medical histories in emergency situations. Under emergency conditions, when it may be impractical for health care providers to interact with a visual display of patient data, a “speaking” medical record may be useful. We are investigating the use of a voice synthesizer in conjunction with MyAngelWeb^®, an Italian web-based medical record service. Only the textual subset of patient medical records was considered and restructured according to the needs imposed by voice communication. The quality of the received messages was tested. Some quantitative features, including the number of words and time durations, were considered together with other subjective features, including intelligibility of single words and overall significance of the voice messages. Provided that the linguistic architecture of a medical records' text is arranged to minimize the number of choices presented to the user, and phrases are kept short with few acronyms, health care providers can satisfactorily interact with the service.. Audible medical record delivery may be considered as an effective enhancement to those datasets needed in emergencies.

The wide availability of high bandwidth public wireless networks as well as the miniaturisation of medical sensors and network access hardware allows the development of advanced ambulant patient monitoring systems. The MobiHealth project developed a complete system and service that allows the continuous monitoring of vital signals and their transmission to the health care institutes in real time using GPRS and UMTS networks. The MobiHealth system is based on the concept of a Body Area Network (BAN) allowing high personalization of the monitored signals and thus adaptation to different classes of patients. The system and service has been trialed in four European countries and for different patient cases. First results confirm the usefulness of the system and the advantages it offers to patients and medical personnel.

Cardiologic Emergency Project is based on a hospital network in Milan, Italy, in order to provide patients with more efficient first aid immediately after the occurrence of an Acute Coronary Syndrome. The Project includes ECG transmission from running ambulances to the 118 telephone central help desk, and from there to the suitable hospital. Since the maximum total transfer time should stay within a few tens of minutes, and given that a number of different factors may cause very dangerous delays, the effective coordination of several healthcare systems, devices and organizations is critical. Monitoring of the activities on each component is a must. Cardiologic Emergency Project uses a Web application devoted to the monitoring and evaluation of the service levels. Web applications allow the quantitative monitoring of the durations of extra-hospital operations. Several types of tables and graphics are automatically filled for the best care of the patient. For example, given a lengthy total time request by a satisfactory full ECG transmission, the system allows analysis of the ECG machine, of the cellular phone partial-only coverage along the ambulance pathway, of the transfer time in rush hours, etc., to determine which elements in the process can be improved to avoid future delays.

For more than 10 years the Scandinavian countries have been focusing on utilizing information technology to increase efficiency in the delivery of healthcare services. Over the last 3 years all three countries have built closed secure IP-based healthcare networks that cover nearly all aspects of the national healthcare sector. The next step is to connect the national networks and integrate them into one large Scandinavian healthcare network. This paper describes the history of e-health in the Scandinavian Countries, the challenges and emerging trends.