by: Perry W. Payne, Jr., MD/JD/MPP

The Journal of Medical Internet Research recently published an article in which a team of researchers from multiple countries conducted a structured literature review to assess the scope of policy issues that individuals, institutions and governments face when implementing eHealth programs.

eHealth, which broadly refers to the use of electronic/digital processes and devices for health or health care purposes, is recognized in developed and developing countries as a potential way to increase access to health information and help health professionals respond more efficiently to the needs of patients and communities, especially in remote areas.

Implementing good eHealth solutions for institutions or nations requires well written policies. The researchers of this study defined eHealth policy as “a set of statements, directives, regulations, laws, and judicial interpretations that direct and manage the life cycle of eHealth.” They indicated that if these policies don’t exist, institutions and nations will be unable to maximize the benefits of eHealth.

Why review the state of eHealth policy?

Their study was based on the premise that eHealth requires unique policies and strategies in order to be properly implemented and integrated into health objectives at the national and international level.

For example, if eHealth policies do not promote access to eHealth solutions, societies could have widening gaps in health status and health literacy levels between different sectors of their populations instead of increased health equity. The researchers also noted that the World Health Assembly called for improved eHealth policies when it asked member states to create long term strategic plans for the development and implementation of eHealth.

Based on these findings, the authors conducted a detailed review of the literature “to determine the scope of policy issues faced by individuals, institutions, or governments in implementing eHealth programs.” The researchers did not seek to recommend any particular policies, only to provide details of the key issues that institutions and nations face. This information may serve as a conceptual framework for legislatures throughout the world seeking to address the unique policy concerns raised by eHealth technologies.

Literature Review Methodology

The researchers reviewed literature from peer-reviewed journals and grey literature (such as newspapers, government publications, etc.). For peer-reviewed journals, they searched pubmed.gov using the terms “eHealth, telehealth, telemedicine, health informatics, electronic health records, health telematics, guidelines, policies, rules, and plans.” This list could have been expanded to include different subsets of eHealth, such as mHealth, medical apps, and more. Given the FDA’s focus on medical apps, a more expansive approach would have improved the researchers’ search for policy issues relevant to eHealth.

The researchers selected articles written in English and published from 1998 – 2008. According to the researchers, they removed articles “beyond the scope” of their study. However, “beyond the scope” is not clearly defined. Thus, why some articles were selected and others were omitted is not clearly explained by the researchers.

950 articles were identified initially and decreased to 150 after the researchers removed duplicate articles and applied their “beyond the scope” test to the list of articles. Subsequently, the reviewers used another unclear methodology to whittle this number down to 40 articles that were reviewed. From these articles, a list of key policy issues was developed.

For grey literature, the researchers performed a Google search using the same search terms as they used for the peer-reviewed literature search. They identified 20 national and international policy papers and documents. Policy issues were extracted from these.

In a final step, the researchers used an undefined process to further refine their complete list of policy issues and group them into categories and themes “for better understanding.”

Key Findings of the Study

The researchers identified 99 eHealth policy issues which they grouped into 9 themes as follows:

  • Networked care

  • Interjurisdictional practice

  • Diffusion of eHealth/digital divide

  • eHealth integration with existing systems

  • Response to new initiatives

  • Goal-setting for eHealth policy

  • Evaluation and research

  • Investment

  • Ethics in eHealth

The researchers also categorized the policy issues based on the “levels” where the policies should be developed. The different levels and the researchers’ definition of them are as follows:

  • Global: this level deals with the policies of global complementarity, such as standardization and interjurisdictional care

  • Jurisdictional (national and provincial/subnational): this level deals with the policies required to facilitate care within a health jurisdiction—that is, national or provincial/subnational governments

  • Individual Institutions: this level deals with the policies required to facilitate eHealth at the local level—that is, individual institution or practice

In their article, the researchers group the policy issues under each theme by the level at which the policy needs to be created. For example, for the theme of networked care, researchers stated that electronic health record standardization is a global policy issue, regulation of appropriate technologies is a jurisdictional issue, and reimbursement/remuneration is an institutional/individual issue.

While the categories are useful, what is not clear from the article is which issues are the most important policy concerns based on existing literature. Hence, policy makers looking to address the most important topics (such as those which impact the most people) are not able to find this information based on this current study.

Future Research that is Needed

As stated above, there are a number of issues not addressed by this article and thus more research is needed in this area. The researchers also provide next steps for future research in their article. First they indicated that existing policies at all of the three levels they identify – global, national, and institutional – should be identified and studied. They indicated that the success and failures of these policies should be assessed and used to inform the future work of policy makers.

This approach should lead to more evidence-based, or at least evidence informed, policies in this area. Hence, this research is a start to understanding the policy concerns in this area, but much more work needs to be done in order to inform policy makers of how to best address this evolving area of technology.