1) E-health provides opportunities to address challenges from changing demographics like chronic disease management and multiple morbidities, but faces challenges from incongruent policies, one-size-fits-all technologies, and treatment burden. 2) Rapidly developing technologies and increasing technology use provide opportunities if developed with user perspectives, but a biomedical focus risks widening inequalities. 3) Successful e-health requires normalizing services, engaging professionals, learning from experiences, and addressing research funding and evidence quality issues.

1. E-Health Challenges and
Opportunities
Professor Frances S Mair - Professor of Primary Care Research
Head of Section of General Practice and Primary Care
(Centre for Population and Health Sciences)
University of Glasgow
Frances.Mair@glasgow.ac.uk

2. Based on Underpinning Research
• NIHR SDO/135/2006 Understanding the Implementation and
Integration of e-Health Services. With May, Finch, Murray, Wallace,
Sullivan, O’Donnell. 2006-09.
• SFC. eHealth: Addressing eValuation, implEmentation and
integratioN (HAVEN) With Laing, Boddy, Gray, O’Donnell,
McConnachie, Sullivan, Wyatt, Godden, Heaney, Peterkin.2007-08.
• DoH. Integrating Telecare Systems for Chronic Disease
Management in the Community: What Needs to be Done? With May,
Rogers, Finch, Exley, Cornford, Kirk, Robinson. 2007-09.
• CSO. Identifying and understanding the role of boundaries in
facilitating or preventing e-health implementation in health and
social care: a case study approach. With; O'Donnell. Boddy, Heaney,
King. Ongoing.
• And a decade of DoH funded work with May and Finch.

3. What Do I Mean By e-Health?
• Management Systems
• Communications Systems
• Decision Support Systems
• Information Systems.

4. Management Systems

5. Communication Systems
• Examples are telemedicine and telecare applications.

6. Copyright ©2005 BMJ Publishing Group Ltd
Sullivan, F. et al. BMJ 2005;331:955-957
Computerised Clinical Decision Support
• For e.g. Decision support for hypertension

7. Information Resources

8. What are the Opportunities?
1. Policy Context
2. Changing Demography
3. Chronic Illness
4. Multiple Morbidity
5. Rapidly Developing Technologies
6. Increasing Use of Technology Generally
7. Abundance of pilot and demonstration projects to
learn from
8. Growing Evidence Base
9. Research Funding To Support New Developments

9. Opportunity – 1 Policy Support
– NHS Plan
– Delivering for Health
– ‘Self-Care – A Real Choice’
– Our health, our care, our say: a new direction for
community services.
– Our NHS Our Future – Darzi review
– Better Health, Better Care Action Plan 2007.
– E-Health Strategy 2008-2011.
– President Obama wants to computerize the nation's
health care records in 5 yrs as evidenced by the Health
Information Technology for Economic and Clinical Health
(HITECH) Act

10. Opportunities 2 + 3
• Changing demographics and
health care challenges

13. Need to Move From Reactive to Proactive Models of Care
Healthcare is still largely built around an
acute, episodic model of care that is ill-
equipped to meet the requirements of
those with chronic health problems.

14. Chronic Illness – NOT JUST THE OLD!
• The idea that chronic illness is an “old people’s” fate no
longer applies.
• Increasing numbers of young and middle-aged people are
developing some form of chronic health problem.
• Recent evidence from the USA points to a rapid increase
in the number of children and teenagers with chronic
health conditions since the 1960s, in particular as a
response to growing levels of obesity.
Perrin, J., Bloom, S. and Gortmaker, S. (2007) The increase of childhood chronic conditions
in the United States, JAMA, 297: 2755–9.

15. Opportunity 4
Multiple Morbidity

16. Chronic Disease a Growing Epidemic
• One of the greatest challenges that will face health
systems globally in the twenty-first century will be
the increasing burden of chronic diseases (1).
• An estimated two-thirds of those who have
reached pensionable age have at least 2 chronic
conditions (2,3).
1. WHO (2002) Innovative Care for Chronic Conditions: Building Blocks for Action. Geneva:
WHO.
2. van den Akker, M., Buntinx, F., Metsemakers, J., Roos, S. and Knottnerus, J. (1998)
Multimorbidity in general practice: prevalence, incidence, and determinants of co-
occurring chronic and recurrent diseases, J Clin Epidemiol, 51: 367–75.
3. Wolff, J., Starfield, B. and Anderson, G.F. (2002) Prevalence, expenditures, and
complications of multiple chronic conditions in the elderly, Arch Intern Med, 162: 2269–
76.

17. Impact on Health Care Utilisation
In England, people with chronic illness account
for 80% of general practice consultations and
approximately 15% of people who have three
or more problems account for nearly 30% of
inpatient days
Wilson, T., Buck, D. and Ham, C. (2005) Rising to the challenge: will the NHS
support people with long-term conditions? BMJ, 330: 657–61.Wilson et al. 2005.

18. E-Health Can Provide Solutions
• Telecare for self management
• ALTs for the frail and those with cognitive and other
impairments.
• Electronic health records to share information about
those with complex multiple morbidity
• CDSS’s that can help health professionals deal with
complex patients
• The Internet – a valuable resource for patients,
carers and professionals.

19. Opportunity 5 – Rapidly Developing Technologies
• Increasing speed of communications and of
access to information allowing increased capacity to
transfer data e.g. Full motion video is now available
on mobile ‘phones and personal digital assistants
(PDAs) with sufficient speed and resolution to be
used in healthcare
• Rapidly developing area of personal and
ubiquitous computing e.g. GPS and “smart toilets”

20. Rapidly Developing Technologies Examples
• Ongoing improvements in Healthcare analytics
tools – when information is digitized and networks
established, HPs are able to analyze health data across
an array of various populations to facilitate faster
diagnosis and treatment. E.g. CDC National Electronic
Disease Surveillance System (NEDSS) which plays a
vital role in the investigation of outbreaks and the
monitoring of disease trends.

21. Opportunities 6 – Increasing use of Technology
• In the UK digital TV uptake has reached 90%
of the population
• In 2000 15,400,000 Internet Users (26.2%)
• In 2005 35,807,929 Internet Users (59.8%)
• In 2010 51,442,100 Internet Users (82.5%)1
1.http://www.internetworldstats.com/eu/uk.htm

22. Opportunities 7 –Experience From Pilots/Services
• CfH
• GPASS
• Lots of Telecare and Telemedicine
Pilots
• SSA

23. Opportunities 8 - Growing Evidence Base
• A systematic review of the benefits of home telecare
for frail elderly people and those with long-term
conditions. Barlow et al. 2009. From Database of
Abstracts of Reviews of Effects (DARE) – Concluded that
telecare improved care for frail elderly people and people
with chronic conditions
• Structured telephone support or telemonitoring
programmes for patients with CHF. Inglis et al.
Cochrane Database of Systematic Reviews 2010 –
Concluded – this type of monitoring effective in reducing
risk of all-cause mortality and CHF-related
hospitalisations in patients with CHF; improve QoL and
reduce costs.

24. Opportunities – 9 Research Funding
Wide range of e-Health funding opportunities:
• Technology Strategy Board
• EPSRC
• Wellcome Trust/DoH Health Innovation
Challenge Fund
• NIHR
• MRC

25. What are the Challenges?
1. Incongruent Policies
2. One size fits all approach to technology
3. Problems of Treatment Burden
4. Biomedical models of technology development
5. Need to avoid widening inequalities
6. Insufficient normalised e-Health services.
7. Engaging with health professionals
8. Lack of learning.
9. Poor quality evidence
10.Research Funding not always targeted correctly.

26. Challenge 1 – Incongruent Policies
• e-Health initiatives DO NOT obviously
intersect with clinical and practice
priorities
• Thus health professionals have little
incentive to utilise e-Health and this may
underpin many of the problems related to
e-Health implementation and integration

27. Challenges 2 - One size fits all approach to technology
• ALTs to provide disease management programs that
facilitate early intervention and promote optimum
management are vital.
• We NEED personalisable systems that can be used by
those with a wide range of capabilities; and be easily
configurable based on user needs, preferences,
abilities, social and organisational contexts.
• Most new technologies follow the “biomedical model”
and neglect user perspectives.

28. Challenges – 3 and 4
1. Problems of Treatment Burden
2. Disease Centred models of technology development

29. What is Treatment Burden?
Includes:
• All interventions aimed at preventing or managing
disease and its complications, improving QoL, and
avoiding premature death.
• The sense making, logistical, organisational, enacting
and appraisal work that patients need to undertake.
• ALL SELF CARE ACTIVITIES.
Overburdened patients may be a result of complex, chronic,
comorbidities BUT ALSO RESULT FROM problems of
healthcare systems themselves1,2
1. Gallacher, May, Montori, & Mair. Assessing treatment burden in chronic heart failure patients.
Heart 2010 96 (suppl 1): 37-38
2. May, Montori and Mair. We need Minimally Disruptive Medicine. BMJ 2009, 339.

30. Patient Centred Care
• Need to move from disease centred care to patient
centred
• New technologies can just PERPETUATE these
problems BUT instead should help change the way we
deliver services.
• SO SERVICE REDESIGN NEEDS TO ACCOMPANY
TECHNOLOGICAL INNOVATION

31. Challenge 6 - Need to avoid widening inequalities
• World wakes up to digital divide By Jane
Wakefield Technology reporter, BBC News 2010.
“There is a widening gap between those with access
to technology and those without.”
• Why isn't the government closing the digital
divide? Michael Cross guardian.co.uk, 2009.
“Because it is failing to match high-level policy with
funding where it's needed”
Lane Fox's Digital Inclusion Task Force, aim to get
the 6M hardest-to-reach Britons online by 2012.

32. Challenge 7- Normalising services
• While new technologies are subject to very
rapid development, the professional,
organizational and institutional terrain on
which this technology is set in play is much
less amenable to change.
• A key problem is that of integration into
professionals’ patterns of service delivery.

33. Utilisation of E-Health by Professionals
• Complex
• Can change the dynamics of professional
roles and relationships
• Affects the organisation of clinical work
• ‘Professional resistance’ to new technologies
often reflects organisational problems at the
level of integrating new systems with existing
structures of service provision and delivery
e.g. Problems across service boundaries like
health and social care.

34. Challenge 7 – Engaging with Health Professionals.
• It is essential to communicate a clear rationale for
implementing e-Health services.
• Effective engagement with users, though known to
promote uptake and utilisation, is still not being
achieved in practice.
• Safety and reliability of e-Health systems must be
made transparent to users.
• Tensions between national and local policy priorities
are problematic.

35. Challenge 8 – Lack of Learning
• Royal Society Digital Healthcare Report 2006 Not
Heeded
• SSA using electronic health records successful in
some places but not others.
• We DON’T “DO ONCE AND SHARE”

36. Challenge 9 – Poor Quality Evidence
• Disparities between results reported in trials and those
obtained in routine clinical practice mean that much of
the reputed evidence base for clinical decisions is of
limited value (1)
• Systematic review of barriers and facilitators to e-Health
implementation demonstrate that the literature
overemphasises organisational issues and neglect
socio-technical (2)
1) Hampton, J.R. (2003) Guidelines: for the obedience of fools and the guidance of wise
men? Clin Med, 3: 279–84.
2) Mair et. al. http://www.sdo.nihr.ac.uk/projdetails.php?ref=08-1602-135. SDO Project -
08/1602/135

37. Challenge 10 – Research Funding Problems.
• Not Innovative Enough!

38. Recommendations 1
• Congruency between local and national policies and
priorities will facilitate successful implementation of e-
Health services.
• Monitoring and evaluation should be an integral
component of new e-Health services when they are
commissioned.
• Formalised mechanisms need to be put in place to
ensure ongoing 3 way dialogue between designers,
implementers and professional users.
• Ensure lessons are learned from successive e-Health
projects
• Allow for flexibility in local conditions

39. Recommendations 2
• Patient benefits and benefits to NHS, professionals
and caregivers need to be transparent
• Clear Rationale
• Collaborative/Teamworking
• Champions
• Engagement with Stakeholders
• Embed applications in normal care processes
• Adequate Resources
• Education and support- not simply about what a
system can do, but also what it cannot and not
restricted merely to the learning of IT skills

40. Concluding Thoughts
• e-Health strategy and e-Health systems need to be
embedded rather than ‘added on’
• Strategy needs to reflect an appreciation of the scale
of the implementation task
• A key issue for successful implementation of e-health
services is that of greater understanding of the
interplay between social and technical aspects of
new technological systems in the context of health
care, and how this is accommodated by users and
organisations.

41. A Challenging Agenda – but
not insurmountable!