EDITORIALS
Improving the credibility of electronic health technologies
JEWC van Gemert-PijnenI,*; S WynchankII; HD CovveyIII; HC OssebaardIV
IDepartment of Psychology, Health and Technology, University of Twente, Drienerlolaan 5, Enschede, 7500 AE, Netherlands
IITelemedicine and mHealth, Medical Research Council, Cape Town, South Africa
IIINational Institutes of Health Informatics, Canada
IVNational Institute for Public Health and the Environment, Bilthoven, Netherlands
Geissbuhler & Al-Shorbaji's call for papers on e-health is a landmark in the development of the field of e-health.1 Rising health-care expenditures, the demographic transition, the threat of infectious diseases and increasing multimorbidity make innovation in global health care delivery necessary,2 and e-health technologies are a promising innovative tool for meeting these challenges. In 2005, a World Health Assembly resolution acknowledged e-health's potential for improving health systems and safety, quality and efficiency in health care.3 E-health can also improve health equity by facilitating access to health information and services. However, the success of e-health is lagging behind expectations. Studies have shown health care innovation to be very complex and there is little evidence that e-health technologies can improve health care.4 Why is this so and how can we erase current doubts about the value of e-health?
The classic approach to e-health development has generated scepticism because it is technology-driven, thereby fostering the notion that e-health is merely about technological intervention. This has led to the design of stand-alone devices and device-based applications that ignore the complexity of real life. The classic model has also slowed the diffusion of innovations into care. Innovation calls for education and training rather than for specific applications. It also calls for better models of reimbursement and governance tailored to patient engagement and home care. The fallacy that implementing e-health is a one-step process leads organizations to budget for implementation and to neglect maintenance. This often results in financial disaster, under-used technologies and stakeholder dissatisfaction.5 No wonder evaluations show disappointing results, not to mention the fact that classic evaluation methods are seldom appropriate for assessing e-health interventions.
E-health's suboptimal impact and the rapid proliferation of emerging technologies point to the need to replace the classic e-health model with a new, "holistic" view that sees in e-health a means for reforming health care by creating an infrastructure for participation and eliminating the traditional division of labour and time-and place-dependent delivery modalities.6 Based on our experience and research, we have constructed a holistic perspective on the international evidence base needed to crank up e-health's credibility:
To optimize health care delivery, we must integrate traditional care with care enhanced by information technology and address policy barriers to e-health. This will avoid waste and replace high-cost hospital care with low-cost primary care and prevention.
To ensure safety and efficacy we must create systems that enhance treatment adherence and reduce costs. We need to introduce e-health curricula in medical and nursing schools, facilitate continuing medical education and tele-learning, and increase collaboration in health informatics.7
To make care accessible, we must enhance transparency and accountability, implement appropriate business models for e-health, and develop appropriate indicators to assess process, maturity, productivity and outcomes.
To implement evidence-based e-health interventions, we must collaborate internationally to evaluate the impacts of such interventions, generating indicators to guide investment.
Credibility is reinforced by experiences in developing countries, where e-health projects seek mainly to expand health services to poor and remote rural areas. Teleconsultations among health-care professionals are educational and save transportation costs. For instance, over 90% of patients infected with the human immunodeficiency virus (HIV) have skin lesions whose nature is indicative of the stage of infection. In South Africa, teledermatology has resulted in competent, referral-free local management of many HIV-associated skin problems.8 Many tele-education programmes for health-care workers and telesurveillance programmes for disease detection have also been successful in developing countries.9
Technologies designed for developed countries are often incompatible with developing countries' infrastructure, habits and culture. Local users must therefore develop their own e-health interventions. Disease management projects should cease being "disease-centred" and become "people-centred", with a shift from institutional care to community-and home-based care. This would entail parallel changes in funding, training, administration and treatment formats.
Now it is time to recapitulate the lessons learnt. We need a holistic approach to e-health development that is evidence-based and people-centred, that takes into account how people live within their own environments and that focuses on responding to stakeholders' needs and improving care. Clarity regarding financial responsibility for e-health interventions is important. In the recent debate on a new definition of health,10 the value of self-management was underscored. This is precisely what e-health supports. Better research is crucial, not necessarily more research.
Technological and social innovations go hand-in-hand, and the capacity for innovation is increasing in developing countries. This, together with a growth in local public-private research and development partnerships, may represent the only sustainable means of improving health systems' effectiveness in developing nations.11 E-health's potential is far from being exploited, but its proven successes are reason for confidence. 
References
1. Geissbuhler A, Al-Shorbaji N. Establishing an evidence-base for e-health: a call for papers. Bull World Health Organ 2011;89:394. doi: 10.2471/BLT.11.090274 PMID: 21673852
2. Medical devices: managing the mismatch: barriers to innovation in the field of medical devices (Background paper 6). Geneva: World Health Organization; 2010.
3. Resolution WHA58.28. eHealth. In: Fifty-eighth World Health Assembly, Geneva, 16-25 May 2005. Resolutions and decisions. Geneva: World Health Organization; 2005. Available from: http://apps.who.int/gb/ebwha/pdf_files/WHA58-REC1/english/Resolutions.pdf [accessed 7 March 2012] .
4. Black AD, Car J, Pagliari C, Anandan C, Cresswell K, Bokun T et al. The impact of eHealth on the quality and safety of health care: a systematic overview. PLoS Med 2011;8:e1000387. doi: 10.1371/journal.pmed.1000387 PMID: 21267058
5. Coiera E. Why system inertia makes health reform so difficult. BMJ 2011;342:d3693. doi: 10.1136/bmj.d3693 PMID: 21700652
6. van Gemert-Pijnen JEWC, Nijland N, Van Limburg AHM, Ossebaard HC, Kelders SM, Eysenbach G et al. A holistic framework to improve the uptake and impact of eHealth technologies. J Med Internet Res 2011;13:e111. doi: 10.2196/jmir.1672 PMID: 22155738
7. Paterson G, Shaw N, Grant AM, Delisle E, Leonard K, Mitchell Corley S, et al. Cross-Canada EMR case studies: analysis of physicians' perspectives on benefits and barriers. In: Advances in Health Informatics Conference (AHIC 2010): the realities of eHealth. Kitchener: AHIC; 2010.
8. Colven R, Shim M-HM, Brock D, Todd G. Dermatological diagnostic acumen improves with use of a simple telemedicine system for underserved areas of South Africa. Telemed J E Health 2011;17:363-9. doi: 10.1089/tmj.2010.0163 PMID: 21599529
9. Wynchank S, Fortuin J. Telenursing in Africa: In: Telenursing. Khumar S, Snooks H, editors. New York: Springer Verlag; 2011.
10. Huber M, Knottnerus JA, Green L, van der Horst H, Jadad AR, Kromhout D et al. How should we define health? BMJ 2011;343:d4163. doi: 10.1136/bmj. d4163 PMID: 21791490
11. Gardner CA, Acharya T, Yach D. Technological and social innovation: a unifying new paradigm for global health. Health Aff (Millwood) 2007;26:1052-61. doi: 10.1377/hlthaff.26.4.1052 PMID: 17630448
* Correspondence to: JEWC van Gemert-Pijnen (e-mail: j.vangemert-pijnen@utwente.nl).