THE DANGERS OF E-HEALTH
Shane O’Hanlon
Graduate Entry Medical School, University of Limerick, Limerick, Ireland
Keywords: e-Health, Health informatics, Patient safety, Evaluation, Assessment.
Abstract: In 2005 there were 51 unique definitions of e-Health in use, and a wide range of themes covered, suggesting
a lack of clarity on the subject. It is an exciting area with much potential. There is a proliferation of activity,
including huge funding invested by the European Commission. Given the large financial investment, we
should ensure that the return is an effective e-Health intervention, and a resultant improvement in patient
safety. But can e-Health actually do harm? All doctors are aware of the potential for harm, for example in
telemedicine there are numerous reports of adverse events. There is little work in the scientific literature on
the dangers of e-Health. The evidence base for e-Health is strikingly narrow, and there are few high quality
studies demonstrating that patient safety benefits. Most studies do not have a structured system of reporting
adverse outcomes. This leads to some ambiguity as to whether clinicians should advocate for e-Health on
behalf of their patients. Other sectors have already embraced evaluations. We need a phased system of
evaluation, with clear and transparent processes for reporting outcomes. High quality studies should be
conducted and the results published so that all stakeholders can make an informed decision.
1 WHAT IS e-HEALTH?
Many people could give their interpretation of what
e-Health means, but is there a standard definition? In
2001, Eysenbach noted that everyone was talking
about it, but ‘few people have come up with a clear
definition’ (Eysenbach, 2001). An excellent
systematic review of the area in 2005 highlighted
that there were 51 unique definitions in use (Oh,
2005). There were a wide range of themes covered,
but ‘no clear consensus about the meaning of the
term’.
Some feel that the term should remain in the
business sector, and question its place in the
academic environment (Eysenbach, 2001). It
certainly appears to have been founded in the
intersection between academia, healthcare and
business. There is no doubt that each group has
different aims and objectives for e-Health. These
may not give the same results.
Although e-Health has morphed over the last ten
to fifteen years, it is now becoming reasonably clear
what it entails. The European Commission (EC)
Information Society has provided the following
definition: ‘e-Health means Information and
Communication Technologies [ICT] tools and
services for health’. The academic area of Health
Informatics is also concerned with information and
communication, but technology to a lesser extent. E-
Health also covers the practical application of the
academic side of Health Informatics.
Patients are to the fore in e-Health, and the
Commission also notes that ‘widespread
implementation of eHealth will enable more
“patient-friendly” healthcare services to be
developed.’ It is clear that existing clinical practice
needs to continue its shift toward the patient-
centrism, and e-Health seems to be a potent way of
doing this.
The result of all this activity is that e-Health is
now an exciting area with much potential. It is
useful to examine some current projects to further
contextualise the discussion.
2 CURRENT ACTIVITY IN
e-HEALTH
The European Commission is to the fore in
advocating for more work in e-Health. They have
already spent 500 million euro on it since the early
nineties, and note that [t]his has placed Europe in a
leading position in the use of regional health
networks, electronic health records in primary care
423
O’Hanlon S..
THE DANGERS OF E-HEALTH.
DOI: 10.5220/0003294504230426
In Proceedings of the International Conference on Health Informatics (HEALTHINF-2011), pages 423-426
ISBN: 978-989-8425-34-8
Copyright
c
 2011 SCITEPRESS (Science and Technology Publications, Lda.)

and deployment of health cards.’ There is no doubt
that funding also drives further activity in private
industry.
The Seventh Research Framework Programme
aims to invest more than 50 billion euro in the
period 2007-2013, with prioritisation of e-Health.
This financial injection can give a high impact to e-
Health and such large scale funding should
definitely have a visible effect. But there is inherent
risk in such an outlay. For example, Coiera has
noted that when countries invest in major
information and communication technology systems
for healthcare, it is actually visible in the GDP
(Gross Domestic Product) (Coiera, 2010)
epSOS is an example of how e-Health can have a
measurable pan-european effect. Many European
member states are currently involved in design and
implementation of electronic health records. epSOS
‘aims at building and evaluating a service
infrastructure demonstrating cross-border
interoperability between electronic health records in
Europe’. Similarly the CALLIOPE project ‘creates
an open forum to support the implementation of
interoperable eHealth infrastructures and services
across Europe’. Interoperability has reached the
forefront of the effort, as it has become clear that
many individual autonomous efforts have greater
potential if run in parallel.
Worldwide, there is a growing emphasis on e-
Health, particularly in the United States as a result of
the Obama stimulus plan. The HITECH legislation
awards financial incentives for successful efforts.
Sensibly, they must show ‘meaningful use’. Even
before this there have been successful e-Health
implementations – for example by Kaiser
Permanente and the Veteran’s Association. These
efforts increasingly allow patients to access their
health information, and lead other countries by
example. One of the meaningful use requirements is
that population and public health must be improved.
It seems logical that this will be achieved by using
technology, but is there a demonstrable benefit?
3 THE EVIDENCE BASE IN
e-HEALTH
Clinicians have been trained to keep a sharp focus
on evidence based medicine. This involves staying
up to date with a vast quantity of regularly published
medical trials, guidelines and warnings. This
indoctrination is effective and leads to the common
question ‘What is the evidence?’ The
pharmaceutical industry is now very familiar with
this approach, and is involved in promoting and
conducting many drug research trials. It is widely
accepted that no drug can reach the market without
going through a systematic and careful evaluation of
product effectiveness, and equally the side effect
profile being examined in detail. This latter process
is one that continues many years after a product is
released.
The idea of having evidence for e-Health should
not now come as a surprise. Although there is a
certain excitement for a clinician to see impressive
new technology, the same process of validation is
now being applied as has happened in
pharmaceuticals. One example is Health Technology
Assessment, which may examine the economic
benefit of an intervention that is being introduced on
a national basis. The cases of faecal occult blood
testing, or the vaccine for cervical carcinoma
highlight this process. So have e-Health developers
stepped up to the plate?
A search on the MEDLINE database (where
most clinicians go to access up-to-date trial data) for
‘ehealth or e-Health’ shows that there have been
only 28 human clinical trials published in the last 10
years. With such paucity of evidence, why are we
spending so much on the area? Perhaps a wider
search is justified.
4 CASE STUDY: e-HEALTH
INTERVENTIONS FOR OLDER
PEOPLE
Our research group presented findings recently
which suggested that there is actually a proliferation
of research in the area of e-Health, but it can be
difficult to access (O’Hanlon, 2010). Using a
detailed and heterogeneous strategy, we searched for
e-Health interventions which were developed
specifically for older people, or tailored to services
for older people. In fact we were able to find 3,158
studies which were in some way concerned with e-
Health interventions. From this trove, we then
searched in more detail to see which trials had
shown concrete benefit for older people, again in the
last ten years. The final result was only 57 trials
meeting these criteria.
Our study concluded that the number of good
quality trials showing beneficial effects specifically
for older people is small. We suggested that more
research was needed in this area before large scale
adoption of these interventions.
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These findings were hugely disappointing. Most
doctors have seen examples of technology
improving patient care; or more probably
improvements in their own life due to technology.
The internet has such huge potential that it almost
seems disingenuous to suggest that the evidence
base for e-Health is not what we might expect.
Rather, it seems logical that e-Health should be a
huge boon for healthcare.
With our patients being thrust towards the centre
of the e-Health strategy, what role should clinicians
take? Should we encourage patients to embrace e-
Health as much as they can, or should we act as a
shield against it? The fact that there is a dearth of
evidence suggests two conclusions: first, research
should be a core element of any funding strategy;
and second that as things stand we cannot
wholeheartedly embrace e-Health interventions
without some caution. Our patients deserve the best
– but they need to be sure that it is safe.
5 PATIENT SAFETY
Reason’s ‘Swiss Cheese Theory’ suggests that
adverse clinical events can occur, even with several
layers of protection. Clinical medicine is an area
fraught with safety issues and potential harms for
patients. Approximately one in ten patients sustains
an adverse event while in hospital. It has been
reported that 15% of these events lead to impairment
or disability lasting more than 6 months. In one
study, adverse events led to a mean increase in
length of stay of 8 days. There is considerable
weight behind any argument that all healthcare
interventions need to be risk-proof.
Despite this, many e-Health interventions do not
have a robust safety analysis performed before they
are introduced. Perhaps there is a prevailing opinion
that e-Health cannot cause harm. Coiera has been
watching recent ICT developments in many
countries and has noted that we have not yet had ‘the
first health information technology plane crash’
(Coiera, 2010). This could be due to high safety
standards, good planning, or possibly good luck.
There have been numerous minor incidents in many
countries such as unnecessary radiation doses being
administered, health records being hacked into, and
electronic records simply having the wrong
information. But given how widespread ICT is
becoming in healthcare, there is huge potential for a
very significant adverse event, with catastrophic
impact for patients. The patient safety agenda must
penetrate into e-Health development, just as it now
has entered other areas of medicine.
6 POTENTIAL DANGERS OF
e-HEALTH
Because it is currently low priority on the e-Health
agenda, consideration has not been adequately given
to what may occur if e-Health harms patients. All
doctors are aware that telemedicine can be harmful –
video imaging may not have suitable resolution;
using distance communication tools may encourage
doctors not to attend in person, even when nearby;
and when patients are left at home with self-
monitoring tools they may not continue to use them
as regularly as they should (just like medications).
Despite this a search for ‘telemedicine dangers’
produces just 8 results on MEDLINE. There is little
written to comment critically on e-Health
interventions, and few studies report
systemicatically on adverse outcomes.
Interaction between humans and computers has
been well studied, and it is clear that the introduction
of computers to clinical practice leads to a
sometimes dramatic sociotechnical change. A simple
but common example of placing a computer in the
general practitioner (GP) consulting room has had
the result of altering the doctor-patient dynamic. It
has been argued that computers must be recognised
as a key part of the consultation. (Purves, 1996)
Margalit concurs, adding that the computer is now a
‘party in the visit’. (Margalit, 2006) It is interesting
to note that a recent study comparing computer use
in 2001 and 2008, GPs now show greater reluctance
to use computers. (Noordman, 2010) Having a
computer in the room negatively impacts on body
posture of the GP, and the amount of information
given by the GP to the patient.
These striking findings may seem to have
relatively little effect overall, but subtle changes in
communication between doctors and patients can
lead to a dramatic reduction in the amount of useful
dialogue. It is easy for patients to think that a doctor
who focuses on a computer cares little for the core
reason they came to consult them. Doctor’s visits are
already too brief, and Noordman’s study also
showed that when using the computer they were
actually shorter than when it was not used.
With these seemingly minor examples in mind, it
is useful to consider what one of the core raisons
d’etre of e-Health is: to improve patient care. In fact,
tools such as clinical decision support systems
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(CDSS) were introduced in an attempt to reduce
human error. We should be more structured in how
we assess these tools from now onwards to ensure
that they do not reduce one risk while
simultaneously augmenting another one.
7 A FRAMEWORK FOR
EVIDENCE
It is unsurprising that evaluation of e-Health has
previously been highlighted as a necessity. But why
has it not been instituted in a transparent, user-
friendly way? Nguyen suggested that the US Food
and Drug Administration (FDA) system of
classification should be adopted to e-Health. Phase I
determines safety and effect. Phase II is a clinical
trial which establishes efficacy. Phase III confirms
effectiveness in a larger group, possibly comparing
to another intervention, and looks at adverse effects.
Phase IV consists of post-marketing surveillance
studies.
This simple schema could be adopted as the
standard for evaluation of e-Health interventions. It
may not fit all study types, but it would promote
transparency, confidence and awareness of e-
Health’s benefits and risks.
8 CONCLUSIONS
It is foolish to imagine that poor outcomes cannot
occur due to e-Health. All technology has potential
to harm, or to alter existing dynamics so that
existing layers of protection do not work effectively.
It is time to recognise the dangers of e-Health and to
work proactively to limit this danger and ensure a
safer future for all users of health services.
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