eHEALTH RESEARCH, THEORY
AND DEVELOPMENT
This is the first book to provide a comprehensive overview of the social
and technological context from which eHealth applications have arisen, the
psychological principles on which they are based, and the key development and
evaluation issues relevant to their successful intervention.
Integrating how eHealth applications can be used for both mental and physical
health issues, it presents a complete guide to what eHealth means in theory, as
well as how it can be used in practice. Inspired by the principles and structure
of the CeHRes Roadmap, a multidisciplinary framework that combines and uses
aspects from approaches such as human-centred design, persuasive technology
and business modelling, the book first examines the theoretical foundations of
eHealth and then assesses its practical application and assessment.
Including case studies, a glossary of key terms, and end of chapter summaries,
this groundbreaking book provides a holistic overview of one of the most important
recent developments in healthcare. It will be essential reading for students,
researchers and professionals across the fields of health psychology, public health
and design technology.
Prof. Dr. Lisette van Gemert-Pijnen is Professor in Persuasive Health Technology
at the University of Twente, The Netherlands and Adjunct Professor at the University
of Waterloo, Canada. She founded the Centre for eHealth and Wellbeing Research
(www.cewr.nl). Her research focuses on the development and the implementation
of persuasive eCoaching systems to increase trust, engagement and adherence
to eHealth technologies, and to foster implementation of these technologies in
practice.
Dr. Saskia M. Kelders is Assistant Professor at the Centre for eHealth and
Wellbeing Research of the University of Twente, The Netherlands and Extraordinary
Professor at the Optentia research focus area of the North-West University, South
Africa.
Hanneke Kip is a PhD student at the Centre for eHealth and Wellbeing Research
of the University of Twente, The Netherlands, with a background in psychology
and an interest in behaviour change and improvement of mental healthcare via
technology. Her current research focuses on the development, implementation and
evaluation of eHealth technologies in forensic mental healthcare.
Prof. Dr. Robbert Sanderman is Professor in Health Psychology at both the
University of Groningen and at the University of Twente, The Netherlands. His
research focuses on psychological and social adaptation to chronic life-threatening
illness and on the use of psychological interventions, including eHealth tools.
eHEALTH RESEARCH,
THEORY AND
DEVELOPMENT
A Multidisciplinary Approach
Edited by Lisette van Gemert-Pijnen,
Saskia M. Kelders, Hanneke Kip, and
Robbert Sanderman
First published 2018
by Routledge
2 Park Square, Milton Park, Abingdon, Oxon OX14 4RN
and by Routledge
711 Third Avenue, New York, NY 10017
Routledge is an imprint of the Taylor & Francis Group, an informa business
© 2018 selection and editorial matter, Lisette van Gemert-Pijnen, Saskia M.
Kelders, Hanneke Kip, and Robbert Sanderman; individual chapters, the
contributors
The right of Lisette van Gemert-Pijnen, Saskia M. Kelders, Hanneke Kip,
and Robbert Sanderman to be identified as the authors of the editorial
material, and of the authors for their individual chapters, has been
asserted in accordance with sections 77 and 78 of the Copyright, Designs
and Patents Act 1988.
All rights reserved. No part of this book may be reprinted or reproduced or
utilised in any form or by any electronic, mechanical, or other means, now
known or hereafter invented, including photocopying and recording, or in
any information storage or retrieval system, without permission in writing
from the publishers.
Trademark notice: Product or corporate names may be trademarks or
registered trademarks, and are used only for identification and explanation
without intent to infringe.
British Library Cataloguing-in-Publication Data
A catalogue record for this book is available from the British Library
Library of Congress Cataloging-in-Publication Data
A catalog record for this book has been requested
ISBN: 978-1-138-23042-2 (hbk)
ISBN: 978-1-138-23043-9 (pbk)
ISBN: 978-1-315-38590-7 (ebk)
Typeset in Interstate
by Apex CoVantage, LLC
CONTENTS
Preface
List of contributors
vii
xv
PART 1
Underpinnings of eHealth
1 Introducing eHealth
Lisette (J.E.W.C.) van Gemert-Pijnen, Hanneke Kip,
Saskia M. Kelders and Robbert Sanderman
2 Psychological principles and health behaviour change:
applications to eHealth
Jane Walsh and Eimear Morrissey
1
3
27
3 Opportunities of technology to promote health and well-being
Saskia M. Kelders and Matthew Howard
48
4 Healthcare as a complex adaptive system
H. Dominic Covvey
69
5 Mental health and eHealth technology
Stephen M. Schueller
91
6 Public health, behavioural medicine and eHealth technology
Rik Crutzen, Rosalie van der Vaart, Andrea Evers and
Christina Bode
111
PART 2
eHealth development, implementation and evaluation
7 Holistic development of eHealth technology
Hanneke Kip and Lisette (J.E.W.C.) van Gemert-Pijnen
129
131
vi
Contents
8 The contextual inquiry
Hanneke Kip, Nienke Beerlage-de Jong and Jobke Wentzel
167
9 Value proposition design and business modelling
Bart Nieuwenhuis
187
10 Human-centred design
Catherine Burns
207
11 Persuasive health technology
Lisette (J.E.W.C.) van Gemert-Pijnen, Saskia M. Kelders,
Nienke Beerlage-de Jong and Harri Oinas-Kukkonen
228
12 The complexity of eHealth implementation: a theoretical
and practical perspective
Marcel Pieterse, Hanneke Kip and Roberto R. Cruz-Martínez
247
13 User engagement
Stefano Triberti, Saskia M. Kelders and Andrea Gaggioli
271
14 Evaluating eHealth
Floor Sieverink, Nadine Köhle, Ken Cheung, Anne Roefs,
Hester Trompetter, Julia Keizer, Annemarie BraakmanJansen and Saskia M. Kelders
290
15 The future of eHealth, technology and psychology
Lisette (J.E.W.C.) van Gemert-Pijnen
Glossary
Index
319
330
344
PREFACE
Aim and readership
Aim of the book
This book brings together relevant knowledge from eHealth research and practice. We aim to describe the theory behind and methods that accompany the
development, implementation and evaluation of eHealth technologies, from a
psychological and technological point of view. While doing this, we apply a holistic approach. This holistic approach towards eHealth development refers to the
integration and combination of the perspectives of the people involved with the
technology, the (healthcare) context in which it is being used and developed, and
the eHealth technology itself. The spine of this book is inspired by the principles
and structure of the CeHRes Roadmap, a multidisciplinary framework that combines and uses aspects from approaches like human-centred design, psychology,
persuasive technology, and business modelling. By reading this book, you will
acquire more insight into what eHealth is, what its theoretical underpinnings are
and how and why it should be developed, implemented and evaluated. You will
learn this in multiple ways: by means of theories, applied research and examples
from practice.
Target groups of the book
This book has multiple target groups. It is, first of all, suited for bachelor students
of studies related to mental and somatic health and healthcare. Some examples
are psychology, health sciences, mental health promotion or health informatics.
Because this book covers main principles and theories, more depth can be added,
so it is also well suited for master and PhD students. The book’s focus on the practical application of theoretical principles, methods and case studies derived from
practice ensures that it is of added value for people working in practice, for example, designers, policy makers or healthcare professionals working with eHealth
technologies. Finally, since the book is not focused on local healthcare settings or
on specific cases but on underlying concepts, and authors from multiple countries
are involved, it can be used internationally.
viii
Preface
Organization of the book
Structure
This edited book focuses on the theoretical underpinnings, development, implementation and evaluation of eHealth. It accounts for the perspective of the user,
context and technology. Consequently, eHealth, technology and psychology are
Table 0FM.1 Overview of chapters and authors
Part 1
Chapter 1
Underpinnings of eHealth
Introducing eHealth
Chapter 2
Psychological principles and
behaviour change: applications
to eHealth
Jane Walsh and Eimear Morrissey
Chapter 3
Opportunities of technology to
promote health and well-being
Saskia M. Kelders and Matthew Howard
Chapter 4
Healthcare as a complex
adaptive system
H. Dominic Covvey
Chapter 5
Mental health and eHealth
technology
Stephen M. Schueller
Chapter 6
Public health, behavioural
medicine, and eHealth
technology
Rik Crutzen, Rosalie van der Vaart,
Andrea Evers, and Christina Bode
Part 2
eHealth development,
implementation and evaluation
Chapter 7
Holistic development of eHealth
technology
Hanneke Kip and Lisette (J.E.W.C.) van
Gemert-Pijnen
Chapter 8
The contextual inquiry
Hanneke Kip, Nienke Beerlage-de Jong,
and Jobke Wentzel
Chapter 9
Value proposition design and
business modelling
Bart Nieuwenhuis
Chapter 10
Human-centred design
Catherine Burns
Chapter 11
Persuasive health technology
Lisette (J.E.W.C.) van Gemert-Pijnen,
Saskia M. Kelders, Nienke Beerlage-de
Jong, and Harri Oinas-Kukkonen
Chapter 12
The complexity of eHealth
Implementation: a theoretical
and practical perspective
Marcel Pieterse, Hanneke Kip and
Roberto Cruz Martinez
Chapter 13
User engagement
Stefano Triberti, Saskia M. Kelders,
Andrea Gaggioli
Chapter 14
Evaluating eHealth
Floor Sieverink, Nadine Köhle, Ken
Cheung, Anne Roefs, Hester Trompetter,
Julia Keizer, Annemarie BraakmanJansen and Saskia M. Kelders
Chapter 15
The future of eHealth,
technology and psychology
Lisette (J.E.W.C.) van Gemert-Pijnen
Lisette (J.E.W.C.) van Gemert-Pijnen,
Hanneke Kip, Saskia M. Kelders, and
Robbert Sanderman
Preface ix
intertwined throughout the chapters and discussed from theoretical and practical
perspectives. Chapters are written by experts in their domain but are all embedded
in the book’s main structure and incorporate its main principles. Following this, the
book is divided into two sections: the first one on theoretical underpinnings, the
second on eHealth development, implementation and evaluation. An overview of
chapters and their authors is provided in the following table.
How should this book be read?
Every chapter starts with a brief introduction of its main topic, followed by learning goals that provide the main topics of the chapter. These learning goals pinpoint
what the author(s) finds most important and assist in distinguishing main matters
from side matters. Throughout the text, key terms are printed in italics, their definition can be found in the glossary at the end of the book. Furthermore, case studies
derived from practice are provided in boxes or sometimes plain text to illustrate
abstract concepts. All chapters also contain references to other chapters when
matters are discussed that are explained more elaborately elsewhere. Each chapter ends with several take-home messages that summarize the most important
lessons learned from the chapter. Finally, key references are provided for learners
who want to know more about the content matter of the chapter.
What should be expected from the chapters?
To provide an overview of the main topics of each chapter, the learning goals per
chapter are provided below.
Chapter 1 – Introducing eHealth
After completing this chapter, you will be able to:
•
•
•
•
•
explain the relationship between technology, psychology and health, and connect them to this book’s vision of eHealth.
state several areas of application of eHealth and provide accompanying examples.
name several benefits and barriers of eHealth in development, implementation, evaluation and use in practice.
explain what a holistic vision of eHealth entails and why it is required to overcome the barriers and achieve the benefits.
name and explain the importance of the five pillars of holistic eHealth
development.
Chapter 2 – Psychological principles and health
behaviour change: applications to eHealth
After completing this chapter, you will be able to:
•
provide definitions of psychology, health psychology and positive psychology,
and explain how they relate to health, well-being and technology.
x
•
•
•
•
Preface
explain how self-management and health behaviours impact health and how
and why technology can support these behaviours.
provide an overview of the science of health behaviour change with an emphasis on the Behaviour Change Taxonomy, and explain its relation to eHealth.
discuss developments in eHealth technologies for health behaviour change –
both the development and evaluation of health behaviour change models and
their application to real-world settings.
discuss the challenges associated with the successful integration of eHealth
technology to healthcare delivery in order to enable behaviour change in
practice.
Chapter 3 – Opportunities of technology
to promote health and well-being
After completing this chapter, you will be able to:
•
•
•
•
•
explain the advantages of technology for health and know what possibilities of
technology induce these advantages.
discuss the evolution of technology, in particular, technologies relating to
eHealth.
discuss different examples of technologies and their opportunities for health
and well-being.
explain the basics of common building blocks of technology, namely, machine
learning, natural language processing, image recognition and neural networks.
name and explain different software design models.
Chapter 4 – Healthcare as a complex adaptive system
After completing this chapter, you will be able to:
•
•
•
elucidate what eHealth is intended to deliver, by showing how eHealth can help
us realize the full potential of the health system in sustaining human health.
decide if an application of eHealth will be of value to humans and supportive
of their health.
intervene in the health system more effectively by both understanding and
taking advantage of the characteristics of complex systems, and by seeing
these characteristics to be of value rather than just problems.
Chapter 5 – Mental health and eHealth technology
After completing this chapter, you will be able to:
•
•
•
describe the predominant forms of eMental health interventions.
explain the differences between supported and unsupported eMental health
interventions.
explain the potentials of eMental health interventions to overcome barriers to
traditional treatments.
Preface xi
•
•
discuss deficits in eMental health intervention, research and practice.
infer how differences in digital mediums create differences in eMental health
interventions.
Chapter 6 – Public health, behavioural medicine
and eHealth technology
After completing this chapter, you will be able to:
•
•
•
state the effectiveness of the use of eHealth to stimulate healthy lifestyle
behaviours and psychological adjustment.
provide examples of the application of eHealth within the fields of public health
(focusing on primary and secondary prevention) and behavioural medicine.
discuss the specific possibilities and challenges within the fields of public
health and behavioural medicine with regard to the use of eHealth.
Chapter 7 – Holistic development of eHealth technology
After completing this chapter, you will be able to:
•
•
•
•
•
explain the need for a holistic, iterative and multidisciplinary development
approach for eHealth technology.
describe and define the five phases of the CeHRes Roadmap, state their main
objectives and explain the rationale behind each phase.
list several suitable methods for eHealth development, implementation and
evaluation, and explain the added value of a multi-method approach for each
phase.
explain how the phases of the CeHRes Roadmap are interrelated and connect
this to an iterative, agile development approach.
explain the relationships between formative evaluation, holistic development
and the involvement of stakeholders in eHealth development, implementation
and evaluation.
Chapter 8 – The contextual inquiry
After completing this chapter, you will be able to:
•
•
•
•
•
explain why and in what way the contextual inquiry is essential for the eHealth
development process.
provide concrete examples from practice to illustrate the relevance of conducting a good contextual inquiry for the development of good eHealth development.
name and explain the relevance of multiple research methods that are used in
the contextual inquiry.
explain the identification, analysis and added value of stakeholders during the
contextual inquiry, and connect this to the entire eHealth development process.
connect the contextual inquiry to holistic development using the terms user,
context and technology.
xii
Preface
Chapter 9 – Value proposition design and business modelling
After completing this chapter, you will be able to:
•
•
•
•
•
•
describe that eHealth technologies are resources for business to create value
propositions for their customers within the context of a business value network.
analyze the business value networks using graphs to identify flow of products
and services on one hand and the flow of payments on the other hand.
translate added value as perceived by key stakeholders into value propositions
delivered by business to their customers.
explain what relationships, channels and revenue models are needed to deliver
the value propositions to the customers.
describe what activities, resources and partners are needed to create these
value propositions.
explain how to develop feasible business value networks with business using
viable business models.
Chapter 10 – Human-centred design
After completing this chapter, you will be able to:
•
•
•
•
•
explain basic principles and rationale behind Human-Centred Design and
understand its relevance for eHealth design.
discuss the importance of using requirements, name different types of requirements and connect them to different eHealth design issues.
name and explain several methods and approaches that are suitable for HCD
and connect them to eHealth design.
describe several types of prototypes and connect them to iterative design and
the different phases of HCD.
explain the relevance of evaluation for HCD and compare the goals of several
common evaluation techniques for different design stages.
Chapter 11 – Persuasive health technology
After completing this chapter, you will be able to:
•
•
•
•
•
explain what persuasive technology is and in what way domains such as
persuasive communication, health promotion, social marketing, technology
acceptance and human-media interaction are underlying foundations.
analyze the added value of persuasive technology in the context of improving
health.
explain the PSD model, name the four categories and provide examples of
accompanying persuasive features.
explain in what way persuasive technology can be used to develop and evaluate eHealth technologies.
provide examples of how persuasive features can be integrated into an eHealth
technology.
Preface xiii
Chapter 12 – The complexity of eHealth implementation:
A theoretical and practical perspective
After completing this chapter, you will be able to:
•
•
•
•
•
explain the complexity of eHealth implementation.
name and explain differences in implementation approaches such as the
RE-AIM framework and the Diffusion of Innovation Theory.
critically analyze the applicability of existing implementation approaches,
frameworks and models to practice.
name and explain eHealth implementation principles related to development,
financing, healthcare organizations and technology.
identify points of improvements for eHealth implementation from a theoretical
and practical point of view.
Chapter 13 – User engagement
After completing this chapter, you will be able to:
•
•
•
•
provide a definition and state the importance of the concepts acceptance,
adoption and adherence.
explain the concept and value of user engagement.
explain the importance of intentions and dovetailing eHealth technologies
using the Perfect Interaction Model.
name ways of evaluating user engagement.
Chapter 14 – Evaluating eHealth
After completing this chapter, you will be able to:
•
•
•
•
•
explain why classical evaluation methods such as randomized controlled trials
should not be the only approach for evaluating eHealth.
explain why eHealth can be seen as a black box and how evaluation can contribute to opening the black box.
explain the need for and difference between evaluation of effectiveness, efficiency, adherence and engagement, and how to connect them to a holistic
approach of eHealth evaluation.
name and explain several methods for the evaluation of effectiveness, efficiency, adherence and engagement: RCTs, SMART adaptive randomization,
fractional factorial designs, N of 1, Ecological Momentary Assessment, log data
analysis, and Health Technology Assessment (HTA).
state several reasons for the importance of a proper holistic evaluation of
eHealth technologies.
xiv
Preface
Acknowledgements
First, we would like to thank all authors for their valuable contributions. Their continuous efforts have resulted in a comprehensive and coherent book that offers
multiple perspectives on the important topic of technology for health and wellbeing. Also a very special thanks to our student reviewers whose feedback assisted
us in writing a book that is valuable to students from different disciplines and backgrounds: Felix Smoletz, Femke van de Lagemaat, Gulsen Öcal, Kaija Troost, Kamila
Skolik, Lida David, Marcel Hoeve, Marileen Kouijzer, Mariska ter Horst, Stefan Perk,
Stina Nagelmann and Talin Yakob. We would also like to thank Russell George and
Alex Howard from Taylor & Francis for giving us the opportunity to create this
book and for their assistance during the whole process. Furthermore, we would
like to thank our colleagues at the Centre for eHealth and Wellbeing Research of
the University of Twente for their enduring support. Finally, a very big thank you to
Roberto Cruz Martinez for all of his hard work in setting up the student reviews, the
great Excel sheets, and getting the book ready to be published.
CONTRIBUTORS
Editors
Prof. Dr. Lisette van Gemert-Pijnen is Professor at the University of Twente in
Persuasive Health Technology and has an appointment at the University Medical
Center Groningen and University of Waterloo (Canada). Lisette founded and
coordinates the Centre for eHealth and Wellbeing Research at the University of
Twente (www.cewr.nl) and developed the CeHRes Roadmap to develop, implement
and evaluate health interventions and technologies. Her research and tuition
focuses on personalized healthcare, in particular on the development and the
implementation of persuasive eCoaching systems to increase trust, engagement
and adherence to eHealth technologies, and to foster implementation of these
technologies in practice.
Dr. Saskia M. Kelders received her PhD in 2012. Her dissertation focused on
keeping people engaged with (mental) health interventions using persuasive
technology. She is now Assistant Professor at the Centre for eHealth and Wellbeing
Research of the University of Twente and Extraordinary Professor at the Optentia
research focus area of the North-West University, South Africa. Her research
interests are positive psychology, persuasive technology and digital interventions.
Ongoing research projects are focused on using individual engagement to
personalize eHealth interventions. Methods used are, for example, analysis of
log data, experimental studies and randomized controlled trials. Examples of
interventions Saskia works on are web-based gamified interventions and mobile
apps to increase well-being.
Hanneke Kip is a PhD student who works at the Centre for eHealth and Wellbeing
Research of the University of Twente. She also teaches in psychology and health
sciences. Her PhD project takes place at Transfore, a forensic hospital with both
inpatients and outpatients. Her research focuses on the development, implementation
and evaluation of eHealth technologies in forensic mental healthcare. Her research
interests include participatory development, monitoring biopsychosocial factors via
technology, virtual reality, behaviour change theories and data-driven coaching of
aggression.
xvi
Contributors
Prof. Dr. Robbert Sanderman was trained as a clinical psychologist and is
Professor in Health Psychology (since 1999) – both at the University of Groningen
and at the University of Twente, The Netherlands. His research is in the area of
psychological and social adaptive processes in patients with a chronic somatic
disease, in which he focuses on the development over time of quality of life and
psychological mechanisms in adjustment. In addition, he is involved in studies
testing the efficacy of psychosocial interventions to improve quality of life among
patients, and more recently also got involved in research on eHealth. He has
supervised over 50 PhD students and has been President of the European Health
Psychology Society.
Chapter authors
Dr. Nienke Beerlage-de Jong received her PhD in 2016. Her dissertation focused
on how persuasive eHealth technology that is developed from a socio-technical
perspective can contribute to infection prevention and to the fight against
antimicrobial resistance. Her research interests mainly lie in persuasive design,
participatory development, gamification and decision support. She now works as a
postdoctoral researcher at the Department of Psychology, Health and Technology
at the University of Twente. Currently, she is involved in research projects aiming
to develop technologies to support risk communication and crisis communication
among healthcare professionals during outbreaks of zoonotic infections.
Christina Bode is psychologist and is Associate Professor and Director of the Selfmanagement & Health Assessment Lab at the Department of Psychology, Health
and Technology at the University of Twente. Her research and teaching is dedicated
to the question of the conditions under which people with chronic illnesses can
live a vital and meaningful life and how this aim can be facilitated and achieved
with technology such as innovative measuring and monitoring of patient-reported
outcomes and by self-management interventions.
Annemarie Braakman-Jansen, PhD, finished her studies in Health Sciences at
Maastricht University in 1995 and obtained her PhD on the epidemiological project
‘Prognosis in Early Arthritis’ at VU University Amsterdam (2003). From 2001 to
2006 she worked as a policy advisor at the National Health Care Institute, Amsterdam,
and gained extensive experience in the field of health economics. Since 2006 she has
been Assistant Professor at the Centre for eHealth & Wellbeing Research at the
University of Twente. Her focus is on design, implementation, process and (cost)
effectiveness evaluation of persuasive health technology interventions that can be
used to improve healthcare as well as the health of individuals or communities, and
she coordinates several PPS projects.
Catherine Burns is Professor in Systems Design Engineering at the University of
Waterloo, Canada, where she directs the Advanced Interface Design Lab and the
Centre for Bioengineering and Biotechnology. Catherine’s research is in human
Contributors
xvii
factors engineering, where she is well known for her work in Cognitive Work
Analysis, Ecological Interface Design and the development of decision-support
systems. In this area she has contributed over 250 publications and is the co-author
of seven books. She is a Fellow of the Human Factors and Ergonomics Society.
At the University of Waterloo, Catherine teaches Human Factors of Health Care
Systems, and Computer Interface Design.
Ken Cheung, PhD, is Professor of Biostatistics at Columbia University in New York
City. He has general interests in the development and evaluation of evidencebased treatments, interventions and policies at all phases of translational
research. He is an expert in adaptive designs in clinical trials, SMART designs for
behavioural intervention technologies, N-of-1 studies, implementation studies, and
the statistical learning methods for high-dimensional physical activity data. He is a
recipient of the IBM Faculty Award on Big Data and Analytics and an elected Fellow
of the American Statistical Association.
Dominic Covvey is a retired Professor formerly at the University of Waterloo
and the University of Ontario Institute of Technology. He is currently President of
the National Institutes of Health Informatics. His research has been in healthcare
workflow and Health Informatics competencies. His primary continuing interest
is in writing and the teaching of Health Informatics. Dominic is a Fellow of the
American College of Medical Informatics, of HIMSS and of CIPS, a Senior Member
of the IEEE, and a retired CIPS Information Technology Certified Professional. He
received the 2011 COACH Leadership in the Field of Health Informatics Award.
Rik Crutzen is a member of the Department of Health Promotion at Maastricht
University/CAPHRI in The Netherlands. He is a psychologist and e-communication
specialist by background and has ample experience within the field of health
promotion. The overarching theme of his work is how technological innovations
can be used to greatest effect in the field of health promotion to increase the
public health impact of these innovations.
Roberto R. Cruz-Martínez is a PhD candidate of the Department of Psychology,
Health & Technology at the University of Twente. He is a psychologist by training,
with a master’s degree in Sport and Exercise Psychology and a master of science
degree in Health Psychology & Technology. His research focuses on the development
and implementation of eHealth technology that provides self-management support
to patients with chronic diseases.
Andrea Evers is Professor of Health Psychology and Head of the Department
of Health, Medical & Neuropsychology at Leiden University. She uniquely
combines fundamental and applied science by focusing both on basic research
on psychoneurobiology (e.g. placebo and stress mechanisms) and translational
research on screening and innovative interventions for somatic conditions (e.g.
eHealth tools and self-management interventions).
xviii
Contributors
Andrea Gaggioli studied Experimental Psychology at the University of Bologna
and obtained a PhD. degree in Psychobiology from the Faculty of Medicine of the
Public University of Milan. He is currently Associate Professor of General Psychology
at the Università Cattolica del Sacro Cuore in Milan, Italy, and Senior Researcher
at Applied Technology for Neuro-Psychology Lab (ATN-P Lab), I.R.C.C.S. Istituto
Auxologico Italiano, Milan, Italy. His main research focus is Positive Technology – a
field that studies how interactive technologies (with an emphasis on virtual reality
and ambient intelligence systems) can be used to enhance cognitive and socioemotional processes in individuals and groups.
Dr. Matthew Howard received his PhD in Biological Sciences in 2002 from Imperial
College London and has subsequently held roles across Start-Up Biotech, Big
Pharma, Life Science Consulting and Technology Leadership. He is now Director
of Artificial Intelligence at Deloitte UK and focused on cross-sector and healthcare
applications of AI. Prior to Deloitte, Matthew was the European Lead for IBM
Watson Health, working with leading cognitive AI platforms in the field of clinical
decision support in genomics and oncology.
Julia Keizer, MSc. is a PhD candidate at the University of Twente, where she received
both her bachelor’s and master’s degrees in Health Sciences cum laude. Complex
healthcare-related issues form the base of her research, in which cooperation
with healthcare workers and bridging theory and practice are crucial. Previous
research focused on improving proactive palliative care for oncology patients and
on decision-making processes of healthcare workers for surgeries in frail elderly
cancer patients. Her current research focuses on supporting healthcare workers in
limiting antibiotic resistance and infections in hospitals.
Nadine Köhle, PhD, received her PhD in 2016. Her PhD thesis describes the
participatory development and mixed-methods evaluation of a Web-based self-help
intervention for partners of cancer patients. Her general research interests include
supporting partners of cancer patients and informal caregivers in general, positive
psychology (such as Acceptance and Commitment Therapy, mindfulness and selfcompassion), eHealth, and participatory design. She now is Assistant Professor at
the Department of Psychology, Health & Technology at the University of Twente.
Eimear Morrissey (BA, MSc.) is a PhD candidate and Irish Research Council Scholar
at the School of Psychology in NUI, Galway. Her research is based around digital
interventions for adherence to medication and self-management guidelines in a
hypertensive population.
Prof. Dr. L.J.M. Nieuwenhuis is both Professor in Quality of Service of Telematics
Systems at the Industrial Engineering and Business Information Systems
Department of the Faculty of Behavioural, Management and Social sciences
at the University of Twente, and Professor of Business Services Innovation at
the Fontys International Business School in Venlo. He is owner and managing
Contributors
xix
partner of the consultancy firm K4B Innovation. His main research interests
are business modelling and service innovation. He studies and applies business
modelling in existing and new companies. His research interests include service
innovation and servitization in manufacturing enterprises.
Harri Oinas-Kukkonen is Professor of Information Systems in the University of
Oulu, Finland. He has been listed among the 100 most influential ICT experts in the
country and a key person to whom companies should talk when developing their
strategies for ICT services. He is the creator of the Persuasive Systems Design
(PSD) model for developing ICT interventions that influence human behaviours.
His current major research interests include persuasive design, health behaviour
change, social innovation, the next generation of the Web and humanized
technologies.
Marcel Pieterse is Associate Professor at the Department of Psychology, Health
and Technology at the University of Twente. He obtained his PhD in 1999 on the
design and implementation of a brief smoking cessation intervention for Dutch
general practitioners. He has been involved in numerous implementation projects
since then. His research interests are treatment and prevention of addictions,
healthcare interior design supporting recovery, and automatic processes in
health behaviour. Ongoing studies involve physiological monitoring of stress with
wearable devices, cognitive bias retraining in alcohol addiction using computerbased and mobile technology and anxiety reduction during bronchoscopy using
virtual reality technology.
Anne Roefs is Associate Professor at the Faculty of Psychology and Neuroscience
of Maastricht University. Her research aims at understanding cognitive and
neural processes in (ab)normal eating behaviour. She conducted many studies
on attention and implicit cognitive processes, and expanded her work to fMRIresearch on food reward processing in the brain, and to the development of a
self-learning E-Coach for weight loss. For this E-Coach she used recent insights
in network models and analyses. She published 86 international journal articles,
and her H-index is 35. Her work has been supported by multiple grants, including
a NWO VIDI grant.
Stephen M. Schueller, PhD, is Assistant Professor of Preventive Medicine at
Northwestern University and a faculty member of Northwestern’s Center for
Behavioral Intervention Technologies (CBITs) in the United States. He is trained
as a clinical psychologist. His work focuses on using technologies to make mental
health resources more available and impactful. His research has examined the
design, deployment and evaluation of Internet sites and mobile applications for
the treatment and prevention of mental disorders, mainly depression, and for
promoting well-being. He also explores how these interventions can be integrated
into systems of care and the importance of human support to increase engagement
and benefit.
xx
Contributors
Floor Sieverink, PhD, is a researcher at the Centre for eHealth and Wellbeing
Research of the University of Twente. Her PhD research focused on the evaluation
of a personal health record (PHR) to understand what differences PHRs can make
in healthcare, why PHRs make these differences, and why PHRs may or may not
have the expected impact. Her research interests include the implementation and
evaluation of eHealth and persuasive design to create adherence.
Stefano Triberti obtained his PhD in psychology in 2016. He now is post-doc
researcher at Università Cattolica del Sacro Cuore in Milan, where he teaches
Ergonomics and User Experience, and Communication Psychology. His main
research interests are the use of new technologies to promote health and wellbeing (eHealth, Positive Technology), and the psychological factors impacting on
User Experience, especially for simulative technologies such as virtual reality and
video games.
Dr. Hester Trompetter (1987) is Assistant Professor at the Department of
Medical and Clinical Psychology at Tilburg University, The Netherlands. Her
research focuses on the role of positive psychological resources – in particular,
self-compassion, acceptance and positive emotions – in adaptive coping and
functioning of individuals suffering from chronic pain and other forms of somatic
and psychiatric illness. She also studies the effects of interventions targeting these
resources, such as Acceptance & Commitment Therapy and Compassion Focused
Therapy. Hester has a special interest in methodologies focused on the individual,
such as N-of-1 designs and experience sampling methods.
Rosalie van der Vaart is a member of the Health, Medical & Neuropsychology
Unit, Institute of Psychology at Leiden University in The Netherlands. She is a
researcher and teacher in health and medical psychology at Leiden University
and specializes in eHealth and chronic diseases. The main aim in her work regards
the development, evaluation and implementation of online self-management
interventions, taking into account the needs, wishes and skills of stakeholders and
the facilitators and barriers in clinical practice.
Jane Walsh (PhD) is the Director of the mHealth Research Group and a lecturer in
Health Psychology at the National University of Ireland (NUI), Galway. Her research
interests are underpinned by the theme ‘Health Behaviour for Healthy Ageing’.
Her research mainly involves developing optimum digital interventions for health
behaviour change to enhance health and well-being.
Dr. Jobke Wentzel received her PhD in 2015. She researched and developed
eHealth technology to support healthcare professionals to prevent and combat
antimicrobial resistance. In addition, she has worked on research projects focused on
the development, evaluation or implementation of eHealth, eMental health and
accessible multimodal technology. Jobke’s research focuses on human-centred
design, participatory development, persuasive technology and accessibility.
PART 1
Underpinnings of eHealth
1
Introducing eHealth
Lisette (J.E.W.C.) van Gemert-Pijnen,
Hanneke Kip, Saskia M. Kelders and
Robbert Sanderman
eHealth, the use of technology to improve health, well-being and healthcare is increasing rapidly, see Figure 1.1 for an example. More and more
innovative technologies have been introduced in healthcare and consumer
practice, and are being studied by researchers. In this chapter, you will see
that eHealth can have many advantages, like cost-effectiveness, process
optimization and an increased reach and impact. It can improve the quality of care, for example, by significantly improving health and well-being,
by enabling healthcare professionals to adhere more to guidelines and by
resulting in higher satisfaction of patients. However, despite these advantages, eHealth has not yet reached its full potential. Many eHealth technologies are not used as much or in the way as was intended, the intended
goals on efficiency and effectiveness are not achieved or problems with
financing the technology are encountered. From this it becomes clear that
there is room for improvement in the development, implementation and
evaluation of eHealth.
In this chapter, we introduce eHealth and describe its emergence, the visions on
eHealth in improving health and well-being and making healthcare more efficient
and effective. We describe in what ways eHealth has been used in practice and
what the added value of eHealth can be, showing observed benefits and barriers. Furthermore, the chapter introduces a participatory development approach,
a holistic approach to guide the development, implementation and evaluation of
eHealth technologies and interventions. The chapter ends with an outline of the
book. After completing this chapter, you will be able to:
•
•
explain the relationship between technology, psychology and health, and connect them to this book’s vision of eHealth.
state several areas of application of eHealth and provide accompanying
examples.
4 Lisette (J.E.W.C.) van Gemert-Pijnen et al.
Figure 1.1 An example of how technology can be used to
support our health and well-being
Source: © Image used under license from Shutterstock.com
•
•
•
name several benefits and barriers of eHealth in development, implementation, evaluation and use in practice.
explain what a holistic vision of eHealth entails and why it is required to overcome the barriers and achieve the benefits.
name and explain the importance of the five pillars of holistic eHealth
development.
Why eHealth?
The essence of healthcare is to provide the best care possible that meets the
needs of patients and their caregivers. However, due to declines in birth rates
and longer life expectancies, the number and proportion of older people in
our developed society is growing. An ageing population implies an increase
in the chances of age-related illnesses like coronary heart disease, diabetes,
and/or lung diseases. These chronic diseases cannot be cured, but they can be
self-managed to maintain an acceptable quality of life. Older people may have
more than one of these conditions (called ‘multi-morbidity’), which makes
the demand for successful care even more complex. It is important to support
these older people so that they can manage their own chronic disease(s) as
best as possible.
At the same time, fewer working-age adults are available to support the increasing number of older people. Preserving high standards of patient-centred care will,
therefore, be a challenge in the near future. Not surprisingly, all this leads to the
concern that a healthcare system with an acceptable quality of care will become
too expensive to sustain. In most countries, the delivery of the necessary care with
fewer resources is considered to be a major political challenge. The healthcare
system is in great need of innovation.
Introducing eHealth
5
Figure 1.2 Examples of technologies that can be used
to improve health and well-being
Source: © Image used under license from Shutterstock.com
A particular trend in the world today is that patients and their ‘informal caregivers’ (such as family members) are more in the lead of their own healthcare. This
is in contrast to the traditional model, in which a professional caregiver is in the
lead and makes most of the decisions. This enhanced status and empowerment
of patients and their informal caregivers increases the involvement of patients
in the management and treatment of their health and well-being. A cooperative
model of healthcare encourages and expects active involvement of all the parties
involved – the patient, caregivers and healthcare professionals alike. This concept
of ‘participatory health’ is also applicable to prevention, physical fitness, nutrition,
mental health, end-of-life care, homecare and other fields related to an individual’s
health. This increasing importance of participatory health requires innovative ways
of support.
Researchers and policy makers from all over the world are looking for these
innovative solutions, and many have been thought of and tried out in practice. Serious future options include: de-hospitalization, organizing healthcare into regional
networks, adequate homecare, and the concentration of highly specialized, complex care in one location. Since a large proportion of the population has access to
and uses the Internet in their daily lives (via, for example, a PC, tablet, wearables
and/or smartphone; see Figure 1.2), the role of technology is emphasized in such
solutions, both within and outside of healthcare.
Ways of looking at using technology to support health
With the introduction of the Internet, eHealth became popular as an instrument for
communication between patients and caregivers and for providing health-related
information instead of paper-based information and telephone-guided communications. In 2001, an influential paper by Eysenbach called ‘What is eHealth’ started a
6
Lisette (J.E.W.C.) van Gemert-Pijnen et al.
discussion about it which resulted in many views and definitions (Oh, Rizo, Enkin, &
Jadad, 2005). These definitions all described eHealth as a way to communicate via
technology but failed to address the reasons for doing this and the implications of
using technology in healthcare.
Beyond the emerge of several definitions, different taxonomies appeared which
represent different ways of looking at eHealth (van Gemert-Pijnen, Peters, & Ossebaard, 2013):
•
•
•
Categorizing eHealth technologies according to their place in the healthcare
continuum: describing services to support care delivery (diagnostics, therapy,
treatment, etc.), to manage care (personal health records, portals, etc) or to
promote prevention and education as part of public health self-management
programmes.
Categorizing eHealth technologies according to the characteristics of the
technology: describing the capacities of devices and systems to support
human-computer interactions, to monitor and coach people and to develop
tailored and personalized health interventions. For example, robotics, domotics, wearable devices, virtual reality, personal health records or web-based
applications.
Categorizing eHealth technologies according to their influence on the healthcare system: describing the infrastructure for healthcare, emphasizing the possibilities of technologies to innovate or disrupt healthcare. Examples include
social media, wearables and collaborative decision-making support systems
to develop an infrastructure that breaks through traditional care with patientcentric care models.
What this shows is that the field of eHealth is very broad and, more importantly,
that eHealth has an impact on many aspects related to healthcare and wellbeing. We have seen that the Internet created new opportunities for exchange
of information and for interactions among patients and between patients and
caregivers. These opportunities empowered patients because they have become
more active participants in management of their health and well-being, and this
has impacted the healthcare infrastructure, for example, by providing care that
is affordable and accessible everywhere and anytime, and by sharing knowledge
to everyone who has access to the Internet. As Eysenbach already stated in
2001, eHealth is more than just introducing technology in healthcare (Eysenbach, 2001):
eHealth is an emerging field in the intersection of medical informatics, public
health and business, referring to health services and information delivered or
enhanced through the Internet and related technologies. In a broader sense,
the term characterizes not only a technical development, but also a state-ofmind, a way of thinking, an attitude, and a commitment for networked, global
thinking, to improve healthcare locally, regionally, and worldwide by using
information and communication technology.
Introducing eHealth
Box 1.1
7
eHealth terminology
Within this book, several terms that are used in the field of eHealth interventions are used. Many of them can be used interchangeably, but they all have
their specific meaning, as is explained below.
eHealth: The use of technology to support health, well-being and
healthcare.
eHealth technology: The actual technological instrument via which
health, well-being and healthcare are supported, often information
or communication technology.
eHealth intervention: An eHealth technology specifically focused on
intervening in an existing context by changing behaviour and/or
cognitions.
Health informatics: The interdisciplinary study of the design, development, adoption and application of IT-based innovations in healthcare
services delivery, management and planning. Also called ‘medical
informatics’.
Behaviour change interventions: Behavioural change interventions are
interventions designed to affect the actions that individuals take with
regard to their health.
The Eysenbach statement is beyond defining eHealth merely as a tool or a
device to change information or to facilitate communication. eHealth disrupts
the healthcare infrastructure and delivery, and it implies that people should
have the capacities and capabilities to use technology to support self-care and
to create novel ways of healthcare delivery; affordable, accessible and feasible
for all. eHealth is a process to transform healthcare, taking into account the
whole human being in the context of living and working. This context is continuously changing due to demographics, changes in roles and role-players in
healthcare and the growing capacities of technology to generate and communicate data.
Throughout this book, the term eHealth will be used in multiple forms. Box 1.1
provides a brief overview of the terminology used.
eHealth: technology and psychology
eHealth: technology
eHealth and technology are inseparable, since the first is not possible without the
second one. Therefore, well-functioning technology is a necessary precondition for
a good eHealth intervention, and a good design that appeals to users is beneficial
as well. Because of this, it seems logical to pay attention to the role of technology
within eHealth, but unfortunately this is often overlooked.
8
Lisette (J.E.W.C.) van Gemert-Pijnen et al.
Developments in the domain of eHealth are dependent on the development of
technologies. The first eHealth technologies were websites with plain text, mainly
because the technology back then did not offer many more options. However, soon
eHealth became increasingly interactive, making it possible to communicate with
its users. Since then, new ways for technology to monitor and communicate with
us are always emerging. Technology also offers users the possibility to communicate with each other, for example, enabling patients to contact their physicians
or other patients, and the possibilities in this area are still evolving. At this point,
technology is increasingly becoming part of us and our daily lives. This humanizing
technology is very relevant for eHealth: the 24/7 monitoring of our physical state
and behaviour offers many options for coaching health and well-being. However,
this raises several ethical concerns about how far we can go in this, how reliable
feedback of technology should be, and who the owner of all of the collected data is.
Another important issue for eHealth is the balance between following the newest
trends and innovations in technology, which might have unknown effects, or using
well-researched but less state-of-the-art technologies.
An important point with respect to technology is, regardless of the type of technology, the fit with the user and context. If the users feel like the technology does
not match their needs and preferences, or cannot be embedded in their routines,
it will not be used. A technology should fit the way people live and work, their
socio-economic backgrounds and the way they make decisions about their health
and well-being (Beerlage-De Jong, 2016; Wentzel, 2015). This match is important
for concepts like user engagement, adherence, trust and involvement, that will be
fully explained later in the book (see Chapter 13). To put it bluntly: the better the
fit with user and context, the more likely it is that a technology will be used and
is effective. In order to achieve this, a good development process is essential. For
instance, system design models for technology design are not always suitable for
eHealth development, since a focus on matters like the user perspective, the context and financing is also needed. To conclude: technology is essential for eHealth,
and developers should always make sure that there is a good fit between the technology, the user and the context (van Gemert-Pijnen et al., 2013).
eHealth: psychology
eHealth aims to improve health and well-being, using technologies. Often, a change
in people’s cognitions and behaviours is required to achieve this, but changing behaviour via interventions has proven to be very difficult. Merely using a well-functioning
and nice-looking technology doesn’t suffice: theories and approaches from psychology should be used to create technologies that can enable behaviour change.
Research has shown that eHealth interventions that use psychological behaviour
change theories are more effective in changing behaviour than those that do not
(Webb, Joseph, Yardley, & Michie, 2010). Consequently, approaches such as behaviour change techniques (Michie et al., 2013) or persuasive features (Oinas-Kukkonen
& Harjumaa, 2009) should be used in eHealth interventions. Behaviour change techniques are derived from abstract psychological theories and can be used in interventions (see Chapter 2). Persuasive technology aims to persuade users in a positive
way to make better choices for their health and well-being. It does this by using
Introducing eHealth
9
the characteristics and possibilities of technology, such as cues for communication
(text, speech, video, graphics), anonymity, or its possibility to access situations in
which human persuaders are not allowed (see Chapter 11). The use of these kinds of
approaches in a design increases the chances of effective behaviour change.
Furthermore, eHealth technologies have to be used by people, so they should fit
their perspective. Merely using theory doesn’t account for this important aspect.
When theory-based interventions are created behind a desk, without talking to
actual people, chances are that they don’t appeal to or fit the user, since the developers can be mirroring themselves and are thus implicitly designing for themselves. Designing for your target group requires knowledge of how people think
and behave. Psychological theories and methods can be used to get a grasp of this,
since psychology pays a lot of attention to analyzing and explaining human behaviour via research methods such as interviews, observations and questionnaires.
Integrating psychology and technology
Psychology and technology are both important ingredients for successful
eHealth interventions and should be intertwined. Figure 1.3 visualizes this
Figure 1.3 Technology can influence our cognitions, and our cognitions influence
the way we view and use technology
Source: © Image used under license from Shutterstock.com
10
Lisette (J.E.W.C.) van Gemert-Pijnen et al.
interrelationship. However, in many cases, the content of an intervention is
developed by social scientists, and the technology is created separately, by
engineers or technology designers. Understandably, both groups speak different languages, often causing a lack of collaboration or project management.
For example, a team of psychologists might have a certain design in mind to
deliver the content for an intervention. They communicate this to designers
who have to ‘translate’ the delivered content into a technology that fulfils the
need of content experts. Unfortunately, this often proves to be challenging
because of misunderstandings or differences in preferences and experiences.
Consequently, content and technology are often developed independently
from each other, which often causes the perspectives of the user and stakeholder to be forgotten along the way. To prevent this, collaboration is key.
Content and technology developers not only should closely communicate with
each other but should also be in frequent touch with users and other stakeholders to ensure that an eHealth intervention is an integrated whole that fits
all stakeholders’ needs as closely as possible.
Benefits of eHealth
The first part of this chapter has given a high-level idea of why eHealth is necessary. In this section, we will discuss in more detail why eHealth can be of added
value. eHealth can have different advantages in different contexts and for different
people. Therefore, an exhaustive list of all the possible eHealth benefits is impossible to compile. Also, not all benefits will always be true for every eHealth technology. Again, this is because the technology’s added value will be different depending
on the context and the people. The benefits below are provided to give an idea of
some of eHealth’s advantages for healthcare and people in general. They refer to
the access to care that eHealth can enhance, the empowerment of patients and
healthy people via eHealth, its possibilities for innovating healthcare and the way
we look at health and well-being, and its potential for improving quality of care.
Access to care
Via eHealth, healthcare can become available independent of time and place
because people can access it whenever and wherever they need it. An example
is someone who has a busy working schedule and trouble making appointments
with his or her diabetes nurse. eHealth provides a way for him or her to have some
of her consultations occur online, through secured email contact. Furthermore,
someone living in a remote area might, instead of driving for an hour, use Skype to
contact his or her general practitioner.
eHealth can also create a lower threshold to access healthcare, which entails
that more people have a possibility to access healthcare (WHO, 2016). With easier
access, healthcare becomes more equally distributed among people, allowing for
an improvement in healthcare equity. For example, online support groups enable
social networking and emotional support of isolated individuals. However, a precondition for the actualization of this benefit is online access and a satisfactory
Introducing eHealth
11
amount of (computer) skills. eHealth can also remove thresholds to healthcare like
stigmatization. An example of this is the provision of anonymous online consultations or anonymous peer-to-peer online communication. An HIV patient who may
be uncomfortable finding help in person might be more willing to talk with peers
online.
Empowerment
Technology may empower people by giving them the opportunity to take more
control of their own healthcare. Technology can enable people to choose when
and where they want to access healthcare. In this way, they are more in control of
their own health and care process. Furthermore, people can be empowered when
they are educated about their health and more aware of their own health data.
For example, technology can give people access to their own health data, which
increases people’s knowledge about their own health, through personal health
records or via self-generated data via monitoring technologies such as wearables.
Patient-centredness is another important advantage. Technology can enable
people to choose when and where they want to access healthcare. Also, the information people can collect can make it easier for them to make their own informed
health decisions, or to have more equal discussions with their doctors, since
patients are becoming experts on their own health.
Finally, care professionals can be empowered as well. Technology can provide
tailored support on medical decision making, among other things, via data-driven
diagnosis support and artificial intelligence. Watson (see Chapter 3) is a questionanswering technology that uses natural language and has the computational
power to facilitate informed decision making using big data. Quick diagnoses and
precise and personalized medicine is made possible by such systems, and this leads
to more transparent healthcare decisions because it is known on what grounds
decisions have been made.
Innovation
New technologies and new applications of technologies open up a whole range
of possibilities for healthcare (see Chapter 4). The mere use of technology will
not automatically result in long-lasting and positive change, but it can provide
the groundwork for sustainable change in healthcare by supporting important
movements within the domain such as patient-centred care and integrated care.
A straightforward example of this is the opportunities that technology can create for easy communication, audio and video, between different healthcare
professionals.
The possibilities that eHealth offers can be seen as a catalyst for innovation in
healthcare. Technology has the ability to change the way healthcare is delivered
by stimulating all involved stakeholders to critically think about how they deliver
or receive care. This opens up new ways of thinking, which can in turn stimulate
innovation. For example, think of a wearable that monitors the movement of COPD
patients 24/7, this information can be extremely valuable to doctors since it might
be used to predict exacerbations.
12
Lisette (J.E.W.C.) van Gemert-Pijnen et al.
Quality of care
The quality of healthcare can be improved via highly efficient, innovative systems
and by effective interventions that lower costs and increase safety by reducing
human errors. eHealth technologies can incorporate medical guidelines and quality
standards for healthcare, for example, via an app that supports nurses in prescribing antibiotics to patients at their bedsides. This makes following guidelines or
standards independent of individual care providers’ skills and knowledge and an
integral part of the regular process. Information systems can even monitor realtime compliance with guidelines to support safety at work.
Effectiveness can also be improved by using the possibilities of technology to
improve traditional interventions and treatments. For instance, think of an intervention for stimulating activity and monitoring stress levels in depressive patients,
where wearables can track a person’s activities during the entire day. The collected
data can be used to provide tailored advice, something that current traditional
interventions and therapists cannot do.
Efficiency is an important benefit as well, since eHealth can require fewer
resources to achieve the same quality of care and effects on health and well-being.
Teledermatology – the use of audio and video communication in the assessment
and treatment of skin conditions and tumours – can decrease the number of doctor
visits, saving costs and time.
eHealth: in practice
eHealth is increasingly being used in practice. In this section, we will provide several examples to give you an idea of what eHealth can look like and to see how the
benefits may be achieved. Within the field, there is not one categorization that is
perfect and always applicable, mainly because of the continuously evolving possibilities of technology. We use a categorization below that is based on the level of
involvement of specific stakeholders: self-care and prevention, supportive care and
societal health.
Self-care and prevention
In this domain, the patient or health consumer is in the lead: technology can be
used to foster self-management in an easy and convenient way (see Figure 1.4 for
an example). Examples are using a website or app to find health-related information, talking to peers with similar health issues in a discussion forum or following a self-help course to quit smoking or lose weight. Sometimes a healthcare
professional can be involved, for example, when he or she answers a question
in an e-consultation or gives feedback within a self-help course, but this is not
necessary.
In its simplest form, self-care and prevention technologies can be employed
to provide information on health and well-being. There are many websites dedicated to offering credible and understandable health information. A straightforward example is a website where you can find a lot of information on the
influence of alcohol on your brain. However, most eHealth technologies provide
Introducing eHealth
13
Figure 1.4 An example of how technology, in this case a smartwatch that monitors
physical states and an app, can be used to self-manage health
Source: © Image used under license from Shutterstock.com
not only information but also an opportunity to interact with the system. These
decision aids are a way to allow the user to interact with the information. For
example, they can be simple question-and-answer systems that help health consumers or patients make a decision on what to do with a certain health complaint or disease. Decision aids can help you to decide whether you need to
visit a doctor, or assist you in choosing the type of therapy that best suits you,
for example, whether or not to have surgery for carpal tunnel syndrome. Ideally, these systems are based on medical protocols. In addition, technology can
support interaction with others in multiple ways. There are technologies that
support interaction between people with similar health issues, like discussion
forums. Technology can also support interaction with care providers, for example, through moderated discussion forums or e-consultation. In the latter case,
these systems should enable safe and secure communication and account for
privacy rules.
Another form of self-care and prevention can be found in technologies that
support (self)-monitoring of health-related information. For example, the quantified self-movement is enabled by industrial companies providing wearables like
14
Lisette (J.E.W.C.) van Gemert-Pijnen et al.
smartwatches that track, trace and trigger behaviours and moods to support
healthier lifestyles or to reduce medical issues. Activity and sleep trackers have
become more popular and mainstream in recent years and have inspired many
individuals to monitor many aspects of their daily life through technology. These
devices can help you gain insight into how healthy you actually are. Some examples
are the Misfit, the Apple watch, and the Fitbit. Also, these wearable technologies
are more and more used in medical settings, using wearable sensors (e.g. EEG and
ECG) generating real-time data about health-related variables (heart rate, blood
pressure, glucose levels, etc.).
The last example of self-care and prevention in eHealth technologies are online
(self-help) treatments. These exist for many lifestyle areas, such as physical activity, diet and smoking, but also for mental health. Many online treatments can be
followed without support from a therapist, such as for depressive complaints, but
there are also online treatments available with therapist support, open to anyone,
even without a prescription from a healthcare provider. Also, these online interventions are being increasingly used in combination with face-to-face therapies, called
blended care (Wentzel, van der Vaart, Bohlmeijer, & van Gemert-Pijnen, 2016).
Ideally, online treatments are based on evidence-based protocols and grounded
in theories like Cognitive-Behavioural Therapy or Acceptance and Commitment
Therapy. They often use a fixed structure of lessons. For example, every lesson
starts with an explanation of the purpose of the lesson, followed by assignments,
exercises and useful information provided by experts.
Supportive care
This domain is characterized by more involvement of the healthcare professionals
and, ideally, healthcare professionals and patients work together to manage or
improve the health of the patient or client. In this domain, the care process is often
more complex than in self-care and prevention, as caregivers are involved for a longer period of time, or multiple caregivers are involved, as is visualized in Figure 1.5.
The care of patients with a chronic disease such as diabetes is an example of this.
eHealth can play an important role in supportive care. For instance, it can improve
the information exchange across professionals or between professionals and their
patients, as well as provide online self-management support, and monitor the performance of disease management programmes.
An example of the role of eHealth in supportive care is telemedicine. In 1995,
teledermatology, a form of telemedicine, became one of the first examples of
eHealth among healthcare professionals. In teledermatology, telecommunication
is used to exchange long-distance medical information, for example, by means
of video conferencing. This can enable one dermatologist to ask for another colleague’s opinion about skin conditions based on actual images. As compared to
just a text message or phone call, images can help dermatologists give more reliable advice. This case shows eHealth as a valuable tool to support care decision
making.
Electronic personal health records (PHRs) are another example of promising
eHealth technology for supportive care and chronic disease management. A PHR is
Introducing eHealth
15
Figure 1.5 An example of the role that technology can play in
the healthcare process. Patient data is automatically collected and sent to a General Practitioner.
It is also stored in a database that saves this information and makes it available to other healthcare
professionals
Source: © Image used under license from Shutterstock.com
an electronic application through which individuals can access, manage and share
their health information and that of others for whom they are authorized, in a
private, secure and confidential environment. Recently, many PHRs have added
functionalities in order to support disease management. Besides sharing clinical
and personal data (e.g. disease history, test results, treatment plans and appointments) between patients and care providers, these systems often include functions
to support self-management like working on health-related goals while being supported by a care provider and/or the system, and patient-care provider communication, which allows patients to keep in touch with their care provider or make new
appointments.
Societal health
In this domain, patients and healthcare professionals are both involved, but the
lead is at a higher, societal level. Societal health focuses on broad health-related
issues that might affect individuals. However, societal health issues can never be
solved by the behaviour of just one individual (like self-care) or by a small group of
people (like supportive care). Societal health issues demand that governments play
a vital role in creating policies and regulations. In turn, healthcare inspectorates
must implement and maintain these policies and regulations. Examples of such
broad societal health issues are the prevention, spread and control of diseases and
infections as well as access to healthcare for everyone. As you can imagine, due
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Lisette (J.E.W.C.) van Gemert-Pijnen et al.
to its large reach, interactivity and ability to provide easy access to information,
eHealth is often seen as a way to improve the health and well-being of individuals
on a large scale. Since eHealth can help to change people’s attitudes and behaviour,
it can be used to address societal health issues or gain information about them.
First, eHealth can influence the attitude or awareness of individuals about societal health issues. An example of this is the CDC (the U.S. Centers for Disease Control and Prevention) ‘Solve the Outbreak’ game. In this game, you become a disease
detective trying to fight an outbreak before it can spread any further. The goal of
this app is for the general public to learn about diseases, their outbreaks and the
complexity of managing those outbreaks.
Second, it can be used to support behaviour that is compliant with guidelines
that are required to manage broad health-related issues. Technology can help
healthcare professionals follow policies or guidelines in a care environment, for
example, in managing their use of antibiotics in order to decrease the spread of
resistant bacteria. This is a societal health issue, where, for example, the government plays an important role in creating the policies on how to deal with this challenge. Technology can assist in translating such policies into action.
Finally, technology can support communication between health professionals
about societal health issues. An example of this is the risk communication, decision making and education of healthcare professionals about zoonoses. Zoonoses
are infectious diseases of animals that can be naturally transmitted to humans,
like Lyme disease and MRSA. A technology such as a serious game can be used to
support this.
eHealth barriers
Multiple (potential) benefits of eHealth were described earlier. However, in practice,
eHealth technologies are often not as successful as expected: not all potential benefits are reached. There are multiple barriers that cause this gap between the current situation and the potential. Some of the most important ones are described
below. Attention will be paid to barriers with regard to the implementation of an
eHealth technology in practice, (potential) ethical barriers and barriers on evidence and research on eHealth technologies.
Implementation barriers
Implementation of eHealth refers not only to its introduction in a specific context
but also to its dissemination and long-term use. A successful eHealth intervention
should be embedded in practice and used as was intended, but multiple factors
can negatively influence its uptake in practice (Greenhalgh et al., 2017, also see
Chapter 12).
First of all, a lack of incentives to use technology can result in a resistance to
use it. For eHealth to be used it should be financially feasible, but often there are no
obvious financial benefits, and it is not clear enough who pays for what. For example, e-Consultation failed because the reimbursement for using it in a general practitioners practice was lower than face-to-face visits. Incentives can also be related
Introducing eHealth
17
to perceived benefits for people’s health and well-being. Self-management portals
to support patients with chronic care, although proven effective, are often not used
because patients feel they are not benefitting enough. This could happen because
of the distinct ‘feeling’ caused by the lack of human support in self-management
portals. When people’s needs are not acknowledged and thought through during
the development process, the eHealth technology can lack commitment and support because people do not perceive enough financial or personal benefits.
Also, a lack of eSkills can hinder the uptake of eHealth technologies. Merely using
the Internet is not a guarantee people have the capacities and skills to manage
their own health with technology. Digital health literacy is often assumed, although
many people are not educated or trained to use technologies or to understand selfmanagement data visualized via graphs or tables. This lack of familiarity with technology can have a negative impact on the reach of health technologies, since highly
educated people often benefit more than people with a lower education level.
Furthermore, there often is a lack of motivation to start or continue using an
eHealth technology among users and other stakeholders. eHealth technologies
touch the lives and work of many people. When the interests of these people are
not acknowledged and thought through, the new eHealth technology can lack support. Think of nurses who have been told to start using an app that they haven’t
agreed to use in the first place and which may not fit into their individual work
routines. Once people have accepted a technology, motivation can still be an issue:
many people stop using a technology prematurely or do not use all of the available
opportunities. This issue is called non-adherence and indicates that eHealth interventions are not always motivating enough to use in the long term, which hampers
effectiveness.
Lack of confidence in technology is another barrier. People might fear that they
will be substituted by technology, for example, in the case of robots. Also, a wellknown problem in practice is the fear that a technology might decrease the quality
of treatment: a psychologist might fear that the use of technology in treatment
will negatively impact the therapeutic relationship with his or her client. Creating
confidence and showing how technology can have added value for people should
be part of the introduction and implementation strategies to innovate healthcare.
Technologies are developed using different software and hardware elements,
with the frequent result of systems not being interoperable. This makes it difficult
or even impossible to communicate information from one system to another. In
other words, interoperability is low. For example, wearables to monitor behaviour
are sometimes not compatible with other apps on a smartphone. Or data generated by systems that track activities, mood and food intake are not interoperable
with platforms to translate the data into personalized coaching strategies.
Finally, unclear regulations can hinder successful use of eHealth technologies
in practice. Often there is lack of clarity about legal issues. Think about who is
ultimately responsible for an online diagnostic system. What happens if a monitoring and coaching system does not refer a patient to a hospital when it actually
should have done so? Who is responsible when a wrong suggestion is made? More
attention should be paid to legislation issues on a national level and within health
institutions.
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Lisette (J.E.W.C.) van Gemert-Pijnen et al.
It is clear that issues that might hinder implementation need to be identified
in advance so that they can be accounted for before the technology is fully developed: a good development process increases the chances of good implementation
(see Chapter 12). In a good development process, attention is paid to the values
of the users and other stakeholders, the characteristics and nature of the context
in which the technology will be used and the design of the technology itself (see
Chapter 7).
Ethical barriers
The barrier of regulations touches upon the topic of ethics and its importance for
eHealth. Of course, ethics is not a new phenomenon with respect to health information, but the use of technology in healthcare raises many new ethical issues that
have to be accounted for. The process of storing and sharing health data becomes
beyond peoples’ ability to directly control. This impacts multiple factors that should
be addressed to increase the chances of eHealth’s success in the long term.
Privacy and security are obstacles people perceive when using technologies to
share health or medical information. Who is the owner of the information? And
how do we know who has access to the information? Companies might sell personal health information or can use this information to make decisions about peoples’ health conditions. For example, companies provide technologies to monitor
physical activity, sleeping and eating behaviours with monitoring devices such as
smartwatches. These devices collect data that can be analyzed using algorithms to
personalize health and provide tailored feedback to people on how to reach their
goals. These data provide much insight into people’s health and might be misused
by, for example, health insurance companies to increase their premiums for people
with an unhealthy lifestyle.
The lack of transparency is not a new phenomenon per se compared to traditional care, but the difference is that the ‘clinical eye’ of a caregiver is missing.
For example, people receive tailored feedback on their behaviour but often do not
have any idea what decision rules ground the personalized feedback. Technology
provided by industrial companies requires clear policy and rules about the transparency of data.
The quality of information is another ethical aspect. To what extent can we trust
the information that is provided by the Internet? Think of Wikipedia pages that can
provide unreliable and incorrect information about symptoms or treatments, or a
system that provides wrong feedback about the amount and intensity of physical
activity for an obese person. Credibility of information can be guaranteed by companies that check the information using certain standards or by providing medical approvals by appropriate regulatory agencies, such as the U.S. Food and Drug
Administration or the U.K. Medicines Control Agency.
People use technology for self-regulation, like devices for self-testing health.
An issue is how this impacts the autonomy and trustworthiness of healthcare. For
example, self-regulation is possible by using sensors for monitoring and automated
coaching. However, these monitoring devices are not ‘tested’ following medical
standards, using clinical trials. People adopt self-regulation devices rapidly, and
Introducing eHealth
19
infiltration with medical practices is ongoing. This can put medical professionals
under pressure: how should we cope with information from data that is not based
on medical standards? How should we respect patients’ self-judgements? How
should we use self-test information in clinical consultations?
It becomes clear that these ethical issues are pivotal to eHealth’s success to
ensure that negative consequences are avoided. We should study these ethical
issues in depth. Stakeholders such as software developers, caregivers, patients and
equipment suppliers should participate in ethical discussions to ensure that we are
proactive in the ongoing path of innovations.
Evidence barriers
A critique on eHealth interventions is the limited large-scale -evidence of the costeffectiveness of eHealth interventions and the little information on long-term effects
on health and healthcare. More good, long-term evidence is needed: the more we
know about what works, why and for whom, the more we can optimize eHealth.
The main barrier regarding evidence can be found in the study designs that
are used to evaluate many eHealth interventions, as they don’t always address
the full picture. In general, the effects of web-based interventions are measured
with the golden standards for clinical interventions (Randomized Controlled Trials;
RCTs). These experimental or sometimes quasi-experimental studies use cut-off
measurements at fixed points in time to determine if an eHealth intervention was
successful in improving predetermined outcomes. An example would be whether
an intervention was successful in reducing depressive complaints or increasing
physical activity. However, these conventional pre-post comparisons do not help
us understand what elements of the intervention contributed to outcomes. Factors
such as costs, usage of the technology and other outcome variables should be
measured continuously since they are also really important processes. The need
for this type of evidence requires other evaluation methods.
Another barrier to evidence is related to this main issue: we do not have enough
knowledge on the process of adherence, which refers to the question of whether
the technology is used as was intended by the developers. We know that many
people are not adherent: they stop using the technology prematurely, or do not use
all of its different possibilities, which might have a negative influence on the intervention’s impact. More knowledge is required on what impact this non-adherence
has on effectiveness and what factors can predict or even influence adherence to
eHealth interventions.
Furthermore, as was mentioned before, mere information on effectiveness on
specific outcome measures doesn’t suffice for eHealth. Since it is always used
within specific contexts and can influence the way healthcare is delivered, information on eHealth’s impact on these contexts is required as well. Consequently,
we need information on the reach of eHealth to, for example, find out which share
of the target group actually accessed an intervention. Matters such as adoption –
answering questions about when and how people started using the technology –
and the implementation process should be studied as well to get a holistic view of
the impact of the eHealth technology.
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Another issue that has to be addressed to ensure that the quality of eHealth evidence increases is related to the way evaluation studies are reported. Many studies
have a rather myopic view on technology and evaluation, meaning that they do
not provide enough information about matters that need to be reported to ensure
replicability of studies and interventions. For example, in most cases it is unclear
which software functionalities and development methods have been used to create
the technology. Studies do not report why and how a certain technology was used,
developed and implemented: evaluation is merely outcome driven and little to no
attention is paid to the quality of the evaluated technology. As a consequence, it is
impossible to identify what specific features of technology could have contributed
to the effects of the eHealth interventions, and replication is hardly possible. To
overcome this problem, a CONSORT checklist was developed to guide how ‘eHealth
and mHealth trials should be reported, in particular related to reporting sufficient
details of the intervention to allow replication and theory-building’ (Boutron, Altman, Moher, Schulz, & Ravaud, 2017).
Finally, eHealth technology is not fixed: it can be tailored to different user profiles,
and can be constantly updated and adapted by developers or users. In controlled,
experimental studies with only a few measurements, these changes in technology
are often not considered as subject for research, though they are important. A flexible intervention requires a flexible evaluation approach, which can be provided by
agile science. In agile science, development and evaluation occur in parallel, iteratively, until the eHealth technology has been optimized to fit the complex context in
which behaviour occurs. Advanced methods such as time series and log data can be
used to provide ongoing information about the use of technology and its impact on
the context and people. This kind of information is necessary to take eHealth evaluation to the next level and overcome evidence barriers.
It is important to overcome these evidence barriers to increase the added value
of eHealth in practice. We need not only more evidence on effectiveness but also
more insight into the working elements of eHealth interventions. This requires
both applied and fundamental research. Applied research focuses on matters such
as good design, implementation, use of in practice and effectiveness of an intervention, all within specific contexts. Fundamental research aims to make generic
claims about constructs such as adherence, behaviour change theories, persuasive elements or tailoring. It is needed to empirically ground eHealth in theories
on, for example, behaviour change and well-being. The results of experiments and
empirical studies can be used to validate abstract theory-driven behaviour change
models or to develop new models to predict reach, usage and adherence. These
models are useful for applied research in which they can be used to, for example,
optimize interventions.
A holistic approach towards eHealth
development and evaluation
As we have seen, eHealth has many proven and potential benefits, but there are
still many barriers that need to be overcome. One way to overcome these barriers
is to employ a holistic approach towards eHealth development and evaluation.
Introducing eHealth
21
In 2011, a review on the potential and limitations of existing eHealth frameworks
was conducted to find their value in overcoming these barriers (van Gemert-Pijnen
et al., 2011). A main outcome was that these kinds of issues are expected to be
avoided by applying a participatory development process that creates a good fit
between technological, human and contextual factors. However, most existing
frameworks were found to have a rather conceptual approach instead of practical
guidelines, and lacked the stakeholder-driven approach that is required in eHealth
development (van Gemert-Pijnen et al., 2011).
Based on this review and prior research, a holistic approach was proposed.
Holism in general refers to the notion that individual elements in a complex
system are determined by the relations they bear to the other elements. This
means that all aspects of a larger whole are interrelated, and separate analysis of its parts should be avoided (James, 1984). For eHealth development, this
means that constructs as technology, people and context are all interrelated and
interdependent, and are all part of one whole instead of separate elements (Van
Gemert-Pijnen et al., 2011).
Such a holistic approach is required since eHealth is much more than a thing
or tool. It entails creating an infrastructure for supporting health, organizing care,
disseminating knowledge and communication via technology. eHealth developers should be aware of the impact that technology can have on people (patients,
citizens, healthcare professionals, policy makers) and their sociocultural context
(healthcare organization, homes). Approaches such as participatory development,
human-centred design (see Chapter 10), business modelling (see Chapter 9) and
persuasive design (see Chapter 12) can be combined into a framework that supports the developers in this. The CeHRes Roadmap does just that: it combines
these approaches and thus provides a framework to develop a technology that
fits the human and contextual perspective (see Chapter 7). The Roadmap is underpinned by five pillars of eHealth development, which are based on existing frameworks, insights from practice and empirical research (van Gemert-Pijnen et al.,
2013; van Gemert-Pijnen et al., 2011). These pillars are described in the following
section.
eHealth development is a participatory
development process
Many eHealth technologies are known to have acceptance problems, which can
be attributed to insufficiently meeting the needs of users (Eysenbach, 2008). To
prevent dominance of experts when making decisions about development, and to
account for the user and context, stakeholder participation is essential (van de
Belt, Engelen, Berben, & Schoonhoven, 2010). In this so-called participatory development, stakeholders are involved during the entire development and evaluation
process. These stakeholders include the users, but other stakeholders are essential
for a proper development, implementation and evaluation as well. Merely involving users might cause a dominance of the user perspective (Bødker, Kensing, &
Simonsen, 2009) and can lead to overlooking the needs of other stakeholders who
will use, implement or be in any way involved with the technology (see Chapter 8).
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Lisette (J.E.W.C.) van Gemert-Pijnen et al.
Development ‘with’ instead of ‘for’ stakeholders entails their active involvement in activities related to the development, implementation and evaluation
of eHealth. Their roles can range from informant to actual co-creator (Scaife,
Rogers, Aldrich, & Davies, 1997; Yip et al., 2013). Stakeholders help to create the
technology by means of being involved in activities like identifying their needs
for the technology, improving the technology based on their input or identifying
critical issues for implementation (Carr, Howells, Chang, Hirji, & English, 2009).
However, participatory development does not always have to be about creating
new technologies. Existing technologies can be redesigned and reused in different contexts, and it is important that stakeholders are involved in that process as
well (see Chapter 10).
eHealth development creates new ecosystems
for improving health and healthcare
The use of eHealth technology is never isolated but is influenced by and influences the context in which it is used. In the case of eHealth, the context differs, for
example, ranging from a hospital and its organization to a user’s home and personal life. For eHealth technologies to reach their potential, a good fit with this context is required. Consequently, eHealth development creates novel structures and
processes for healthcare delivery; an ecosystem for healthcare emerges. eHealth
reshapes healthcare, since it intervenes with traditional healthcare characteristics.
Some of these changing characteristics are a change in place-dependant delivery,
a new division of labour, new regulations for the use of technology financing, and a
shift from hospital to home-based care (see Chapter 4).
eHealth development is intertwined with
implementation
Too often, implementation is seen as post-design activity that is executed only
after the design of a technology or other kind of product is finished. However,
current visions of eHealth development state that implementation plays an important role right from the start. As we have discussed, many issues can arise during
implementation in practice (Broens et al., 2007; May et al., 2007). If these potential
implementation issues are identified during the earliest stages of the development
process, they can be addressed before the actual implementation starts. Decreasing, making a plan to account for, or eliminating these implementation issues
before implementation reduces the chances of their having a negative effect on
the implementation (see Chapter 12).
Also, involving the perspective of the users, other stakeholders and the context
from the beginning increases the chances of a good fit with the technology, which
in turn increases the chances of a smooth implementation process. The better the
fit and interrelationship, the higher the chances of successful implementation in
practice. This means that actively involving stakeholders in the development process and making sure their needs are incorporated in the technology contributes
to implementation as well.
Introducing eHealth
23
eHealth development is coupled with persuasive design
eHealth can be used for multiple purposes: to support self-management behaviour,
to educate, to share personal information, to influence attitudes or to facilitate communication between people. But regardless of its main goal, all eHealth technologies
have in common that they are always used by people. These people expect technology to support them in doing the right thing, show understanding, giving them information that is relevant for themselves, rewarding their behaviour and being easy and
intuitive to use. People often have to be supported in changing their behaviour and
attitudes, and technology has the potential to do this (see Chapter 12).
Persuasive technology is technology aimed at influencing behaviour and attitudes. This refers to behaviour and attitudes that contribute to an improved health
and well-being but also to behaviour and attitudes related to (the use of) the technology. Persuasive technology can have a positive influence on using the technology in the intended way and in the long term; it has the potential to improve
adherence (Kelders, Kok, Ossebaard, & Van Gemert-Pijnen, 2012). If a technology
is used in the right way, it is more likely to reach its health-related goals. In other
words: persuasive technology supports people in improving their health and wellbeing by using the system in the intended way.
eHealth development requires continuous
evaluation cycles
eHealth development is not a linear process with consecutive steps. It is an iterative,
flexible and dynamic process during which constant changes can be made to development activities and their results. Consequently, evaluation should also be seen as
cyclic, longitudinal research and development activities interwoven with all development phases, without a fixed end. This means that evaluation doesn’t take place
only at the end of the development process; just like implementation, it is not a postdesign activity. Formative evaluation starts at the beginning of the development and
continues during every development activity. Each product of a development phase
can and should be critically checked, analyzed, evaluated and adapted based on
the results of this formative evaluation. It can take on different forms, for example,
verifying outcomes of a phase with users, checking the relation with the outcomes
of previous phases, or gathering stakeholders’ opinions on a specific idea. In every
case, its main goal should be checking that the outcomes of activities still match
the context, stakeholders and outcomes of previous phases. Formative evaluation
provides concrete tools to further improve the process and technology in order to
reach an optimal fit between technology, stakeholders and context (see Chapter 7).
Furthermore, much eHealth research focuses on evaluating the effectiveness
of an implemented technology to make claims about whether the goals have been
reached. Less attention is paid to outcomes related to the healthcare context and
the interaction between the user and the technology, which can be seen as equally
important. Just like eHealth development, evaluation should be holistic: it has to
focus on the technology, users and the context. Also, evaluation does not have
a fixed end point, since its results can be used to further improve or change a
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Lisette (J.E.W.C.) van Gemert-Pijnen et al.
technology. Once implemented, a technology is not fixed but can be redesigned.
These improvements or changes should be evaluated as well, and again, more
changes can be made based on the outcomes of the new evaluation cycle. Evaluation doesn’t have to be the end point of the development process, since a technology is never really finished. This requires an iterative, flexible and dynamic view on
evaluation (see Chapter 14).
Roadmap to the book
The concept of holism is intertwined throughout the pillars: they emphasize the
importance of a good fit between technology, people and their context. Holism
is an essential principle of this book since all chapters are connected by these
interrelated concepts. The first part of the book (Chapters 2 through 6) will
elaborate on the background of eHealth by focusing on the interrelationship
between technology, psychology and healthcare and by introducing eHealth’s
use in prevention and somatic and mental healthcare. The second part of this
book (Chapters 7 through 14) pay attention to holistic eHealth development,
design, implementation and evaluation. The CeHRes Roadmap provides the
backbone for this part. More information on this book’s main goals and structure can be found in the Preface.
Summary
This first chapter introduced the domain of eHealth and described the relationship between technology, psychology and healthcare. It provided an overview of
current visions of eHealth. The chapter made clear that changes in healthcare,
society, technology and the behavioural sciences are all related to eHealth, directly
or indirectly. This results in many advantages of eHealth, but in practice, barriers
are still experienced. In order to overcome these barriers and achieve the benefits,
a holistic, multidisciplinary approach is advocated. Such a development approach
will likely result in an eHealth technology that fits the people and their environments. The take-home messages for this chapter are:
•
•
•
•
•
eHealth has many actual and potential advantages for health, well-being and
healthcare and can be divided into self-care and prevention; supportive care
and societal health.
In practice, many barriers of eHealth are experienced with regard to implementation in practice, ethics and evidence.
A holistic vision of eHealth is advocated: the technology, people and their contexts are all intertwined.
A holistic development, design, implementation and evaluation process can
create eHealth technologies that overcome the barriers and achieve the
benefits.
The CeHRes Roadmap can support holistic eHealth development and is based
on approaches such as participatory development, human-centred design,
business modelling and persuasive design.
Introducing eHealth
25
Key references for further reading
Eysenbach, G. (2001). What is e-health? Journal of Medical Internet Research ,
3 (2).
Greenhalgh, T., Wherton, J., Papoutsi, C., Lynch, J., Hughes, G., Hinder, S., . . . &
Shaw, S. (2017). Beyond adoption: A new framework for theorizing and evaluating
nonadoption, abandonment, and challenges to the scale-up, spread, and sustainability of health and care technologies. Journal of Medical Internet Research,
19(11), e367.
van Gemert-Pijnen, J. E. W. C., Nijland, N., van Limburg, M., Ossebaard, H. C., Kelders,
S. M., Eysenbach, G., & Seydel, E. R. (2011). A holistic framework to improve
the uptake and impact of eHealth technologies. Journal of Medical Internet
Research, 13(4).
van Gemert-Pijnen, J. E. W. C., Peters, O., & Ossebaard, H. C. (Eds.). (2013). Improving
eHealth. Den Haag, The Netherlands: Eleven International Publishing.
World Health Organization. (2016). Global diffusion of eHealth: Making universal health
coverage achievable. In Report of the third global survey on eHealth (pp. 11–76).
Geneva: World Health Organization.
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