A Model for Measuring e-Health Status Across the World

Background

The application of information and communication technology (ICT) in the healthcare industry, which is known as e-health, aims at improving the efficiency, effectiveness, accessibility, and quality of healthcare services. ¹ The successful development and deployment of e-health could also facilitate aspects such as public health management, education, and research. However, there are noticeable differences in applying e-health in different countries. In developing countries, inadequacy or a lack of investment in e-health is an important issue because these countries might still struggle with meeting individuals' primary needs such as housing, food, and education. ² In contrast, developing countries have been benefiting from ICT in different areas such as education and healthcare to improve better service delivery to their citizens.

e-Health, as the term suggests, is heavily built on ICT infrastructure, including equipment, network, and communication standards. ³ Reports by the International Telecommunication Union (ITU) in 2009 and 2010 showed that according to the level of development, the average ICT Development Index Indicator was about 6.5 for developed countries and a little above 3.0 for developing ones. ^4,5 Developing the infrastructure for e-health and providing supportive procedures including maintenance services require considerable financial allocations for healthcare. The shortage of financial resources, however, has been a barrier to e-health developments, in particular in developing countries. ⁶ An ITU report revealed that developed countries enjoy the benefits of e-health programs more than developing countries. ¹ Therefore, the economic capacity of a given country has a pivotal role to play in determining the status of e-health in that country. ⁷ There are three factors influencing e-health status: health level, ICT potential, and economic capacity. International organization such as the WHO, the ITU, and the World Bank (WB) periodically grade countries based on these factors.

In 2000, the WHO graded the health status of its 191 members based on a performance improvement indicator of health systems. ⁸ It is notable that there has not yet been any update for the mentioned indicator and ranking. ⁹ This indicator is composed of subindicators, such as health level, health distribution, responsiveness distribution, and financial fairness. ⁸ In 2010, the grading of 159 countries by the ITU was based on development of ICT as an indicator. On this basis, the ITU divided countries into four groups: high-income countries, countries with upper middle income, those with lower middle income, and low-income countries. ¹⁰

Although e-health is a global approach and different countries have already set strategies for developing health information infrastructure, there are still noticeable differences in developing and deploying e-health worldwide. Determining the e-health status of countries, developing indicators, and presenting a measurement model for e-health status can help to identify the differences seen in different countries, in terms of e-health developments. ^11,12 This in turn could help to ease the development and deployment of e-health programs. There have been studies by international organizations regarding the e-health status of countries. For example, the ITU determined the e-health status of 10 and 22 countries in 1999 and 2006, respectively. ^13,14 In 2007, the United Nations Economic and Social Commission for Asia and the Pacific considered the e-health status of some Pacific and Asian countries. ^15,16 In addition, the Inter-American Telecommunication Commission considered the e-health status of some American countries in 2003. ¹⁷ In 2005 and 2007, the European Commission in its plan on e-health asked its members to report their e-health status annually. ^18,19 In 2006, the WHO published a report on the e-health status of 112 member countries. ¹¹ It is interesting to note that none of the organizations and bodies mentioned created e-health measurement indicators for grading e-health status, and this motivated us to conduct the current study, which aimed to present a model for assessing e-health status.

Materials and Methods

This research was conducted using a cross-sectional design in which the e-health status of different countries was studied considering three influential factors: health level, economic capacity, and ICT potential. Among these factors, the ICT potential is of great significance. In this study, the required data related to the e-health status in Iran and other countries were gathered through reviewing documents ^3,5,18 and reports ^11,14,19 related to e-health and information technology (IT) management.

The review of the documents together with seeking experts' opinions led to developing a data-gathering tool composed of five main indicators for assessing e-health status. Having IT capabilities and the experience of managing medical informatics and e-health projects were regarded as the criteria for selecting the experts. The experts' opinions were sought using a questionnaire (Table 1). The questionnaire addressed the e-health key aspects, such as the availability of information centers, running courses on medical informatics, and national e-health programs and projects. Each key aspect was composed of a set of indicators and their related subindicators, which were regarded as “e-health status indicators” (EHSIs).

An attempt was made to assure that EHSIs could address a wide range of options, including a minimum and maximum range of facilities indicating e-health status. The experts were asked to indicate whether they agreed or disagreed with including each indicator in the model and to give a weight coefficient between 1 and 10 to each indicator. The average of the weight coefficient was ultimately considered as the score of each indicator. Then, a total score ranging from 0 to 45 was calculated for each country, and based on the total score, the countries were divided into five groups—very low (0–9), low (10–18), middle (19–27), high (28–36), or very high (37–45)—in terms of e-health status. In the last step, the model was examined in a pilot study; the ITU ranking approach ⁵ in which countries are divided into four groups (high income, upper middle income, lower middle income, and lower income) was used as the basis for sampling, and almost one-third of each group was selected randomly. As a result, 13 of 33 countries from the high-income group, 9 of 33 countries from the upper middle-income group, 12 of 48 countries (including Iran) from the lower middle-income group, and 12 of 47 countries from the lower-income countries were selected. Finally, the selected countries were ranked from 1 to 20 based on their total scores and the group that they belonged (Table 2).

Based on the experts' opinions and the approaches noted above, a measuring tool was developed that was sent to several experts in the field, and their comments were applied. The reliability of the tool was tested through using the test–retest method (r=0.84).

The indicators of the scoring guide (EHSI) include:

• The indicator for medical informatics education or health informatics included two subindicators, and each of these had an independent score. If a country had two mentioned subindicators, the subindicator with the higher score would be considered.

Results

The present study led to developing a measuring tool and a method for assessing e-health status, and ultimately an e-health model was proposed highlighting key aspects influencing e-health developments. Table 1, which shows e-health status indicators and their related weight coefficient, was used as a scoring guide.

Table 2 presents scores and the e-health status of studied countries based on e-health status indicators. Countries such as Austria, England, Germany, United States, Belgium, Sweden, The Netherlands, Finland, and Spain had the highest score, staying at the top of Table 2. Some countries, such as Ethiopia, Nepal, and Mozambique, as seen in Table 2, are located at the bottom (score of 7 and rank of 20). Several countries, including Iran, Cyprus, and Lithuania (score of 25 and rank of 11), are placed in the middle group.

Table 3 compares the e-health status ranking scale with ranking scales by the ITU (ICT Development Index Indicator scale), WB (income scale), and WHO (health scale).

Discussion

The results of this study are in line with the universal ranking systems that suggest that e-health development is influenced by three key factors: ICT potentials, health level, and economic capacity. The results showed that 83% of the countries that are regarded as very high level and 44% of the countries that are considered as high level based on the ITU ranking scale would also be placed in the very high and high groups according to the e-health status ranking scale. In addition, 46% of the middle-level countries in the ITU ranking scale are seen in the middle group of the e-health status ranking scale. Similarly, 81% of countries that were graded as low-level countries according to the ITU ranking scale were also considered to be in the low and very low groups of e-health status ranking.

e-Health cannot exist without ICT infrastructure, which consists of networking facilities, hardware equipment, and software. In addition, the development of e-health could be facilitated by developing legal frameworks and setting related policies. However, there are problems facing the development of e-health, in particular in developing countries. In this regard, the ITU suggests that developed countries have benefited from a well-developed ICT infrastructure, whereas developing ones have not made noticeable progress in e-health implementation because of infrastructural deficits. ⁵ According to the findings of the current study, it appears that there is a relationship between the e-health status of a given country and its economic status. For example, based on the WB's ranking scale, 74% of countries with a high income level and higher than middle income level are in the very high and high groups of e-health status, and 92% of low-income level countries and lower than middle ones are in the low and very low groups of e-health status. ^10,20 This is supported by a WHO report ¹¹ suggesting the relation between e-health status and the WB's grouping of countries' income levels; this implies that those countries with a high income level and even those with a higher than middle income level have a greater chance of successful e-health developments compared with those with low and lower than middle income level. Studies also suggest differences among developed and developing countries in relation to the application of e-health. ^{7,21 –23} A WHO report ² suggested that developed and high-income countries apply ICT in providing healthcare services, training healthcare staff, and providing distant consultation for remote areas; however, developing countries, especially those with a low income level, do not apply ICT in the healthcare sector. For example, African countries that have high levels of epidemic and endemic diseases could have progressive improvement in healthcare delivery if they had more adoption of ICT in the healthcare sector. ² However, further statistical analyses are needed to confirm the relationship between income level and e-health developments and deployment in different countries.

The findings of the current study also suggest the seeming relationship between the healthcare status of a country and its e-health status, as the average grade of the health systems' performance improvement indicator was higher in the higher groups of e-health. The deployment of e-health could lead to better service delivery and fair distribution of healthcare services, ²⁴ and these are key aspects of the health systems' performance improvement indicator. ⁸ Again, further statistical analysis of the above-mentioned relationship is suggested.

Conclusions

The key aspect of the current study that makes it distinct from other studies in the e-health field is the creation of a measurement model of e-health status and suggesting a method and an instrument for assessing e-health status. The model designed could be used by international organizations and bodies such as the WHO and the ITU by providing some modifications and adding some indicators to determine e-health status. In conclusion, it can be suggested that infrastructure, the level of health, the economic capacity of countries, and developing the necessary policies play a pivotal role in e-health developments.