Introduction
Within the umbrella of e-commerce, one area, e-health, has yet to reach its full potential in many developed countries, let alone developing countries. Each country is positioned differently and has varying potential and preparedness regarding embracing e-commerce technologies generally and e-health in particular. Given the macrolevel nature of many issues pertaining to the development of e-health (Alvarez, 2002), in order to be more effective in their e-health initiatives, it is important for countries to assess their potential, identify their relative strengths and weaknesses, and thereby develop strategies and policies to address these issues to effectively formulate and implement appropriate e-health initiatives. To do this effectively, it is valuable to have an integrative framework that enables the assessment of a country's e-health preparedness. This article serves to develop such a framework that can be applied to various countries throughout the globe, and from this generate an e-health preparedness grid. In so doing, we hope to facilitate better understanding of e-health initiatives and thus maximize their power.
background
Reducing health care expenditure as well as offering quality health care treatment is becoming a priority globally. Technology and automation have the potential to reduce these costs (Institute of Medicine, 2001; Wickramasinghe, 2000); thus, e-health, which essentially involves the adoption and adaptation of e-commerce technologies throughout the health care industry (Eysenbach, 2001; Wickramasinghe, Misra, Jenkins, & Vogel, 2006), appears to be a powerful force of change for the health care industry worldwide.
Health care has been shaped by each nation's own set of cultures, traditions, payment mechanisms, and patient expectations. Therefore, when looking at health systems throughout the world, it is useful to position them on a continuum ranging from high government involvement (i.e., a public health care system) at one extreme to little government involvement (i.e., a private health care system) at the other extreme, with many variations of a mix of private and public in between. However, given the common problem of exponentially increasing costs facing health care globally, irrespective of the particular health system one examines, the future of the health care industry will be partially shaped by commonalties such as the universal issue of escalating costs and the common forces of change including (a) empowered consumers, (b) e-health adoption and adaptability, and (c) a shift to focus on the practice of preventative- vs. cure-driven medicine. Additionally, there will be four key implications, namely, (a) health insurance changes, (b) workforce changes and changes in the roles of stakeholders within the health system, (c) organizational changes and standardization, and (d) the need for health care providers and administrators to make difficult yet necessary choices regarding practice management.
The Goals of E-HEALTH
In order to develop a robust framework, it is imperative to understand the many goals of e-health. These goals, taken together, perhaps best characterize what e-health is all about (or what it should be about; Journal of Medical Internet Research [JMIR], 2003). Specifically, significant goals of e-health include the following.
Efficiency: One of the promises of e-health is to increase efficiency in health care, thereby decreasing costs. One possible way of decreasing costs would be by avoiding duplica-tive or unnecessary diagnostic or therapeutic interventions, through enhanced communication possibilities between health care establishments, and through patient involvement (Health Technology Center, 2000). The Internet will naturally serve as an enabler for achieving this goal in e-health.
Quality of care: Increasing efficiency involves not only reducing costs, and thus is not an end in and of itself, but rather should be considered in conjunction with improving quality, one of the ultimate goals of e-health. More educated consumers (as a result of the informational aspects of e-health) would then communicate more effectively with their primary care providers, which will, in turn, lead to better understanding and improved quality of care.
Evidence: E-health interventions should be evidence based in the sense that their effectiveness and efficiency should not be assumed but proven by rigorous scientific evaluation and support from case histories. Web-accessible case repositories facilitate the timely accessibility of such evidence and thus help in achieving the necessary support of a diagnosis or treatment decision. The evidence-based medicine goal of e-health is currently one of the most active e-health research domains, yet much work still needs to be done in this area.
Empowerment of consumers and patients: By making the knowledge bases of medicine and personal electronic records accessible to consumers over the Internet, e-health opens new avenues for patient-centered medicine, enables patient education, and thus increases the likelihood of informed and more satisfactory patient choices (Umhoff & Winn, 1999).
Education of physicians and consumers: Online sources (continuing medical education for physicians, and health education and tailored preventive information for consumers) make it easier for physicians as well as consumers to keep up to date with the latest developments in the medical areas of their respective interests. This, in turn, is likely to have a positive impact on the quality of care vis-a-vis the use of the latest medical treatments and preventive protocols.
Extension of health care: Extending the scope of health care beyond its conventional boundaries, in both a geographical sense as well as in a conceptual sense, leads to enabling such techniques as telemedicine and virtual operating rooms, both of which are invaluable in providing health care services to places where it may otherwise be difficult or impossible to do.
Ethics: E-health involves new forms of patient-physician interaction and poses new challenges and threats to ethical issues such as online professional practice, informed consent, privacy, and security issues (Healthcare Advisory Board, 2002). However, this is not an intrinsic feature of e-health but rather a feature of the Internet technology, which is the foundation for all e-business initiatives; therefore, e-health along with e-government, e-insurance, e-banking, e-finance, and e-retailing must all contend with these ethical issues. Given the nature of health care, these issues could be more magnified.
Equity: To make health care more equitable is one of the aims of quality identified by the American Institute of Medicine (2001) generally and is one of the goals of e-health.
However, at the same time there is a considerable threat that e-health, if improperly implemented and used, may deepen the gap between the "haves" and the "have-nots," hence the need for a robust framework to ensure the proper implementation of e-health initiatives. In particular, some of the key issues for equity revolve around broad access and familiarity with the technology.
Prerequisites for e-health
In order to actualize and thereby support the key goals of e-health presented above, it is necessary to have four critical prerequisites for any successful e-health initiative, namely, ICT architecture and infrastructure; standardized policies, protocols, and procedures; user access and accessibility policies and infrastructure; and finally government regulation and control. These will now be briefly discussed in turn.
ICT Architecture and Infrastructure
The ICT infrastructure typically includes phone lines, fiber trunks, submarine cables, T1, T3, OC-xx, ISDN (integrated services digital network), DSL (digital subscriber line), and other high-speed services used by businesses, as well as satellites, earth stations, and teleports. A sound technical infrastructure is an essential ingredient to the undertaking of e-health initiatives by any nation. Such infrastructures should also include telecommunications, electricity, access to computers, Internet hosts, ISPs (Internet service providers), and available bandwidth and broadband access. To offer good multimedia content and thus provide a rich e-health experience, one would require high bandwidth. ICT considerations are undoubtedly one of the most fundamental infrastructure requirements.
Networks are now a critical component of the business strategies for organizations to compete globally. Having a fast microprocessor-based computer at home has no meaning unless you have high-bandwidth-based communication infrastructure available to connect computers with the ISP. With the explosion of the Internet and the advent of e-com-merce, global networks need to be accessible, reliable, and fast to participate effectively in the global business environment. Telecommunications is a vital infrastructure for Internet access and hence for e-commerce. One of the pioneering countries in establishing a complete and robust e-health infrastructure is Singapore, which is in the process of wiring every home, office, and factory to a broadband cable network that will cover 98% of Singaporean homes and offices (Wickramasinghe, 2007a).
standardization policies, protocols, and procedures
E-health by definition spans many parties and geographic dimensions. To enable such far-reaching coverage, significant amounts of document exchange and information flow must be accommodated. Standardization is the key for this.
Once a country decides to undertake e-health initiatives, standardization polices, protocols, and procedures must be developed at the outset to ensure the full realization of the goals of e-health. Fortunately, the main infrastructure of e-health is the Internet, which imposes the most widely and universally accepted standard protocols such as TCP/IP (transmission-control protocol/Internet protocol) and HTTP (hypertext transfer protocol). It is the existence of these standard protocols that has led to the widespread adoption of the Internet for e-commerce applications.
The shift to e-health by any country cannot be successfully attained without the deliberate establishment of standardization policies, protocols, and procedures that play a significant role in the adoption of e-health and the reduction of many structural impediments (Samiee, 1998).
user Access and Accessibility policies and infrastructure
Access to e-commerce is defined by the WTO (World Trade Organization) as consisting of two critical components: (a) access to Internet services and (b) access to e-services (Pana-gariya, 2000); the former deals with the user infrastructure, while the latter pertains to specific commitments to electronically accessible services. The user infrastructure includes the number of Internet hosts and number of Web sites, the number of Web users as a percent of the population as well as ISP availability and costs for consumers, the PC penetration level, and so forth. Integral to the user infrastructure is the diffusion rate of PCs and Internet usage. The United States and the United Kingdom have experienced the greatest penetration of home computers (Samiee, 1998). For developing countries such as India and China, there is, however, very low PC penetration and teledensity. In such a setting, it is a considerable challenge then to offer e-health since a large part of the population is not able to afford to join the e-com-merce bandwagon. Countries thus have to balance local call charges, rentals, subscription charges, and so on; otherwise, the majority of citizens will find these costs a disincentive. This is particularly significant for developing and emerging nations where access prices tend to be out of reach for most of the population. Upcoming new technologies hold the promise to increase connectivity as well as the afford-ability level, and developing countries will need to seriously consider these technologies. In addition to access to PCs and the Internet, computer literacy is important; users must be familiar not only with the use of computers and pertinent software products, but also with the benefits and potential uses of the Internet and World Wide Web (Samiee).
Governmental Regulation and control
The key challenges regarding e-health use include (a) cost effectiveness, that is, e-health must be less costly than traditional health care delivery, (b) functionality and ease of use, meaning it should enable and facilitate many uses for physicians and other health care users by combining various types and forms of data as well as be easy to use, and (c) e-health must be secure. One of the most significant legislative regulations in the United States is the Health Insurance Portability and Accountability Act (HIPAA; Protegrity, 2001).
Given the nature of health care and the sensitivity of health care data and information, it is incumbent on governments not only to mandate regulations that will facilitate the exchange of health care documents between the various health care stakeholders, but also to provide protection of privacy and the rights of patients. Some countries, such as China and Singapore, even control access to certain sites for moral, social, and political reasons while elsewhere, transnational data flows are hindered by a plethora of regulations aimed at protecting domestic technology and related human resource markets (Gupta, 1992; Samiee, 1998; Wickramasinghe, 2007a). Irrespective of the type of health care system, that is, whether it is 100% government driven, 100% private, or a combination thereof, it is clear that some governmental role is required to facilitate successful e-health initiatives.
key impact of e-health
The significance of the preceding four prerequisites for e-health initiatives will be modified by the impacts of IT education, morbidity, cultural and social dimensions, and the world economic standing as elaborated upon below.
Impact of IT Education
A sophisticated, well-educated population boosts competition and hastens innovation. According to Michael Porter (1990), one of the key factors to a country's strength in an industry is strong customer support. Thus, a strong domestic market leads to the growth of competition, which leads to innovation and the adoption of technology-enabled solutions to provide more effective and efficient services such as e-health and telemedicine. As identified earlier, the health consumer is the key driving force in pushing e-health initiatives. We conjecture that a more IT-educated health care consumer would then provide stronger impetus for e-health adoption.
Impact of Morbidity Rate
There is a direct relationship between health education and awareness and the overall health standing of a country. Therefore, a more health-conscious society, which tends to coincide with a society that has a lower morbidity rate, is more likely to embrace e-health initiatives. Furthermore, higher morbidity rates tend to indicate the existence of more basic health needs (World Health Organization [WHO], 2003). Hence, treatment is more urgent than the practice of preventative medicine and thus e-health could be considered an unrealistic luxury; in some instances, such as when a significant percentage of a population is suffering from malnutrition-related diseases, e-health is even likely to be irrelevant at least in the short term. Thus, we conjecture that the modifying impact of the morbidity rate prioritizes the level of spending on e-health vs. other basic health care needs.
Impact of cultural and social Dimensions
Health care has been shaped by each nation's own set of cultures, traditions, payment mechanisms, and patient expectations. While the adoption of e-health, to a great extent, dilutes this cultural impact, social and cultural dimensions will still be a moderating influence on any countries' e-health initiatives.Another aspect of the cultural and social dimension relates to the presentation language of the content of the e-health repositories. The entire world does not speak English, so the e-health solutions have to be offered in many other languages. The e-health supporting content in Web servers and sites must be offered in local languages, supported by pictures and universal icons. This becomes a particularly important consideration when we look at the adoption and diffusion of evidence-based medicine as it will mean that much of the available evidence and case-study data will not be easily accessible globally due to language barriers.
Therefore, for successful e-health initiatives, it is important to consider cultural dimensions. For instance, an international e-commerce study by International Data Corp. indicates that Web surfing and buying habits differ substantially from country to country (Wilson, 1999), and this would then have a direct impact on people's comfort in using e-commerce generally and e-health in particular, especially as e-health addresses a more fundamental need. Hence, the adoption of e-health is directly related to one's comfort with using the technology and this in turn is influenced in a major way by cultural dimensions. Also connected to cultural aspects is the relative entrepreneurial spirit of a country. For example, Hofstede (1980) indicates that in a cultural context, Indians score high on "uncertainty-avoidance" criteria when compared to their Western counterparts. As a result, Indian nationals, for example, do not accept change very easily and are hostile toward innovation. This then would potentially pose a challenge to the start-up of e-health initiatives, whose success depends on widespread adoption for their technological innovations. Thus, we conjecture that fear of risk and absence of an entrepreneurial mind-set as well as other cultural and social dimensions can impact the success of e-health initiatives in a given country.
Impact of World Economic standing
Economies of the future will be built around the Internet. All governments are very aware of the importance and critical role that the Internet will play on a country's economy. This makes it critical that appropriate funding levels and budgetary allocations become a key component of governmental fiscal policies so that such initiatives will form the bridge between a traditional health care present and a promising e-health future. Thus, the result of these initiatives would determine the success of effective e-health implementations and consequently have the potential to enhance a country's economy and future growth.
The World Economic Forum's global competitiveness ranking measures the relative global competitiveness of a country. This ranking takes into account factors such as physical infrastructure, bureaucracy, and corruption. Thus, we conjecture that when weak physical infrastructure is combined with high levels of bureaucracy and corruption, this will lead to significant impediments to the establishment of successful e-health initiatives.
A Framework For assessing E-health Potential
In order to understand numerous critical considerations to facilitate prudent decision making concerning any e-health initiative, it is most useful to have one integrative framework that not only brings together the eight goals of e-health but also the prerequisites and key impact aspects. We propose the framework shown in Figure 1 as such an integrative framework to assess the e-health potential and preparedness of countries as well as potential barriers for any particular e-health initiative. Health care polices are generally developed to a large extent at a macro, country level and thus we believe it is also necessary when looking at e-health to first take a macro perspective and analyze the level of the country in terms of embracing e-health. The framework highlights the key elements that are required for successful e-health initiatives and therefore provides a tool that allows analysis beyond the quantifiable data into a systematic synthesis of the major impacts and prerequisites. The framework contains four main prerequisites, four main impacts, and the implications of these prerequisites and impacts to the goals of e-health. By examining both the prerequisites and the impacts, it is now possible to assess the potential of a country and its preparedness for e-health as well as its ability to maximize the goals of e-health in a systematic and careful manner.
Figure 1. A framework for assessing a country's or region's e-health potential
future trends
In developing an e-health initiative, a good first step for any country is to assess its standing with respect to the four prerequisites and four impacts discussed above. In this way it will be possible to evaluate its preparedness with respect to these parameters and consequently devise appropriate policies and strategies for an effective and successful e-health initiative. As e-health initiatives become more prevalent and mature, it will also become necessary to continually update and refine many aspects, most especially the knowledge and data content (Puentes, Bali, Wickramasinghe, & Naguib, 2007; Wickramasinghe, 2007b). To do this in a systematic fashion so that at all times it is possible to leverage the extant knowledge base, we anticipate that the application of the tools and techniques of knowledge management will begin to play a growing role in the future developments of all e-health initiatives, and we urge for more research in this area.
conclusion
E-commerce, as noted by the United Nations secretary general's address, is an important aspect of business in the 21st century. No longer then is it a luxury for nations, but rather it is a strategic necessity in order for countries to achieve economic and business prosperity as well as social viability. One of the major areas within e-commerce that has yet to reach its full potential is e-health. This is due to the fact that health care generally has been slow in adopting information technologies. Furthermore, there is a shortage of robust frameworks that may be used as guidelines for assessing countries' e-health preparedness and identifying the key areas and deficiencies that need to be addressed in order for successful e-heath initiatives to ensue. In addition, e-health is more than a technological initiative; rather, it also requires a major paradigm shift in health care delivery, practice, and thinking. We have attempted to address this gap by developing a framework that identifies the major factors involved in assessing the e-health preparedness of countries, thereby facilitating them in focusing their efforts on the relevant issues that must be addressed in order for successful e-health initiatives to follow (the goals of e-health are realized). An outcome from our analysis indicates that the relative health care system (i.e., whether government driven, public, or two tier) would appear to have less significance in establishing successful e-health initiatives. The first step in the development of any viable e-health strategy is to make an assessment of the current state of e-health preparedness and then to move to a state of higher preparedness. Finally, we note that with respect to our framework, other parameters also exist and could also be considered important, perhaps even as important as the ones we used. However, we believe that the framework will still function the same way (i.e., provide a useful tool for any country trying to determine and develop a successful e-health initiative) irrespective of the number of parameters; in this regard, we preferred simplicity over complexity.
key terms
Efficiency: One of the promises of e-health is to increase efficiency in health care, thereby decreasing costs.
E-Health: It is health care delivery supported and enabled through the use of information systems and information technology, especially Web-based technologies.
Equity: This refers to making health care more equitable.
In particular, some of the key issues for equity revolve around broad access and familiarity with the technology.
Evidence Based: E-health interventions should be evidence based in the sense that their effectiveness and efficiency should not be assumed but proven by rigorous scientific evaluation and support from case histories.
Framework: It is the conceptual structure used to solve a complex issue.
IT Infrastructure: It is the combination of hardware, software, networking, and telecommunications that forms the foundation for supporting IT capabilities in place.
Morbidity: This refers to either the incidence rate or to the prevalence rate of a disease.
Telemedicine: Telemedicine is the use of information systems and information technology to provide or facilitate the delivery of clinical-care evidence-based medicine. It also involves the application of uniform standards of evidence gained from previous cases to facilitate superior medical-practice outcomes.