According to this definition, eHealth is "the use of information and communication technologies (ICT) for health; examples include treating patients, conducting research, training health professionals, tracking diseases and monitoring public health" (World Health Organization 2016b). Similarly the European Commission defines eHealth as: "the use of modern information and communication technologies to meet the needs of citizens, patients, healthcare professionals, healthcare providers as well as policy makers" (European Commission 2003). For example, the opening passage of a report from the Institute of Medicine of the National Academies (US): “Health and healthcare are going digital.
In Europe, eHealth was an important component of the European Commission's eEurope Action Plan endorsed at the Feira European Council in June 2000. Most European countries have taken steps to implement e-prescribing solutions while the goal of the European Union is to have a cross-border electronic system that will enable patients to obtain electronic prescriptions anywhere in Europe (World Health Organization 2016a). Furthermore, the electronic transmission of prescriptions may allow secondary uses of the data (eg facilitating the checking and payment of pharmacy claims and the accumulation of information to support quality health care and effective cost management).
Sixteen EU Member States have already included e-prescriptions in their national strategies or e-health implementation plans in 2006; in 2011 this number was increased to 22 (Stroetmann et al. 2012). The cases are linked to the context of each country, the specificities of the healthcare systems, the technological maturity of the healthcare environment and the different institutional actors. The cross-examination of the cases can provide a number of insights on different implementation approaches and in general on the dynamics of infrastructural evolution.
These services respond to the growing interest in using the Internet as a source of health information and to the problem of the variable quality of available information.
Drivers for Patient-Oriented eHealth Projects
There is increasing awareness of the need to provide platforms that can receive and integrate this type of data, often through “third party” or non-health solutions. Overall, e-prescribing is better defined than patient-facing services in terms of functionality and in many cases is deeply embedded in pre-existing applications and prescribing tools. Nevertheless, both e-prescriptions and patient-centered services have the potential (and often the explicit goal) to transform healthcare.
Patient-centered eHealth services are typically seen as opportunities to pursue broader and more radical innovations aimed at empowering patients and facilitating the transition from provider-centric to patient-centric healthcare. E-health is therefore not only about more effective "tools" for solving certain problems, but must be considered as part of longer and more transformative processes. For example, electronic tools are changing the clinical encounter between health professional and patient (May 2007; Winthereik 2008).
These sometimes exist within the healthcare providers' organization, and sometimes they may build on applications that are not part of the formal healthcare system. The eHealth infrastructures can be part of nationally driven initiatives, or of initiatives resulting from local actions, e.g. It is expected that eHealth infrastructures will help governments improve the quality and efficiency of healthcare and achieve better coordination of care.
The basic premise for this book is the recognition that technology is not an invariant in a process of transformation – rather we can expect that every solution will be contested and that it will change shape during realization, implementation and use. The stories of building e-health infrastructures included in this book illustrate several aspects of such complex interactive processes of transformation. Evaluation of the e-prescribing service in primary care: final report on findings from the evaluation at early implementation sites.
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Information Infrastructures
- Introduction
- Information Infrastructures
- Installed Base
- Challenges of Installed Base Cultivation
The information infrastructure perspective encourages such a temporally extended process view and the "installed base". Studies of information infrastructures emphasize the durability and centrality of existing practices, conventions, tools and systems, and this "installed base" is seen to have a fundamental influence on the development of information infrastructures. This perspective emphasizes that "infrastructure does not grow de novo: it struggles with the "inertia of the installed base" and inherits strengths and limitations from that base." (Star and Ruhleder 1996, p. 113).
The notion of installed base generally refers to the number of installations or products sold. The size of the installed base and the existence of complementary products, through self-reinforcing growth mechanisms, can determine market success or failure (see e.g. Farrell and Saloner 1986; Schilling 1999). The main argument is that information infrastructures are never designed from scratch, but are developed through the evolution of an installed base.
We must keep in mind that an installed base is not a given 'thing', rather it is a conceptual tool. Rather than asking "what is the installed base" we should ask "when is an installed base". The concept of installed base is a meaningful tool for examining and reflecting on the challenges faced in infrastructure development.
The general strategy of changing the perspective of information infrastructure - "cultivating the installed base" - indicates a strategy that starts from what exists (the installed base). Managing the further evolution of the installed base is challenging, as it requires building on the installed base and transforming it at the same time. The paradoxical relationship between the installed base and infrastructural development initiatives cannot be resolved by simplistic approaches eg.
Rather, our argument is that the installed base matters in each case in a specific and contingent way. This book aims to bring empirically and theoretically based knowledge of how the installed base matters. The book's empirical analyzes investigate the various strategies in which infrastructure "builders" engage with (or ignore) the installed base.
The two categories of cases, e-prescribing infrastructures and government patient-oriented e-health platforms, are differently positioned in relation to the installed base. Moving beyond universal best practices that can be lethal and unresponsive to actual challenges requires developing an awareness of the installed base.
Strategies for Building eHealth Infrastructures
- Introduction
- E-Prescription
- Overview of the Case Studies on E-Prescription
- Strategies Towards the Installed Base
- Patient-Oriented eHealth Platforms
- Overview of the Case Studies on Patient-Oriented eHealth
- Strategies Towards the Installed Base
- Working with the Installed Base for Building eHealth Infrastructures
More specifically, we present the actual scope of the various initiatives (i.e. the actual services involved), their starting points and their motivations. We then compare the different cases in terms of the observed strategies with respect to the installed base. However, the economic situation in the country played a role in the acceleration of the project.
Finally, in the case of e-prescribing in UK hospitals, the interests of vendors played an important role. An approach that is friendly to the installed base appears to be the one that has a better chance of establishing new infrastructure and reaching a stage where infrastructure adoption and use gain momentum. From the perspective of existing practices and technologies, the project approach can be said to be "hostile to the installed base" given the mismatch between the novelty of the rapid project and the existing arrangements in the surrounding environment.
In general, all six cases had to deal with what we described as the 'paradox' of the installed base in the chapter on "Information Infrastructure and the Challenge of the Installed Base". The various access options provided have been directly linked to the characteristics of the installed base over the years. Patient-oriented e-health initiatives require good coordination across several different actors already present in the domain as parts of the installed base (central and local government, healthcare providers in primary care and in the specialist sector including hospitals, software vendors, patient associations).
In the case of Norway, the Directorate of Health managed the development of the platform by setting priorities and maintaining ownership of services. With the introduction of this framework, ownership and control of services began to separate. The ministry relinquished ownership of the new services, but not control over them (it retained the right to decide which new services would be offered).
In the Italian case, the Ministry of Health, represented by the city councilor, was the protagonist and played a leading role in both the design and realization of the project. Although the private portals were not linked to the platform, several components of the public eHealth infrastructures were connected. Since several of the external solutions linked to the portal were developed abroad, it proved to be a challenge to keep up with the new releases of the APIs.
At the beginning of the project, the portal's sponsors linked the development to the publicly shared electronic health record. In the cases from Denmark, Norway, Sweden and Catalonia, the strategies adopted were generally 'installed base-friendly' in the sense that all developments were based on broad consensus and transformations were attempted in small steps.
