Towards a Unified Understanding of eHealth and Related Terms –

Proposal of a Consolidated Terminological Basis

Lena Otto

, Lorenz Harst

, Hannes Schlieter

, Bastian Wollschlaeger

Peggy Richter

and Patrick Timpel

Chair of Wirtschaftsinformatik, esp. Systems Development, Technische Universität Dresden, Dresden, Germany

Research Association Public Health Saxony, Center for Evidence-Based Healthcare, Faculty of Medicine

Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany

Chair of Technical Information Management Systems, Technische Universität Dresden, Dresden, Germany

Prevention and Care of Diabetes, Department of Medicine III, Faculty of Medicine Carl Gustav Carus,

Technische Universität Dresden, Dresden, Germany

Keywords: eHealth, Telemedicine, Telehealth, mHealth, Terminological Ontology.

Abstract: The impact of digitization on healthcare gives rise to interdisciplinary concepts such as eHealth. However,

achieving improvements in research and innovation requires a valid and unified understanding of the

common terminology. Yet, a heterogeneous usage of different terms regarding eHealth can be observed.

This leads to a deficient communication between researchers and practitioners, impeding the diffusion, i. e.

extensive practical implementation of innovative health concepts. To address this problem, our aim is to

consolidate and harmonize eHealth-related terminology. To this end, a literature analysis was conducted to

identify established definitions and to formulate a terminological ontology for the related concepts. The

current results show a consistent definition of the terms digitization, ICT, and telematics. In contrast,

telemedicine, telehealth, eHealth, and mHealth were identified as conflictingly defined terms. Consequently,

the proposed ontology serves as a first guidance to support an adequate use of the included terms. Further

systematic research of terms is needed to verify the current concept of the ontology. Additionally,

specifying the connection between the ontology and the elements of healthcare systems is required for a

deeper understanding of the influence of digitization in healthcare.

1 INTRODUCTION

Telemedicine and eHealth are said to change the

way healthcare is delivered. These concepts are seen

as potential solutions to overcome communication

breakdowns (loss of information), avoid multiple

assessments, and improve quality of care as well as

patient satisfaction (Kruse et al., 2013).

Approximately 20 % of physicians in Canada are

currently using eHealth tools on a daily basis in

routine care (Razmak and Bélanger, 2017). In 2013,

53 % of all Americans had looked up plausible

medical conditions online before consulting their

physicians (Fox and Duggan, 2013). Looking at the

91 % of all Americans who own a smartphone, up to

13 % of them use health apps. Smartphone owners

use their phones in 31 % of the cases to obtain health

information, most commonly using fitness and diet

apps of any shape (Fox and Duggan, 2013). In

general, internet health information seeking is able

to improve the patient-physician relationship (Tan

and Goonawardene, 2017).

In 2002, five years before the launch of the first

iPhone, Eng delivered a broad definition of the term

eHealth. It was defined as „the use of emerging

information and communication technology,

especially the Internet, to improve or enable health

and health care” (Eng, 2002). It was lately adopted

to also accommodate to the usage of mobile

technologies to deliver care, which then is

sometimes called mHealth (Nacinovich, 2011).

Today however, there is growing disparity among

scholars as to what should be subsumed under the

term eHealth and its related terms. Its meaning

might vary between research institutions, although a

standardized definition was provided by the WHO in

2006 (Lewis, 2015). The same is true for the term

telemedicine. In 2014, a group of 100 specialists,

Otto, L., Harst, L., Schlieter, H., Wollschlaeger, B., Richter, P. and Timpel, P.

Towards a Uniﬁed Understanding of eHealth and Related Terms – Proposal of a Consolidated Terminological Basis.

DOI: 10.5220/0006651005330539

In Proceedings of the 11th International Joint Conference on Biomedical Engineering Systems and Technologies (BIOSTEC 2018) - Volume 5: HEALTHINF, pages 533-539

ISBN: 978-989-758-281-3

533

partaking in the Federal Telemedicine Work Group

announced by the U.S. Department of Health and

Human Services, came up with seven unique, yet all

slightly diverging definitions of telemedicine (Doarn

et al., 2014). eHealth and mHealth, however, are

sometimes also used instead of or synonymously to

the terms telemedicine or telehealth. Consequently,

there is a strong need for both empirical and practical

definitions as a basis for further research of any kind.

Despite this uncertainty regarding the definition

of eHealth, there seems to be a remarkable scientific

consensus about what to expect from this

technology. Eng (2002) formulates the somewhat

vague hope that eHealth might improve healthcare,

and, thereby, ultimately health itself. Other authors

have gone far beyond that. In an attempt to adapt the

ten “E’s” concerned with eCommerce to the domain

of eHealth-technologies, Eysenbach assumes that

eHealth might enhance quality of care, while also

creating a previously unknown knowledge basis for

each patient. This might in turn empower patients to

make more informed decisions about their health or

treatment. According to Eysenbach, this will

ultimately encourage an all new relationship

between patient and caregiver (Eysenbach, 2001).

The evident gap in scientific research described

above is intended to be closed by targeting the

disparity in definitions and therefore the inconsistent

application of the terms telemedicine, telehealth,

eHealth, and mHealth.

The aim of this paper is to develop a

consolidated view (1) to define the individual terms

and (2) to synthesize their interrelations and

delimitations. A terminological ontology is specified

in this paper. It serves as an instrument for eHealth-

researchers to monitor adequate applications of

related terms.

For facilitating a common understanding,

ontologies are a widely-used tool in a great variety

of domains as they allow a specification of domain

concepts and the relationships among them in a

formalized manner. Therefore, they offer the

possibility to describe domain knowledge and the

semantics of terms. In technical applications, e. g. in

the field of computer science, health informatics or

biomedicine, knowledge modelling ontologies are

used to create knowledge bases, which in turn serve

as the foundation of decision-support systems

(Heijst, 1997), e. g. for medical emergency coordi-

nation (Sujanto et al., 2008). However, other types

of ontologies are used to specify taxonomies across

different domains (terminological ontologies, Heijst,

1997) in order to facilitate semantic interoperability,

such as Open Biomedical Ontologies, SNOMED

Clinical Terms (Ganzha et al., 2016) or the Gene

Ontology (The Gene Ontology Consortium, 2000).

In contrast to this data-centric application of

ontologies, the focus of this paper lies on discussing

the general relations of concepts in the eHealth and

telemedicine domain.

2 METHODS

The inclusion of terms was conducted starting from

the concept of eHealth. A literature study in the field

of healthcare and connected fields (e. g. health

informatics or health communication) was carried

out to identify the relevant definitions, starting with

those concerned with eHealth. In a next step, related

concepts such as telemedicine, mHealth, telehealth

as well as ICT, telematics, and digitization were

included. These interrelated terms were introduced

and explained to achieve a broad understanding of

the surrounding domain.

Based on an overview of established definitions,

a coherent definition of and the relations between

the terms are derived. The resulting interrelations

and delimitations are illustrated in an ontology.

Identified conflicting definitions and relations

between terms are discussed. Afterwards, a

terminology concerning eHealth and healthcare

related terms is proposed. The paper ends with a

summary and an outlook on further research.

3 DEFINITION OF RELEVANT

TERMS

The literature analysis starting from the term eHealth

yielded several terms of the healthcare domain. As

eHealth is largely based on technology, the research

presented here began with exploring the technology-

related terminology. The identified terms and

concepts as well as their dependencies are depicted

as a terminological ontology in Figure 1. The terms

and concepts are shown as nodes in the diagram.

The different edges connecting the nodes represent

the relationships between the concepts. Their

semantics, based on the UML class diagram

notation, are added as labels. References containing

the definitions of concepts and justifications for the

relations were added to each element in the diagram.

It was observed that the analysed terms and their

relationships are defined to different degrees of

consistency in the research community. To indicate

this, debatable relations are depicted in italic style.

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534

In the following section, definitions and

explanations for the different concepts represented

in the proposed ontology are provided. Consistent

definitions for the terms digitization, information

and communication technology as well as

telematics were identified.

The increasing level of digitization affects every

area of society. The use of digital instead of

analogue signals, besides changing the way of

people’s work, also broadens the abilities of

technological systems (Hagen, 2017). To enable

digitization and its diffusion in all areas of life, the

use of information and communication technology

(ICT) is required (Hagen, 2017).

Information and communication technology

“refers to both different types of communications

networks and the technologies used in them. [...][It]

fulfil[s] or enable[s] the function of information

processing and communication by electronic means”

(OECD, 2014).

Strongly related with ICT and also used in the

healthcare sector is the term telematics. Telematics

combines the theories of telecommunication with

informatics (Alpay and Heathfield, 1997). This

concept plays an important role for healthcare as it

describes “the transmission of information across

distances” (Alpay and Heathfield, 1997). For this

reason, it also enables changes in the way care is

delivered (Dasgupta and Deb, 2008).

Concepts like eHealth, mHealth, telehealth,

and telemedicine are among these new ways of care

delivery. All of them introduce technical

components into the domain of medicine, health and

wellbeing. Apart from this common denominator,

controversial definitions of the terms were found.

eHealth, for example, “refers to tools and

services using information and communication

technologies that can improve prevention, diagnosis,

treatment, monitoring and management” (EC, 2015).

In addition, it also supports care provision using

different new services and systems, such as

electronic health records or telemedicine services

(EC, 2015). eHealth is therefore mostly related to

healthcare by involving professional service

providers as well as focusing on patients and their

(everyday) behaviour and lifestyle.

Telemedicine, in contrast, is exclusively

focusing on aspects of healthcare: The European

Commission (2015) and Sood et al. (2007), who

reviewed 104 different definitions of telemedicine,

conclude that telemedicine is part of eHealth. The

use of ICT over distances to deliver “healthcare

services and medical education” (Sood et al., 2007)

is characteristic. The involvement of professional

service providers is therefore obligatory for

telemedicine services (WHO, 1997). Among the 104

studies reviewed by Sood et al., there are important

differences in the understanding of telemedicine,

pointing out the existing heterogeneity of the

terminology: Telemedicine may “range from simple

e-mail-based store-and-forward technologies to

complex remote surgical technologies that employ

robotics” (Sood et al., 2007). Following the

European Commission (2015), this understanding

describes the term eHealth instead of telemedicine.

Unlike telemedicine, mHealth describes “the use

of mobile communications for health information

and services” (Nacinovich, 2011), which is possible

without the direct involvement of health service

providers. Especially the transmission of health

information using mobile communications can be

carried out exclusively by the patients themselves

(PWC, 2013). In general, it has to be pointed out that

mHealth is not a well-defined concept. Nacinovich

(2011) is one of few authors who proposed a

definition, which, however, is still quite broad.

Another concept related to the considered terms

is telehealth. While Sood et al. (2007) define it as a

generic term for telemedicine, the World Health

Organization (2010) describes both terms as being

equivalent. Nevertheless, both terms can also be

distinguished based on the involved healthcare

providers: Telemedicine can be seen as a service

exclusively delivered by physicians (WHO, 1997),

while telehealth includes the delivery of services by

all existing healthcare providers (WHO, 2010). Yet,

it is stated in the WHO group consultation on tele-

medicine from 1997, that “health telematics” as the

broader term is not restricted to any involvement of

health professionals, as it also includes the generic

term “health-related activities” (WHO, 1997).

Considering the uncertainty about how to

adequately define and delimitate the terms

telemedicine and telehealth, a decision about their

hierarchical relationship is difficult but nevertheless

required. To this end, the distinction between health

and wellness may serve as an additional indicator to

resolve this uncertainty.

While health and wellness are often used

interchangeably, different meanings are established

ever since the WHO first defined health as “a state

of complete physical, mental and social well-being

and not merely the absence of disease or infirmity”

(WHO, 1948). It is the word “complete” that has led

to criticism of the WHO definition, for it is said to

make it overly inclusive (Stoewen, 2015).

Nevertheless, as Stoewen points out, this broad

scope acknowledges the fact that health does not

Towards a Uniﬁed Understanding of eHealth and Related Terms – Proposal of a Consolidated Terminological Basis

535

only depend on environmental or socio-economic

factors, but also on the individual’s lifestyle and

therefore on wellness (Stoewen, 2015).

The individual’s responsibility for his or her

wellness is embodied in the definition by the U.S.

National Wellness Institute, which considers

wellness “an active process through which people

become aware of, and make choices toward, a more

successful existence” (National Wellness Institute,

2015). Apart from the individual responsibility

advocated here, it also becomes clear that wellness

can not only be achieved with the aid of a health

practitioner, as it is also reflected in Kirch’s (2008b)

definition of well-being. On the other hand,

healthcare delivery, used synonymously to medical

services, is also defined as prevention and treatment

of diseases through the healthcare system (Kirch,

2008a). The latter embodies health professionals of

any shape.

In conclusion, health according to the WHO’s

early definition is a state of holistic well-being,

while wellness is the individual’s way to preserve

and enhance that state (Stoewen, 2015).

For their systematic review on health and

wellness technologies used in underserved areas,

Montague and Perchonok (2012) rely on the same

holistic definition of health and the understanding of

wellness technologies as having “little or no

interaction with the health care system” (Montague

and Perchonok, 2012). Instead, they take

technologies primarily used by the consumer into

account, thereby paying their respect to the

individual’s responsibility embodied in the term

wellness.

As previously mentioned, contradicting defini-

tions exist for some of the investigated terms.

Especially the scope of eHealth, telemedicine, and

telehealth can be conceived differently. Due to the

diffuse separation between the terms themselves, a

strong overlap can be recognised. Accordingly, the

terms telehealth and telemedicine can be further

differentiated by applying them to the concepts of

health and well-being/ wellness. While eHealth and

telehealth use a holistic understanding, telemedicine

focuses on medical and diagnostic elements

requiring the involvement of physicians.

A conclusive assessment of the various

definitions is not part of this paper, but it is one of

the topics that were identified for further research.

4 RELATIONSHIPS BETWEEN

THE CONSIDERED CONCEPTS

In the following section, the aim is to explain and

justify the relationships in the developed ontology

using definitions and logical reasoning. The result is

shown in Figure 1.

For the implementation of digitization, ICT is

needed (Hagen, 2017). Therefore, both terms have a

connection, with digitization being the dependent

term. Another connection regarding ICT is to

telematics. Telematics is enabled by ICT and

therefore depends on it (Alpay and Heathfield,

1997). On the other hand, telematics is an enabling

concept for eHealth. Due to the possibility of

overcoming distances on the basis of ICT, it is a

foundation for eHealth and related concepts (EC,

2015; Sood et al., 2007).

At the same time, eHealth is a generic term for

different related concepts. Even though mHealth is

not defined conclusively as a whole, it is nevertheless

defined as a part of eHealth as it does not necessarily

involve service providers (Nacinovich, 2011), as it is

the case for telehealth and telemedicine.

Figure 1: Terms and relations based on literature analysis.

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536

As described with the definitions above,

telemedicine can be seen as a subcategory of

telehealth (Sood et al., 2007) and eHealth (WHO,

2010) at the same time. Resulting from both views,

as they exist simultaneously, telehealth needs to be a

subcategory of eHealth while being a general term

encompassing telemedicine.

Especially the relationships between eHealth and

telemedicine as well as telemedicine and telehealth

are not defined consistently. A logical separation is

possible based on their focus on either health

(telemedicine) or both health and wellness/ well-

being (eHealth, telehealth). However, on the basis of

a diffuse separation between the particular terms, the

delimitation between them is not clear as well. In

order to illustrate this, these relations are depicted in

italic style in Figure 1.

Nevertheless, each term and relationship was

justified by at least one definition. Despite the fact

that an ontology for the main terms is provided, a lot

of different meanings regarding some terms and

their delimitations will remain. Hence, our explicit

description of existing relationships provides a

consistent basis for further work.

5 NEXT STEPS

So far, the ontology provides only a technological

point of view. A next step can be a connection to “real

life”, which mainly includes different care models and

their relevant stakeholders. As digitization affects

every area of life (Hagen, 2017), eHealth along with

related technologies and concepts directly affect

human beings. Within the grey box in Figure 2, a

proposal for the integration of patients and other

stakeholders into the provided ontology is displayed.

Telemedicine as a concept of care cannot be

conceived without the underlying care processes,

e. g. care models. Care models exist as a

combination and interaction of different participants,

such as service providers, who treat patients and

get paid by funding agencies. The components of

care models show a certain variability (WHO, 2016).

Depending on the primary objective of a care model

and its target disease or population, it varies to a

considerable extent (Broese van Groenou and Boer,

2016; Davidson et al., 2006; Wagner et al., 1996).

Consequently, detailed analyses and further

discussions are needed to develop an evidence-based

link of care models with the developed ontology.

As represented in Figure 2, the terms are justified

by definitions. Only funding agencies were not

found to be adequately defined. Because our focus is

on the German health system, a specific definition

regarding funding agencies needs an enhanced

examination, taking into account the framework of

the German health system. Finding an appropriate

definition and further justifying the proposed

relationships with applied care provision (see grey

box, Figure 2) will be addressed in future research.

Taking the current ontology as a foundation, the goal

is to further develop it to a reliable and scientifically

proven ontology for eHealth and related terms,

Figure 2: Proposal on how to connect the health care domain to the terminology.

Towards a Uniﬁed Understanding of eHealth and Related Terms – Proposal of a Consolidated Terminological Basis

537

especially with respect to patients. A potential way

to validate the provided ideas is to conduct an expert

workshop as suggested by Gammon et al. (2015).

6 CONCLUSION AND OUTLOOK

Due to the identified heterogeneity and uncertainty

regarding the definitions of eHealth and related terms,

the focus was on the provision of a consolidated view

for interdisciplinary studies. Furthermore, this

consolidated view can help to understand and support

quality assessments and facilitate the diffusion of

innovative care concepts into practice.

To reach this aim, a terminological ontology was

created via a two-step procedure. Firstly, the

underlying technological concepts of eHealth and

related terms were identified using an extensive

literature analysis. Secondly, a proposal was made to

extend the ontology and to include care models, by

conducting a literature analysis. Finally, an outlook

was developed describing next steps to validate and

further develop the provided ontology.

All in all, an overview of eHealth, telemedicine,

telehealth, and mHealth as well as related terms could

be provided. Nevertheless, it was found that for some

terms insufficient definitions (e. g. mHealth) and

unclear delimitations are prevalent in the research

community. Especially the connections between tele-

medicine, telehealth, and eHealth need to be clarified.

Systematic reviews for additional terms in the

proposed ontology-extension (Figure 2) should

follow, in order to establish definitions substantiated

by the research community and infer appropriate

relations. Moreover, it needs to be verified if all

adjacent concepts are already represented in the

ontology proposal, as e. g. the term digitization also

possesses a processual character, which possibly

impacts additional concepts.

The presented work is intended to further enhance

discussion and thereby improve the quality of

telemedicine research and innovation. As a result, this

work is a valuable contribution to eHealth research as

it contains theory- and evidence-based knowledge of

the domain terminology. It reveals the importance of a

common terminology and it therefore provides the

foundation for an interdisciplinary understanding.

ACKNOWLEDGEMENT

The work for this paper was funded by the European

Social Fund and the Free State of Saxony (Grant no.

100310385).

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