While in both Israel and Portugal, the interviewees mentioned that patient empowerment has increased, there were some disagreements, especially among patients’ organizations who expressed concerns regarding the risk of having patients get more information through Internet and Social Media. When interviewing the patients’ association in Portugal, the respondents mentioned that with some diseases the importance of eHealth tools is tremendous. Our respondents included one from an association related with respiratory diseases and another related with diabetes. In the first case, the interviewee mentioned that when the patient has a respiratory disease and weather conditions are not favorable, eHealth tools such as email, Internet, and mobile applications could be a great resource of communication, as in those cases it is very difficult to reach the hospital. Moreover, according to our respondents, ePrescriptions (electronic prescriptions) can help chronic disease patients get their prescriptions without going every time to visit their physician However, they also stress that face-to-face interaction is also important, especially to cope with patient anxiety. As one of them stated: “people need from the physician”.
Regarding the effect of the information found in the Internet on patient empowerment, the interviewees agreed that it is very important
“The physician can give you technical details, but is good to be informed and educated” (Interviewee from a Portuguese patients’ association). Contrary to studies that suggest that patients may not get the right information [
18] this interviewee feels that Internet accessed information would increase the effectiveness of discussions with patients.
“diabetes is a part of life of people with diabetes and diabetes control reflects how people will live in the ….environment so we need to have proper implementation…people with diabetes they pay a difficult price to communicate with the healthcare team because people with diabetes they are their own managers of diabetes and in some point of their life they will communicate with the healthcare, they will go to consultation and they go to patient’s procedures but for 90 % of the time they would, they are managing the diabetes” (Interviewee from a Portuguese patients’ association).
Also in Israel, interviewees highlighted the increasing role of the patients. Once they are aware of the possibilities and the barriers they can overcome, “the patient is more educated, and can be really a partner in such a treatment, should be a partner” (Member of the Israeli MOH), and should be involved.
Some of the respondents in the Israeli sample pointed to the risk that involved patients may not be able to discern between good and bad medical information found on the Internet. Another problem can be
too much information:
“Go to Google and try to ask a very simple question, I give you an example, what antibiotic I need to take for a specific infection, you will get in average between 6 to 7 million pages, you read the first two and that’s all, it is really a way to activate the patient?…” (Interviewee from an Israeli private company)
Still, most respondents saw access to such information in a positive light. One of the physicians interviewed in Israel mentioned:
“The educated consumer is our best customer. I don’t mind my patients knowing, having a look on the Internet to look up for their illnesses, if they are going to take responsibility of their health in that way I am for it”.
It seems that the health plans need to balance the provision of care through eHealth with the personal care provided by the physician. “You need to have balance, you need to balance, the need for care that simple physicians…will remain, this will not replace the physicians, would complement it…I have a problem now in providing care, we are providing care that it is sometimes ineffective that does not manage to get the patient involved enough and this could be an excellent tool for patient engagement…” (Interviewee from an Israeli health plan)
Regarding the increasingly proactive role of patients, an interviewee from the Portuguese MOH mentioned that
“I think that patients are starting to have now a place they did not have”, referring to the fact that in the last years the Ministry has started thinking about the patients as stakeholders. Interestingly, and somewhat differently from the Israeli perspective, this change is derived from use of ICT for administrative purposes. For example, the first initiative was “eBooking”, or the possibility to book an appointment with the general practitioners through Internet. Building on this, most of the important initiatives aimed at enhancing consumer voice were started. As an example, the MOH in Portugal has launched a Health Portal in 2008. This portal operates through a network involving all agencies reporting to the MOH, with a central core consisting of the General Secretariat of the MOH and the Central Administration of the Health System. All citizens can access and use it for free. It is intended to be a gateway that provides direct access to up to date information on health issues, as well as online services, news, health information and information regarding the institutional organization of the sector. It also offers search services about several health topics and other information on services offered by hospitals and health centers, such as their schedules, and pharmacy hours.
“This means, of course, that they now contact the help line, they criticize, and they say this is not correct in my information; I think that if you have a button for… I think this kind of disease, you know, I cannot record my disease, you don’t have it in the drop list…I think we did not have a reason to meet patients’ associations and things like that…now they interact in the portal directly or we want them to do so, so, they will have an opinion, and they will have an opinion, and the project is growing, and I think should grow faster, and next year we will have to invest in that…” (Interviewee from the Portuguese MOH).
Some of the patient’s associations will be plugged to the portal and information will be available. “I think that increased a lot the transparency of the information”, he added. According to the interviewee this portal is an important communication channel between the patients and the healthcare system.
Similarly, in Israel the relationship between ICT and patient role and satisfaction arose. From the interviews it was not clear if the patients need to be in the first stage of every implementation program in eHealth, but they are an important part of the evaluation of those programs, “we have a lot of input from the patients” said a key manager from one of the Israeli health plans, talking about satisfaction surveys done in the sick fund.
As mentioned by another key informant from another health plan
"by definition, you have to click in”. The main areas of patient involvement were communication and feedback (from periodical surveys), social networks and patient education.
“gradually, the attitude in the world is patient empowerment, this is the attitude, health is so expensive, without the support of the patient we cannot achieve anything, patient empowerment is a very important value, now we are communicating with patients through the Internet, no other way, this is the world” (Interviewee from an Israel research institute)
Impact of eHealth on physicians and medical organizations
When asked how the patient-physician relationship has changed, one of the interviewees in Portugal said that patients know more now as a result of Internet browsing and this shift in access to information can influence patient confidence in physicians,. The latter need to be prepared: “That brings a huge responsibility to healthcare professionals because they have to know that patients look for that information” (Interviewee from a Portuguese patients’ association).
Regarding issues like adaptation and change of paradigms of physician interaction with new technologies, results in both countries were similar, highlighting physicians’ reluctance.
“…also the caregivers should feel comfortable with the technology; when we started to implement medical records you know, computerize medical records, the physicians had a hard time, you know, they have to talk, look to the patients, talk to the patient, feel the patient-now they have to press keys…” (Interviewee from an Israeli health plan)
“They get used to that, physicians always they, they are slow to accept changes, so every change is difficult for them. … there are also, I think there some good points as when they say what will happen with such a technology… for example I saw some concerns about patients getting to the data so they say, how they are going to understand the data, now they will have many, many questions and this bothers all the physicians, and so on, so there are many, many questions” (Interviewee from the Israeli MOH).
These barriers were overcome as physicians began to understand the benefits of the tools and with the arrival of a new generation of physicians. This view was shared by the Portuguese interviewees. One of the interviewees in Portugal mentioned that it is important to share the ownership of innovation with the physicians as they may be reluctant to change:
“…you have to bring physicians to innovation, and sometimes they resist, sometimes they don’t like, but sometimes they don’t like because they are used, they are not in the center of innovation, sometimes you bring innovation to tell them what to do, instead of using them to tell how innovation should be done, so there is also this kind of gap.” (Interviewee from a private Portuguese technology company).
“It was variable, as expected it could depend on the specialties, could depend on the age of the physician, the interest in technology also and it depends also what was in written form before, and the we try to reproduce exactly what was written before” (Interviewee from a Portuguese patient’s association).
According to the interviewee from the Portuguese diabetes patients’ association, during the first two years of implementation the association used the two systems, paper and electronic, but in the end the move to the electronic was mandatory for all physicians. The main barrier was that physicians were not used to technology, however the association motivated its physicians by showing the importance of sharing information and providing clinical information.
Physicians’ behavior can be affected by eHealth tools by changing the way decisions are made. For one of the interviewees, one of the most important advantages of eHealth tools is that it improves the way medical decisions are made by physicians as they have access to more information in real time about their patients, reducing the risk of malpractice.
From the side of the organization, eHealth tools can be a solution to the increasing costs the healthcare system faces today: “eHealth for me is how to enable technology to help the healthcare system to build this new reality where they can provide better care at a lower cost” mentioned the interviewee from a technology company located in Lisbon.
Perceptions about the government
As other studies revealed, all the interviewees agreed that the Portuguese government has an important role in the implementation of eHealth services and its development [
4]. According to the interviews, most of the software implemented in the hospital and healthcare services community was developed by the government which facilitates the interoperability between some of the systems.
One of the interviewees mentioned: “The Portuguese health system is based on a National Health Service (NHS). This NHS is the main provider and the main funder of health care. Thus, the implementation of eHealth on a nationwide scale is highly dependent on the government.”
Apparently, according to one of the interviewees, the role of the government could be divided into different stages but the tradition was that the Portuguese MOH was generally the developer. Then in 2000 there was a strong debate about the role of the government, including the idea that government should focus more on regulation and outsource the development of software [
4]. In the end, mainly due to economies of scale and the high level of dependency of hospitals on the software created by the MOH, it was decided to build in house solutions.
“[interoperability] is easier… the risk there, have to accept the risk, is that you will have such a big thing taking care of so many things, that if it doesn´t move, most of the system doesn’t move” (Interviewee from the Portuguese MOH).
In addition, other interviewees observed that government intervention may slow down innovation,
“to be honest if this only depends on the politicians, they come and go every four years, and every time they stop everything, people in the field, should be, should be a lot more involved and also be responsible for keeping the trend…” (Interviewee from a Portuguese private company)., The interviewee also added that one of the roles that the public system should have is to support and facilitate the investments of the private sector, and moreover, that there should be more cooperation between the private and public sector in order to not slowdown the pace of innovation for better patient care. (Table
3).
Table 3
Comparison of Israel and Portugal-eHealth in the country
ICT development indicators
a
| | |
ICT Development Index | 6.19 | 5.77 |
ICT Development Index rank | 27 | 32 |
Cellular subscribers per 100 hab (2011) | 122 | 115 |
eHealth Policies
a
| | |
National eGovernment Policy | Yes (2004) | Yes (before 2000) |
National eHealth Policy | Yes (in process) | Yes (2008) |
Regulation on eHealth | Yes | Yes |
National telemedicine policy | No | Yes |
mHealth initiatives are conducted in the country | Yes | Yes |
Formal evaluation and/or publication of mHealth initiatives | No | No |
Results from the research
| | |
Time of development of eHealth initiatives | 1985 | 1990 |
Starter of initiatives | Health plans (bottom-up) | Government (top-down) |
Innovation | Innovation culture, start-up nation | Slow innovation in the area |
Interoperability | Yes (since 2014) | Yes (since 2007) |
Health Portal | Yes | Yes |
In Israel the story was different. The implementation of eHealth tools has typically been an initiative of the health plans, rather than the government. This is a consequence of the Israeli management and innovation culture. After the healthcare system reform law of 1995, healthcare providers
“understood that without data, they will be lost, they will lose in the competition with the other health plans, and this is a management aspect and also can be used very efficiently for quality improvement like the different… the quality improvement indicators that we are using” (Interviewee from a Israeli health plan).
“…the current government and MOH decided to work differently, ´we should continue including what is already in place. This is a different approach to that in many places in the world, in the world, this is how it works, in many places when they try to dictate everything, like England, the UK, after 20 billion pounds already, and it has failed miserably” (Interviewee from an Israeli private company).
The health plans were key players in developing the different information systems in Israel. “There was no involvement of the MOH in all of what we did to set up our information system”, mentioned a key informant from one of the health plans. “There is a mixed blessing here that they let us do what we need to do and they don’t …(get) in our way … that’s an advantage but on the other hand there are a lot of issues that have to be addressed and should be addressed nationally”, she added. But when asked about a more active government role, the answers from the interviewees were mixed. The roles attributed to the government ranged from watchdog/regulator to a more policy-oriented role in dealing with issues from a national perspective, such as adoption of a national eHealth strategy, or economic and ethical aspects of eHealth tools.
Another issue is the topic of interoperability, meaning the capability of sharing information between different organizations. In this sense, one key informant from another healthcare organization mentioned “Sick funds had to do it by themselves and they did it quite well I think locally, and because we couldn’t not advance towards the integration, that I believe is strongly necessary, the government is now stepping in and it’s playing an important role, even without providing the large sums of money and maybe even by taking credit for what is happening ….this is a very good thing, and it’s good for everyone” (Interviewee from an Israeli health plan).
Barriers and challenges
Answers about barriers and challenges vary between the interviewees. One representative of the Portuguese MOH mentioned that one of the most important barriers and challenges is the expectation from people that eHealth effects are immediate. He mentioned that this is an important issue as most of the eHealth initiatives could take time to be fully implemented.
When talking about costs, interviewees did not agree. While some of them thought that high costs and unknown cost-effectiveness may be a barrier, others mentioned that eHealth initiatives do not necessarily need to be cost effective but simply effective. “Nobody asks you if your bank account was cost-effective” (Interviewee from the Portuguese MOH). In other words, the deployment of eHealth and mHealth should not be slowed down by premature demands for proof of cost effectiveness.
Lack of leadership seems to be important for some of the interviewees as one of the barriers for implementation: “… action does not result from speeches” (Intverviewee from a Portuguese private company).
Another barrier mentioned by one of the members of a Portuguese patient association was the fact that in some cases patients may feel that they do not receive anything in return for their input and for their information. The interviewee mentioned the importance of two-way information (Table
4).
Table 4
Comparison of Israel and Portugal-main barriers and challenges (according to the interviewees)
Lack of knowledge of applications | No | No |
Cost effectiveness unknown | No | No |
Lack of legal policies/regulation | Yes | - |
Perceived costs too high | No | Yes/No |
Underdeveloped infrastructure | No | No |
Lack of research | Yes | - |
Lack of leadership | - | Yes |
Physicians | Yes | Yes |
In Israel, interviewees mentioned the lack of regulation, the lack of research, and physicians as the main the barriers. Technology and costs did not seem to be barriers to overcome for them, similar to their Portuguese counterparts.
Regarding the lack of regulation, as mentioned by one of the interviewees, technology is moving so fast that it is very difficult for the regulatory system in Israel to move along at the same pace.
“Confidentiality, this is the major concern for the citizens of this country and then you understand that efforts to collect all the medical data about someone can be used in order to take good care of him but can be used by people that do not really want to take care of him, to know things about him, or you know to insurance companies, different intelligence agencies and so on, it’s something that should be restricted and I believe that the national project is taking good care of this” (Interviewee from an Israeli health plan).