A systematic review of reviews to identify key research opportunities within the field of eHealth implementation

Challenges

The identified challenges to the implementation and utilisation of eHealth are as follows:

C1: stakeholders and system users. The functional and non-functional requirements along with the best interests of individual stakeholders should be better integrated into the design and implementation of eHealth applications. There is a need for active involvement and collaboration from all those involved, therefore requiring understanding between all those concerned as well as combined participation and familiarity with associated processes. ⁵ For eHealth to progress, key factors relating to the end-user such as their attitudes,^6–8 and their education^9–12 prior to implementing an eHealth service should be considered. However, additional factors such as the level of training provided to an end-user^7,9,13 after an eHealth service has been implemented should also be considered. Further barriers such as negative user engagement and technological disconnect^14–17 need to be measured and can be overcome by putting greater importance on the development of new user skills as well as uniting such ideas with organisational changes, for example, providing regular on-the-job training (theory and practical). The examined literature consequently emphasises the significance of the role of end-users and therefore highlights the importance of user-centred design, that is, to develop an improved appreciation of the design and development process from the user's point of view and to focus on developing a detailed representation of the user's perspective. ¹⁸

C2: technology and interoperability. Challenges surrounding integration/interoperability^19–24 and standardisation of technologies/lack of data standards^9,25,26 were two barriers that appeared often in the analysed set of literature. Interoperability should allow for the unified integration of varied technologies to enable secure and fast access to health data and to patient information situated in different locations. However, the barriers identified also suggest a need for the standardisation of system components and services so that healthcare providers can avoid issues such as lack of data standards permitting the exchange of clinical data. ²⁶ One such recent technology that can be used to overcome such hurdles is Fast Healthcare Interoperability Resources (FHIR). FHIR is the latest standard developed by HL7, which describes data formats and elements known as resources and provides users an application programming interface for the exchange of electronic health records. The literature also states that despite the availability of eHealth interoperability, data standards adoption has been slow and requires more effort and commitment to progress its growth. Barriers such as user friendliness, user interfaces^7,27 and legacy systems, ²¹ which still play an integral role in everyday healthcare service delivery, contribute to this problem. This highlights the discrepancy and potential of developing interoperable and standardised technologies ²⁸ that facilitate developing user-friendly, engaging and easily accessible eHealth applications. ²⁹

C3: cost-effectiveness and sustainability. The availability of funding^30,31 and other resources^11,32 directly contributes to the impact of the other identified categories of challenges as well as how well implemented a solution is in practice. Many of the costs are associated with the development of eHealth services and technologies throughout the system development life cycle, such as the costs associated with deployment and training ⁹ as well as the cost of ongoing maintenance of the service or technology in question. A lack of sustained and sufficient funding from stakeholders such as governing bodies, for example, the government, ³³ indirectly affects the quality of service that healthcare providers can give their patients. A further problem, agreeing on reimbursement, ²⁴ can be a challenge for new technologies, especially as they are of unproven value, ⁷ and when some technologies are initially viewed as too expensive to integrate into everyday clinical practice. ³¹ The literature, therefore, highlights the need to improve cost effectiveness and avoid initiatives that are considered wasteful. ³² The literature also recommends that future eHealth programmes should demonstrate the cost effectiveness of eHealth programmes. ²⁵ A further recommendation is for new initiatives to invest in developing areas of eHealth and emerging trends such as in the field of social computing, deep learning and Internet of things.

C4: legal clarity and legal framework. Another major area of challenge revolves around the legalities and legislation involved when developing and introducing an eHealth solution into everyday clinical practice. Legal challenges^9,21,34 such as the lack of a legal framework can limit end-user confidence and need to be addressed prior to any implementation. Legal barriers appear to emerge over time, and the growing use of eHealth technologies and services makes predicting and preventing them a challenge. There is also the responsibility of adapting to changing legal barriers, for example, when a law has been updated or amended. In terms of security, the obligation for confidentiality ⁷ and clarity around health data ownership^23,35 indicate these should be considered carefully and specified in the documentation accompanying the design and implementation of an eHealth application. The literature discusses how end-users prefer using tools and services safe in the knowledge that their privacy is being protected and is not being compromised.^9,23,36 However, a grey area that has not been discussed or elaborated upon by the analysed set of literature, and requires further examination, is liability. An example of this is in the case of unwanted events such as technical failures or other circumstances that result in severe harm to a patient and/or to their personal information.

C5: organisational context and regional differences. The final key barrier to note from the literature is that of challenges that arise from within the local environment and challenges that affect different demographics. The analysed literature reveals that first-world citizens have comparatively more wealth and resultantly better education, ²² whereas the developing world is often faced with hurdles such as larger populations ³⁷ and larger geographical areas to cover,^11,37 as well as slower internet adoption rates. In terms of population health, inequalities also exist between urban and rural areas in less developed countries.^11,37,38 However, a problem that exists globally is that even within regions, there can be challenges due to local organisational context.^6,15,37,39 Different hospitals and healthcare centres, for example, adopt and practice their own rules and regulations. ¹¹ These establishments are also tied to organisational bureaucracy, human resources, ⁶ various unconnected information and communications technology (ICT) systems and services ¹¹ and organisational workflow support. ²⁰ One key message from the literature suggests that numerous organisations fail to acknowledge that many barriers to the implementation and utilisation of eHealth lie within the organisation itself. ⁴⁰ For eHealth to advance healthcare services in this area, the literature recommends that eHealth applications could potentially be implemented at a level above existing organisation-centred and process-controlled systems.

Opportunities

The identified opportunities for the implementation and utilisation of eHealth are as follows:

O1: participation and contribution signify the need for communities and backing stakeholders (both internal and external) to participate in active policy forums and knowledge generation. ¹⁵ Not only will this help stakeholders to understand each other's viewpoints but it will also establish a shared platform. Within this category key areas of discussion and interest as stated in the literature include identifying funding and resourcing, ³² agreeing upon policy and practice,^7,32,37 establishing standardisation^7,19,32 and data sharing. Another area of interest is the research into improving and maximising access to healthcare data and relevant health information through online ⁴¹ and information technology (IT) services. ¹⁴ As mentioned previously, one way this could be tackled is by using standards such as HL7's FHIR. The literature recommends that discussion and development efforts will need to take place throughout several scheduled and recorded meetings, therefore allowing all stakeholders sufficient time to come to mutual understandings and common agreements. Further discussion areas include recognising and addressing the factors that affect the healthcare system from a governing perspective and clarifying where eHealth fits into the continuum of care.^7,15 There also seems to be a great need to develop eHealth policies and strategies on a national level, which can be addressed by forming special bodies responsible for developing an integrated plan for the implementation of eHealth initiatives. ⁶

O2: foundations and sustainability relate to all the work surrounding building the initial infrastructure of any eHealth project. It also relates to the establishing of IT architectures and services as well as targeting appropriate design and delivery of eHealth projects. ¹⁴ Within this category, key areas surrounding foundation include connectivity,^14,19,32 health centre infrastructure^22,42 infrastructure management, ⁷ eHealth network^20,22 and shared services and integration.^20,22 There is also a need to improve and enhance information security and privacy, along with the development of relevant laws and regulatory frameworks. Stakeholders of eHealth projects should also consider how they would overcome challenges that arise due to barriers associated with liability. A gap identified from the literature was the need to make more data available for secondary use, such as research and the development of more uniform guidelines. ⁴³ Further gaps also highlighted the need to improve existing IT architecture and the usability of IT systems themselves. In terms of sustainability, an imperative here was to create and achieve economies of scale, to ensure both combined and local efforts are long lived. ⁷ By doing so it is intended that this will help stakeholders see the implications of any key decisions they make, especially for those that would influence the direction of growth of an eHealth project.

O3: improvement and productivity relate to the service delivery provided to the public, more specifically, to opportunities where eHealth offers a supplemental or improvement to healthcare services, thus, maximising the benefits of these existing services. The emphasis is on improving the efficiency and effectiveness of eHealth solutions and healthcare services^44–46 along with the responsibility to develop process support and change management. The argument here is that there are already enough eHealth solutions used in everyday practice, but we need to improve upon these solutions so they are being utilised well into the long term. ⁴⁷ Within this category, the areas of interest include alternate service delivery models, ³⁵ decision support, ²⁹ telehealth/telemedicine ²⁹ and supported peer collaboration. The literature also indicates that many systems fail to fulfil security, patient privacy, data ownership ³⁸ and data quality requirements, ⁴⁸ highlighting these and similar areas that need to be considered and addressed before the implementation of any eHealth project. Researchers and developers also need to learn how to apply these eHealth tools and services fully to extend their ability to study and influence health behaviour as well as engage patients.^44,49 They also need to ensure these solutions achieve the intended effects set out at the inception of the project. ⁵⁰

O4: identification and implementation relates to the recognition of eHealth applications and subsequent implementation into routine practice. Clinical decision support systems and community-appropriate information management solutions for patients and the public are two examples of where information processing can contribute to better models of care. In this category, key areas of interest include exploiting the use of EHR/EMR, ³⁶ public health information^12,16 administrative and information systems^20,25 and performance monitoring and benefits evaluation.^17,22 According to the literature, the introduction of new solutions into daily healthcare practice is still lacking or missing.^20,22 Other literature argues that there are too many solutions in practice, regardless of whether they deliver the intended results. Implementing solutions listed in the above key areas of interest could narrow this gap as well as open further opportunities for novel and innovative solutions. The literature also highlights the fact that many solutions either fail to offer ease of use or are not considered affordable, everyday solutions. Therefore, supporting a growing demand for original eHealth solutions that are easy to use and good value but also provide users with a range of societal benefits ²⁹ needs solutions that lie at the heart of exploiting the potential of ICT to improve public health.