Research Article: Evaluating eHealth: Undertaking Robust International Cross-Cultural eHealth Research

Date Published: September 15, 2009

Publisher: Public Library of Science

Author(s): David W. Bates, Adam Wright, Aziz Sheikh

Abstract: David Bates and Adam Wright discuss the opportunities and challenges of undertaking international collaborations in eHealth evaluation research, and make recommendations for moving forward.

Partial Text: eHealth—the use of electronic tools in delivering health care [1]—is rapidly emerging as an international priority in nations at all levels of development, yet the benefits and priorities have not clearly been defined. The result is that there is an urgent need for additional research in this area. International research to evaluate the impact of eHealth would be especially helpful, and unless this begins to take place potential economies of scale may not be realized.

We believe that eHealth has enormous potential for improving care in all nations. Although islands of substantial progress exist, this potential remains largely unrealized globally. While some commentators have suggested that electronic records may be out of reach for developing nations, an increasing body of work shows that use of electronic tools can result in large health improvements, even in resource-poor environments [2]–[5], and the World Wide Web means that the latest information is now available anywhere there is an Internet connection, which in itself represents a huge development.

HIT has often been implemented at a very local level, such as at a practice or hospital level, without adhering to any specific standards. However, there have been some examples of HIT implementation with standardization, for example across a network, or region, or sometimes with national coordination. The Netherlands and Denmark, for example, have succeeded in providing some national coordination. Yet many problems occur for any hospital or practice that wishes to implement HIT, and the current fragmented approach of most nations requires each individual hospital or practice to surmount the problems they confront themselves.

Perhaps the most important of the opportunities is that a huge number of problems—like how to authenticate users or which drug–drug interactions really matter—have already been solved by someone, so that enabling sharing of solutions could dramatically reduce the costs of proceeding with HIT implementation, as well as improving the chances of success. As one example, organizations throughout the world are struggling with which specific medication-related electronic decision support to implement. Sets of such decision support are available for purchase from a number of vendors, but none of these sets fully meets provider needs. Yet a core set of medication-related decision support would likely be the same for all providers. The concept that a core exists for specific areas is true not only for the domain of decision support, but for many other areas of eHealth as well.

Despite the numerous opportunities for international eHealth collaboration, there are also very substantial challenges. There are an estimated 261 languages with more than 1 million native speakers [14], and many of these languages use varying alphabets. Despite recent developments in automation of translation, the large number of languages presents substantial challenges in translating decision support and in other eHealth applications. In developing countries, most eHealth activity is targeted towards health care professionals, who usually master an international vehicular language. Translation of applications to local languages also raises the issue of literacy because literacy varies substantially among providers, and this is especially an issue if information is made available to patients.

There is now a wide range of examples of international eHealth collaboration and research, such as a collaboration between the Regenstrief Institute in Indiana ( and the University of Indiana with the Moi University Faculty of Health Sciences in Kenya. This collaboration has led to the development of OpenMRS (, an open-source electronic medical record designed to help track care for patients with HIV, which is now being using in a number of locations in Africa (Figure 1) [2],[3]. OpenMRS has enabled a series of retrospective studies, covering topics from assessment of outcomes for HIV-infected orphan and non-orphan children in Kenya [17], to an evaluation of the impact of an emergency plan for AIDS relief on expansion of HIV care services [18]. While much of the work on health information technologies such as OpenMRS has focused so far on development (rather than evaluation), one evaluation of OpenMRS focused on challenges in developing and maintaining a concept dictionary in a resource-poor setting, and found that most new concepts were proposed only once [19].

There are several ways to stimulate evaluation of international eHealth collaborations, including: (1) promoting education about the importance of conducting eHealth research, (2) developing coherence in description of eHealth interventions, (3) agreeing on common outcomes measures, and (4) improving reporting, indexing, and systematic reviewing of the literature on eHealth.

A great deal might be gained if robust international evaluation of eHealth goes forward. In areas outside health, tremendous improvements in efficiency of resource utilization have already been realized, and there is every reason to suspect the benefits in health from implementation of eHealth may be similar. Clearly, if this is to be achieved, numerous obstacles—only some of which have been discussed—would need to be surmounted. However, that should be possible. Already, today, the availability of medical information has been revolutionized by the Web. Twenty years ago, the only knowledge resources in many areas in the developing world were textbooks, some of which were decades old. In contrast, today it is possible to find medical knowledge using only a cell phone almost anywhere—such changes in technology are likely to transform care, both in the developing world and outside it. To enable this transformation, a wide array of research on eHealth and its benefits will be essential.



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