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What is cell phone eHealth

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					What is cell phone eHealth?

Jeffery Loo

Abstract
This literature review introduces eHealth and then examines cell phones used for eHealth.

It begins with a general introduction of eHealth and then outlines the different types of
information and communication technology used in healthcare communication and
interventions. There will be a focus on Internet applications as this technology was the first
instantiation of eHealth. Many of the healthcare issues surrounding the Internet exist for cell
phones as well.

Afterwards, the available types of cell phone eHealth services are outlined by reviewing current
research studies. Issues surrounding eHealth development for cell phones are then examined.

Finally, research gaps and needs are identified with suggestions for future investigation.

Table of Contents

1.      Introduction .............................................................................................................................. 3

2.      What is eHealth? ..................................................................................................................... 3

3.      Types of eHealth technology................................................................................................... 5

4.      Prevalence and promotion of eHealth..................................................................................... 5

5.     Advantages of eHealth ............................................................................................................ 6
     5.1. General advantages of information and communication technology for eHealth ........... 6
     5.2. Advantages of the Internet for eHealth ............................................................................ 7
     5.3. Advantages of cell phones for eHealth ............................................................................ 8

6.     Disadvantages of eHealth ..................................................................................................... 10
     6.1. Disadvantages of general information and communication technology for eHealth ..... 10
     6.2. Disadvantages of cell phones for eHealth ..................................................................... 11

7.      Types of eHealth functions possible through information and communication technology . 12

8.     The body of eHealth research ............................................................................................... 13
     8.1. Overview of the eHealth research base ........................................................................ 13
     8.2. Evaluation of the technology medium ............................................................................ 13
     8.3. Usage-based evaluation ................................................................................................ 13
     8.4. Evidence for eHealth efficacy ........................................................................................ 16

9.     Types of cell phone eHealth services currently provided ..................................................... 16
     9.1. Review of cell phone eHealth research ......................................................................... 17
     9.2. Images of cell phone eHealth applications .................................................................... 28
       9.2.1. Behavior change – physical activity........................................................................ 28
       9.2.2. Data collection, data analysis and health information – asthma............................ 29
       9.2.3. Self-management/monitoring – asthma ................................................................. 30
       9.2.4. Self-management/monitoring – diabetes and hypertension .................................. 32
       9.2.5. Self-management/monitoring – weight management ............................................ 32
                                                                                                                                              2


      9.2.6.       Monitoring by health professional and data collection – cancer ............................ 33
      9.2.7.       Medical administration – appointment making ....................................................... 33
      9.2.8.       Medication management ........................................................................................ 35
      9.2.9.       Diagnosis and teleconsulting – skin cancer ........................................................... 35

10.   Cell phone eHealth issues ................................................................................................. 36
  10.1.    Mobile healthcare ....................................................................................................... 36
  10.2.    Technology divide ....................................................................................................... 36
  10.3.    Health disparities ........................................................................................................ 36
  10.4.    eHealth literacy ........................................................................................................... 37

11.      Future research.................................................................................................................. 38

12.      References ......................................................................................................................... 40
                                                                                                  3



1. Introduction
Cell phone eHealth is the use of cell phones to deliver healthcare services. It is a relatively new
field. According to a keyword search in PubMed, “eHealth” did not appear in the research
literature until 2000.

While research remains in its infancy, there is a great deal of optimism for the cell phone’s
potential in healthcare. The convenience, connectivity and simple computing power of this
technology have been recognized by researchers and professionals alike.

This literature review introduces cell phone eHealth. It does not intend to be an exhaustive
review. Making generalizations for an emerging field is difficult when much of the research are
pilot or feasibility studies, and few controlled studies are conducted on outcomes (Kaplan,
2006).

The objectives of this review are to:
   1. define eHealth and its functions
   2. examine the advantages and disadvantages of eHealth
   3. outline the cell phone eHealth services available
   4. examine implications and issues surrounding cell phone eHealth
   5. provide an overview of the research base and research needs

Internet applications for health services will be discussed alongside the cell phone. Examining
the Internet is a natural segue to cell phone eHealth, since the Internet was one of the first
instantiations of “eHealth” and many of its issues relate to the cell phone.

2. What is eHealth?
eHealth falls under the umbrella term of medical informatics. According to the MeSH
Thesaurus, medical informatics is “the field of information science concerned with the analysis
and dissemination of medical data through the application of computers to various aspects of
health care and medicine” (2007). Researchers contend that medical informatics should focus
on understanding people and new models of care and not be solely concerned with technology
(Wyatt and Sullivan, 2005).

There are multiple definitions for eHealth. In a systematic review of the literature up to 2004, 51
unique definitions were found (Oh et al., 2005).

Two succinct definitions summarize the breadth of explanations:

               e-health is the use of emerging information and communications
               technology, especially the Internet, to improve or enable health
               and healthcare (Eng, 2001).

               e-health is an emerging field of medical informatics, referring to
               the organization and delivery of health services and information
               using the Internet and related technologies. In a broader sense,
               the term characterizes not only a technical development, but also
               a new way of working, an attitude, and a commitment for
               networked, global thinking, to improve health care locally,
                                                                                                    4


               regionally, and worldwide by using information and communication
               technology (adapted from Eysenbach 2001 cited in Pagliari et al.,
               2005).


Suggested functions for eHealth to support include: “dissemination of health-related information,
storage and exchange of clinical data, interprofessional communication, computer-based
support, patient-provider interaction and service delivery, education, health service
management, health communities, and telemedicine, among others” (Pagliari et al., 2005).

eHealth differs from telemedicine. While telemedicine is the delivery of health care and the
sharing of medical knowledge using telecommunications (Kundu and Sarangi, 2004 cited in
Kaplan, 2006); it differs because it involves “a health professional at one or both ends of the
communication” (Wyatt and Sullivan, 2005).

From the varied eHealth definitions, general themes have been identified (Pagliari et al., 2005):
    Electronic communication through networked digital information and
       communication technology, primarily the Internet.
      eHealth differs from medical informatics because it does not include fixed
       technologies (e.g., X-ray equipment, diagnostic tools) or pure
       bioinformatics research.
      There is a variety of stakeholders, including: providers, patients, citizens,
       organizations, managers, academics and policymakers. In Europe, more
       inclusive eHealth models exist, in contrast to the experience in the USA,
       where “bottom-up” health systems and cultures are more prominent
       (Detmer, 2005 cited in Pagliari, 2005).
      eHealth is marked by a sense of optimism and a focus on its benefits,
       potential and rapid evolution. For instance, the 58th World Health
       Assembly (of the World Health Organization) has passed an eHealth
       resolution (WHA 58.28) recognizing its potential for health-care delivery,
       public health, research and health-related activities for the benefit of both
       low- and high-income countries; and encourages the development of
       eHealth applications (World Health Assembly, 2005).
      eHealth represents an evolution towards patient-oriented and effective
       healthcare systems, which includes new ways of thinking. As Kaplan
       (2006) notes: eHealth is “both a structure and […] a way of thinking about
       the integration of health services and information using the Internet and
       related technologies”.

Conceptual models were developed to define eHealth. They include:
    the 5 C’s, which focus on eHealth functions and capabilities that include: content,
      connectivity, community, commerce and care (Eng, 2001);
    the 10 essential E’s, which identify important eHealth values and characteristics
      including: efficiency, enhancing quality, evidence based, empowerment, encouragement,
      education, enabling, extending, ethics, and equity (Eysenbach, 2001);
    a 4-pillar model that includes: clinical applications, healthcare professional continuing
      education, public health information, and education and lifetime health plans
      (Richardson, 2003 cited in Pagliari et al., 2005).
                                                                                                   5




3. Types of eHealth technology
eHealth may employ a variety of information and communication technology for service
deployment. Emerging technologies are especially promising, with the following noted for their
potential healthcare impact: satellite communications, wireless networks, palmtop technologies,
new mobile telephones, Digital TV, the WWW, virtual reality, nanotechnology and the
intersection of bioinformatics and health informatics (Pagliari et al., 2005).

An important feature of these technologies is automation and personalization. An important
example is the personal agent. This is software that can represent the individual on different
types of computers, such as handheld computers, personal computers and cell phones (Wyatt
and Sullivan, 2005). With personal agents, health records and information may be
personalized, stored and shared in an electronic environment.

eHealth has been conceptualized for wearable and portable hardware. Known as personal
health management systems, PHMSs connect individuals to computerized health information
networks (Gatzoulis and Iakovidis, 2007; Koch, 2006). Individuals wearing detection devices
may have their vital signs continuously monitored and communicated to health information
systems.

4. Prevalence and promotion of eHealth
A number of factors are driving eHealth services and the demand for such services (as
identified by Wyatt and Sullivan, 2005):
     Consumer forces: Increasingly, consumers demand the personalization of information
         and services, where and when it is convenient for them. In addition, eHealth may be a
         democratizing force, as citizens may communicate with their physicians and other
         patients more freely.
     Changes in the healthcare system: eHealth may address staff shortages and personnel
         issues, as automated, tele-outsourced, or home-based services are provided. In
         addition, eHealth may reallocate some of the health service costs to the consumer.
         Consumer-oriented resources may also address the heavy demand for healthcare
         services and possibly improve outcomes (Office of Disease Prevention and Health
         Promotion, 2006).
     Technology offers new functions that may be more reliable, functional or cheaper.
     Political forces: eHealth tools may improve self-management and medical adherence.
         National policy may also embrace eHealth for coordinating health services and
         promoting equality and patient independence. In the UK, such policies have been
         developed for meeting government health targets. Increasingly, public policy favors
         consumer responsibility in personal health management (Office of Disease Prevention
         and Health Promotion, 2006).

eHealth applications are driven by a number of stakeholders. eHealth initiatives have been
driven by citizen-patients, professionals, and national and regional health networks (Silber,
2004). Sometimes these stakeholders join forces in an integrated service. A prominent
example is NHS Direct Online, a multi-channel eHealth service network in the UK
(http://www.nhsdirect.nhs.uk/index.aspx) (Gann, 2004). Patients have access via telephone,
Internet or interactive television to health information services provided by professionals from
the public health service.
                                                                                                       6



Increasingly, there is worldwide recognition that information and communication technology may
improve healthcare effectiveness and efficiency (Institute of Medicine, 2001 cited in Pagliari,
2005). National strategies have been formed for the development of health information
infrastructures in North America, Europe and Australia (references 2 through 5 cited in Pagliari,
2005). For instance, the UK National Programme for Information Technology (now known as
Connecting for Health) is developing a national information strategy.

Towards the promotion of eHealth, research has examined factors for design and
dissemination. In the US, the Office of Disease Prevention and Health Promotion (2006) of the
federal government conducted a comprehensive review on consumer eHealth tools. Their goal
was to identify and analyze the critical factors in expanding the reach and impact of these tools
in a diverse population. This project was seen as a contribution towards eliminating health
disparities and improving health literacy. The study identified user characteristics important
towards the effective design, dissemination and use of eHealth tools including: languages
spoken; socioeconomic position; disabilities; age, development and role issues; interest in
health information; and attitudes towards privacy and protection of personal health information.
These factors reflect the abilities of individuals to have the access, ability and interest in using
eHealth tools.

Strategies for promoting eHealth tools were also recommended in the study by the Office of
Disease Prevention and Health Promotion (2006). The report recommended:
     Providing access and training to underserved communities by using existing community
       infrastructure, such as libraries and community technology and community-based
       organizations
     Developing statewide strategies that involve multiple partners
     Reaching out to target audiences
     Supporting research addressing diverse audiences

There are international efforts to promoting consumer eHealth. In the European Union, major
projects have identified priorities and strategized towards advancing eHealth. For example, the
eHealth ERA team on behalf of the European Commission, Information Society and Media
Directorate General have studied the possibilities and means of a “smart European health
space” (eHealth ERA, 2007). In the international realm, a global policy for eHealth has been
developed by the World Health Organization: the Global Observation for eHealth (GOe) (W HA,
58.18). This sets out global initiatives for championing eHealth development worldwide.

5. Advantages of eHealth
5.1. General advantages of information and communication
     technology for eHealth
eHealth is viewed as a promising tool by health researchers and professionals, particularly for
the potential of information and communication technology to improve health and the healthcare
system (Alvarez, 2002 cited in Oh et al., 2005). Some believe these technologies will support
health behavior change and chronic disease management and prevention (Ahern et al., 2006).
For family practice, researchers purport that interactive computer technologies may address
barriers to lifestyle counseling, such as lack of time, poor organization of information, cost of
intervention, and concerns about patient reactions (Glasgow et al., 1999). Computer
technologies may address these barriers by organizing information and appointments,
                                                                                                      7


assessing user needs, and providing training and education in an automated manner.
Furthermore, information and communication technology may also provide distributed access to
health knowledge and reduce geographical barriers through electronic as well as wireless
connectivity (Iluyemi, 2007).

Some particular advantages of information and communication technology for healthcare are
listed in Table 1:

Table 1. Advantages of information and communication technology for healthcare
       Convenience and ease of use
       Provide emotional support (especially from peers) (e.g., online discussion boards,
        email)
       Objectivity and anonymity
       Widespread applicability
       Search and personalized display capabilities
                     - identified by Glasgow et al. (1999) for family practice and lifestyle counseling
       Instantaneous interactivity: immediate feedback through automated responses
       Convenience: eliminates time restrictions on access to intervention and educational
        materials
       Appeal: younger audience members have reported greater preference for computer
        delivered information (Fotheringham, Wonnacott and Owen, 1999 cited in Fotheringham
        et al., 2000)
       Flexibility: users have access to services where and when it is convenient
       Individual tailoring
       Automated data collection
       Credible simulations: virtual environments for role-playing and skills practice in
        simulation technologies
       Openness of communication: responses to sensitive questions may be more open
        when interacting with computers as opposed to other people directly (Robinson et al.,
        1998 cited in Fotheringham et al., 2000)
       Multimedia interfaces: audio and video capabilities may reduce the literacy skills
        required by users
          - identified by Fotheringham et al. (2000) for Internet strategies for preventive medicine

5.2. Advantages of the Internet for eHealth
It is useful to explore the advantages of the Internet for eHealth, since this modality was the first
instantiation of eHealth programming (Strecher, 2007) and many of its features extend to other
information technologies. The following are advantages identified by Strecher (2007):
       Reach: A large number of people may be reached for relatively low costs. The rapid
         increase in Internet use, particularly for health interests, attests to this potential (Bensley
         et al., 2004).
       Many people use the Internet: In 2005, over 78% of adults in the US have web access,
         with the largest increases in Internet access among low-income and older Americans
         (Center for the Digital Future, 2005 cited in Strecher, 2007). Also, 79% of respondents
         in an Internet use survey reported searching for health information (representing roughly
         95 million Americans) (Fox, 2005 cited in Strecher, 2007).
       A preferred resource: For example, in a study examining health information
         preferences, the Internet was cited as a source used by 40% of breast cancer patients in
                                                                                                    8


       the first 16 months after diagnosis (Sutherland et al., 2003 cited in Strecher, 2007). It
       was also found that the Internet was used more frequently than other resources such as
       books, videos, volunteers, support groups and telephone information services.
      Convenience: 93% of online health information seekers report the importance of
       obtaining information at any hour (Rainie and Packel, 2001 cited in Strecher, 2007).
      Impersonal qualities: The Internet may provide anonymity and prevent the discomfort
       of speaking with human health professionals (Frisby et al., 2002 cited in Strecher, 2007).
       This may elicit openness and honesty among respondents to potentially embarrassing
       and sensitive questions (Kissinger et al., 1999; Locke et al., 1992; Gribble et al., 2000 all
       cited in Strecher, 2007)
      Preferred for data collection: computer-based systems are sometimes preferred to
       paper-based questionnaires by respondents and researchers (Bernhardt et al., 2001;
       Paperny et al., 1990 all cited in Strecher, 2007).
      Interactivity: The Internet offers four types:
            o user navigation – picking and choosing in a virtual information environment
            o collaborative filters – discovering what others like you are doing
            o expert systems – automated systems that collect user characteristics and then
                provide feedback and messages tailored to the user’s needs; these systems are
                based on algorithms reflecting the standards of a human expert (Velicer, 1993
                cited in Strecher, 2007)
            o human-to-human interaction – the Internet is a channel for people to meet with
                other people and share information in online support groups (Brennan and Fink,
                1997 cited in Strecher, 2007). Patients may also contact health professionals via
                email.
      Reduced delivery costs for health interventions and information dissemination.
      Timeliness of online access anytime of the day.
      Reduction of time, geographic and mobility barriers (Griffiths et al., 2006 cited in
       Strecher, 2007)
      Positive health results have been demonstrated in randomized trials of Internet-based
       interventions for smoking cessation, hazardous drinking, weight management, diabetes,
       asthma, tinnitus, stress, anxiety and depression, complicated grief, encopresis, chronic
       back pain, HIV, insomnia, headache and multiple risk factors (researcher studies are
       listed in (Strecher, 2007)).

Further details of the advantages and disadvantages of Internet-based delivery of healthcare
services and information may be found in Tate and Zabinski (2004).

5.3. Advantages of cell phones for eHealth
This focus of this review is cell phones. While telephone-based health interventions have
existed prior to the development and adoption of cell phones (Friedman, 1998), this is not a
topic for detailed discussion. Readers may review the advantages of telephone-based
interventions in (Clark et al., 2007; Bunn et al., 2005; Car and Sheikh, 2003; Studdiford et al.,
1996). Nevertheless, the advantages of cell phones for eHealth are similar to those for
telephones.

Cell phones have been recognized for their potential in eHealth. Kaplan describes its promise
as tremendous, but not yet fully realized due to technical, financial and regulatory barriers
(2006). Much of the research are pilot or feasibility studies with anecdotal reports. These types
of research are limited in providing rigorous and grounded evidence for effectiveness (Kaplan,
2006).
                                                                                                9



There is a strong drive towards cell phone eHealth. There are many cell phone users: the cell
phone is an information and communication technology that is widespread and seemingly
ubiquitous with high rates of consumer penetration. Worldwide in 2002, cell phone subscribers
overtook land line phone subscribers, across geographic regions, socio-demographic variables
(e.g., gender, income, age), and economic factors (Feldmann, 2003 cited in Kaplan, 2006).
Therefore, deploying eHealth through cell phones may be convenient and far-reaching.

In addition to the general advantages listed in section 5.1, some specific advantages of cell
phones include (identified by Kaplan (2006) and Boland (2007)):
     Dynamic, multi-way interaction between health professional and patient
     Managing time constraints: cell phones are conveniently available computers and may
        engage patients in self-care, thus reducing the time demands of health providers
     Anytime, anywhere access and communication in extensive cell phone networks.
        Cell phones offer freedom from wired and geographic restrictions.
     Low start-up cost and high social value, even in resource-poor areas. The purchase
        of a cell phone is relatively cheaper than Internet-accessible computers. There is
        evidence that the digital divide for cell phones is less than the divide for Internet and
        other communication technology use (Forestier et al., 2002 cited in Kaplan, 2006).
     Easy to use: Relative to the Internet, cell phones may be easier to use for individuals
        with low level computer skills.
     Text messaging functionalities (SMS: Short Message Service):
            o Typically costs less than voice messaging
            o Messages may reach people even when phones are switched off
            o Relatively silent notification, permitting conversation and message transmission
                 when voice conversations are neither convenient nor appropriate
            o Highly used. For example, in 2000, text messages in the UK hit 1.42 billion.
     Communication of simple messages and data through voice and short text messages
                                                                                                 10



6. Disadvantages of eHealth
6.1. Disadvantages of general information and communication
     technology for eHealth
A number of potential disadvantages have been identified by researchers:

Table 2. Potential disadvantages of information and communication technology for eHealth – in
general

      Cost (especially the initial investment for technology transitions)
      Complexity for some potential users
      Rapid technological changes and incompatibilities of different applications
      Potential for misinformation
      Confidentiality risks
      Limited breadth of appeal for some audiences
      Social justice concerns
                                                                              (Glasgow et al., 1999)
      New technologies create new knowledge, more data, and new expectations and
       applications
                                                                                     (Madani, 2006)
      Safety and cost-effectiveness are not clearly understood; lack of evidence
      Possibility of lifestyle intrusiveness for users
      Concerns about data privacy in electronic networks
      Concerns of private interests in telecommunications (advertisements, private control,
       lack of regulations)
      Health disparities and digital divide issues
      Potential for public campaigns against eHealth
                                                                          (Wyatt and Sullivan, 2005)
      Consumer concerns for privacy and control of health information
      User requirements may not be met
      Lack of accessibility due to financial, geographic and structural variables
                                         (Office of Disease Prevention and Health Promotion, 2006)
      Social and public health policy concerns for individuals who lack web access.
       Particularly for individuals who rely on public spaces for Internet access, such as
       libraries, there may be barriers to open communication, anonymity, and convenience.
      Set up costs may be prohibitive for health care providers
                                                                         (Fotheringham et al., 2000)
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6.2. Disadvantages of cell phones for eHealth
In addition to the general issues in section 6.1, a number of potential disadvantages for cell
phones have been identified by Kaplan (2006):

Table 3. Potential disadvantages of cell phones for eHealth

       Cell phone network coverage may intermittent in some parts of the world, with possible
        high costs in remote areas
       Potentially high costs: e.g., cell phone coverage in out-of-network locations, data
        transmission costs
       Low bandwidth of cell phones: e.g., text messages have a maximum of 160 characters;
        however, the technology is rapidly changing with higher bandwidth for images, Internet
        access and videos
       Difficult to conduct real-time interaction through text messaging as data entry may be
        cumbersome on tiny keypads
       Small cell phone screens may be difficult to read
       Literacy concerns: e.g., computing and reading difficulties
       Privacy of data, communication and services (especially in public spaces): potential for
        stigmatization when the public observes individuals using eHealth applications
       Creating a sustainable, large-scale cell phone eHealth service requires agreement
        among different stakeholders and their agendas (see Table 4)
       Lack of evidence on safety and efficacy (see section 8.4 for details)
                                                                                    (Kaplan, 2006)

The following table outlines the difficulty of differing agendas among stakeholders (from Kaplan
(2006).

Table 4. Stakeholder positions for cell phone eHealth
                       Patient              Healthcare provider          Cell phone company

Focus          Individual                 Individual/Care Group       Potential clients

Outcome        Absence and                Absence and                 Product sales
               amelioration of disease    amelioration of disease

                                          Reduce cost of care
Motivation     Well being through         Professionalism through     Profit through new sales,
               treatment                  treatment                   new products, and
                                                                      marketing user
                                          Profit through cost         acceptance.
                                          containment
                                                                                               12



7. Types of eHealth functions possible through information
   and communication technology
Table 5 lists functions that eHealth applications may serve (based on (Eng, 2001), (Atkinson
and Gold, 2002) and (Office of Disease Prevention and Health Promotion, 2006)):

Table 5. eHealth functions for general information and communication technology
                   Function                                            Example
Relay general or individual health information       Web pages and online databases
Enable informed decision making                      Databases of examples and issues,
                                                      decision support tools, risk assessment
                                                      and multimedia.
                                                     These tools may illustrate cases, and help
                                                      the user to make decisions about
                                                      insurance programs, healthcare providers,
                                                      behavior and treatments
Promote healthful behaviors                          Promote adoption and maintenance of
Behavior change/prevention                            positive behaviors (such as smoking
                                                      cessation) through interventions, services,
                                                      and programs delivered via ICTs.
Promote peer information exchange and                Share information and support among
emotional support (online communities)                patients and peers via online support
                                                      groups, etc.
Promote self-care and management                     Provide tools, information and support in
                                                      electronic environments for achieving and
                                                      maintaining healthy behavior such as diet
                                                      and exercise.
Manage demand for health services                    Delivery of health services through ICT
                                                      rather than in-person
Disease management                                   Offer monitoring, recordkeeping and
                                                      communication with health professionals in
                                                      order to manage chronic diseases (e.g.,
                                                      transmitting vital signs and health
                                                      measurements for remote monitoring)
Healthcare information management                    Keep and manage personal health records
                                                      in electronic environments
Health communication                                 Communicate with health professionals,
                                                      agencies and other supports
Remote patient monitoring                            Monitoring devices (for weight, glucose
                                                      levels or blood pressure) may be linked to
                                                      communication networks in order to
                                                      transmit patient measurements to health
                                                      professionals (Forkner-Dunn, 2003)

eHealth behavior management models have been developed for deploying such applications.
Bensley et al.’s model (2004) fits with two established health behavior intervention models, the
Transtheoretical Model and the Theory of Planned Behavior. Case studies have been
                                                                                                  13


conducted on the application of this model in several health situations: parent-child nutrition
education by the US Department of Agriculture, asthma management among university staff
and students, and HIV prevention in South African women (Bensley et al., 2004).

8. The body of eHealth research
What are the domains of inquiry in eHealth research? What are the research issues? This
section explores these questions.

8.1. Overview of the eHealth research base
The bulk of eHealth research centers on two issues: (1) evaluation of eHealth tools and Internet
use in the public domain; and (2) the development and evaluation of eHealth tools in research
settings (Office of Disease Prevention and Health Promotion, 2006).

In a majority of eHealth research, the findings contribute towards the optimism for the
technology. However, research conclusions are typically not conclusive due to a lack of
rigorous research methodologies, such as randomized controlled trials, and a lack of diversity in
the samples (Office of Disease Prevention and Health Promotion, 2006).

The worldwide research needs for eHealth tools and services have been identified in a survey
conducted by the Global Observatory for eHealth (GOe) of the World Health Organization
(WHO Global Observatory for eHealth, 2006). To develop eHealth, the following has been
proposed: (1) provision of generic tools (e.g., electronic health records, drug registries,
directories of health service providers), (2) providing access to existing tools (e.g. directories
and finding aids), (3) facilitating knowledge exchange, (4) providing eHealth information to help
nations deploy eHealth services, and (5) educating patients and health professionals of eHealth
applications.

8.2. Evaluation of the technology medium
The technology medium of eHealth interventions has hardly been addressed. Many studies
examine the outcomes of the message delivered by the eHealth tool; however, little is known
about the effect of the technology itself and its related components on users and their health
(Kaplan, 2006). Some questions that arise are: How does the telephone, in itself, affect our
health behavior? Do certain technologies make healthy lifestyle choices more amenable to
adoption?

8.3. Usage-based evaluation
The evaluation of eHealth usage can be organized into the following five domains developed by
the Office of Disease Prevention and Health Promotion (2006):
    1. Access
    2. Availability
    3. Appropriateness
    4. Acceptability
    5. Applicability

The following table defines these domains and some of their research issues.
                                                                                                  14


Table 6. Domains of eHealth inquiry (Office of Di sea se Prevention and Health Promotion, 2006)
Domain of inquiry     Definition/Sample questions                           Issues
                     Uptake and use of eHealth tools          Research bias towards individuals
                                                               with Internet access and functional
                     How many people know about                levels of computer and technology
     Access
                     eHealth tools?                            skills
                     How many are employing these             Diffusion and dissemination
                     tools?
                     Examines meaningful access               Information seeking styles
   Availability      (i.e., having the tools people want      Personal characteristics shaping
                     and need)                                 eHealth use
                     The fit between user and the tool        Cultural relevance
                                                              User perceptions on credibility,
                     The suitability for diverse user          content, quality and readability
Appropriateness
                     needs and characteristics (e.g.,
                     cultural appropriateness, literacy
                     and technological needs)
                     Whether people find the tools          Ease of use
                     satisfactory                           Satisfaction
  Acceptability
                                                            Usage over time
                                                            Usability
                     Utility and outcomes of eHealth       Effects on:
                     tools                                  Knowledge and information needs
                                                            Attitudes and beliefs mediating
                                                               behavior change (e.g. self-
                                                               efficacy, motivation, intention,
                                                               expectations, optimism)
  Applicability                                             Social support
                                                            Decision support
                                                            Health behaviors (adherence, diet,
                                                               physical activity, risky behavior)
                                                            Health outcomes
                                                            Negative outcomes
                                                                                               15


The issue of eHealth usage may be examined from the different perspectives of the
stakeholders (see Table 7. Potential eHealth value propositions for major stakeholdersTable 7).

Table 7. Potential eHealth value propositions for major stakeholders
Stakeholder                               Benefits Sought From Consumer eHealth
Consumers (e.g., patients, informal        Private, 24/7 access to resources
caregivers, information intermediaries)    Expanded choice and autonomy
                                           New forms of social support
                                           Possibility of better health
                                           More efficient record management
                                           Lower cost healthcare services
                                           Avoidance of duplication of services

Consumer advocacy and voluntary              Greater capacity for health management and
health organizations (e.g., AARP,             education for constituents
American Cancer Society)                     New communication channels
                                             More efficient service to constituents
Employers, healthcare purchasers,            Healthier employees more capable of health
and third-party payers                        management
                                             Lower healthcare costs
Community-based organizations                Constituents with greater capacity for health
                                              management and well-being
                                             Healthier communities
                                             Lower cost healthcare services
Clinicians                                   Greater efficiency
                                             Better communication
                                             More adherent and satisfied patients
Healthcare organizations                     More patient self-care and health management
                                             Lower administrative costs
                                             Improved quality and patient outcomes
Public health programs                    A healthier population more capable of self-care
                                           and less at risk for avoidable disease
e-Health developers                      Sustained use of e-health products
                                         New sources of support for product development
                                           and evaluation
Industry and commerce                    New advertising vehicles
                                         Wider markets for products
Policymakers and funders (public and  Effective means of implementing programs and
private)                                   policies
                                         Cost-containment or cost-reduction strategies
                                         Quality improvement strategies
Copied from (Office of Disease Prevention and Health Promotion, 2006)

An important area for study is cost savings and return on investment. It is particularly relevant
to healthcare organizations, insurers, employers and government (Office of Disease Prevention
and Health Promotion).
                                                                                                  16


8.4. Evidence for eHealth efficacy
Evidence that demonstrates eHealth’s effectiveness as a health intervention is scarce.
Rigorous efficacy studies for cell phone eHealth are scarce. Kaplan notes that “convincing
evidence regarding the overall cost-effectiveness of mobile phone telemedicine is still limited
and good-quality studies are rare” (2006). Generalizations are difficult to draw from existing
studies as different outcome measurements are used and few employ controlled trials (Kaplan,
2006). That said, thorough studies are currently underway, with a prime example being
Cochrane Reviews on eHealth for smoking cessation.

Some studies demonstrate no effect of eHealth interventions. Strecher (2007) points to “well-
designed evaluations of well-conceived Interent-based [eHealth] interventions” that have found
no effect, particularly (Marks et al., 2006; Patten et al., 2006 – both cited in Strecher, 2007).

Other studies show mixed results for eHealth efficacy. For example, Norman et al. reviewed
the efficacy of eHealth interventions for physical activity and dietary behavior change in studies
published between 2000 and 2005 (2007). Forty-nine studies met the inclusion criteria of an
eHealth intervention using electronic technology with measured outcomes at baseline and
during follow-up. Results found that 21 of 41 (51%) studies were superior to a comparison
group (3 physical activity, 7 diet, 11 weight loss/physical activity and diet). Also, 24 studies had
indeterminate results, while 4 studies found the comparison intervention had outperformed the
eHealth application.


9. Types of cell phone eHealth services currently provided
According to the academic research literature, cell phone eHealth serves a number of functions.
As an overview, some of the services that have been deployed or piloted include:

      Behavior change interventions
      Data collection and analysis
      Diagnosis: transmitting cell phone pictures for teleconsulting (Massone et al., 2007)
      Education
      Health communication
      Information sharing
      Medical adherence
      Medical administration including appointment setting
      Monitoring by health professional
      Reminder services
      Self-management / monitoring

Research studies on the above mentioned services are reviewed in the following sec tion.

In addition, a market analysis report identified 101 uses of cell phones for healthcare (Wireless
Healthcare, 2005?). Categories of functions and services include:
     Clinical decision making
     Data collection
     Diagnosis
     Health recruitment and contact: e.g., locating blood donors
     Medical administration: clinical, informational, etc.
     Medical testing
                                                                                             17


      Medical tool
      Messaging/alert service for public health
      Patient monitoring
      Records management
      Reminders
      Support for health professionals
      Support: peer and informational supports

Other studies have examined eHealth services delivered through specific features on cell
phone. Atun and Sittampalam investigated the uses and benefits of text messaging (SMS) in
health care delivery (2005) from the perspective of the health provider. Text messaging is being
used for: (1) enhancing the efficiency of service delivery (through reminders and improved
communications); (2) improving diagnosis, treatment and rehabilitation of illness (through
remote services, patient monitoring, improved communications and delivering behavioral
change interventions); (3) conducting public health initiatives, such as health interventions,
contact tracing for communicable diseases and health information delivery.

9.1. Review of cell phone eHealth research
Cell phone eHealth research studies are reviewed in Table 8. Studies were selected to provide
an overview of the cell phone eHealth landscape and to demonstrate the diversity and range of
services. The goal was to provide a comprehensive overview and not be exhaustive.

For more reviews of research studies, please refer to Kaplan (2006), who has conducted a
review examining different research projects.
                                                                                                                                                              18




Table 8. Review of cell phone eHealth research
    Usage             Health        Intervention                  Country   Audience /      Research            Research outcomes               Reference /
    category          condition /                                           Sample          study                                               Comments
                      Disease
1   Behavior          Physical      Physical activity program,    UK        46              Randomized          Test group had greater          (Hurling et al.,
    change            activity      Internet- and cell phone-               randomized      controlled trial.   self-reported intention to      2007)
                                    based.                                  to test         Outcome             exercise, higher level of
                                    Includes tailored                       group; 30 in    measures =          moderate physical
                                    solutions for perceived                 control         self-report of      activity (average weekly
                                    barriers, exercise                      group with      physical            increase = 2h18min), and
                                    scheduling tool, cell                   no access to    activity,           lost more percent body
                                    phone and/or email                      system or       readings from       fat than control group
                                    reminders, message                      feedback.       wrist-worn          (statistically significant at
                                    board, real-time                        Mean age =      accelerometer       alpha = 0.05)
                                    feedback.                               40.4 (s.d. =    that monitors
                                                                            7.6)            physical
                                                                                            activity
2   Behavior          Smoking       Providing advice for          USA       HIV-positive,   Assess impact       Cell phone intervention         (Vidrine et al.,
    change            cessation     quitting, nicotine patches,             adult           of cell phone       group exhibited favorable       2006)
                                    self-help materials, and 8              smokers.        intervention on     changes in the mediator         Comparison
                                    proactive counseling                    Control         hypothesized        factors, with the               between
                                    sessions via cell phone.                group           mediators for       exception of social             groups are
                                                                            received all    smoking             support, which was              questionable:
                                                                            interventions   cessation (i.e.,    rejected from the               while the
                                                                            except for      change in           mediator hypothesis.            intervention
                                                                            cell phone      depression,         The intervention resulted       group received
                                                                            counseling      anxiety, social     in decreased symptoms           cell phone call
                                                                            (n=47).         support, and        of distress.                    counseling,
                                                                            Intervention    self-efficacy).                                     the control
                                                                            group n=48      Measures =                                          group did not
                                                                                            the mediator                                        receive similar
                                                                                            factors,                                            counseling.
                                                                                            biochemically
                                                                                            confirmed
                                                                                            cessation
                                                                                            outcomes
                                                                                                                                                        19

    Usage           Health         Intervention                Country   Audience /      Research           Research outcomes             Reference /
    category        condition /                                          Sample          study                                            Comments
                    Disease
3   Adherence       Medication     Healthcare professionals    USA       HIV-infected    Pilot program      Most participants found       (Puccio et al.,
                    adherence      placed cell phone call                young adults    Daily calls for    service helpful, with an      2006)
                    for HIV        reminders for medication              (16-24 years    initial 4 weeks;   acceptable level of
                                   adherence.                            old)            frequency was      intrusion.
                                   Youth were provided with              beginning       then tapered.      Calls were deemed
                                   free cell phones.                     HAART drug      Perceived          annoying initially by
                                                                         regimen         intrusiveness      patients, but less
                                                                         5               or helpfulness     annoying by week 12.
                                                                         participants    of service,        Some participants
                                                                         completed       missed             appreciated the calls,
                                                                         the study       medication         especially for
                                                                                         doses, and         opportunities to ask
                                                                                         laboratory         health questions.
                                                                                         tests (viral       Viral suppression waned
                                                                                         load) were         for majority of patients;
                                                                                         assessed at 4      researchers believe 12-
                                                                                         week intervals     week intervention is not
                                                                                         for 12 weeks,      sufficiently long.
                                                                                         with a follow-
                                                                                         up at week 24.

4   Self-           Cardiac        Blood pressure, weight      Austria   14 patients     Monitoring for     Over 90 day period,           (Scherr et al.,
    management/     dysfunctions   measurements, and                     with chronic    90 day period.     average submission per        2006)
    monitoring                     medication dosage data                heart failure   Examining          patent was 102 (s.d 43).
    Health                         transmitted via mobile                6 patients      reliability,       On average, 83% (s.d.
    communication                  phone for telemonitoring.             with            acceptability      22) of submissions were
                                   Physicians receive                    hypertension    and feasibility    successfully transmitted.
                                   emails to alert out-of-                               of system.         Stability and accessibility
                                   range conditions.                                     Survey             both above 98%.
                                                                                         questionnaire.     From survey on
                                                                                                            experiences (n=18), high
                                                                                                            acceptance of program,
                                                                                                            increased awareness
                                                                                                            experienced, and interest
                                                                                                            in continuing program at
                                                                                                            personal expense.
                                                                                                                                                       20

    Usage              Health        Intervention                 Country   Audience /     Research         Research outcomes            Reference /
    category           condition /                                          Sample         study                                         Comments
                       Disease
5   Self-              Diabetes      Blood pressure monitor       Canada    Focus          Focus groups     From pilot study,            (Trudel et al.,
    management/        Hypertensio   and glucometer linked to               groups: 24     to develop       significant improvement      2007)
    monitoring         n             cell phone (Bluetooth-                 type II        system.          in blood pressure            Authors note
    Health                           enabled) transmits data                diabetics      Pilot study of   measures at ambulatory       need for
    communication                    to central data repository             with           system.          (24 hour) and 2-week         clinical trial to
                                     where clinical rules are               hypertension                    intervals (statistically     confirm results
                                     applied and alerts                     , 18 family                     significant at p < 0.01).    and to
                                     generated.                             physicians                      Focus groups established     examine
                                     Alerts sent to physician               Pilot study:                    design principles for        adherence
                                     and to the patient (via                32 diabetics                    system.                      issues.
                                     text and phone                         with
                                     messages).                             hypertension
                                                                            completed
                                                                            study

6   Information        Diabetes      Transfer blood glucose       Norway    15 children    Parent and       Parents valued sense of      (Gammon et
    sharing                          readings from child's                  (9-15 y.o.)    child            reassurance.                 al., 2005)
    Self-monitoring/                 monitor to parent's                    with type 1    experiences      System easily integrated
    management                       mobile phone.                          diabetes       and              into everyday life.
                                                                            Their          satisfaction     Reduction of parental
                                                                            parents        were collected   intrusion for children who
                                                                            (n=30)         via              monitored regularly.
                                                                                           questionnaire.   Increased
                                                                                           Interviews       nagging/reminders by
                                                                                           (with 9          parents for children who
                                                                                           parents).        measured irregularly -
                                                                                                            possibly leading to
                                                                                                            conflict.
                                                                                                            Parents expressed
                                                                                                            concern about age-
                                                                                                            appropriateness
                                                                                                            (especially for
                                                                                                            adolescents) and
                                                                                                            children's independence
                                                                                                            and sense of
                                                                                                            responsibility.
                                                                                                                                                   21

    Usage         Health        Intervention                 Country   Audience /     Research          Research outcomes           Reference /
    category      condition /                                          Sample         study                                         Comments
                  Disease
7   Self-         Diabetes      Patients transmit daily      Spain     23 diabetic    User              Patients sent an average    (Ferrer-Roca
    management/                 measurements including                 patients (18   satisfaction      of 33 messages/month.       et al., 2004)
    monitoring                  glucose levels to server.              y.o. and       survey.           Overall user satisfaction
                                Text message feedback                  over).         System use        (26% survey response
                                to acknowledge, provide                               log analysis.     rate only).
                                help or offer warning                                 Cost analysis.    Concerns about cell
                                messages of health                                                      phone plan costs.
                                conditions.                                                             Projected cost to
                                Calculates and sends                                                    diabetes manager is
                                health measures                                                         €3/month.
                                (glycosylated
                                haemoglobin result) to
                                patient.

8   Self-         Diabetes      Patients send self-          South     25             Comparison        Intervention group had       (Kim, 2006)
    management/                 monitored blood glucose      Korea     randomized     between           improved blood glucose
    monitoring                  levels and drug                        patients to    intervention      concentrations, relative to
    Education                   information to an Internet             intervention   and control       control group (statistically
                                server via wired                       group (mean    groups.           significant at p < 0.05).
                                connection or cell phone.              age = 46.8).   Pre-/post-test.   Reporting of results was
                                Nurse reviews patient                  26             Outcome           unclear.
                                records and data to send               randomized     measurement
                                weekly recommendations                 patients to    = blood
                                for self-management via                control        glucose level
                                SMS or Internet.                       (mean age =    indicators
                                                                       47.5).
                                                                                                                                                 22

    Usage         Health        Intervention            Country   Audience /      Research          Research outcomes            Reference /
    category      condition /                                     Sample          study                                          Comments
                  Disease
9   Self-         Calorie       PmEB, a cell phone      USA       Varied.         Iterative R&D     Feasibility study results    (Tsai et al.,
    management/   monitoring    application for self-             Feasibility     methodology.      below.                       2006)
    monitoring    for weight    monitoring of caloric             study with      Usability study   High scores for PmEB
                  managemen     balance in real time.             15 clinically   Preliminary       usability, compliance and
                  t                                               overweight      feasibility       satisfaction.
                                                                  or obese        study             PmEB scored as highly if
                                                                  individuals     measuring         not better than paper
                                                                  (18 years       compliance        group in most all
                                                                  and older)      and               categories (however,
                                                                                  satisfaction      lacking tests of statistical
                                                                                  with 15           significance).
                                                                                  participants      From thematic analysis of
                                                                                  randomized        qualitative interviews:
                                                                                  into 3 groups     PmEB is motivating,
                                                                                  (paper diary,     helpful for developing
                                                                                  PmEB with 1       weight management
                                                                                  daily prompt,     practices, convenient,
                                                                                  PmEB with 3       and easy to use.
                                                                                  daily prompts)    Negative comments =
                                                                                                    food entry was
                                                                                                    challenging, disliked
                                                                                                    prompts
                                                                                                                                                   23

     Usage         Health        Intervention                Country   Audience /      Research          Research outcomes           Reference /
     category      condition /                                         Sample          study                                         Comments
                   Disease
10   Self-         Asthma        Cell phone monitoring       UK        Focus group     Focus group       Participants felt the       (Pinnock et al.,
     management/                 system.                               and trial       discussion        technology may facilitate   2007)
     monitoring                  Symptoms and peak                     interventions   after a           guided self-management;     In a related
                                 flows transmitted to                  conducted       demonstration     however, dependence on      questionnaire
                                 central server; immediate             with a mix of   of the            professional or             survey on
                                 feedback provided for                 34 adults       technology.       technological support       professional
                                 control and appropriate               and             In-depth          may develop.                and patient
                                 actions.                              teenagers       interviews of 9   Provides confidence for     attitudes to the
                                                                       with asthma     participants      new patients to             technology,
                                                                       and 14          before and        understand and control      results
                                                                       asthma          after a 4-week    their asthma.               exhibited
                                                                       nurses and      trial of the      Concerns that increased     minority
                                                                       physicians.     system.           dependence may be           interest, with
                                                                                                         unhelpful for long term     the
                                                                                                         self-management.            enthusiastic
                                                                                                         Participants appreciated    minority
                                                                                                         the on-going record         concerned
                                                                                                         generated for               about clinical
                                                                                                         consultations.              benefits,
                                                                                                                                     impact on self-
                                                                                                                                     management,
                                                                                                                                     and workload
                                                                                                                                     and costs
                                                                                                                                     (Pinnock et al.,
                                                                                                                                     2006).
                                                                                                                                                       24

     Usage             Health        Intervention                Country   Audience /      Research         Research outcomes          Reference /
     category          condition /                                         Sample          study                                       Comments
                       Disease
11   Data collection   Asthma        Electronic peak flow       UK         10 asthma       Qualitative      Strengths = easy to use,   (Cleland et al.,
     and analysis                    meter linked to a cell                patients, 2     interviews on    fast, saved time,          2007)
     Health                          phone, where symptoms                 research        participants'    improved awareness of
     information                     are transmitted and                   staff           experiences      asthma conditions,
                                     stored on a server.                   members         with the         identified problems,
                                     System includes an                                    system.          facilitated virtual
                                     interactive service for                                                communication.
                                     reviewing their readings                                               Weaknesses =
                                     and finding data on                                                    dissatisfaction and
                                     weather conditions (that                                               frustration with
                                     affect asthma conditions).                                             technology interface and
                                                                                                            failures.
                                                                                                            Future development =
                                                                                                            more system feedback
                                                                                                            on conditions, training
                                                                                                            and support for staff.

12   Data collection   Asthma        Electronic peak flow        UK        38 asthma       Observational    Patients sent peak flow    (Ryan et al.,
     and analysis                    meter linked to a cell                patients        study over 9     readings once a day 68%    2005)
                                     phone.                                under 18 yo.    months, with     of the time and twice a
                                     Software transmits                    and 53          compliance to    day 55% of the time.
                                     readings to server with               patients over   technology       From 46 participants who
                                     feedback in the form of               18 yo.          use as primary   responded follow-up
                                     an asthma trend analysis.                             outcome for      questionnaire, 74% felt
                                                                                           analysis.        system improved self-
                                                                                           Questionnaire    management and 69%
                                                                                           follow-up.       were satisfied or very
                                                                                                            satisfied.
                                                                                                            Positive features
                                                                                                            identified = increased
                                                                                                            awareness, increased
                                                                                                            information, feedback,
                                                                                                            ease of use
                                                                                                                                                        25

     Usage             Health        Intervention                Country   Audience /   Research         Research outcomes            Reference /
     category          condition /                                         Sample       study                                         Comments
                       Disease
13   Monitoring by     Cancer        WHOMS - Wireless            Italy     97 cancer    Patients asked   Only 56 of the patients      (Bielli et al.,
     health                          Health Outcomes                       inpatients   to complete a    agreed to try cell phone     2004)
     professional                    Monitoring System, an                              ten-item         survey.
     Data collection                 Internet-based system                              questionnaire    61% of responses were
                                     that delivers structured                           regarding        complete.
                                     questionnaires via cell                            symptoms.        Patients who did not
                                     phone for self-reported                                             participate were typically
                                     outcomes on symptoms                                                older, received less
                                     and quality-of-life.                                                education, and were less
                                     Survey response via cell                                            familiar with new
                                     phone keypad entry.                                                 information and
                                     Questionnaire responses                                             communication
                                     delivered to health                                                 technology.
                                     professionals for patient
                                     monitoring.
                                                                                                                                                      26

     Usage           Health        Intervention                 Country   Audience /      Research          Research outcomes           Reference /
     category        condition /                                          Sample          study                                         Comments
                     Disease
14   Health          Sexual        Text message delivery of     UK        Patients        For untreated     Individuals with CT         (Menon-
     communication   health test   test results for Chlamydia   London    attending a     and infected      infection and who employ    Johansson et
                     results       trachomatis infection.       area      sexual          individuals, a    the text message            al., 2006)
                                                                          health clinic   comparison of     notification service were
                                                                                          the time to       contacted and received
                                                                                          treatment         treatment sooner.
                                                                                          between the       Median time to treatment
                                                                                          intervention      = 8.5 days vs 15.0 days
                                                                                          group and the     for control group;
                                                                                          control group.    statistically significant
                                                                                          The control       difference (p=0.005)
                                                                                          group were
                                                                                          notified by
                                                                                          standard
                                                                                          methods (clinic
                                                                                          re-attendance,
                                                                                          results phone
                                                                                          line).
                                                                                          Measures =
                                                                                          demographic
                                                                                          data,
                                                                                          attendance
                                                                                          data, staff
                                                                                          hours to
                                                                                          deploy service
                                                                                                                                              27

     Usage      Health         Intervention             Country   Audience /     Research          Research outcomes            Reference /
     category   condition /                                       Sample         study                                          Comments
                Disease
15   Reminder   Appointment    Text message reminders   UK        Patients at    Identify impact   Text message is effective    (Milne et al.,
     service    notification   of forthcoming medical             outpatient     on reducing       for sending last minute      2006)
                               appointments.                      clinics of a   "no-shows" at     reminder to patients.        In article
                                                                  major          medical           Modest impact for "partial   background,
                                                                  children's     appointments.     booking" appointments.       authors
                                                                  teaching       Compared          Limited coverage,            describe text
                                                                  hospital.      "no-show" rate    particularly among the       message
                                                                                 between           elderly.                     services at
                                                                                 patients who      Cheaper, more reliable       different
                                                                                 received text     and timelier than sending    hospitals that
                                                                                 message           paper letters.               were
                                                                                 reminders and                                  terminated due
                                                                                 those who did                                  to operational
                                                                                 not.                                           difficulties.
                                                                                   28



9.2. Images of cell phone eHealth applications
9.2.1. Behavior change – physical activity




Figure 1
Weekly schedule for planning physical activity (on an Internet-ba sed interface)
(Hurling et al., 2007)
                                                                                            29


9.2.2. Data collection, data analysis and health information – asthma




Figure 2
The Piko meter, connecting cable and Motorola V600 phone
(Cleland et al., 2007)




Figure 3
(a) Screen shot of mobile phone demonstrating the previous two weeks’ peak flow readings.
(b) Final screen on conclusion of the se ssion
(Cleland et al., 2007)
                                                                       30


9.2.3. Self-management/monitoring– asthma




Figure 4
Example of a mobile phone based monitoring system (E-san Ltd: mmO2).
(Pinnock et al., 2007)




Figure 5
Patient enters diary symptom s on cell phone.
(Boland et al., 2007)
                                                                                              31




Figure 6
Patient receives instant feedback and action plan.
(Boland et al., 2007)


Figure 6 depicts an asthma cell phone application that also includes features for (Boland, 2007):
     Personalized diary
     Medical regiment information and schedules
     Automated system reminders and tailored messages
     Action plans
     Summary and detailed patient data
     Web portal with provider drill down capability
     Exception reports on noncompliant patients
                                                                                                32


9.2.4. Self-management/monitoring – diabetes and hypertension




Figure 7
Mobile phone based remote patient monitoring system
(Trudel et al., 2007)



9.2.5. Self-management/monitoring– weight management




Figure 8
Screenshots of the PmEB mobile phone client. (a) is the main application menu. (b) is the current
caloric balance page. (c) is the meal selection page. (d) is the history page.
(Tsai et al., 2006)
                                                                                                 33


9.2.6. Monitoring by health professional and data collection – cancer




Figure 9
Questionnaire compilation using a cell phone. The question i s di splayed on the left, and the
answer set a ssociated with each question is di splayed on the right
(Bielli et al., 2004)



9.2.7. Medical administration – appointment making




Figure 10
Intelligent SMS – Appointment reminder
(Nokia, 2005)
                                             34




Figure 11
Intelligent SMS – Appointment rescheduling
(Nokia, 2005)




Figure 12
Intelligent SMS – Appointment confirmation
(Nokia, 2005)
                                                                                              35


9.2.8. Medication management




Figure 13
An internet-ba sed system and novel mobile home -based device for the management of
medication - with drug compliance reminder via cell phone, medical reminder and medication
compliance monitoring. Drug compliance reminder via cell phone: (a) medication reminder and
(b) medication compliance monitoring (Nugent et al., 2007)

9.2.9. Diagnosis and teleconsulting – skin cancer




Figure 14
This dermoscopic image of a pigmented skin lesion has been captured applying the cellular
phone on a pocket epiluminescence microscopy device.
(Massone et al., 2007)
                                                                                                   36




10. Cell phone eHealth issues
10.1. Mobile healthcare
Mobile healthcare (also known as mHealth) is a class of technologies that includes cell phone
eHealth as a subset. mHealth is defined as the combination of mobile and wireless
technologies with eHealth (Iluyemi, 2007). It may include the integration of medical sensors and
mobile computing devices into a medical system (Madani, 2006). The advantages include
providing real time patient care with fewer time and geographic limitations. It is important to
recognize that cell phones are simply one of many options for portable information and
communication technology in healthcare.

10.2. Technology divide
Information and communication technology in healthcare may be a barrier to individuals lacking
technology access. This “divide” could reinforce the barriers to medical knowledge and
information, which typically fall along social, financial and other involuntary lines (Kaplan, 2006).
In addition, people lacking access to computer technologies are typically underserved in the
healthcare system and experience the greatest health disparities (Eng et al., 1998).

There are two categories of eHealth technology divide: (1) hardware, which includes the
machines and the communications network, such as the Internet; and (2) software and content,
such as online support groups and health information (Viswanath and Kreuter, 2007). Hardware
issues affect both patients and healthcare providers, who may lack the resources to invest in a
new eHealth system. Software and content barriers take many forms, including cultural barriers
to understanding health information and web page usability difficulties.

While some research indicates that seniors and many minority groups are one of the quickest-
growing segments among Internet users (references 22, 23, and 25 cited in Forkner-Dunn,
2003), other barriers may arise such as an inability or inadequate skill set to utilize particular
technology features. Forkner-Dunn (2003) and Eng (2001) encourage the study of these and
other barriers towards the successful design and deployment of eHealth, including: literacy,
disabilities, and cultural factors.


10.3. Health disparities
Disparities in health and healthcare access are increasingly prominent concerns for research
and practice (Gibbons, 2005).

There is little consensus on the cause of these disparities, but many believe it is related to
socio-cultural, behavioral, economic, environmental, biological or societal factors (Gibbons,
2005). While the social and physical factors are increasingly a focus in the advancing research,
the role of the information environment has been neglected in the scientific inquiry (Viswanath
and Kreuter, 2007).

eHealth has been proposed to ameliorate health disparities. Authorities have suggested greater
research and investment in information technology for particular functions (Gibbons, 2005):
                                                                                                     37


      Improve health communication. The Institute of Medicine has called for initiatives that
       may enhance patient-provider communication, trust and cultural appropriateness of care
       (Smedley et al., 2003 cited in Gibbons, 2005).
      Deliver interventions such as behavior change support.
      Improve access to quality information. The real-time and anywhere access of electronic
       information may be more accessible than traditional, print materials.

In hopes that eHealth will help “eliminate, not exacerbate” health disparities, Viswanath and
Kretuer (2007) recommend a research agenda that:
     Identifies and articulates specific disparity issues
     Enhances survey sampling and measures to address disparities
     Critically examines eHealth and communications policies that could affect health
       disparities

Issues of social justice and disparities have been addressed in codes of ethics developed for
eHealth (Wyatt and Sullivan, 2005).


10.4. eHealth literacy
eHealth literacy is “the ability to seek, find, understand, and appraise health information from
electronic sources and apply the knowledge gained to addressing or solving a health problem”
(Norman and Skinner, 2006). There are six literacy types that form the foundational skills for an
optimum eHealth experience (Norman and Skinner, 2006):
    1. traditional literacy and numeracy
    2. media literacy
    3. information literacy
    4. computer literacy
    5. science literacy
    6. health literacy: “the degree to which individuals have the capacity to obtain, process and
        understand basic health information and services needed to make appropriate health
        decisions” (Office of Disease Prevention and Health Promotion, 2006)

The first three skills address analytical skills while the final three are context-specific skills
requiring specialized training. Norman and Skinner have identified specific problems for each
skill set and recommend ameliorative resources (2006).

There is a measurement tool for eHealth literacy. eHeals, the eHealth Literacy Scale, was
designed to (1) assess self-perceived skills in using information technology for health, and (2)
determine the fit of eHealth programs with consumers (Norman and Skinner, 2006, eHeals).
The scale consists of an eight item measure that evaluates the consumer’s knowledge, comfort
and perceived skills at using electronic health information for health issues. The measurement
has undergone empirical validation with a youth population (Norman and Skinner, 2006,
eHeals).
                                                                                                     38



11. Future research
Table 9 lists the gaps, problems and needs in cell phone eHealth research and outlines the
related research questions.
Table 9. Areas for future investigation
 Gaps / problems / needs                   Research topics                        Supported by
                                                                                   researchers
Appropriate use of cell           Identifying critical components and        (Office of Disease
phone eHealth                      optimal conditions for use                 Prevention and
                                                                              Health Promotion,
                                                                              2006)
Civil liberties: privacy          Protecting privacy of electronic           (Office of Disease
infringement                       health information                         Prevention and
                                  Public policy development                  Health Promotion,
                                                                              2006)
Effectiveness of cell phone       Cost effectiveness                         (Kaplan, 2006)
eHealth                           Health outcomes                            (Office of Disease
                                  Evaluation                                 Prevention and
                                  Usability                                  Health Promotion,
                                                                              2006)
Effects on the patient and        Stakeholder analyses                       (Oh et al., 2005)
the provider                      Ethnographic studies
Evaluation methods and            Addressing concerns regarding the          (Ahern et al., 2006)
challenges                         sensitivity, validity and reliability of
                                   outcome measures
                                  Application of rigorous
                                   methodologies such as controlled
                                   trials
                                  Diverse sampling
                                  More qualitative studies
Health disparities                Addressing gaps in healthcare              (Ahern et al., 2006)
                                   access
Health information behavior       Information use, processing,               (Jones et al., 2005)
                                   sharing and control with technology
Inconclusive studies and          Systematic reviews and meta-               (Kaplan, 2006)
mixed results                      analyses
                                  Continued research
Poor understanding of the         User needs, perceptions,                   (Strecher, 2007)
user’s experience                  experiences, characteristics and
                                   expectations
Regulation and policies           Review of telecommunications and           (Kaplan, 2006)
supportive of eHealth              healthcare policies
Technical quality                 Linking research with system               (Office of Disease
                                   development                                Prevention and
                                  Interoperability                           Health Promotion,
                                                                              2006)
                                                                              (Ahern et al., 2006)
                                                                                                     39


Gaps / problems / needs                    Research topics                     Supported by
                                                                                researchers
Thoughtful and participatory      Stakeholder needs, priorities and       (Kaplan, 2006)
eHealth development by             perspectives                            (Office of Disease
stakeholders                      Diffusion and dissemination of          Prevention and
                                   technology                              Health Promotion,
                                  Building viability and sustainability   2006)
                                  Quality of eHealth tools and            (Pagliari et al., 2005)
                                   services                                (Ahern et al., 2006)
                                  Evidence-based strategies               (Strecher, 2007)
                                  User involvement
                                  Integration of eHealth with other
                                   health informatics developments
                                  Consensus and standardization
                                  Multidisciplinary collaboration
                                                                                                 40



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