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) 11 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 12. 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