EHealth has many proven and potential benefits, but there are still many barriers that need to be overcome. One way to overcome these barriers is to employ a holistic approach towards eHealth development and evaluation.
In 2011, a review on the potential and limitations of existing eHealth frameworks was conducted to find their value in overcoming these barriers (van Gemert-Pijnen et al., 2011). A main outcome was that these kinds of issues are expected to be avoided by applying a participatory development process that creates a good fit between technological, human and contextual factors. However, most existing frameworks were found to have a rather conceptual approach instead of practical guidelines, and lacked the stakeholder-driven approach that is required in eHealth development (van Gemert-Pijnen et al., 2011).
Based on this review and prior research, a holistic approach was proposed. Holism in general refers to the notion that individual elements in a complex system are determined by the relations they bear to the other elements. This means that all aspects of a larger whole are interrelated, and separate analysis of its parts should be avoided (James, 1984). For eHealth development, this means that constructs as technology, people and context are all interrelated and interdependent, and are all part of one whole instead of separate elements (Van Gemert- Pijnen et al., 2011).
Such a holistic approach is required since eHealth is much more than a thing or tool. It entails creating an infrastructure for supporting health, organizing care, disseminating knowledge and communication via technology. eHealth developers should be aware of the impact that technology can have on people (patients, citizens, healthcare professionals, policy makers) and their socio-cultural context (healthcare organization, homes). Approaches such as participatory development, human centred design, business modelling and persuasive design can be combined into a framework that supports the developers in this. The CeHRes Roadmap does just that: it combines these approaches and thus provides a framework to develop a technology that fits the human and contextual perspective. The Roadmap is underpinned by five pillars of eHealth development, which are based on existing frameworks, insights from practice and empirical research (van Gemert-Pijnen et al., 2013; van Gemert-Pijnen et al., 2011).
These pillars are described here:
Many eHealth technologies are known to have acceptance problems, which can be attributed to insufficiently meeting the needs of users (Eysenbach, 2008). To prevent dominance of experts when making decisions about development, and to account for the user and context, stakeholder participation is essential (Belt, Engelen, Berben, & Schoonhoven, 2010). In this so-called participatory development, stakeholders are involved during the entire development and evaluation process. These stakeholders include the users, but other stakeholders are essential for a proper development, implementation and evaluation as well. Merely involving users might cause a dominance of the user-perspective (Bødker, Kensing, & Simonsen, 2009) and can lead to overlooking the needs of other stakeholders who will use, implement, or be in any way involved with the technology.
Development ‘with’ instead of ‘for’ stakeholders entails their active involvement in activities related to the development, implementation and evaluation of eHealth. Their roles can range from informant to actual co-creator (Scaife, Rogers, Aldrich, & Davies, 1997; Yip et al., 2013). Stakeholders help to create the technology by means of being involved in activities like identifying their needs for the technology, improving the technology based on their input, or identifying critical issues for implementation (Carr, Howells, Chang, Hirji & English, 2009). However, participatory development does not always have to be about creating new technologies. Existing technologies can be re-designed and re-used in different contexts, and it is important that stakeholders are involved in that process as well.
eHealth development is not a linear process with consecutive steps. It is an iterative, flexible and dynamic process, during which constant changes can be made to development activities and their results. Consequently, evaluation should also be seen as a cyclic, longitudinal research and development activities interwoven with all development phases, without a fixed end. This means that evaluation doesn’t only take place at the end of the development process; just like implementation it is not a post-design activity. Formative evaluation already starts at the beginning of the development and continues during every development activity. Each product of a development phase can and should be critically checked, analysed and evaluated and adapted based on the results of this formative evaluation. It can take on different forms, for example, verifying outcomes of a phase with users, checking the relation with the outcomes of previous phases, or gathering stakeholder’s opinion on a specific idea. In every case, its main goal should be checking that the outcomes of activities still match the context, stakeholders, and outcomes of previous phases. Formative evaluation provides concrete tools to further improve the process and technology, in order to reach an optimal fit between technology, stakeholders and context.
Furthermore, much eHealth research focuses on evaluating the effectiveness of an implemented technology to make claims about whether the goals have been reached. Less attention is paid to outcomes related to the healthcare context and the interaction between the user and the technology, which can be seen as equally important. Just like eHealth development, evaluation should be holistic: it has to focus on the technology, users, and the context. Also, evaluation does not have a fixed end-point, since its results can be used to further improve or change a technology. Once implemented, a technology is not fixed, but can be redesigned. These improvements or changes should be evaluated as well, and again, more changes can be made based on the outcomes of the new evaluation cycle. Evaluation doesn’t have to be the end-point of the development process, since a technology is never really finished. This requires an iterative, flexible and dynamic view on evaluation.
The use of eHealth technology is never isolated, but is influenced by and influences the context in which it is used. In the case of eHealth, the context differs, for example, ranging from hospital and its organization to a user’s home and personal life. For eHealth technologies to reach their potential, a good fit with this context is required. Consequently, eHealth development creates novel structures and processes for healthcare delivery; an ecosystem for healthcare emerges. eHealth reshapes healthcare, since it intervenes with traditional healthcare characteristics. Some of these changing characteristics are a change in place- dependant delivery, a new division of labour, new regulations for the use of technology, financing, and a shift from hospital to home-based care.
eHealth can be used for multiple purposes: to support self-management behaviour, to educate, to share personal information, to influence attitudes, or to facilitate communication between people. But regardless of its main goal, all eHealth technologies have in common that they are always used by people. These people expect technology to support them in doing the right thing, show understanding, giving them information that is relevant for themselves, rewarding their behaviour, and being easy and intuitive to use. People often have to be supported in changing their behaviour and attitudes, and technology has the potential to do this.
Persuasive technology is technology aimed to influence behaviour and attitudes. This refers to behaviour and attitudes that contribute to an improved health and wellbeing, but also to behaviour and attitudes related to (the use of) the technology. Persuasive technology can have a positive influence on using the technology in the intended way and on the long term; it has the potential to improve adherence (Kelders, Kok, Ossebaard, & Van Gemert-Pijnen, 2012). If a technology is used in the right way, it is more likely to reach its health-related goals. In other words: persuasive technology supports people in improving their health and wellbeing by using the system in the intended way.
Too often, implementation is seen as post-design activity that is executed only after the design of a technology or other kind of product is finished. However, current visions on eHealth development state that implementation plays an important role right from the start. As we have discussed, many issues can arise during implementation in practice (Broens et al., 2007; May et al., 2007). If these potential implementation issues are identified during the earliest stages of the development process, they can be addressed before the actual implementation starts. Decreasing, making a plan to account for, or eliminating these implementation issues before implementation reduces the chances of them having a negative effect on the implementation.
Also, involving the perspective of the users, other stakeholders and the context from the beginning increases the chances of a good fit with the technology, which in turn increases the chances of a smooth implementation process. The better the fit and interrelationship, the higher the chances of successful implementation in practice. This means that actively involving stakeholders in the development process and making sure their needs are incorporated in the technology contributes to implementation as well.
