18

eHealth

Heidi D. Campbell, Ph.D.*

*Chair, Dept. of Mass Communication, North Greenville University (Greenville, South Carolina)

Introduction

When was the last time you were at the doctor, the emergency room, or other healthcare provider? When you were there, how many encounters with technology did you have? Did you fill out patient information online? Did the nurse check your blood pressure and temperature with a digital device? Did the doctor use a computer or tablet in the exam room? Did the prescription you received go directly to the pharmacy via electronic delivery? When you left the office, did you think about the diagnosis and treatment and seek further clarification or information online or on a mobile app? This is eHealth—the use of electronic information and communication technologies in the field of healthcare (Cashen, Dykes, & Gerber, 2004).

eHealth affects everyone and is one of the fastest growing areas of innovations in communication technology. Throughout this textbook you have read about the impacts of the digital revolution and how it has affected every aspect of our lives. The rapidly decreasing size of computer technology in the form of mobile phones and tablets, near ubiquitous Internet access and increasing bandwidth speeds, the connectedness of social media, and cloud computing have created the perfect storm for eHealth to burst on the scene and fundamentally change healthcare as we once knew it (Topol, 2013).

Essentially, eHealth is empowering consumers to play a bigger role in managing their own health. Patients now have access to their own electronic health records (EHR) and can access information about every common illness known. This shifts the balance of healthcare and creates a way for individuals to take control of their own health by focusing on personalized health plans and prevention.

Definitions

•  eHealth—the use of electronic information and communication technologies in the field of healthcare.

•  EHR—Electronic Health Records are electronic versions of patients’ medical history maintained by the healthcare provider.

•  mHealth—or mobile health is the use of mobile technologies such as cellphones and tablets for health communication and delivery of health information.

•  Health eGames—electronic games used to promote health and wellness.

•  Gamification—the application of different aspects of game playing to encourage engagement with a product or service.

Background

Convergence of digital technologies has given health communication increased traction over the past 30 years. However, the history of medicine is rich with information-sharing from the earliest days of recorded history. It is the sharing of information that is critical to the growth of healthcare in this digital age.

The first recorded evidence of healthcare predated the use of paper, pens, or even books. They were chronicled in cave paintings in France dating back thousands of years (Hall, 2014). The cave art depicted the use of plants to treat ailments. Early evidence of surgeries and the use of anatomy in diagnosis were found in Egypt around 2250 BC (Woods & Woods, 2000). These drawings were some of the first forms of health communication because they documented health conditions and treatments for future generations of physicians.

It wasn’t until the 19th century that the field of medicine advanced exponentially with developing sciences and growing knowledge of chemistry, anatomy, and physiology. The mass dissemination of information can be credited to innovations in mass communication, which delivered vital medical information to doctors and healthcare workers. Medical information was communicated through the use of telegraphs, printed journals, books, photography, and telecommunications (Kreps et.al, 2003).

Computers have been used in healthcare since the early 1970s, serving as an administrative tool by storing patient information and medical practitioner records. Developments in surgical and diagnostic instruments continued, but it wasn’t until 1995 that the information floodgates were opened to provide individuals access to a pool of knowledge about every aspect of their healthcare through the Internet (Kreps et al., 2003).

Innovations in communication technology also created concerns regarding the protection of patient information on the Internet. In 1996, the Health Insurance Portability & Accountability Act (HIPAA) propelled the healthcare industry to adopt new ways of safeguarding the privacy of health records. HIPAA gave more control of information to the consumer, but because of the regulated safeguards, the healthcare industry has been slow to adopt technologies that would give patients ready access to their own medical records. The days of limited access to personal health information are long gone as innovations of communication technologies that are designed to facilitate the flow of information between the healthcare provider and the healthcare consumer have been established.

Recent Developments

mHealth

•  mHealth companies generated $10 billion in revenue in 2015, a figure that’s expected to reach $31 billion by 2020 (Vranova, 2015).

•  62% of smartphone users have looked up health or medical information on their devices (Smith, 2015).

•  Some 58% of smartphone users have downloaded a health related app (Krebs & Duncan, 2015).

mHealth, or mobile health, is the use of mobile technologies such as cellphones and tablets for health communication and delivery of health information. Gone are the days when cellphones were used to simply make a call; now phones are multifunctional tools performing as photographic and video devices, word processors, electronic organizers, and now even ECGs (electrocardiograms) or thermometers to monitor your health. There are more than 7.9 billion unique mobile devices on the planet, with 36% of mobile phones in use today being smartphones. (Cisco, 2015).

Technologies in eHealth have been featured at major technology shows worldwide for the past few years as an introduction to a rapidly growing industry. That growth has been exponential as new innovations have been adopted in virtually every area of the healthcare industry. The rapid growth can be attributed in part to ubiquitous mobile technologies which connect users to health information.

Apps

Mobile technologies for eHealth are expanding through software applications and the use of mobile apps. More than 6.1 billion users are expected to use mobile apps on their smartphones by the year 2020, and the healthcare and business sectors are quickly jumping on the opportunity to engage individuals through health apps (Ericsson, 2016). The number of health & fitness apps has more than tripled since 2009 with more than 165,000 mHealth applications in major app stores (HIMSS, 2015). These apps allow smartphones to carry out diverse eHealth functions from monitoring physical activity to monitoring heart rhythms with a mobile ECG (Costello, 2013).

Corporations and makers of mHealth apps have found that their success comes from consistent engagement with the use of gamification, which is the application of game playing to encourage engagement with a product or service (Weintraub, 2012). Gamification uses challenges, points, badges, and leaderboards to encourage continuous participation. Many healthcare organizations are using this type of engagement to keep employees and customers engaged in healthy lifestyles, including diet and exercise. The use of gamification in mobile apps incentivizes healthy choices, encourages accountability, and provides a higher level of satisfaction to users.

Telemedicine

Telemedicine has grown exponentially since the first remotely-performed surgery in 2001 and has affected many aspects of healthcare (Collen & Ball, 2015). Telemedicine is the use of telecommunication and information technologies to connect healthcare to patients and patient’s mHealth data remotely. Telemedicine provides a convenient and consistent way to transmit medical information, imaging, and other data a healthcare provider might need for diagnostics and prescriptive assessments (Topol, 2015).

Telemedicine is not just a healthcare option for people living in rural or remote locations. It is now being used to connect healthcare practitioners with patients as a means of healthcare cost savings by meeting patients wherever they are through a mobile device or computer connectivity. Companies such as Doctors on Demand provide access to board certified doctors or psychologists at a much lower cost than an urgent care facility.

Telemedicine could help reduce healthcare costs by more than $6 billion a year, according to analysis by Towers Watson (2013), a global financial and technological consulting firm. Towers Watson found that more than 35% of employers offer telemedicine services as a low cost alternative to ER or doctors’ office visits for nonemergency health issues. While employers see the financial benefits of telemedicine, employees are lagging behind in actual use with less than 10% of employees utilizing the benefit (Watson, 2015).

Issues with telemedicine involve a decreased human interaction which could prevent a medical practitioner from identifying issues that may only be recognized in person. Technological issues include broadband access and Internet connectivity that may be limited or intermittent for some users. The increasing number of patient data breaches will continue to be an issue and companies offering telemedicine will need to work to protect the privacy of patient information

Figure 18.1

Doctors on Demand

Source: Doctors on Demand

Social Media

The healthcare industry has turned to social media to share information that will promote both individual and community health practices. Hospitals, physicians and healthcare providers are connecting with patients on social media providing connections with preventative healthcare, health crisis readiness, and general healthcare information on popular social media sites such as Facebook, Twitter, YouTube and Pinterest. With more than two-thirds of all American adults using social media, it’s not surprising that the healthcare industry would use this communication medium to connect with patients (Perrin, 2015). The majority of hospitals have a Facebook page (94.4%) and Twitter account (51%) while nearly all have a Yelp page for reviews (99%) and foursquare page for patients to check-in online (99%). While the vast majority have adopted social media, the consistent use is more prevalent among larger hospital systems in urban areas (Griffis, et al., 2014).

Research shows that there is a level of trust with social media. Nearly 90% of respondents between the ages of 18 to 24 said they would trust medical information shared by others on their social media networks (PWC, 2015). Another 41% are using social media to make decisions about which doctors or hospitals to use while 34% said the information they find in social networks affects their decision about what medication to take (PWC, 2015). Not surprising was the fact that older respondents were much more protective of their health information on social media.

Figure 18.2

eHealth Technology Spectrum

Source: H. Campbell

Health e-Games

Health e-Games is a $6.6 billion market (Donner, Goldstein, & Loughran, 2012). Global revenue from video gaming is projected to grow to $93.8 billion by 2019 (PWC, 2015). Innovations in cloud gaming, mobile gaming, and social media gaming have been the driving forces behind the growth of this industry, and the trend towards eHealth and health e-games is expected to significantly impact the gaming industry (Donner et al., 2012). Major video game companies such as Nintendo, Sony, and Microsoft have developed consoles, games, and accessories that not only provide entertainment enjoyment, but also improve overall quality of life (QOL) by engaging consumers with health literacy and education to help them take control of their health through entertaining and interactive games (Nintendo, 2015).

Health e-games can be classified into four key areas:

•  Exergames—or games that involve physical movement and interactivity

•  Health and nutrition—used in weight management and meal planning

•  Brain fitness—meant to improve cognitive function

•  Condition management—used to manage chronic health issues such as diabetes, asthma, or cancer

The exergames category of the video game industry is a $6.7 billion segment of the video game market and dominates the health e-game sector (Donner et al., 2012). Games using motion tracking, balance boards, and other types of controllers are categorized under exergames and range from dancing to snowboarding to golf.

Nintendo has led in health gaming, primarily through health and fitness accessories and games, including the Wii Fit, which sold nearly 23 million units worldwide in 2015 and is used for consumer fitness as well as physical therapy in hospitals and clinics worldwide (Nintendo, 2015). The next generation of this product is the Wii Fit Plus, which incorporates the Wii accessories including the Wii U consoles, Wii Balance Boards, and the wearable Fit Meter. The game features some of the same activities from the original Wii Fit like yoga and strength training, as well as new activities that incorporate the system’s innovative second-screen controller, the Wii U GamePad. The game incorporates the Fit Meter, which allows people to wirelessly track daily activity, from calories burned to steps taken and compare accomplishments with other users online (Nintendo, 2016).

Nintendo has also partnered with companies like Bayer to engage diabetic patients in gaming. Bayer’s Didget™ is the only glucose monitor designed specifically for children and incorporates gamification. The unit connects to Nintendo gaming systems and rewards children for consistent testing of their blood sugar (Bayer, 2014).

Consumers can expect to see more of these kinds of partnerships and innovations in eHealth in the future including the insurance industry. Major health insurance companies use health e-games in their well-ness programs to encourage group participation in healthy activities, such as diet and exercise, while also lowering costs resulting from claims. Companies such as Aetna, CIGNA, Inland Empire Health Plan, Humana, and Kaiser Permanente offer e-games that encourage healthy eating and increased physical activity (Donner et al., 2012).

UnitedHealth Group is one of the leaders in the insurance industry using gaming to encourage healthier living among their insured. The company has partnered with Kanami, producer of the DanceDanceRevo-lution games to create the Activate for Kids exergame program. DanceDanceRevolution “Classroom Edition” is an interactive video game that combines dance movements with fast music and stimulating visuals. The goal of the exergame program is to help fight childhood obesity and encourage physical activity and healthy eating for all children, and the program seems to be working. A study conducted on the program found that overweight children involved in a 16-week weight loss program that used the DanceDanceRevolution exergame lost two and a half times their body mass index compared to those children who only dieted. UnitedHealth Group introduced their “Exergame” in classrooms in California, Florida, Georgia, and Texas; however, the program is expected to be adopted in other states as well. Watch for expanded growth in the health e-game market over the next five years (Trost et al, 2014).

Wearables

Another area of innovation in eHealth is in the wearable technologies that communicate biometric data regarding your heart rate, blood pressure, glucose levels and more. Consumers are eager to collect this data believing it will help them effectively monitor their own health. In 2015, wearable health devices reached $1.8 billion in revenue in the U.S. (CTA, 2015). Wearables include clothing, wristbands, watches, earphones, sensor rings, computerized contact lenses, and dermal patches equipped with sensors that wirelessly collect and transmit health data over extended periods of time with minimal lifestyle disruptions.

Pedometers and Wristbands

The most widely used wearable device for health and fitness is the pedometer, which measures the number of steps an individual has taken. The pedometer has undergone several levels of innovation and has evolved into a more powerful digital device. Wristbands dominate the wearable fitness devices, and many of the major sports companies have designed wristbands that wirelessly communicate with smartphones to measure steps, physical activity, sleep patterns, and calories burned. The Fitbit Alta sold more than one million units in the first month of release in 2016 making it one of the fastest selling fitness trackers on the market (Suvarna, 2016). Other health and fitness wristbands available include Nike’s Fuel-Band, Adidas’ miCoach, and Up4 by Jawbone which all work similarly by recording physical data and connecting wirelessly to a smartphone loaded with the designated app (Business Wire, 2014).

Figure 18.3

Wristbands and Smartwatches

Source: Fitbit

The Federal Drug Administration (FDA) has issued guidelines for regulatory review of health apps intended to be used as an accessory to a regulated medical device, or transform a mobile platform into a regulated medical device. The only mobile apps that are currently regulated by the FDA are those that are used as an accessory for a regulated medical device, or transform the mobile platform into a regulated medical device (FDA, 2016).

Smartwatches

Smartwatches combine the functionality of simple time keeping with sensor and computational power that can monitor biometrics and instantly record and report the data to your mobile device or online monitoring account. Smartwatches can perform a myriad of tasks including tracking steps taken, distance traveled, activity rates, tracking sleep patterns, and alerting the user when they have achieved health goals making this device the fastest growing eHealth wearable product in the health and fitness technology sector. Of those likely to buy a health and fitness wearable, a smartwatch is likely to be their top choice (CTA, 2015). Major tech companies, such as Apple, Garmin, Pebble, Samsung, Sony, and Motorola have all developed smart watches that have mobile connectivity and also serve as a fitness companion.

Figure 18.4

Apple Watch used in Healthcare

Source: Apple Watch

Developers are working on advanced sensors that will take eHealth wearables, such as wristbands, to a new level in health monitoring. Smart Monitor’s Smart Watch is a device with mobile connectivity that alerts the user of impending convulsions, tremors, or seizures. The watch connects with a smartphone and alerts users when repetitive motion is detected and then connects with chosen emergency contacts with alerts and GPS coordinates of where the individual Smart Watch user is located. Other data collected by the Smart Watch is then compiled for review by the user and can be shared with a healthcare provider (Smart Monitor, 2014). This type of technology is gaining ground for users with these types of critical conditions.

Google Lens

Google Lens is an “eye mountable device” or a supercomputer that sits on the eye like a contact lens. The Google Lens has all the features that Google Glass had including display features, picture and video recording, gaming, and real time Internet search capabilities (Google Inc., 2016). Google Lens has positive implications for diabetic patients. According to the CDC, there are 29.1 million people in the United States who have diabetes (CDC, 2014). Google Lens will give more freedom to these patients by continuously measuring glucose in tears using a wireless chip and miniaturized sensors. Google is hoping this smart contact lens will be a more efficient way for people with diabetes to manage their disease (Klonoff, 2014).

Figure 18.5

Google Lens

Source: Google

Clothing

There are companies innovating clothing and textiles with wireless sensors for sportswear and health monitoring. Cityzen Sciences (2014) has developed a smart shirt with enhanced micro sensors equipped with mobile connectivity that enables users to monitor temperature, heart rate, and physical activity. The shirt is also equipped with a global positioning system (GPS) and is used primarily by runners.

While there are sports and fitness applications for smart clothing, the Chronious project in Europe has developed a t-shirt designed specifically for patients suffering from chronic obstructive pulmonary disease and chronic kidney disease. The t-shirt is outfitted with sensors to monitor heart, respiratory, and physical activity. The sensors connect wirelessly to electronic devices in the home, including blood pressure monitors, glucometers, and air quality sensors which then transmit the data to “intelligent data processing software” equipped with algorithms specifically designed to create unique therapies for the patient. This technology has been in use for a few years in Europe and is being tested on patients with other chronic diseases (Bellos, 2013).

Dermal Devices

While wearables such as wristbands have definitely moved into the forefront of eHealth hardware technology, the next innovation in wearables is found in dermal devices equipped with sensors that are attached directly to the body allowing freedom of movement and more precise health monitoring (Ahlberg, 2011). Scientists from the University of Illinois developed a chip tattoo that is applied directly on the skin using electronic components for sensing, communication interfaces, and medical diagnostics. The chip is applied much like a temporary tattoo and is comfortable to wear, unlike other types of probes and sensors (Kim et al., 2011). This type of device connects to a remote device to collect data ranging from ECG type monitoring to brainwave activity. Researchers are working to take this technology to a new level by developing sensors that measure glucose in diabetic patients.

Figure 18.6

Dermal Tattoo

Source: John Rogers

Dexcom, a producer of diabetic products, has produced a continuous glucose monitor (CGM) device implanted just below the skin that checks blood sugar throughout the day and night. The sensor sends data to a cellphone or mobile device and alerts users of spikes or dips in blood sugar allowing the user to monitor their glucose levels more closely. The data can then be downloaded for historical comparison and for healthcare professionals to analyze (Dexcom, 2016).

Robotics

Think of BB-8 or R2D2 from the Star Wars movies.

They were service robots that did everything from making food and flying a Starfighter, to communicating with galaxies far, far away. While those robots were fictional characters in a movie, the idea of a service robot is a reality in healthcare.

Many hospitals are using robots to transport laundry, food, or lab results to a designated place and then go back to their base to await their next assigned task. Robots are also used in healthcare for cleaning and disinfecting facilities using a high-intensity UV light. These robots can help reduce the transmission of diseases and further reduce the health risks (Kilgannon, 2016).

Robots are extremely accurate. Pharmacists who fill a prescription have to read the prescription, find the medicine, count or measure the prescribed medicine, fill the prescription, and then label the prescription based on the dose and instructions. When a pharmacist is busy, these steps may be missed and human errors may occur. It is believed that 2.8% of prescriptions have errors. Pharmaceutical robots have reduced the number of errors in prescriptions to 0% further reducing risks and costs (Bui, 2015).

Figure 18.7

InTouch Health RP-7 Robot

Source: InTouch Health

Rural areas in the U.S. continue to experience shortages in doctors. Fortunately, new technologies in robotics have allowed doctors to meet remotely with patients. Remote robotic access in eHealth is the ability for the doctor to be off-site and project themselves to another location. They have the ability to move, see, hear, and talk as though they were actually there with the patient (Huiner, 2016). These robots can maneuver throughout the hospital making a doctor who is offsite feel as if she is on-site. Ultimately, this technology reduces costs and improves efficiency and safety at hospitals and healthcare facilities (Lee, 2013).

Developing Countries

Developing countries are set to benefit the most from eHealth communication technologies. Millions of people die each year in developing countries due to lack of access to proper medical care. The World Health Organization reports that there is a global shortage of 7.2 million healthcare workers but in the next 20 years, that number is expected to nearly double (GHWA & WHO, 2013). Advances in eHealth communication technologies are helping in this area. eHealth expands healthcare access to remote areas of the globe that never dreamed of having modern medical care.

Technologies such as live video conferencing, uploading of MRI or other scans to a cloud network, and remote monitoring of vital signs such as body temperature, blood pressure, and glucose levels, are all used by healthcare providers located at a distance and sometimes across the globe. All that is needed is a smartphone or computer device coupled with Internet access at both ends to connect patients with quality healthcare.

In emerging and developing nations around the globe, telemedicine is being used where doctors are scarce and resources are non-existent. The World Health Organization (WHO) has said that telemedi-cine is essential to provide healthcare, particularly in settings where access to medical services is insufficient (GHWA & WHO, 2014). In China alone there are 900 million people living in rural areas struggling with scarce healthcare (Lin et al., 2014). With a projected 5.13 billion mobile phone users worldwide by 2017, innovations in telemedicine could be a solution in these underserved areas (eMarketer, Dec 2014).

The number of healthcare professionals using mobile devices around the world is increasing. A global study of patients found that 44% have seen medical professionals using a mobile device during treatment or diagnosis. In Qatar and Saudi Arabia more than half of consumers have seen mHealth used in treatment or in diagnosis (AVG, 2015).

With a projected growth of mobile phone users worldwide and the adoption of new applications of use, mHealth can serve as foundation to economic growth in these developing countries by improving the health of its citizens. The major barriers to the progress of eHealth technologies in developing countries are the lack of technological resources, conflicting health system priorities, and the lack of legal frameworks.

Figure 18.8

Healthcare Worker Using a Cellphone in Ghana

Source: Nana Kofi Acquah and Novartis Foundation

Current Status

The health system in the United States is facing many challenges. The cost of healthcare in the United States is the highest in the world with the average per capita cost reaching US $9,146 (WorldBank, 2016), and the aggregate healthcare spending in the United States is expected to reach US $4.8 trillion by 2021 (CMS, 2011). The Patient Protection and Affordable Care Act (PPACA), commonly known as “Obamacare,” was signed into law on March 23, 2010 and took effect on January 1, 2014. This law prohibits insurers from denying coverage to individuals based on pre-existing conditions and mandates that all individuals who are not already covered by a health plan secure an approved private insurance policy or pay a penalty.

The Patient Protection and Affordable Care Act (PPACA) is fueling eHealth by restricting health spending and creating new business models for healthcare that are more value-based. Historically, the healthcare industry was not rewarded for keeping patients healthy and avoiding expensive treatments; however, PPACA is forcing change to that model by propelling healthcare organizations into the adoption of new technologies to engage and empower patients to take more control of their healthcare.

The use of new technologies and apps that engage consumers is not enough. Full adoption of these new technologies as well as new applications of use will take time and will require a change in the consumer’s behavior. These changes will require incentives for use and compatibility with current technologies, making it easy for users to adopt. As the proliferation of new eHealth technologies continues, it may be harder for consumers to navigate the many options available to them.

Security Issues in eHealth

Security concerns are the biggest inhibitor of adoption of new eHealth technologies. The key security issues in eHealth include security for patient confidentiality, security that enables authentication of electronic health records, and systems security that ensures secure transmission, processing, and storage of health data (Waegemann, 2003). Electronic Health Records (EHR) were believed to be the solution for improved management of an individual’s health, and to be the tool that would give the patient control of their own health by providing access to his or her own medical history (Waegemann, 2002). EHRs have opened the doors for patient access, but have also opened the doors to security risks. The issues of protection of EHRs against intrusion, data corruption, fraud, and theft are of highest concern for healthcare professionals and the patients they serve. As illustrated in Figure 18.9, since 2009 there have been more than 1,437 major breaches of protected health information affecting more than 154 million patient records. Of the 154 patient health records compromised, 113,208,516 occurred in 2015. With 98% of the compromised patient records resulting from IT hacks, the security of online patient records is a top priority for healthcare organizations (Redspin, 2016). Patient information will remain a top priority for governmental agencies, healthcare, and the technology sectors.

Figure 18.9

Total Large PHI Breaches and Records Impacted 2010-2015

Source: Redspin (2016)

Factors to Watch

We live in a highly personalized era where technologies have increased access to a wide range of goods and services. For example, you don’t have to get in your car and drive to the store to get everything you need to survive in this world. You can now access millions of products online and have them delivered to your door, in some cases, the same day. Mobile phones have thousands of personalized accessories, case options, and more than three million apps to choose from (Statista, 2015). This culture of individualized access has created a generation of consumers that expect products and services that are customized to their individual needs. Watch for eHealth options that are highly individualized as these cultural influences spill over into the healthcare sector.

Getting a Job

There are tremendous career opportunities in eHealth. A growing field is health informatics. According to the Bureau of Labor Statistics, employment of health information specialists is expected to grow faster than any other occupation in the US, 22% by 2022. The University of South Florida (n.d.) defines health informatics as “the acquiring, storing, retrieving and using of healthcare information to foster better collaboration among a patient’s various healthcare providers.” Careers in health informatics include nurse informaticist, chief medical information officers, director of clinical informatics, clinical data analyst, and IT consultant. Getting a Masters Degree in Health Informatics or Health Information Management is a good first step. There are also career opportunities in the creation, sales and management of health related technologies such as wearables, apps, and monitoring.

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