Critical analysis of e-health readiness assessment frameworks: suitability for application in developing countries

Abstract

Introduction

e-Health is an innovative way to make health services more effective and efficient and application is increasing worldwide. e-Health represents a substantial ICT investment and its failure usually results in substantial losses in time, money (including opportunity costs) and effort. Therefore it is important to assess e-health readiness prior to implementation. Several frameworks have been published on e-health readiness assessment, under various circumstances and geographical regions of the world. However, their utility for the developing world is unknown.

Methods

A literature review and analysis of published e-health readiness assessment frameworks or models was performed to determine if any are appropriate for broad assessment of e-health readiness in the developing world. A total of 13 papers described e-health readiness in different settings.

Results and Discussion

Eight types of e-health readiness were identified and no paper directly addressed all of these. The frameworks were based upon varying assumptions and perspectives. There was no underlying unifying theory underpinning the frameworks. Few assessed government and societal readiness, and none cultural readiness; all are important in the developing world. While the shortcomings of existing frameworks have been highlighted, most contain aspects that are relevant and can be drawn on when developing a framework and assessment tools for the developing world. What emerged is the need to develop different assessment tools for the various stakeholder sectors. This is an area that needs further research before attempting to develop a more generic framework for the developing world.

Keywords

e-Health e-readiness assessment frameworks models developing countries review

Introduction

e-Health has been defined by the World Health Organization (WHO) as ‘the use of information and communication technologies (ICT) for health’.¹ Major components of e-health consist of electronic records (e.g. electronic health records and electronic medical records), telehealth (including telemedicine and m-health), technology-enabled learning (TEL, including e-learning and social media), e-commerce (e.g. mobile or online fee payment and insurance claims) and disease surveillance. e-Health is recognised as an innovative way to make health services more effective and efficient.^2–4 As such, implementation of e-health systems by governments and healthcare systems is growing worldwide.⁴

Even though ‘embedded’ applications are often viewed as the future of healthcare, success is not always guaranteed.⁴ Successful implementation of ICT initiatives including e-health is never easy and is cited as having a failure rate of up to 70%.⁵ Data on successes and failures for large e-health initiatives are difficult to come by. However, the available track record remains poor. The cost estimates for recent large-scale (national) initiatives in the UK (NPfIT) and USA (HiTECH) are high at £6.8 billion or $25 billion, respectively, and have been terminated as failures (NPfIT) or viewed as a questionable success (HiTECH).^6–8 Barriers to successful implementation may arise at the individual, organisational and wider levels of healthcare systems, and they interact in complex ways.⁹ Implementation failure may not be due to technology failure, but more to do with lack of readiness to use the technology. Failure usually results in substantial losses in time, money (including opportunity costs) and effort.¹⁰ Therefore it is important to assess e-health readiness of the setting (sometimes termed e-health preparedness) before implementation.

e-Health readiness has been defined as the preparedness of healthcare institutions or communities for the anticipated change brought by programmes related to ICT use.¹¹ In any setting it is important to assess potential, identify relevant strengths and weaknesses and thereby develop tactics and policies that address e-health readiness, leading to formulation and successful implementation of appropriate initiatives.¹² e-Health readiness assessment aids this process. There are several published studies and frameworks that have been presented under various circumstances and different geographical regions of the world. The aim of this study is to critically analyse published e-health readiness assessment frameworks, and to establish if any are appropriate for broad application in developing countries. In the discussion, Botswana will be used as an example because there is no such framework and the authors’ goal is to undertake an assessment in the country.

Methods

Several electronic databases (PubMed, EBSCOHOST, Google, Google Scholar, Cochrane Central, ProQuest and IEEE) were searched to locate published studies on e-health readiness assessment or preparedness. The following search terms were used: ‘e-health readiness’, ‘e-health’ AND ‘readiness’, ‘e-health readiness assessment’, ‘e-health readiness assessment tools’, ‘e-health readiness assessment frameworks’, ‘e-health preparedness’, ‘e-health’ AND ‘preparedness’, ‘e-health assessment tools’, ‘telemedicine readiness’, ‘telemedicine’ AND ‘readiness’, ‘telemedicine readiness assessment tools’, ‘m-health readiness’, ‘m-health’ AND ‘readiness’, ‘EMR readiness’ and ‘EHR readiness’. Searches included content in the title, abstract, all fields and free text. Only the first 100 Google and Google Scholar links were reviewed. The search was completed in May 2015 and updated to 31 December 2015. Inclusion criteria were that the publication was a full paper, in English, in a peer-reviewed journal, and presented a framework or model for e-health readiness assessment. The abstracts were reviewed by all authors and inclusion of papers for final review was determined by consensus. These were critiqued on their theoretical foundation, methodology used to develop the framework or model, and suitability and relevance for use in the developing world. The areas of e-health readiness addressed in the papers were categorised to determine what may be considered a full set of areas to be assessed, and the completeness of the frameworks reviewed.

Results

In total, 1830 articles or links were identified. Duplicates (182) were excluded. The remaining abstracts and links were reviewed to determine their suitability and 52 articles met the inclusion criteria. The full papers were then reviewed and 39 were excluded because the paper did not describe a method for assessing e-health readiness (Figure 1). The remaining 13 papers form the basis of this review (Table 1). Eight types of e-health readiness were identified (Table 2). Only one article addressed all the eight types of e-health readiness,³ and six articles covered six or more types (Table 3). The least commonly addressed were societal and government readiness.^3,11,18 There was inconsistent definition or description of the eight types identified, leading to overlap amongst the papers. To develop some consistency, definitions of each of the identified e-health readiness assessment types were extracted from the reviewed literature, and modified to eliminate overlap (Table 2). These enhanced definitions have been developed in a systematic way.

Figure 1.

Screening process for literature review.

Table 1.

Study designs of reviewed e-health readiness assessment papers.

Authors	Purpose of study	Methodology
Campbell et al.¹³ Origin of study: USA (developed country)	Investigation of rural health providers’ perception of telemedicine. Developing a framework for assessing their readiness to adopt the technology.	Qualitative data collected through 57 semi-structured interviews of physicians, nurses and administrative personnel (10 healthcare practices in 4 communities in 3 rural Missouri counties). All sites already had computer infrastructure and video conferencing equipment installed.
Jennett et al.¹⁴ Origin of study: Canada (developed country)	Examined the readiness of a single rural community for the implementation of telehealth services; as the first step in creating a readiness framework.	A qualitative approach using semi-structured telephone interviews and a convenience sample to collect data on telehealth readiness from experts, clinicians, and lay community; supplemented by two community awareness sessions held prior to focus group discussions. In depth interviews were also conducted with community physicians. Setting: a rural Canadian town meeting Statistics Canada’s definition of a rural community.
Oliver and Demiris¹⁵ Origin of study: USA (developed country)	Identified current use of ICT by hospice employees, and assessed their readiness for and receptiveness to the use of telemedicine or other advanced technology in patient’s homes.	An anonymous email survey using a purposive sample from seven hospice programmes in Missouri with 124 respondents. The survey instrument was based on the Organizational Information Technology/Systems Innovation Readiness Scale and the Organizational and Functioning Readiness for Change Scale.
Overhage et al.¹⁶ Origin of study: USA (developed country)	Determining communities’ readiness in creating a Health Information Exchange.	A quantitative analysis and subjective evaluation of 134 responses to an email request for capabilities issued by the Foundation for eHealth to individuals, government agencies, national associations and organisations interested in Health Information Exchange as part of their Connecting Communities for Better Health programme.
Wickramasinghe et al.¹² Origin of study: USA (developed country)	Development of a framework to assess a country’s preparedness for embracing e-health and an e-health preparedness grid for facilitating the assessment of any e-health initiative.	The framework contains four main prerequisites and four main impacts which can be used to assess a Country’s preparedness for e-health. The e-health preparedness grid consists of four quadrants that represent the possible states of preparedness with respect to the key parameters for e-health success. The grid also underscores the moderating role of the four impacts irrespective of the relative positioning on the state of preparedness of a given country.
Snyder and Fields¹⁷ Origin of study: USA (developed country)	Re-examining the psychometric adequacy of the Organizational Information Technology Innovation Readiness Scale (OITIRS), in determining the readiness of three community hospitals to implement a commercial computerised provider order entry medication safety system.	246 clinicians in 22 critical care, intermediate, and medical surgical units across three community hospitals in an integrated healthcare delivery system in Southern California. Using the 48-item OITIRS.
Khoja et al.¹¹ Origin of study: Pakistan (developing country)	Describe the process of designing and constructing e-health readiness assessment tools developed for assessing e-health readiness of healthcare institutions in developing countries.	Based on a review of literature, existing tools, and expert opinion; two tools were developed, one for managers and the other for healthcare providers.
Ojo et al.⁸ Origin of study: South Africa (developing country)	A report of a pilot of a proposed formal model for e-Healthcare readiness assessment in the developing country context.	A quantitative survey of 324 community members around some healthcare facilities within the Uthungulu Health district of KwaZulu-Natal. The model draws from change and change management theories, information technology acceptance, use, and innovation adoption theories. The model includes hierarchical index systems that were established by means of questionnaire survey and statistical analysis.
Li et al.¹⁸ Origin of study: Australia (developed country)	An e-health readiness assessment framework for electronic health records is presented.	The proposed e-health readiness assessment framework is based on integrating components from review of existing frameworks; the constructs of the framework were quantified using connected graph theory.
Rezai-Rad et al.³ Origin of study: Iran (developing country)	An e-health readiness assessment framework for Iran was presented.	A Delphi method was used to develop and test a framework, including for determining weights of the indices The framework was designed based on literature review, e-readiness assessment models, and opinions of ICT and health experts.
Qureshi et al.¹⁹ Origin of study: UK (developed country)	A review article on the determinants of e-health user readiness in the perspective of e-health in Pakistan.	The paper extracts and juxtaposes the determinants of user readiness, using review of existing research to determine the issue in the perspective of e-health in Pakistan.
Jones²⁰ Origin of study: UK (developed country)	Development and validation of a self–completed questionnaire and scoring systems to assess patient e-health readiness.	Based on four factors identified from the literature, a self-completed questionnaire (using pragmatic combination of factual and attitude questions) was drafted and piloted in three stages (the first step had 15 work colleagues and friends of the author, the second step had 20 friends and family of a research assistant, and the third had a convenience sample of 103 houses likely to have a high proportion of more elderly residents). This was followed by a final population based cross sectional household survey of 344 people used to refine the scoring system. This final step also included 17 individuals from the second step in order to assess repeatability.
Schwarz et al.²¹ Origin of study: Australia (developed country)	Explored the readiness of a remote population of New South Wales, Australia, and The Royal Flying Doctor Services South East Section (RFDS SE) to take up e-health innovations.	A convenience sample of patients sequentially attending 15 remote fly-in clinics conducted by Royal Flying Doctor Service South East Section (RFDS SE) medical officers. Completed a semi-structured telephone survey using a modified version of an established survey tool to gather quantitative and qualitative data.14 RFDS SE health staff managers were also surveyed. Information from returned surveys and telephone interviews was coded and entered into an excel database.

Table 2.

Definitions of e-health readiness assessment types.

Type of e-health readiness	Definition
Organisational readiness^{3,10,14,15,17–19,21}	Gauges the extent to which the institutional setting and culture supports and promotes awareness, implementation, and use of e-health innovations (e.g. presence of relevant policies; senior management support).
Technological/infrastructural readiness^{3,10–12,14–18,21}	Gauges the availability and affordability of ICT resources necessary to implement a proposed e-health innovation (e.g. skilled human resources, ICT support, quality ICT infrastructure and power supply).
Healthcare provider readiness^{3,10–15,17–19,21}	Gauges the influence of a healthcare provider’s personal experience; primarily their perception and receptiveness towards the use of e-health technology.
Engagement readiness^{3,10,14,18,21}	Gauges the extent to which members of a community are exposed to the concept of e-health and are actively debating its perceived benefits as well as negative impacts. It also involves gauging the willingness of members of a community to accept training on e-health.
Societal readiness^3,11,18	Gauges the degree of ‘interaction’ associated with a healthcare institution. Interaction is described by three parameters; interaction among members of a healthcare institution, interaction of a healthcare institution with other healthcare institutions, and interaction of a healthcare institution with its local communities.
Core readiness^{3,10,11,14,18,21}	Gauges the extents to which members of a community are dissatisfied with the current status of their healthcare service provision, see e-health as a solution, and express their need and preparedness for e-health services.
Government readiness^3,11,12,19	Gauges the extent to which a country’s government and politicians support and promote awareness, implementation, and use of e-health innovations (e.g. presence of relevant policies and funding).
Public/patient readiness^{3,10–12,14,18,20,21}	Gauges the extent to which members of the public and patients are aware of, and can afford and access, e-health services. It also involves gauging the influence of their personal experiences on their perception and receptiveness towards the use of e-health technology.

Table 3.

Comparison of e-health readiness types addressed by each assessment framework.

Authors	Organisational readiness	Technological/ Infrastructural readiness	Healthcare provider readiness	Engagement readiness	Societal readiness	Core readiness	Government readiness	Public/ Patient readiness	Measures considered
Campbell et al.¹³			X						1
Jennett et al.¹⁴	X	[X]	X	[X]		[X]		X	6
Oliver and Demiris¹⁵	X	X	X						3
Overhage et al.¹⁶	X	X							2
Wickramasinghe et al.¹²		X	X				X	X	4
Snyder and Fields¹⁷	X	X	X						3
Khoja et al.¹¹	[X]	X	[X]		X	X	[X]	[X]	7
Ojo et al.¹⁰	X	X	[X]	X		X		[X]	6
Li et al.¹⁸	[X]	X	[X]	X	X	X		[X]	7
Rezai-Rad et al.³	[X]	X	[X]	X	X	X	[X]	[X]	8
Qureshi et al.¹⁹	X		X				X		3
Jones²⁰								X	1
Schwarz et al.²¹	X	[X]	X	[X]		[X]		X	6
Count	10	10	11	5	3	6	4	8

X = Type of e-health readiness directly considered by the author(s).

[X] = Overlap; type of e-health readiness indirectly considered by the author(s).

Close examination showed some of the identified types of e-health readiness were actually components of, or were related to, other types. As a consequence, although a paper may not have appeared to cover all of the identified types, some of them (or aspects of them) were actually embedded within the e-health readiness assessment types applied in the paper. For example, ‘engagement readiness’ reportedly addressed components of healthcare provider readiness, organisational readiness and, in some instances, public/patient readiness, depending on the context from which it was being presented (i.e. was use of the term ‘members of a community’ intended to mean members of a healthcare institution only or the public and patients as well).^{3,10,14,18,20}

Similarly, societal readiness addressed components of healthcare provider readiness and organisational readiness. But societal readiness also impacts on public and patient readiness, so it addressed the issue of accessibility to e-health innovations by the public and patients as well.^3,11,18 Also, core readiness addressed components of organisational readiness and healthcare provider readiness.^{3,10–12,14,15,17–19,21} Yet in some instances, it also addressed the issue of public and patient readiness,^{3,10–12,14,18,20,21} depending on the context from which it was presented. Primary e-health readiness types identified directly in various frameworks, and areas of overlap, are shown in Table 3.

The theoretical foundation of the frameworks was mentioned in only three papers. The frameworks were based on: the Organizational Information Technology/Systems Innovation Readiness Scale and the Organizational and Functioning Readiness for Change Scale,¹⁵ change and change management theories, information technology acceptance, use, and innovation adoption theories,⁷ and connected graph theory.¹⁸ There was no similarity in reported approaches.

The reviewed articles also addressed e-health readiness assessment from varying perspectives, such as electronic medical records,¹⁸ telemedicine,¹⁴ rural communities,^13,14,21 or developing countries.^3,10,11,19

Discussion

Various e-health readiness assessment frameworks are available, but before a framework is chosen as suitable to conduct an e-health readiness assessment in any setting, it is essential to understand the perspective and/or assumptions followed when the framework and any associated tool(s) were developed. These perspectives were the; institutional level,^{3,11,13,15–19} community level,^10,14,21 and country level.^12,20 As a result, there is little literature evidence of authors considering the influence of the government on overall e-health readiness of a country.

This is of particular importance for developing countries where e-health readiness of a community or institution is largely impacted by readiness at the country or government level. Indeed, in many countries the government is the major custodian of healthcare services, and their willingness to support e-health initiatives will ultimately impact on each country’s overall e-health readiness. Government readiness, which includes for example, having a national ICT policy, was not commonly addressed as a measure of e-health readiness in the reviewed articles, rendering most of the frameworks largely unsuitable for assessing a major aspect of e-health readiness in many developing countries.

To assess e-health readiness comprehensively, the various components (e-records, telehealth, including telemedicine and m-health, TEL and e-commerce) must all be taken into consideration. Furthermore, readiness for one component does not necessarily translate to an overall readiness. Yet the 13 reviewed articles either assessed just one component,^{5,13–15,17,18} or assessed e-health readiness on a general basis.^{3,10–12,16,19–21}

In order to comprehensively assess e-health readiness, all stakeholders must be considered too; these include government, healthcare institutions, healthcare providers, insurers, funders, members of the public, and patients. This requires development of frameworks, and associated tools, that are relevant to each group. For example, some participants of the assessment process might not be exposed to aspects of ICT, requiring different questions asked of them. Some of the reviewed articles failed to address this issue which may result in an unreliable assessment.²² This is exemplified by Khoja et al. who developed e-health readiness assessment tools for completion by managers and healthcare providers only, but within them raised issues like political will that could only be verified by politicians themselves.¹¹ Chipps and Mars faced challenges using this assessment tool when study participants failed to respond to some questions because they were unfamiliar with specific matters raised, or because they felt they did not have the political authority to answer the questions.²² This highlights the need for group specific e-health readiness assessment frameworks and tools.²² Thus, a tool for technical officers to assess technological readiness, would be inappropriate for healthcare providers with little or no information technology background.

It is important to understand the perspective from which authors developed their e-health readiness assessment tools or frameworks. Jones developed a patient questionnaire that was clearly intended for the developed world,²⁰ which asked if patients were able to order repeat prescriptions online or if they were able to see their medical records online, clearly assuming the presence of home Internet connectivity and a healthcare sector with established e-health services.²⁰ Khoja et al.’s tools had statements that implied an e-health plan already existed for the institution being assessed.^11,22 Campbell et al.’s assessment assumes that participants have already been exposed to telemedicine services.¹³ Likewise, Schwarz et al.’s assessment was done from the perspective of a community already exposed to the concept of providing healthcare services through the use of technology.²¹ Overhage et al.’s framework used a tool based on a request for a ‘capabilities instrument’ to be completed by communities requesting funding to develop a health information exchange.¹⁶ Since most of the participants in this study were those that had submitted proposals for funding, their responses may not have reliably provided an accurate assessment of their state of readiness.

The existing frameworks and associated tools, which are largely unsuitable and have shortcomings,^3,10,11,19 cannot be readily used for e-health readiness assessment for individual developing countries. Similarly, some e-health readiness assessment studies focused on rural area settings,^13,14,21 but these were in developed countries and the dynamics of rural areas in developing countries differ greatly. None of the frameworks assessed Internet awareness among members of the public or patients. For example, in presenting their e-health readiness assessment framework for Iran, Rezai-Rad et al. included questions around ‘clear strategies and policies in government’ as well as ‘access to ICT in everyday life’ among the indices with the highest priority.³ Developing countries require consideration of assessment within the context of rural areas. Campbell et al.’s protocol could not be replicated in many developing countries, because it assumed an adequate pre-existing ICT infrastructure (to host the video conferencing equipment and computer workstations installed at all the sites for data collection prior to the investigation).¹³

Oliver and Demiris took a unique approach when assessing e-health readiness in hospice organisations.¹⁵ A shortfall of this assessment is that it did not consider the issue of affordability. In developing countries many hospices are run by non-governmental organisations and churches that struggle with funding thus it is of paramount importance to assess if such organisations could afford implementation of e-health services.

Culture and appropriateness of technology solutions are not considered in current frameworks. Unique social structures exist in many African countries which must be considered when developing e-health readiness assessment tools. In many developing countries there are community leaders as well as tribal leaders (chiefs) who can provide more appropriate information for assessing public readiness as they are very aware of the dynamics as well as socio-cultural factors at play in their communities. None of the tools addressed this concern. Furthermore, the issue of ‘technologically appropriate’ e-health solutions was not articulated.^23–26 For example, developing world countries often face power challenges characterised by frequent power outages. A construct in a framework by Ojo et al. assessed ‘available or accessible ICT and power supply’,¹⁰ highlighting the power supply challenges characteristic of developing countries.²⁸ It is therefore important to assess the suitability and appropriateness of the e-health technology to be implemented.

Eight categories of e-health readiness have been identified from the literature, all of which are relevant to developing countries. No framework directly addressed all categories. When considering possible overlap five papers addressed six or more categories. While none of the existing frameworks is suitable on its own to assess readiness in the developing country context, all frameworks had constructs applicable to the developing world, albeit in part. Accessibility to ICT, including availability and affordability of desired ICT, still remains a challenge in the developing world.²⁷ Therefore it is critical for any e-health readiness assessment framework meant for the developing world to highlight these issues as was the case with some of the frameworks reviewed.^3,10–12 There is need to build on the general shortcoming of all the frameworks, which is failure to assess readiness of different stakeholder sectors with context specific assessment tools.

Botswana as a case study

Botswana, like many developing countries, must now contend with communicable diseases, and the increase in burden of ‘Western’ non-communicable diseases (e.g. diabetes, heart disease, obesity). In Botswana both morbidity and mortality for all ages are still dominated by infectious diseases, with HIV/AIDS and other communicable diseases causing about half of all deaths.²⁹ The infant mortality and under five mortality rates remain high with year on year fluctuations,²⁹ with more than two-thirds of these deaths due to communicable diseases: diarrhoea and pneumonia being the two main contributors. Life expectancy in Botswana is estimated at 54.4 years (48.8 males and 60 females), and there is a skewed distribution of wealth in Botswana,²⁹ with 23.1% of the total population living on less than US $ 1.25 per day.³⁰

Health service delivery in the country is pluralistic, consisting of public, private for profit, private non-profit, and traditional medicine practices.³¹ The Botswana Ministry of Health is mandated with oversight and delivery of health services for Botswana, and is responsible for the formulation of policies, regulations and norms as well as standards and guidelines for health services.²⁹ In 2001, African Union member states signed the Abuja Declaration committing, amongst other pledges, to spend at least 15% of State budget on improvement of the health sector.³² Botswana has achieved this annually since 2004, the only member country to do so.³¹ Some of the budget is used to maintain the 664 healthcare facilities spread throughout the country, as well as the 1052 mobile stops. A mobile stop is a healthcare facility with limited Primary Healthcare Services as well as laboratory services (e.g. specimen collection only). Mobile stops are usually found in remote areas and are visited by a registered nurse, midwife, health education assistant and/or lay counsellors. A shortage of trained and qualified staff remains one of the major bottlenecks affecting the availability of quality healthcare in Botswana.²⁹ According to the ITU, Botswana has a mobile cellular subscription rate (active SIM cards) of 167% with Internet penetration of 18.5% compared to Africa as a region of 93% and 23%, respectively encouraging e-health implementation, including education.³³

The government is the major provider of healthcare services, and has demonstrated its commitment to the effective application of ICT for health, amongst other areas, through the National Information and Communications Technology policy (Maitlamo).³⁴ Botswana is also incorporating mobile health (m-Health) into the Ministry of Health’s long-term strategy.³⁵ However, there is as yet no e-health readiness assessment framework for Botswana, a gap that must be addressed to ensure greater success and sustainability of current and planned e-health initiatives.

Based on the study findings, a suitable e-health readiness assessment tool for Botswana would address the high level role of Government as well as the locally important roles of community and tribal leaders. It would also consider the density, distribution and literacy (general, technological and health) of the population. For example, in Botswana ICT infrastructure as well as Internet awareness and accessibility varies markedly between rural and urban areas, as well as between rural areas. In urban areas, and those rural areas closer to the only two cities in the country, ICT infrastructure is usually comparatively well established and Internet accessibility better. In contrast, communities in rural areas further away from the cities have comparatively low literacy rates, low or no Internet accessibility, and larger elderly populations, as well as individuals who may not even be aware of the Internet or wireless mobile telecommunication technologies.

The results of this study will form the evidence-base to develop an e-health readiness assessment tool for Botswana. However, insight from a broad spectrum of stakeholders must be sought to inform around issues not specifically addressed in identified e-health readiness tools, such as cost, language (over 20 are spoken in Botswana), power (availability, consistency and access) and business cases for wireless and satellite coverage.

Conclusion

Thirteen e-health readiness assessment tools and frameworks were found, each based upon varying assumptions and or perspectives. While the shortcomings of the existing frameworks have been highlighted, there are aspects of most of the frameworks that are relevant and can be drawn upon when developing a framework and assessment tools. Government and societal readiness, which includes cultural readiness, are least often assessed. These are important considerations and challenges in the developing world, as are access to and affordability of ICT infrastructure, ICT literacy and power stability.²⁷ The need to develop different assessment tools for the various stakeholder sectors, more than only managers and health care providers, has been highlighted. The area of e-health readiness assessment needs further research before attempting to develop a more generic framework for the developing world.

Footnotes

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: Research reported in this publication was supported by the Fogarty International Center of the National Institutes of Health under Award Number D43Tw007004.

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