Improving Consumer eHealth
Part 1: The Problem
This two-part series will investigate the positives and the negatives of consumer e-Health solutions. This first post evaluates some possible problems with these solutions.
It seems that everyone (especially in the health informatics world) is talking about consumer eHealth and mobile health solutions, including many governments and healthcare delivery organizations. These groups are also starting to take action by investing in pilot projects and considering large-scale deployments, highlighting the importance of ensuring these investments deliver measurable benefits and provide good value for money.
The Institute for Healthcare Improvement provides a useful tool for assessing proposed new healthcare IT systems. The Triple Aim of Care  proposes systems should simultaneously pursue three dimensions:
- Improving the patient experience of care (including quality and satisfaction)
- Improving the health of populations
- Reducing the per capita cost of healthcare
Resources are limited and budgets are tight in most healthcare organizations, so it is critical that leaders and decision makers choose to invest in systems that benefit both clinicians and patients, plus help to rein in the growing cost of providing care. Approaching the purchase of new systems while keeping in mind the Triple Aim of Care can help to guide those investments and ensure scarce resources are allocated wisely.
Before assessing the current state of consumer eHealth, we first need to define some terms. While there are myriad definitions of consumer eHealth, I chose to define it as electronic devices or software intended for use (at least in part) by non-clinicians to record, monitor or communicate health information, usually outside of traditional care settings’. The definition of mobile health, or mHealth, can be equally difficult to pin down. I chose to define mHealth as ‘mobile devices or apps used to record, monitor or communicate health information. They may be used by clinicians or non-clinicians, both in traditional care settings and elsewhere. Obviously, this definition overlaps with consumer eHealth, therefore, in the context of this blog post, my use of the term “consumer eHealth” will include consumer-oriented mobile solutions.
In Canada, discussion of consumer eHealth tends to focus on a few specific types of systems :
- Patient portals, viewers, and personal health record solutions
- ‘e-Visits’ or ‘e-Consults’; real-time patient interactions with clinicians via the Internet
- ‘e-Booking’; giving patients the ability to book appointments online
- Electronic prescription renewals
- Remote patient monitoring
Systems such as these often succeed at “improving the patient experience of care” (as outlined above in the Triple Aim of Care), particularly in terms of satisfaction and perceived quality. Users report feeling “an increased sense of empowerment” , or having a “greater connection”  with their physician. In an often impersonal-feeling health care system, receiving positive responses such as these is an achievement. The healthcare organizations embracing these popular types of consumer eHealth solutions should be commended.
However, the clinical benefit and cost-effectiveness of many popular consumer eHealth solutions remains unproven ; with the notable exception of remote patient monitoring (for which there is evidence of both clinical benefit and reduced per capita cost of care, especially in the case of chronic disease patients) . Other popular forms of consumer eHealth solution may not be effective in all three dimensions of the triple aim of care. Evidence for clinical benefit or cost effectiveness, especially outside specific patient populations (e.g. diabetes patients) is generally weak at best .
There are other issues as well. Many clinicians – both physicians and nurses – have reservations around their patients using consumer eHealth technologies, citing concerns over patients possibly becoming “too independent” or patients’ use of consumer eHealth applications disrupting or changing clinician roles and workflows . Rolling out patient-facing eHealth solutions also raises significant privacy concerns. Systems must be carefully designed and tested, adding to the effort and expense needed to deploy them; even then, there are inherent risks associated with exposing a system containing personal health information to the public Internet.
Finally, the five types of consumer eHealth solutions outlined above all present some equal of access issues. To be effective, most require a modern computer or smartphone, plus broadband internet access (and, in the case of smartphone apps, access to cellular data networks). Access to these tools may be limited in many communities across Canada. For example, individuals living in rural areas (such as many First Nations communities) may not have ready access to broadband internet connections . The map to the right shows areas underserved by broadband access in Saskatchewan, indicated by the red dots . Thus, the benefits of many consumer eHealth solutions currently deployed accrue disproportionately to relatively affluent residents of urban or suburban areas.
This all sounds pretty grim. Should we give up on consumer eHealth entirely? Is it just a bad idea? Definitely not! As noted above, consumer eHealth solutions are a great way to drive patient engagement, and can provide both clinical benefits and cost savings, when deployed in the right context (like remote patient monitoring for chronic disease patients).
In my next blog post, I will examine what successful consumer eHealth systems have in common, look at some less-hyped (but maybe more effective) approaches to consumer eHealth, and offer some suggestions to healthcare leaders and managers on formulating good policy around consumer eHealth systems.
Chris Nickerson is a Technical Analyst with Gevity’s Architecture & Standards Branch, with over five years’ experience in health informatics. His areas of expertise include healthcare interoperability, risk assessment and process design. Chris is interested in emerging interoperability standards and their applications in the consumer and mobile spaces, as well as the intersection of health policy and technology.
- Institute for Healthcare Improvement, “IHI Triple Aim Initiative”. http://www.ihi.org/engage/initiatives/tripleaim/Pages/default.aspx; accessed June 13, 2016
- Canada Health Infoway, “Consumer Health e-Services”. https://www.infoway-inforoute.ca/en/solutions/consumer-e-services; accessed June 13, 2016
- Zelmer, J & Hagens, S, “Understanding the Gap between Desire for and Use of Consumer Health Solutions”. http://www.longwoods.com/content/23871; accessed June 13, 2016
- Stylus Consulting, “Nova Scotia Personal Health Records Demonstration Project: Benefits Evaluation Report”. https://www.infoway-inforoute.ca/en/component/edocman/1995-nova-scotia-personal-health-record-demonstration-project-benefits-evaluation-report/view-document; accessed June 13, 2016
- Canadian Agency for Drugs and Technologies in Health, “Personal Electronic Health Records: Clinical Effectiveness, Cost-Effectiveness, and Clinical Practice Guidelines”. https://www.cadth.ca/media/pdf/K0267_Personal_Electronic_Health_Records_final.pdf; accessed June 13, 2016
- Canada Health Infoway & EY, “Connecting Patients with Providers: A Pan-Canadian Study on Remote Patient Monitoring Executive Summary”. https://www.infoway-inforoute.ca/en/component/edocman/1890-connecting-patients-with-providers-a-pan-canadian-study-on-remote-patient-monitoring-executive-summary/view-document; accessed June 13, 2016
- Ozbolt, J; Sands, D; et al, “Summary Report of Consumer eHealth Unintended Consequences Work Group Activities: Building Better Consumer eHealth”. https://www.healthit.gov/sites/default/files/final_report_building_better_consumer_ehealth.pdf; accessed June 13, 2016
- Canadian Radio-television and Telecommunications Commission, “Broadband Internet Service Coverage in Canada”. http://www.crtc.gc.ca/eng/internet/internetcanada.htm; accessed June 13, 2016