i n t e r n a t i o n a l j o u r n a l o f m e d i c a l i n f o r m a t i c s 8 4 ( 2 0 1 5 ) 48–57
journal homepage: www.ijmijournal.com
ICT and the future of health care: aspects of health promotion Daniela Haluza a,∗ , David Jungwirth a,b a b
Institute of Environmental Health, Center for Public Health, Medical University of Vienna, Austria Department of Communication Science, ICT & Society Center, University of Salzburg, Austria
a r t i c l e
i n f o
a b s t r a c t
Article history:
Purpose: Increasingly, Information and Communication Technology (ICT) applications enter
Received in revised form
the daily lives of consumers. Availability of various multimedia interfaces offers the oppor-
16 September 2014
tunity to develop and adjust ICT solutions to all aspects of society including health care. To
Accepted 18 September 2014
address the challenges of the ongoing adaptive progress of ICT, decision makers profit from estimates of expectable merits and risks of future technological developments. The aim of
Keywords:
the present study was to assess the prevailing opinions and expectations among Austrian
Delphi survey
stakeholders regarding ICT-assisted health promotion.
Health promotion
Methods: In total, 73 experts (74% males) engaged in the Austrian health care sector par-
Health policy
ticipated in a biphasic online Delphi survey. Panellists were assigned to three groups
ICT
representing medical professionals, patient advocates, and administrative personnel. In a
Public Health
scenario-based questionnaire, experts evaluated potential advantages and barriers as well
Stakeholders
as degree of innovation, desirability, and estimated date of implementation of six future ICT scenarios. Scenario-specific and consolidated overall opinions were ranked. Inter-group differences were assessed using ANOVA. Results: Panellists expected the future ICT-supported health promotion strategies to especially improve the factors living standard (56%), quality of health care (53%), and patient’s knowledge (44%). Nevertheless, monetary aspects (57%), acceptance by patient advocates (45%), and data security and privacy (27%) were considered as the three most substantial hampering factors for ICT applications. Although overall mean desirability of the scenarios was quite high (80%) amongst panellists, it was considerably lower in medical professionals compared to patient advocates and administrative personnel (p = 0.006). This observation suggests a more precautious attitude of this specific interest group regarding technological innovations. Conclusions: The present Delphi survey identified issues relevant for successful implementation of ICT-based health care solutions, providing a compilation of several areas that might require further research. In the light of ageing societies facing the perceived threat of permanent online surveillance, different requirements and expectations of end users
∗ Corresponding author at: Institute of Environmental Health, Center for Public Health, Medical University of Vienna, Kinderspitalgasse 15, A-1090 Vienna, Austria. Tel.: +43 1 40160 34933; fax: +43 1 40160 934936. E-mail address: [email protected] (D. Haluza).
http://dx.doi.org/10.1016/j.ijmedinf.2014.09.005 1386-5056/© 2014 Elsevier Ireland Ltd. All rights reserved.
i n t e r n a t i o n a l j o u r n a l o f m e d i c a l i n f o r m a t i c s 8 4 ( 2 0 1 5 ) 48–57
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should be accounted for by various stakeholders. Thus, close collaboration could facilitate the harmonization process on hot health topics among interest groups. © 2014 Elsevier Ireland Ltd. All rights reserved.
1.
Introduction
Increasing numbers of patients suffering from chronic medical conditions like cardio-respiratory diseases and diabetes mellitus are overwhelming modern health care services with high annual expenses [1]. Addressing these increasing financial challenges, Information and Communication Technologies (ICT) allow for cost-effective disease management as well as patient’s empowerment and health promotion [2]. Together with wireless technologies, especially long-term medical care requirements could be addressed at significant lower expenditures in ambulatory settings or patients’ homes by ICT applications [3]. Implementation of ICT-supported preventive measures might be expensive, but possess a high cost-saving potential in the long run [4]. During the last century and similar to trends observed in other developed countries, the shape of the Austrian population age pyramid changed and became top heavy, i.e., the proportion of children and young people was reduced in favour of the older generation [5]. To address this shift in population structure, new Public Health strategies for promoting pro-active ageing could be of great societal value [6,7]. In all fields of society, especially in the health and geriatric care sector, ICT-enabled innovations designed for consumers with special needs offer a huge opportunity to face the challenges of ageing societies [8–10]. As a first step, ICT-based assistance in everyday life provides the key to consumer’s independency and self care [9]. Further, as suggested by Guillen et al. [11], personalization, mobility, and adaptation of ICT applications could enhance the success of national health promotion and disease prevention programs. To maximize respective Public Health efforts, design and usability of web-based health portals are constantly improved nowadays [12]. Availability of these interactive consumer-orientated online services could exert positive influence on health outcomes including reduction of duplicative testing, hospital (re)admission, and mortality rates due to increase of patients’ knowledge and compliance [13,14]. Anticipation of future ICT developments greatly enhances effective communication between end users and decision makers in scientific, industrial, and clinical settings [15]. So far, empirical research on prevailing opinions regarding ICT use of health care professionals is lacking for Austrian conditions. To close this knowledge gap, the Delphi method serves as a useful research method [16]. Thus, we invited a panel of Austrian experts representing the three interest groups medical professionals (hospital-based doctors as well as community-based general practitioners), patient advocates, and administrative personnel. During a two-round online Delphi process, panellists determined aspects and classified factors for six conceivable ICT scenarios. The present study aimed at identifying expected benefits and perceived challenges of prospect
demands in the specific area of ICT-supported health promotion as well as primary and secondary disease prevention in Austria. As panel members were assigned to a specific stakeholder group based on their professional background, a further study objective was to analyze potential inter-group differences of scenario-based expert opinions.
2.
Methods
2.1.
Identification of future ICT scenarios
The current analysis was part of a larger research project that gathered opinions and expectation of future ICT-assisted health-related aspects by constitutively investigating results of a two-round online Delphi survey. In the study’s initial design and conception phase, we identified three major research fields of interest covering ICT-based health promotion, doctor–patient communication, and pervasive health. The two latter topics are elaborated on in consecutive, though separate scientific articles. Adapted from our previously published paper evaluating the impact of technological applications on doctor–patient communication [17], the current study merely focuses on the expected impact of prospect scenarios on ICT-supported health promotion. Accordingly, we defined the following six hypothetical scenarios based on respective international, peer-reviewed literature.
• Scenario 1 – Compliance: “Personalized information and communication technologies remind patients of punctual intake of prescribed medicine, resulting in higher compliance and thus better therapeutic outcome.” [18–21]. • Scenario 2 – Education: “Scientific, interactive multimedia is broadly accepted and intensively used for Public Health education and preventive medicine.” [22,23]. • Scenario 3 – Cancer risk: “Target-group specific information and communication technology-assisted preventive medicine is widely used to reduce the individual’s cancer risk.” [24–26]. • Scenario 4 – Insurance rates: “Funding of health insurances is deregulated, and insurance rates depend on individual information and communication technology-tracked lifestyle choices.” [27,28]. • Scenario 5 – Activities: “Target-group specific tourist and recreational activities for consumers with similar socioeconomic and medical conditions are a common information and communication technology-based health promotion effort.” [11,29]. • Scenario 6 – Prevention: “Web-based communication tools assist handicapped or elderly people by providing educative information for primary and secondary health prevention.” [11,30].
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2.2.
i n t e r n a t i o n a l j o u r n a l o f m e d i c a l i n f o r m a t i c s 8 4 ( 2 0 1 5 ) 48–57
Delphi survey questionnaire
The first section of the study questionnaire in German assessed socio-demographic data including age, gender, and place of occupation. Further, the second part analyzed each scenario independently using five categories: benefits, barriers, degree of innovation, desirability, and expected date of implementation. The category “benefits” evaluated future merits of the presented scenarios by using the multipleanswer question “Which factors are improved by widely acceptance of the specific scenario in Austria?”. The set of options included the following items: living standard, quality of health care, patients’ knowledge, funding of health care, doctor–patient relationship, as well as no improvement. The category “barriers” measured perceived obstacles by the multiple-answer question “Which factors hamper the implementation of the specific scenario in Austria?”. Possible choices were cost/funding, acceptance by medical professionals, acceptance by patient advocates, acceptance by administrative personnel, data security/privacy, technical prerequisites, regulations/standards, influence of stakeholders, as well as no obstacles. We evaluated “degree of innovation” of each scenario by the single-choice question “In your opinion, how innovative is this scenario for Austria?”, using a 4-point Likert Scale ranging from “not innovative” to “very innovative” as well as the non-response type choice “not applicable”. By answering the dichotomous question “In your opinion, is this scenario desirable for Austria?”, panellists stated “desirability” (desirable/not desirable) of the prospective ICT scenarios. In the last category, experts indicated the “expected date of ICT implementation” when the specific scenario has become established reality in Austria by means of a time line spanning the years 2010–2030. To test the study questionnaire’s comprehensibility, we invited 20 medical professionals engaged at the Medical University Vienna, Austria, to comment on a paperpencil version of the survey. According to their feedback, we adjusted the response format. We developed a two-round online Delphi survey as Computer Aided Application of Written Questionnaires (CAAWQ) [31] within the user-friendly software SoSci Survey (Social Science Survey, Version 2.0.48) [32]. We further customized the PHP (PHP: Hypertext Preprocessor) software by adding content and layout using self-developed applications of Hypertext Markup Language (HTML), Cascading Style Sheets (CSS), and JavaScript (JS).
2.3.
Data collection and analysis
We conducted the biphasic web-based Delphi survey from September to November 2010 in accordance with the principles laid down in the Declaration of Helsinki. We limited participation to experts working in one of the nine Austrian countries. Thus, participants were recruited based on online p-mail address lists provided by all major Austrian health care agencies. For subsequent data analysis regarding inter-group differences, we assigned participants to one of the experts groups (medical professionals, patient advocates, or administrative personnel) according to their professional background. Medical professionals referred to medical
doctors strictu sensu and individuals working in related health care professions (e.g., scientific and nursing staff) were not involved in the survey. After completion of the first wave, aggregated groupspecific outcomes were processed with PHP-Program code. These results were graphically presented to the panellist in the according part of the online questionnaire in the subsequent Delphi round. Survey data was statistically evaluated using Excel spread sheet (Microsoft, Seattle, WA, USA) and SPSS version 17.0 (SPSS Inc., Chicago, IL, USA). We summarized survey responses by frequency counts and means. Group-specific response frequencies of the respective questionnaire section were presented in total percentages for all scenarios consolidated and also separately. For inter-group comparisons of overall picked choices (scenarios 1–6), response frequencies were averaged overall and over groups to calculate a summarized multiscenario score ranging from 1 to 2 (1 = no scenario, 2 = all scenarios). Further, we analyzed group size-weighted distinction of stakeholder groups using analysis of variance (ANOVA). Rounded data were presented and due to rounding errors, some percentages added up to minimal less or more than 100%. The electronic questionnaire survey software prevented missing values due to (partial) item non-response. For all statistical analyses, two-sided level of significance was set at p < 0.05. Eventually, panellists received a final report including summarized survey outcomes by e-mail.
3.
Results
In the first Delphi cycle, we addressed 538 medical doctors (including 80% hospital-based clinicians and 20% communitybased general practitioners), 85 patient advocates, and 108 administrative personnel. Of these (n = 731), 94 individuals fully completed the online study questionnaire, resulting in a response rate of 13%. In the second Delphi phase, 21 participants of round 1 did not fully participate. Overall, 73 participants (mean age = 44 years, SD = 9.4) completed both rounds, of which the majority of participants (74%) were males (mean age = 45 years, females: mean age = 41 years). Regarding group assignment, medical professionals (n = 31, mean age = 46 years) comprised clinicians (n = 29) and general practitioners (n = 2). Representatives of patients advocates (n = 21, mean age = 42 years) were employees of offices of ombudsman (n = 11) as well as patient advocacies (n = 7), and also included communication scientists (n = 2) and one medical ethicist. Administrative personnel (n = 21, mean age = 43 years) worked in governmental organizations (n = 11) as well as in quasi-autonomous non-governmental organizations, i.e., hospitals (n = 10). Panel members ranked factors that could possibly benefit from ICT applications separately for each scenario and also for all six scenarios in order to demonstrate overall inter-group opinions (Table 1). By allowing multiple choices, improvement of living standard achieved the highest overall rank (56%), followed by advancement of quality of health care (53%), and patient’s knowledge (44%).
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i n t e r n a t i o n a l j o u r n a l o f m e d i c a l i n f o r m a t i c s 8 4 ( 2 0 1 5 ) 48–57
Table 1 – Ranking of expected benefits from implementing future scenarios of ICT-assisted health promotion in Austria, stratified by stakeholder groups. In bold: overall total mean. Benefitsb
Expert groupsa 1. Living standard
2. Quality of health care
3. Patient’s knowledge
4. Funding of health care
5. Doctor–patient relationship
6. No improvement
49.5 65.9 57.1 56.4
54.8 51.6 53.2 53.4
33.9 50.8 53.2 44.3
39.8 38.9 42.9 40.4
21.5 21.4 21.4 21.5
17.2 9.5 11.9 13.5
Scenario 1 – Compliance MP 35.5 PA 66.7 AP 66.7 Total 53.4
80.6 71.4 90.5 80.8
38.7 57.1 42.9 45.2
35.5 38.1 57.1 42.5
35.5 42.9 52.4 42.5
9.7 4.8 4.8 6.8
Scenario 2 – Education MP PA AP Total
41.9 61.9 47.6 49.3
48.4 38.1 42.9 43.8
58.1 71.4 81.0 68.5
32.3 47.6 23.8 34.2
22.6 28.6 19.0 23.3
19.4 9.5 4.8 12.3
Scenario 3 – Cancer risk MP 45.2 PA 61.9 AP 57.1 Total 53.4
74.2 76.2 61.9 71.2
22.6 52.4 81.0 47.9
41.9 42.9 47.6 43.8
41.9 33.3 28.6 35.6
12.9 9.5 4.8 9.6
Scenario 4 – Insurance rates MP 25.8 PA 28.6 AP 23.8 Total 26.0
48.4 19.0 33.3 35.6
25.8 38.1 19.0 27.4
80.6 66.7 71.4 74.0
6.5 9.5 4.8 6.8
22.6 23.8 33.3 26.0
Scenario 5 – Activities MP PA AP Total
71.0 90.5 71.4 76.7
41.9 52.4 38.1 43.8
35.5 42.9 47.6 41.1
19.4 19.0 38.1 24.7
9.7 4.8 14.3 9.6
25.8 4.8 14.3 16.4
Scenario 6 – Prevention MP 77.4 PA 85.7 AP 76.2 Total 79.5
35.5 52.4 52.4 45.2
22.6 42.9 47.6 35.6
29.0 19.0 19.0 23.3
12.9 9.5 9.5 11.0
12.9 4.8 9.5 9.6
Scenarios 1–6 MP PA AP Total
a b
Medical professionals (MP), patient advocates (PA), and administrative personnel (AP). Multiple-answer question: “Which factors are improved by widely acceptance of the specific scenario in Austria?”.
A ranking of eight factors revealed overall and intergroup opinions on issues perceived as possible obstacles for implementation of future scenarios on ICT-based health promotion (Table 2). By picking multiple choices, panellists perceived monetary aspects (57%), acceptance by patient advocates (45%), and data security and privacy (27%) as most relevant hampering factor for successful technological innovations. Then, we assessed degree of innovation, desirability as well as the estimated date of approval of the respective ICT scenarios stratified by the three different expert groups (Table 3). Degree of innovation is presented as scenario-based percentage of expert group-specific responses. Perceived desirability differed between groups, as doctors stated considerably poorer
desirability for all scenarios, except scenario 4 – Insurance rates. In general, mean desirability for all scenarios (1–6) was high, reaching nearly 80%, again, except scenario 4 (only 49%). However, overall desirability was lowest in medical professionals (74%) compared to patient advocates and administrative personnel (87% and 81%, respectively). All stakeholder groups perceived the year 2018 as overall mean date estimate for acceptance of the respective future ICT innovations. As aforementioned, we found partly contradictory results for scenario 4 – Insurance rates in all aspects assessed in this Delphi study. Compared to the other scenarios, scenario 4 yielded quite low ratings for improving living standard (26% vs. overall mean 40%), quality of health are (36% vs.
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Table 2 – Ranking of picked choices of expected obstacles for implementing future scenarios of ICT-assisted health promotion in Austria, stratified by stakeholder groups. In bold: overall total mean. Obstaclesb
Expert groupsa 1. Cost, funding
Scenarios 1–6 MP PA AP Total
3. Data security and privacy
4. Acc.c by MP
5. Regulations, standards
6. Technical prerequisites
7. Acc.c by AP
8. Influence of stakeholders
9. No obstacles
46.8 35.7 51.6 45.0
31.7 18.3 27.0 26.5
17.7 15.9 35.7 22.4
24.2 15.1 15.9 19.2
18.3 22.2 12.7 17.8
12.9 4.0 22.2 13.0
9.1 4.8 10.3 8.2
5.9 11.1 11.1 8.9
Scenario 1 – Compliance MP 64.5 PA 57.1 AP 52.4 Total 58.9
54.8 66.7 57.1 58.9
41.9 23.8 38.1 35.6
19.4 23.8 38.1 26.0
22.6 9.5 28.6 20.5
48.4 42.9 42.9 45.2
0 0 4.8 1.4
6.5 4.8 9.5 6.8
0 4.8 0 1.4
Scenario 2 – Education MP 54.8 PA 33.3 AP 47.6 Total 46.6
29.0 23.8 47.6 32.9
0 4.8 9.5 4.1
25.8 33.3 66.7 39.7
29.0 9.5 4.8 16.4
22.6 19.0 9.5 17.8
3.2 9.5 14.3 8.2
6.5 0 9.5 5.5
19.4 23.8 14.3 19.2
Scenario 3 – Cancer risk MP 64.5 PA 71.4 AP 66.7 Total 67.1
54.8 38.1 47.6 47.9
61.3 33.3 33.3 45.2
25.8 14.3 28.6 23.3
29.0 23.8 14.3 23.3
25.8 33.3 14.3 24.7
19.4 0 4.8 9.6
3.2 4.8 4.8 4.1
3.2 4.8 14.3 6.8
Scenario 4 – Insurance rates MP 22.6 PA 9.5 AP 42.9 Total 24.7
71.0 76.2 85.7 76.7
64.5 33.3 52.4 52.1
19.4 14.3 42.9 24.7
45.2 28.6 23.8 34.2
6.5 9.5 4.8 6.8
22.6 0 61.9 27.4
25.8 19.0 38.1 27.4
0 4.8 0 1.4
Scenario 5 – Activities MP 74.2 PA 76.2 AP 61.9 Total 71.2
38.7 4.8 33.3 27.4
12.9 4.8 14.3 11.0
9.7 4.8 9.5 8.2
9.7 9.5 9.5 9.6
3.2 9.5 0 4.1
16.1 14.3 19.0 16.4
6.5 0 0 2.7
3.2 19.0 23.8 13.7
Scenario 6 – Prevention MP 67.7 PA 85.7 AP 66.7 Total 72.6
32.3 4.8 38.1 26.0
9.7 9.5 14.3 11.0
6.5 4.8 28.6 12.3
9.7 9.5 14.3 11.0
3.2 19.0 4.8 8.2
16.1 0 28.6 15.1
6.5 0 0 2.7
9.7 9.5 14.3 11.0
a b c
58.1 55.6 56.3 56.8
2. Acc.c by PA
Medical professionals (MP), patient advocates (PA), and administrative personnel (AP). Multiple-Answer-Question: “Which factors hamper the implementation of the specific scenario in Austria?”. Acc.: acceptance.
53%) as well as patient’s knowledge (27% vs. 44%). On the other hand, it reached the highest rank for enhancing funding of health care (74% vs. 56%). Accordingly, as possible obstacles, acceptance by patient advocates (52% vs. 45%) and data security aspects (52% vs. 27%) were over-represented and monetary considerations were quite under-represented (25% vs. 57%). Furthermore, scenario 4 produced ambiguous results regarding perceived degree of innovation, where far more participants found it not innovative (22%) compared to overall mean (10%) and at the same time very innovative (33% vs. 25%). Moreover, half of the expert panel found
it desirable whereas the other half did not. Additionally, the highest date estimates (2022, maximum 2026) were reported for scenario 4 which was divergent to any of the other scenarios. To further analyze the aforementioned heterogeneous findings of group-specific factor rankings, we examined the overall group size-weighted inter-group differences between the three stakeholder groups (Table 4). Using ANOVA, we found statistically significant intergroup differences for in total eight factors. Expert groups differed regarding overall mean responses regarding two
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Table 3 – Degree of innovation, desirability, and estimated date for implementing future scenarios of ICT-assisted health promotion in Austria, stratified by stakeholder groups. In bold: total mean. Expert groupsa
Scenarios 1 Compliance
Innovationb Not innovative MP PA AP Total
2 Education
3 Cancer risk
4 Insurance rates
5 Activities
6 Prevention
1–6 All
3.2 4.8 0 2.7
3.2 14.3 4.8 6.8
6.5 0 0 2.7
12.9 23.8 33.3 21.9
16.1 9.5 14.3 13.7
12.9 19.0 9.5 13.7
9.1 11.9 10.3 10.3
Barely innovative MP PA AP Total
9.7 28.6 14.3 16.4
25.8 4.8 38.1 23.3
16.1 23.8 23.8 20.5
16.1 19.0 19.0 17.8
12.9 28.6 33.3 23.3
16.1 19.0 38.1 23.3
16.1 20.6 27.8 20.8
Somewhat innovative MP PA AP Total
41.9 42.9 76.2 52.1
58.1 66.7 38.1 54.8
29.0 71.4 47.6 46.6
32.3 33.3 9.5 26.0
41.9 38.1 38.1 39.7
48.4 47.6 33.3 43.8
41.9 50.0 40.5 43.8
Very innovative MP PA AP Total
41.9 23.8 9.5 27.4
12.9 14.3 14.3 13.7
48.4 4.8 28.6 30.1
38.7 23.8 33.3 32.9
29.0 23.8 14.3 23.3
22.6 14.3 19.0 19.2
32.3 17.5 19.8 24.4
Not applicable MP PA AP Total
3.2 0 0 1.4
0 0 4.8 1.4
0 0 0 0
0 0 4.8 1.4
0 0 0 0
0 0 0 0
0.5 0 1.6 0.7
Desirabilityc Desirable MP PA AP Total
80.6 90.5 95.2 87.7
77.4 90.5 85.7 83.6
87.1 95.2 95.2 91.8
51.6 47.6 47.6 49.3
77.4 100 76.2 83.6
71.0 95.2 85.7 82.2
74.2 86.5 81.0 79.7
Not desirable MP PA AP Total
19.4 9.5 4.8 12.3
22.6 9.5 14.3 16.4
12.9 4.8 4.8 8.2
48.4 52.4 52.4 50.7
22.6 0 23.8 16.4
29 4.8 14.3 17.8
25.8 13.5 19 20.3
Dated MP PA AP Total a b c d
2018 2018 2017 2017
2016 2018 2016 2016
2018 2017 2018 2017
2022 2020 2026 2022
2018 2016 2015 2017
2017 2017 2015 2016
2018 2018 2018 2018
Medical professionals (MP), patient advocates (PA), and administrative personnel (AP). Single-choice question: “In your opinion, how innovative is this scenario for Austria?” (%). Single-choice question: “In your opinion, is this scenario desirable for Austria?” (%). Single-choice question: “In your opinion, when will the scenario be widely accepted in Austria?” (mean year estimate).
beneficial aspects, namely living standard (p = 0.015) and patient’s knowledge (p = 0.015). Moreover, besides overall perceived hampering factors (p = 0.047), opinions of panellist groups significantly differed regarding data security and privacy (p = 0.048), technical prerequisites (p = 0.036),
acceptance by administrative personnel (p < 0.0001), and influence of stakeholders (p = 0.046). However, overall degree of innovation (p = 0.084) and the estimated date of acceptance (p = 0.908) of scenarios 1–6 did not significantly differ between groups. Though, we revealed significant differences as
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Table 4 – Group size-weighted inter-group comparisons of overall responses regarding six future scenarios of ICT-assisted health promotion in Austria, stratified by expert groups. In bold: p < 0.05. Expert groupsa ; mean (SD)
Factors
ANOVA Sum2
Mean2
1.4 (0.1) 1.6 (0.2) 1.5 (0.2) 1.5 (0.3) 1.4 (0.3) 1.2 (0.2) 1.1 (0.2)
0.033 0.491 0.019 0.820 0.045 0 0.108
0.017 0.245 0.009 0.410 0.022 0 0.054
0.938 4.315 0.152 6.758 0.306 0 2.114
0.394 0.015 0.859 0.002 0.737 1.0 0.125
1.3 (0.1) 1.6 (0.3) 1.6 (0.3) 1.3 (0.3) 1.5 (0.4) 1.2 (0.2) 1.1 (0.1) 1.2 (0.2) 1.1 (0.1) 1.1 (0.2)
1.3 (0.1) 1.6 (0.3) 1.5 (0.4) 1.3 (0.2) 1.4 (0.4) 1.2 (0.2) 1.2 (0.2) 1.1 (0.2) 1.1 (0.1) 1.1 (0.2)
0.055 0.011 0.269 0.354 0.132 0.180 0.236 0.849 0.080 0.065
0.028 0.006 0.134 0.177 0.066 0.090 0.118 0.425 0.040 0.032
3.138 0.071 1.072 3.103 0.526 1.891 3.416 11.889 3.149 1.264
0.047 0.932 0.345 0.048 0.592 0.155 0.036 0.000 0.046 0.286
2.7 (0.6)
2.7 (0.6)
2.8 (0.6)
1.850
0.925
2.518
0.084
1.7 (0.2)
1.9 (0.1)
1.8 (0.2)
1.8 (0.2)
0.271
0.135
5.409
0.006
2017.9 (2.1)
2017.6 (2.6)
2017.7 (3.4)
2017.7 (2.9)
1.605
0.803
0.096
0.908
MP
PA
AP
1. Benefits Total Living standard Quality of health care Patients’ knowledge Funding of health care Doctor–patient relationship No improvement
1.4 (0.1) 1.5 (0.3) 1.5 (0.3) 1.3 (0.3) 1.4 (0.3) 1.2 (0.2) 1.2 (0.2)
1.4 (0.1) 1.7 (0.2) 1.5 (0.2) 1.5 (0.3) 1.4 (0.2) 1.2 (0.2) 1.1 (0.1)
1.4 (0.1) 1.6 (0.2) 1.5 (0.3) 1.5 (0.2) 1.4 (0.3) 1.2 (0.2) 1.1 (0.1)
2. Obstaclesb Total Cost, funding Acceptance by PA Data security and privacy Acceptance by MP Regulations, standards Technical prerequisites Acceptance by AP Influence of stakeholders No obstacles
1.3 (0.1) 1.6 (0.2) 1.5 (0.4) 1.3 (0.2) 1.4 (0.4) 1.2 (0.2) 1.2 (0.2) 1.1 (0.2) 1.1 (0.1) 1.1 (0.1)
1.2 (0.1) 1.6 (0.3) 1.5 (0.4) 1.2 (0.2) 1.4 (0.3) 1.2 (0.2) 1.2 (0.3) 1.0 (0.1) 1.0 (0.1) 1.1 (0.2)
3. Innovationc Total
3.0 (0.6)
Total
F
p
b
c
4. Desirabililty Total c
5. Date Total a b
c
Medical professionals (MP), patient advocates (PA), and administrative personnel (AP). Overall mean responses to multiple-answer questions (1 = no scenario, 2 = all scenarios); mean (SD): 1. Which factors are improved by widely acceptance of the specific scenario in Austria?; 2. Which factors hamper the implementation of the specific scenario in Austria? Responses to single-choice questions: 3. In your opinion, how innovative is this scenario for Austria? (1 = not innovative, 4 = very innovative; mean, SD); 4. In your opinion, is this scenario desirable for Austria? (1 = no, 2 = yes; mean, SD); 5. In your opinion, when will the scenario be widely accepted in Austria? (mean year, SD).
overall desirability (p = 0.006) was higher in patient advocates and administrative personnel compared to medical professionals.
4.
Discussion
By evaluating prevailing opinions among Austrian health care experts regarding prospect ICT-based health promotion, the current study aimed at closing a research gap. A panel consisting of medical professionals, patient advocates, and administrative personnel participated in a multiscenariobased online Delphi survey. According to Windle [33], these three expert groups were identified as the most important stakeholders in executing Public Health-relevant issues. Additionally, more heterogeneous specifications of panel members represented a broad spectrum of viewpoints and allowed a more realistic estimation of ICT scenarios compared to a homogeneous group. Delphi panellists (n = 73) rated six comprehensible scenarios used as illustration of future ICT applications, specifically designed for individualized and person-centred health promotion. In this verve, we observed statistically significant divergences in group opinions for eight factors, among them the two beneficial aspects living
standard and patient’s knowledge, overall obstacles as well as the hampering factors data security and privacy, technical possibilities, administrative personnel’s acceptance, and stakeholders’ influence, and overall desirability. According to experts’ perception, the three most improved factors in the presented scenarios were living standard (56%), quality of health care (53%), and patient’s knowledge (44%). However, identifying expected hampering aspects seemed to be even more influential for future policymaking processes. In our panel, experts anticipated that monetary exertions (57%) could be considered as the most prominent obstacles for adopting ICT-based health promotion. This result is in line with findings that tremendous expenditures for replacement and technical prerequisites slowed down implementation of ICT solutions in the U.S. healthcare system [34]. Nevertheless, regarding long-term considerations, e-health applications could reduce health spending, especially for treatment and prevention of lifestyle diseases. So, investment in ICT could be regarded as a key factor for pushing prosperity of the entire national economy [35]. Data protection issues were ranked as the third important overall barrier (27%) of implementing the described future scenarios. Confidentiality and preservation of privacy for
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sensitive health care data has always been a hot topic for both consumers and providers [36]. Therefore, decision makers are facing the paramount legal and ethical challenge to develop feasible strategies for assuring both data privacy and security [37]. Regarding self-assessment of group-specific halting attitudes, the overall second ranked obstacle “acceptance by patient advocates”, the fourth ranked obstacle “acceptance by medical professionals” (16% vs. 22% overall), and also the seventh ranked factor “acceptance by administrative personnel” (4% vs. 13% overall) yielded lowest ratings (36% vs. 45% overall) from patient advocates compared to the other panel groups (Table 2). As medical professionals took an intermediate position regarding this matter, administrative personnel rated acceptance by patient advocates (52%), medical professionals (36%), and administrative personnel (22%) highest compared to the other panellists. These observations suggest that patient advocates were least critical and medical personnel were quite neutral concerning the halting role of interest groups relevant for ICT adoption. On the other hand, administrative staff might be well aware of its inherent key position regarding resource allocation for implementation of often costly innovative medical devices and technologies. In conclusion, stakeholders seemed to appraise that ICT adoption by end users including practitioners, patients, and consumers is of vital importance for successful implementation of health promotion-related ICT solutions. As suggested by the literature, acceptance by consumers – especially older and handicapped people – could be raised by using customtailored tools and end-user orientated training and education efforts [38]. Among stakeholders, overall mean desirability of the presented future ICT examples was quite high (80%). This is supported by evaluations on attitudes towards ICT-supported health care that health professionals rated future applications as even more beneficial than already existing ones [39]. Regarding inter-group differences, doctors perceived fewer scenarios as being desirable compared to representatives of patient advocates and health administration personnel (74% vs. 87% and 81%, respectively). Our observation suggests that this interest group might be more sceptical and halting when it comes to innovative ICT implementations in the health care sector. Given that diverse professional groups per se require different ICT solutions [40], this study result is supported with findings that medical doctors compared to other health care staff showed a less positive attitude towards new technological innovations [41]. However, Gund et al. [39] found that medical staff had a highly positive attitude towards both present and future health care-related ICT applications. According to Meade and co-workers [42], rather indistinct factors such as lack of resources (e.g., time, money, and computer skills) were major obstacles for physicians to switch from paper-based to electronic patient records. It is rather unlikely that doctors are suspicious regarding technical developments in general, but our survey found that they might be concerning prospect ICT-assisted changes in health promotion. In this survey, estimates of the predicted date of public approval of presented scenarios were used to seize the
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present level of awareness with and knowledge of experts. Findings pointed towards a date (2018) eight years ahead from the year 2010 when we performed this survey. This was a surprisingly long time period, as the described settings were based on technological applications already available by then. Many consumers of new technologies might raise concerns that sensitive personal data including unhealthy life style habits, chronic diseases, and particularly mental health conditions could be easily accessed by, e.g., potential employers or insuring companies via security leaks [43]. The aforementioned opinions of study participants suggested that the factor data security might be critical for ICT innovations. Stakeholders as spokespersons of the general public interests might reflect the inherent fear that accumulation of electronic health data will probably make us more “transparent”. Therefore, more emphasis should be placed on further evaluations of topics affecting aspects of “big data” as well as surveillance society, as suggested by Neubauer and Heurix [44]. Outstandingly, scenario 4 – Insurance rates showed a different pattern in all of the assessed aspects of ICT-based innovations compared to the other settings. Thus, we identified this respective topic as somehow exceptional. Due to these unexpected observations, we assume that a clear consensus was not reached in this single scenario. Nevertheless, we consolidated the assessed data to report on overall panel opinions on the presented ICT examples. A closer look on possible explanations for the divergent results for scenario 4 in comparison with the other five scenarios could be valuable for demonstrating that the scenarios activated the expert panel to anticipate future ICT scenarios. Thus, we suggest that the panellists were committed and motivated to engage in the survey. Generally, the Delphi process itself was expected to create awareness of the potential power of future ICT applications to shape prospect Public Health strategies for health promotion and disease prevention. The herein reported results need to be considered within the context of several limitations. Clearly, opinions of experts and their expectations regarding future ICT scenarios were influenced by their professional background and personal experiences. Additionally, generalizability and transferability of reported results are limited, because only German-speaking Austrian experts were eligible to participate. Nevertheless, we aimed at providing empirical data on opinions of national interest groups regarding future ICT-assisted health promotion. As another possible limitation, response rate was quite low in this survey, especially among medical professionals. However, the phenomenon of poor and even declining response rates among health care-related professionals is well known [39]. Potential reasons for non-response and overall low survey response rates among doctors might include time investment, concerns about workload as well as out-of-hours commitment [45]. Compared to hospital-based doctors, very few community-based physicians participated in our uncompensated two-round Delphi survey. Consequently, opinions of clinicians were overrepresented in our panel, although physicians might have more impact on every-day exertion and education regarding health promotion. Thus, our results might not fully represent opinions of all Austrian medical
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professionals. Nevertheless, Delphi surveys assemble views of a particular expert panel and are not designed to predict the responses of a larger sample [46]. We consider that a major strength of our study was inclusion of a quite large number of study subjects (n = 73). So, splitting the sample for inter-group comparisons was feasible. Also, panel experts should have enough authority to transform and integrate theoretical findings of a Delphi survey into decision-making processes [46]. In our sample, the majority of participants were engaged in higher-ranking jobs. The lower proportion of female participants reflected the current national gender inequalities in these well-paid positions [47].
5.
Conclusion
ICT-based solutions offer a modern measure to meet both current and future challenges of exploding health expenditures of ageing populations. However, as concerns have been raised regarding data security and safety issues as well as acceptance of various interest groups, stakeholders have to appreciate their societal duty to minimize risks and optimize benefits of technical innovations. The presented data found evidence that medical professionals, patient advocates, and administrative personnel were highly aware of ongoing trends towards digitalization and surveillance society. The rapid progress in future demands of health care requires for intensified co-operation and networking of stakeholders at a quite early stage of planning of Public Health strategies and implementation of health promotion-related ICT tools.
Author contributions The first author provided strategy for data analyses and drafted the manuscript. The second author was responsible for software programming and data collection. All co-authors contributed with comments and revised the manuscript.
Conflict of interest None declared.
Funding None declared.
Acknowledgements The authors are grateful to the participants of the preliminary survey for their helpful and valuable detailed comments and suggestions. The authors also express their sincere appreciation to all members of the expert panel.
Summary points What was known before the study: • Nowadays, ICT applications are widely accepted. • ICT-based health solutions facilitate health promotion and disease prevention. • The challenges of ageing societies have to be addressed by technological innovations. What the study has added to the body of knowledge: • We developed an online survey tool for aggregating data of a two-round online Delphi survey. • The present study provides so far missing empirical data into experts’ perception of future ICT solutions in Austria. • Differences in the expected risks and advantages require closely meshed communication and cooperations between involved stakeholders.
references
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journal homepage: www.ijmijournal.com
ICT and the future of health care: aspects of health promotion Daniela Haluza a,∗ , David Jungwirth a,b a b
Institute of Environmental Health, Center for Public Health, Medical University of Vienna, Austria Department of Communication Science, ICT & Society Center, University of Salzburg, Austria
a r t i c l e
i n f o
a b s t r a c t
Article history:
Purpose: Increasingly, Information and Communication Technology (ICT) applications enter
Received in revised form
the daily lives of consumers. Availability of various multimedia interfaces offers the oppor-
16 September 2014
tunity to develop and adjust ICT solutions to all aspects of society including health care. To
Accepted 18 September 2014
address the challenges of the ongoing adaptive progress of ICT, decision makers profit from estimates of expectable merits and risks of future technological developments. The aim of
Keywords:
the present study was to assess the prevailing opinions and expectations among Austrian
Delphi survey
stakeholders regarding ICT-assisted health promotion.
Health promotion
Methods: In total, 73 experts (74% males) engaged in the Austrian health care sector par-
Health policy
ticipated in a biphasic online Delphi survey. Panellists were assigned to three groups
ICT
representing medical professionals, patient advocates, and administrative personnel. In a
Public Health
scenario-based questionnaire, experts evaluated potential advantages and barriers as well
Stakeholders
as degree of innovation, desirability, and estimated date of implementation of six future ICT scenarios. Scenario-specific and consolidated overall opinions were ranked. Inter-group differences were assessed using ANOVA. Results: Panellists expected the future ICT-supported health promotion strategies to especially improve the factors living standard (56%), quality of health care (53%), and patient’s knowledge (44%). Nevertheless, monetary aspects (57%), acceptance by patient advocates (45%), and data security and privacy (27%) were considered as the three most substantial hampering factors for ICT applications. Although overall mean desirability of the scenarios was quite high (80%) amongst panellists, it was considerably lower in medical professionals compared to patient advocates and administrative personnel (p = 0.006). This observation suggests a more precautious attitude of this specific interest group regarding technological innovations. Conclusions: The present Delphi survey identified issues relevant for successful implementation of ICT-based health care solutions, providing a compilation of several areas that might require further research. In the light of ageing societies facing the perceived threat of permanent online surveillance, different requirements and expectations of end users
∗ Corresponding author at: Institute of Environmental Health, Center for Public Health, Medical University of Vienna, Kinderspitalgasse 15, A-1090 Vienna, Austria. Tel.: +43 1 40160 34933; fax: +43 1 40160 934936. E-mail address: [email protected] (D. Haluza).
http://dx.doi.org/10.1016/j.ijmedinf.2014.09.005 1386-5056/© 2014 Elsevier Ireland Ltd. All rights reserved.
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should be accounted for by various stakeholders. Thus, close collaboration could facilitate the harmonization process on hot health topics among interest groups. © 2014 Elsevier Ireland Ltd. All rights reserved.
1.
Introduction
Increasing numbers of patients suffering from chronic medical conditions like cardio-respiratory diseases and diabetes mellitus are overwhelming modern health care services with high annual expenses [1]. Addressing these increasing financial challenges, Information and Communication Technologies (ICT) allow for cost-effective disease management as well as patient’s empowerment and health promotion [2]. Together with wireless technologies, especially long-term medical care requirements could be addressed at significant lower expenditures in ambulatory settings or patients’ homes by ICT applications [3]. Implementation of ICT-supported preventive measures might be expensive, but possess a high cost-saving potential in the long run [4]. During the last century and similar to trends observed in other developed countries, the shape of the Austrian population age pyramid changed and became top heavy, i.e., the proportion of children and young people was reduced in favour of the older generation [5]. To address this shift in population structure, new Public Health strategies for promoting pro-active ageing could be of great societal value [6,7]. In all fields of society, especially in the health and geriatric care sector, ICT-enabled innovations designed for consumers with special needs offer a huge opportunity to face the challenges of ageing societies [8–10]. As a first step, ICT-based assistance in everyday life provides the key to consumer’s independency and self care [9]. Further, as suggested by Guillen et al. [11], personalization, mobility, and adaptation of ICT applications could enhance the success of national health promotion and disease prevention programs. To maximize respective Public Health efforts, design and usability of web-based health portals are constantly improved nowadays [12]. Availability of these interactive consumer-orientated online services could exert positive influence on health outcomes including reduction of duplicative testing, hospital (re)admission, and mortality rates due to increase of patients’ knowledge and compliance [13,14]. Anticipation of future ICT developments greatly enhances effective communication between end users and decision makers in scientific, industrial, and clinical settings [15]. So far, empirical research on prevailing opinions regarding ICT use of health care professionals is lacking for Austrian conditions. To close this knowledge gap, the Delphi method serves as a useful research method [16]. Thus, we invited a panel of Austrian experts representing the three interest groups medical professionals (hospital-based doctors as well as community-based general practitioners), patient advocates, and administrative personnel. During a two-round online Delphi process, panellists determined aspects and classified factors for six conceivable ICT scenarios. The present study aimed at identifying expected benefits and perceived challenges of prospect
demands in the specific area of ICT-supported health promotion as well as primary and secondary disease prevention in Austria. As panel members were assigned to a specific stakeholder group based on their professional background, a further study objective was to analyze potential inter-group differences of scenario-based expert opinions.
2.
Methods
2.1.
Identification of future ICT scenarios
The current analysis was part of a larger research project that gathered opinions and expectation of future ICT-assisted health-related aspects by constitutively investigating results of a two-round online Delphi survey. In the study’s initial design and conception phase, we identified three major research fields of interest covering ICT-based health promotion, doctor–patient communication, and pervasive health. The two latter topics are elaborated on in consecutive, though separate scientific articles. Adapted from our previously published paper evaluating the impact of technological applications on doctor–patient communication [17], the current study merely focuses on the expected impact of prospect scenarios on ICT-supported health promotion. Accordingly, we defined the following six hypothetical scenarios based on respective international, peer-reviewed literature.
• Scenario 1 – Compliance: “Personalized information and communication technologies remind patients of punctual intake of prescribed medicine, resulting in higher compliance and thus better therapeutic outcome.” [18–21]. • Scenario 2 – Education: “Scientific, interactive multimedia is broadly accepted and intensively used for Public Health education and preventive medicine.” [22,23]. • Scenario 3 – Cancer risk: “Target-group specific information and communication technology-assisted preventive medicine is widely used to reduce the individual’s cancer risk.” [24–26]. • Scenario 4 – Insurance rates: “Funding of health insurances is deregulated, and insurance rates depend on individual information and communication technology-tracked lifestyle choices.” [27,28]. • Scenario 5 – Activities: “Target-group specific tourist and recreational activities for consumers with similar socioeconomic and medical conditions are a common information and communication technology-based health promotion effort.” [11,29]. • Scenario 6 – Prevention: “Web-based communication tools assist handicapped or elderly people by providing educative information for primary and secondary health prevention.” [11,30].
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2.2.
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Delphi survey questionnaire
The first section of the study questionnaire in German assessed socio-demographic data including age, gender, and place of occupation. Further, the second part analyzed each scenario independently using five categories: benefits, barriers, degree of innovation, desirability, and expected date of implementation. The category “benefits” evaluated future merits of the presented scenarios by using the multipleanswer question “Which factors are improved by widely acceptance of the specific scenario in Austria?”. The set of options included the following items: living standard, quality of health care, patients’ knowledge, funding of health care, doctor–patient relationship, as well as no improvement. The category “barriers” measured perceived obstacles by the multiple-answer question “Which factors hamper the implementation of the specific scenario in Austria?”. Possible choices were cost/funding, acceptance by medical professionals, acceptance by patient advocates, acceptance by administrative personnel, data security/privacy, technical prerequisites, regulations/standards, influence of stakeholders, as well as no obstacles. We evaluated “degree of innovation” of each scenario by the single-choice question “In your opinion, how innovative is this scenario for Austria?”, using a 4-point Likert Scale ranging from “not innovative” to “very innovative” as well as the non-response type choice “not applicable”. By answering the dichotomous question “In your opinion, is this scenario desirable for Austria?”, panellists stated “desirability” (desirable/not desirable) of the prospective ICT scenarios. In the last category, experts indicated the “expected date of ICT implementation” when the specific scenario has become established reality in Austria by means of a time line spanning the years 2010–2030. To test the study questionnaire’s comprehensibility, we invited 20 medical professionals engaged at the Medical University Vienna, Austria, to comment on a paperpencil version of the survey. According to their feedback, we adjusted the response format. We developed a two-round online Delphi survey as Computer Aided Application of Written Questionnaires (CAAWQ) [31] within the user-friendly software SoSci Survey (Social Science Survey, Version 2.0.48) [32]. We further customized the PHP (PHP: Hypertext Preprocessor) software by adding content and layout using self-developed applications of Hypertext Markup Language (HTML), Cascading Style Sheets (CSS), and JavaScript (JS).
2.3.
Data collection and analysis
We conducted the biphasic web-based Delphi survey from September to November 2010 in accordance with the principles laid down in the Declaration of Helsinki. We limited participation to experts working in one of the nine Austrian countries. Thus, participants were recruited based on online p-mail address lists provided by all major Austrian health care agencies. For subsequent data analysis regarding inter-group differences, we assigned participants to one of the experts groups (medical professionals, patient advocates, or administrative personnel) according to their professional background. Medical professionals referred to medical
doctors strictu sensu and individuals working in related health care professions (e.g., scientific and nursing staff) were not involved in the survey. After completion of the first wave, aggregated groupspecific outcomes were processed with PHP-Program code. These results were graphically presented to the panellist in the according part of the online questionnaire in the subsequent Delphi round. Survey data was statistically evaluated using Excel spread sheet (Microsoft, Seattle, WA, USA) and SPSS version 17.0 (SPSS Inc., Chicago, IL, USA). We summarized survey responses by frequency counts and means. Group-specific response frequencies of the respective questionnaire section were presented in total percentages for all scenarios consolidated and also separately. For inter-group comparisons of overall picked choices (scenarios 1–6), response frequencies were averaged overall and over groups to calculate a summarized multiscenario score ranging from 1 to 2 (1 = no scenario, 2 = all scenarios). Further, we analyzed group size-weighted distinction of stakeholder groups using analysis of variance (ANOVA). Rounded data were presented and due to rounding errors, some percentages added up to minimal less or more than 100%. The electronic questionnaire survey software prevented missing values due to (partial) item non-response. For all statistical analyses, two-sided level of significance was set at p < 0.05. Eventually, panellists received a final report including summarized survey outcomes by e-mail.
3.
Results
In the first Delphi cycle, we addressed 538 medical doctors (including 80% hospital-based clinicians and 20% communitybased general practitioners), 85 patient advocates, and 108 administrative personnel. Of these (n = 731), 94 individuals fully completed the online study questionnaire, resulting in a response rate of 13%. In the second Delphi phase, 21 participants of round 1 did not fully participate. Overall, 73 participants (mean age = 44 years, SD = 9.4) completed both rounds, of which the majority of participants (74%) were males (mean age = 45 years, females: mean age = 41 years). Regarding group assignment, medical professionals (n = 31, mean age = 46 years) comprised clinicians (n = 29) and general practitioners (n = 2). Representatives of patients advocates (n = 21, mean age = 42 years) were employees of offices of ombudsman (n = 11) as well as patient advocacies (n = 7), and also included communication scientists (n = 2) and one medical ethicist. Administrative personnel (n = 21, mean age = 43 years) worked in governmental organizations (n = 11) as well as in quasi-autonomous non-governmental organizations, i.e., hospitals (n = 10). Panel members ranked factors that could possibly benefit from ICT applications separately for each scenario and also for all six scenarios in order to demonstrate overall inter-group opinions (Table 1). By allowing multiple choices, improvement of living standard achieved the highest overall rank (56%), followed by advancement of quality of health care (53%), and patient’s knowledge (44%).
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Table 1 – Ranking of expected benefits from implementing future scenarios of ICT-assisted health promotion in Austria, stratified by stakeholder groups. In bold: overall total mean. Benefitsb
Expert groupsa 1. Living standard
2. Quality of health care
3. Patient’s knowledge
4. Funding of health care
5. Doctor–patient relationship
6. No improvement
49.5 65.9 57.1 56.4
54.8 51.6 53.2 53.4
33.9 50.8 53.2 44.3
39.8 38.9 42.9 40.4
21.5 21.4 21.4 21.5
17.2 9.5 11.9 13.5
Scenario 1 – Compliance MP 35.5 PA 66.7 AP 66.7 Total 53.4
80.6 71.4 90.5 80.8
38.7 57.1 42.9 45.2
35.5 38.1 57.1 42.5
35.5 42.9 52.4 42.5
9.7 4.8 4.8 6.8
Scenario 2 – Education MP PA AP Total
41.9 61.9 47.6 49.3
48.4 38.1 42.9 43.8
58.1 71.4 81.0 68.5
32.3 47.6 23.8 34.2
22.6 28.6 19.0 23.3
19.4 9.5 4.8 12.3
Scenario 3 – Cancer risk MP 45.2 PA 61.9 AP 57.1 Total 53.4
74.2 76.2 61.9 71.2
22.6 52.4 81.0 47.9
41.9 42.9 47.6 43.8
41.9 33.3 28.6 35.6
12.9 9.5 4.8 9.6
Scenario 4 – Insurance rates MP 25.8 PA 28.6 AP 23.8 Total 26.0
48.4 19.0 33.3 35.6
25.8 38.1 19.0 27.4
80.6 66.7 71.4 74.0
6.5 9.5 4.8 6.8
22.6 23.8 33.3 26.0
Scenario 5 – Activities MP PA AP Total
71.0 90.5 71.4 76.7
41.9 52.4 38.1 43.8
35.5 42.9 47.6 41.1
19.4 19.0 38.1 24.7
9.7 4.8 14.3 9.6
25.8 4.8 14.3 16.4
Scenario 6 – Prevention MP 77.4 PA 85.7 AP 76.2 Total 79.5
35.5 52.4 52.4 45.2
22.6 42.9 47.6 35.6
29.0 19.0 19.0 23.3
12.9 9.5 9.5 11.0
12.9 4.8 9.5 9.6
Scenarios 1–6 MP PA AP Total
a b
Medical professionals (MP), patient advocates (PA), and administrative personnel (AP). Multiple-answer question: “Which factors are improved by widely acceptance of the specific scenario in Austria?”.
A ranking of eight factors revealed overall and intergroup opinions on issues perceived as possible obstacles for implementation of future scenarios on ICT-based health promotion (Table 2). By picking multiple choices, panellists perceived monetary aspects (57%), acceptance by patient advocates (45%), and data security and privacy (27%) as most relevant hampering factor for successful technological innovations. Then, we assessed degree of innovation, desirability as well as the estimated date of approval of the respective ICT scenarios stratified by the three different expert groups (Table 3). Degree of innovation is presented as scenario-based percentage of expert group-specific responses. Perceived desirability differed between groups, as doctors stated considerably poorer
desirability for all scenarios, except scenario 4 – Insurance rates. In general, mean desirability for all scenarios (1–6) was high, reaching nearly 80%, again, except scenario 4 (only 49%). However, overall desirability was lowest in medical professionals (74%) compared to patient advocates and administrative personnel (87% and 81%, respectively). All stakeholder groups perceived the year 2018 as overall mean date estimate for acceptance of the respective future ICT innovations. As aforementioned, we found partly contradictory results for scenario 4 – Insurance rates in all aspects assessed in this Delphi study. Compared to the other scenarios, scenario 4 yielded quite low ratings for improving living standard (26% vs. overall mean 40%), quality of health are (36% vs.
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Table 2 – Ranking of picked choices of expected obstacles for implementing future scenarios of ICT-assisted health promotion in Austria, stratified by stakeholder groups. In bold: overall total mean. Obstaclesb
Expert groupsa 1. Cost, funding
Scenarios 1–6 MP PA AP Total
3. Data security and privacy
4. Acc.c by MP
5. Regulations, standards
6. Technical prerequisites
7. Acc.c by AP
8. Influence of stakeholders
9. No obstacles
46.8 35.7 51.6 45.0
31.7 18.3 27.0 26.5
17.7 15.9 35.7 22.4
24.2 15.1 15.9 19.2
18.3 22.2 12.7 17.8
12.9 4.0 22.2 13.0
9.1 4.8 10.3 8.2
5.9 11.1 11.1 8.9
Scenario 1 – Compliance MP 64.5 PA 57.1 AP 52.4 Total 58.9
54.8 66.7 57.1 58.9
41.9 23.8 38.1 35.6
19.4 23.8 38.1 26.0
22.6 9.5 28.6 20.5
48.4 42.9 42.9 45.2
0 0 4.8 1.4
6.5 4.8 9.5 6.8
0 4.8 0 1.4
Scenario 2 – Education MP 54.8 PA 33.3 AP 47.6 Total 46.6
29.0 23.8 47.6 32.9
0 4.8 9.5 4.1
25.8 33.3 66.7 39.7
29.0 9.5 4.8 16.4
22.6 19.0 9.5 17.8
3.2 9.5 14.3 8.2
6.5 0 9.5 5.5
19.4 23.8 14.3 19.2
Scenario 3 – Cancer risk MP 64.5 PA 71.4 AP 66.7 Total 67.1
54.8 38.1 47.6 47.9
61.3 33.3 33.3 45.2
25.8 14.3 28.6 23.3
29.0 23.8 14.3 23.3
25.8 33.3 14.3 24.7
19.4 0 4.8 9.6
3.2 4.8 4.8 4.1
3.2 4.8 14.3 6.8
Scenario 4 – Insurance rates MP 22.6 PA 9.5 AP 42.9 Total 24.7
71.0 76.2 85.7 76.7
64.5 33.3 52.4 52.1
19.4 14.3 42.9 24.7
45.2 28.6 23.8 34.2
6.5 9.5 4.8 6.8
22.6 0 61.9 27.4
25.8 19.0 38.1 27.4
0 4.8 0 1.4
Scenario 5 – Activities MP 74.2 PA 76.2 AP 61.9 Total 71.2
38.7 4.8 33.3 27.4
12.9 4.8 14.3 11.0
9.7 4.8 9.5 8.2
9.7 9.5 9.5 9.6
3.2 9.5 0 4.1
16.1 14.3 19.0 16.4
6.5 0 0 2.7
3.2 19.0 23.8 13.7
Scenario 6 – Prevention MP 67.7 PA 85.7 AP 66.7 Total 72.6
32.3 4.8 38.1 26.0
9.7 9.5 14.3 11.0
6.5 4.8 28.6 12.3
9.7 9.5 14.3 11.0
3.2 19.0 4.8 8.2
16.1 0 28.6 15.1
6.5 0 0 2.7
9.7 9.5 14.3 11.0
a b c
58.1 55.6 56.3 56.8
2. Acc.c by PA
Medical professionals (MP), patient advocates (PA), and administrative personnel (AP). Multiple-Answer-Question: “Which factors hamper the implementation of the specific scenario in Austria?”. Acc.: acceptance.
53%) as well as patient’s knowledge (27% vs. 44%). On the other hand, it reached the highest rank for enhancing funding of health care (74% vs. 56%). Accordingly, as possible obstacles, acceptance by patient advocates (52% vs. 45%) and data security aspects (52% vs. 27%) were over-represented and monetary considerations were quite under-represented (25% vs. 57%). Furthermore, scenario 4 produced ambiguous results regarding perceived degree of innovation, where far more participants found it not innovative (22%) compared to overall mean (10%) and at the same time very innovative (33% vs. 25%). Moreover, half of the expert panel found
it desirable whereas the other half did not. Additionally, the highest date estimates (2022, maximum 2026) were reported for scenario 4 which was divergent to any of the other scenarios. To further analyze the aforementioned heterogeneous findings of group-specific factor rankings, we examined the overall group size-weighted inter-group differences between the three stakeholder groups (Table 4). Using ANOVA, we found statistically significant intergroup differences for in total eight factors. Expert groups differed regarding overall mean responses regarding two
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Table 3 – Degree of innovation, desirability, and estimated date for implementing future scenarios of ICT-assisted health promotion in Austria, stratified by stakeholder groups. In bold: total mean. Expert groupsa
Scenarios 1 Compliance
Innovationb Not innovative MP PA AP Total
2 Education
3 Cancer risk
4 Insurance rates
5 Activities
6 Prevention
1–6 All
3.2 4.8 0 2.7
3.2 14.3 4.8 6.8
6.5 0 0 2.7
12.9 23.8 33.3 21.9
16.1 9.5 14.3 13.7
12.9 19.0 9.5 13.7
9.1 11.9 10.3 10.3
Barely innovative MP PA AP Total
9.7 28.6 14.3 16.4
25.8 4.8 38.1 23.3
16.1 23.8 23.8 20.5
16.1 19.0 19.0 17.8
12.9 28.6 33.3 23.3
16.1 19.0 38.1 23.3
16.1 20.6 27.8 20.8
Somewhat innovative MP PA AP Total
41.9 42.9 76.2 52.1
58.1 66.7 38.1 54.8
29.0 71.4 47.6 46.6
32.3 33.3 9.5 26.0
41.9 38.1 38.1 39.7
48.4 47.6 33.3 43.8
41.9 50.0 40.5 43.8
Very innovative MP PA AP Total
41.9 23.8 9.5 27.4
12.9 14.3 14.3 13.7
48.4 4.8 28.6 30.1
38.7 23.8 33.3 32.9
29.0 23.8 14.3 23.3
22.6 14.3 19.0 19.2
32.3 17.5 19.8 24.4
Not applicable MP PA AP Total
3.2 0 0 1.4
0 0 4.8 1.4
0 0 0 0
0 0 4.8 1.4
0 0 0 0
0 0 0 0
0.5 0 1.6 0.7
Desirabilityc Desirable MP PA AP Total
80.6 90.5 95.2 87.7
77.4 90.5 85.7 83.6
87.1 95.2 95.2 91.8
51.6 47.6 47.6 49.3
77.4 100 76.2 83.6
71.0 95.2 85.7 82.2
74.2 86.5 81.0 79.7
Not desirable MP PA AP Total
19.4 9.5 4.8 12.3
22.6 9.5 14.3 16.4
12.9 4.8 4.8 8.2
48.4 52.4 52.4 50.7
22.6 0 23.8 16.4
29 4.8 14.3 17.8
25.8 13.5 19 20.3
Dated MP PA AP Total a b c d
2018 2018 2017 2017
2016 2018 2016 2016
2018 2017 2018 2017
2022 2020 2026 2022
2018 2016 2015 2017
2017 2017 2015 2016
2018 2018 2018 2018
Medical professionals (MP), patient advocates (PA), and administrative personnel (AP). Single-choice question: “In your opinion, how innovative is this scenario for Austria?” (%). Single-choice question: “In your opinion, is this scenario desirable for Austria?” (%). Single-choice question: “In your opinion, when will the scenario be widely accepted in Austria?” (mean year estimate).
beneficial aspects, namely living standard (p = 0.015) and patient’s knowledge (p = 0.015). Moreover, besides overall perceived hampering factors (p = 0.047), opinions of panellist groups significantly differed regarding data security and privacy (p = 0.048), technical prerequisites (p = 0.036),
acceptance by administrative personnel (p < 0.0001), and influence of stakeholders (p = 0.046). However, overall degree of innovation (p = 0.084) and the estimated date of acceptance (p = 0.908) of scenarios 1–6 did not significantly differ between groups. Though, we revealed significant differences as
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Table 4 – Group size-weighted inter-group comparisons of overall responses regarding six future scenarios of ICT-assisted health promotion in Austria, stratified by expert groups. In bold: p < 0.05. Expert groupsa ; mean (SD)
Factors
ANOVA Sum2
Mean2
1.4 (0.1) 1.6 (0.2) 1.5 (0.2) 1.5 (0.3) 1.4 (0.3) 1.2 (0.2) 1.1 (0.2)
0.033 0.491 0.019 0.820 0.045 0 0.108
0.017 0.245 0.009 0.410 0.022 0 0.054
0.938 4.315 0.152 6.758 0.306 0 2.114
0.394 0.015 0.859 0.002 0.737 1.0 0.125
1.3 (0.1) 1.6 (0.3) 1.6 (0.3) 1.3 (0.3) 1.5 (0.4) 1.2 (0.2) 1.1 (0.1) 1.2 (0.2) 1.1 (0.1) 1.1 (0.2)
1.3 (0.1) 1.6 (0.3) 1.5 (0.4) 1.3 (0.2) 1.4 (0.4) 1.2 (0.2) 1.2 (0.2) 1.1 (0.2) 1.1 (0.1) 1.1 (0.2)
0.055 0.011 0.269 0.354 0.132 0.180 0.236 0.849 0.080 0.065
0.028 0.006 0.134 0.177 0.066 0.090 0.118 0.425 0.040 0.032
3.138 0.071 1.072 3.103 0.526 1.891 3.416 11.889 3.149 1.264
0.047 0.932 0.345 0.048 0.592 0.155 0.036 0.000 0.046 0.286
2.7 (0.6)
2.7 (0.6)
2.8 (0.6)
1.850
0.925
2.518
0.084
1.7 (0.2)
1.9 (0.1)
1.8 (0.2)
1.8 (0.2)
0.271
0.135
5.409
0.006
2017.9 (2.1)
2017.6 (2.6)
2017.7 (3.4)
2017.7 (2.9)
1.605
0.803
0.096
0.908
MP
PA
AP
1. Benefits Total Living standard Quality of health care Patients’ knowledge Funding of health care Doctor–patient relationship No improvement
1.4 (0.1) 1.5 (0.3) 1.5 (0.3) 1.3 (0.3) 1.4 (0.3) 1.2 (0.2) 1.2 (0.2)
1.4 (0.1) 1.7 (0.2) 1.5 (0.2) 1.5 (0.3) 1.4 (0.2) 1.2 (0.2) 1.1 (0.1)
1.4 (0.1) 1.6 (0.2) 1.5 (0.3) 1.5 (0.2) 1.4 (0.3) 1.2 (0.2) 1.1 (0.1)
2. Obstaclesb Total Cost, funding Acceptance by PA Data security and privacy Acceptance by MP Regulations, standards Technical prerequisites Acceptance by AP Influence of stakeholders No obstacles
1.3 (0.1) 1.6 (0.2) 1.5 (0.4) 1.3 (0.2) 1.4 (0.4) 1.2 (0.2) 1.2 (0.2) 1.1 (0.2) 1.1 (0.1) 1.1 (0.1)
1.2 (0.1) 1.6 (0.3) 1.5 (0.4) 1.2 (0.2) 1.4 (0.3) 1.2 (0.2) 1.2 (0.3) 1.0 (0.1) 1.0 (0.1) 1.1 (0.2)
3. Innovationc Total
3.0 (0.6)
Total
F
p
b
c
4. Desirabililty Total c
5. Date Total a b
c
Medical professionals (MP), patient advocates (PA), and administrative personnel (AP). Overall mean responses to multiple-answer questions (1 = no scenario, 2 = all scenarios); mean (SD): 1. Which factors are improved by widely acceptance of the specific scenario in Austria?; 2. Which factors hamper the implementation of the specific scenario in Austria? Responses to single-choice questions: 3. In your opinion, how innovative is this scenario for Austria? (1 = not innovative, 4 = very innovative; mean, SD); 4. In your opinion, is this scenario desirable for Austria? (1 = no, 2 = yes; mean, SD); 5. In your opinion, when will the scenario be widely accepted in Austria? (mean year, SD).
overall desirability (p = 0.006) was higher in patient advocates and administrative personnel compared to medical professionals.
4.
Discussion
By evaluating prevailing opinions among Austrian health care experts regarding prospect ICT-based health promotion, the current study aimed at closing a research gap. A panel consisting of medical professionals, patient advocates, and administrative personnel participated in a multiscenariobased online Delphi survey. According to Windle [33], these three expert groups were identified as the most important stakeholders in executing Public Health-relevant issues. Additionally, more heterogeneous specifications of panel members represented a broad spectrum of viewpoints and allowed a more realistic estimation of ICT scenarios compared to a homogeneous group. Delphi panellists (n = 73) rated six comprehensible scenarios used as illustration of future ICT applications, specifically designed for individualized and person-centred health promotion. In this verve, we observed statistically significant divergences in group opinions for eight factors, among them the two beneficial aspects living
standard and patient’s knowledge, overall obstacles as well as the hampering factors data security and privacy, technical possibilities, administrative personnel’s acceptance, and stakeholders’ influence, and overall desirability. According to experts’ perception, the three most improved factors in the presented scenarios were living standard (56%), quality of health care (53%), and patient’s knowledge (44%). However, identifying expected hampering aspects seemed to be even more influential for future policymaking processes. In our panel, experts anticipated that monetary exertions (57%) could be considered as the most prominent obstacles for adopting ICT-based health promotion. This result is in line with findings that tremendous expenditures for replacement and technical prerequisites slowed down implementation of ICT solutions in the U.S. healthcare system [34]. Nevertheless, regarding long-term considerations, e-health applications could reduce health spending, especially for treatment and prevention of lifestyle diseases. So, investment in ICT could be regarded as a key factor for pushing prosperity of the entire national economy [35]. Data protection issues were ranked as the third important overall barrier (27%) of implementing the described future scenarios. Confidentiality and preservation of privacy for
i n t e r n a t i o n a l j o u r n a l o f m e d i c a l i n f o r m a t i c s 8 4 ( 2 0 1 5 ) 48–57
sensitive health care data has always been a hot topic for both consumers and providers [36]. Therefore, decision makers are facing the paramount legal and ethical challenge to develop feasible strategies for assuring both data privacy and security [37]. Regarding self-assessment of group-specific halting attitudes, the overall second ranked obstacle “acceptance by patient advocates”, the fourth ranked obstacle “acceptance by medical professionals” (16% vs. 22% overall), and also the seventh ranked factor “acceptance by administrative personnel” (4% vs. 13% overall) yielded lowest ratings (36% vs. 45% overall) from patient advocates compared to the other panel groups (Table 2). As medical professionals took an intermediate position regarding this matter, administrative personnel rated acceptance by patient advocates (52%), medical professionals (36%), and administrative personnel (22%) highest compared to the other panellists. These observations suggest that patient advocates were least critical and medical personnel were quite neutral concerning the halting role of interest groups relevant for ICT adoption. On the other hand, administrative staff might be well aware of its inherent key position regarding resource allocation for implementation of often costly innovative medical devices and technologies. In conclusion, stakeholders seemed to appraise that ICT adoption by end users including practitioners, patients, and consumers is of vital importance for successful implementation of health promotion-related ICT solutions. As suggested by the literature, acceptance by consumers – especially older and handicapped people – could be raised by using customtailored tools and end-user orientated training and education efforts [38]. Among stakeholders, overall mean desirability of the presented future ICT examples was quite high (80%). This is supported by evaluations on attitudes towards ICT-supported health care that health professionals rated future applications as even more beneficial than already existing ones [39]. Regarding inter-group differences, doctors perceived fewer scenarios as being desirable compared to representatives of patient advocates and health administration personnel (74% vs. 87% and 81%, respectively). Our observation suggests that this interest group might be more sceptical and halting when it comes to innovative ICT implementations in the health care sector. Given that diverse professional groups per se require different ICT solutions [40], this study result is supported with findings that medical doctors compared to other health care staff showed a less positive attitude towards new technological innovations [41]. However, Gund et al. [39] found that medical staff had a highly positive attitude towards both present and future health care-related ICT applications. According to Meade and co-workers [42], rather indistinct factors such as lack of resources (e.g., time, money, and computer skills) were major obstacles for physicians to switch from paper-based to electronic patient records. It is rather unlikely that doctors are suspicious regarding technical developments in general, but our survey found that they might be concerning prospect ICT-assisted changes in health promotion. In this survey, estimates of the predicted date of public approval of presented scenarios were used to seize the
55
present level of awareness with and knowledge of experts. Findings pointed towards a date (2018) eight years ahead from the year 2010 when we performed this survey. This was a surprisingly long time period, as the described settings were based on technological applications already available by then. Many consumers of new technologies might raise concerns that sensitive personal data including unhealthy life style habits, chronic diseases, and particularly mental health conditions could be easily accessed by, e.g., potential employers or insuring companies via security leaks [43]. The aforementioned opinions of study participants suggested that the factor data security might be critical for ICT innovations. Stakeholders as spokespersons of the general public interests might reflect the inherent fear that accumulation of electronic health data will probably make us more “transparent”. Therefore, more emphasis should be placed on further evaluations of topics affecting aspects of “big data” as well as surveillance society, as suggested by Neubauer and Heurix [44]. Outstandingly, scenario 4 – Insurance rates showed a different pattern in all of the assessed aspects of ICT-based innovations compared to the other settings. Thus, we identified this respective topic as somehow exceptional. Due to these unexpected observations, we assume that a clear consensus was not reached in this single scenario. Nevertheless, we consolidated the assessed data to report on overall panel opinions on the presented ICT examples. A closer look on possible explanations for the divergent results for scenario 4 in comparison with the other five scenarios could be valuable for demonstrating that the scenarios activated the expert panel to anticipate future ICT scenarios. Thus, we suggest that the panellists were committed and motivated to engage in the survey. Generally, the Delphi process itself was expected to create awareness of the potential power of future ICT applications to shape prospect Public Health strategies for health promotion and disease prevention. The herein reported results need to be considered within the context of several limitations. Clearly, opinions of experts and their expectations regarding future ICT scenarios were influenced by their professional background and personal experiences. Additionally, generalizability and transferability of reported results are limited, because only German-speaking Austrian experts were eligible to participate. Nevertheless, we aimed at providing empirical data on opinions of national interest groups regarding future ICT-assisted health promotion. As another possible limitation, response rate was quite low in this survey, especially among medical professionals. However, the phenomenon of poor and even declining response rates among health care-related professionals is well known [39]. Potential reasons for non-response and overall low survey response rates among doctors might include time investment, concerns about workload as well as out-of-hours commitment [45]. Compared to hospital-based doctors, very few community-based physicians participated in our uncompensated two-round Delphi survey. Consequently, opinions of clinicians were overrepresented in our panel, although physicians might have more impact on every-day exertion and education regarding health promotion. Thus, our results might not fully represent opinions of all Austrian medical
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professionals. Nevertheless, Delphi surveys assemble views of a particular expert panel and are not designed to predict the responses of a larger sample [46]. We consider that a major strength of our study was inclusion of a quite large number of study subjects (n = 73). So, splitting the sample for inter-group comparisons was feasible. Also, panel experts should have enough authority to transform and integrate theoretical findings of a Delphi survey into decision-making processes [46]. In our sample, the majority of participants were engaged in higher-ranking jobs. The lower proportion of female participants reflected the current national gender inequalities in these well-paid positions [47].
5.
Conclusion
ICT-based solutions offer a modern measure to meet both current and future challenges of exploding health expenditures of ageing populations. However, as concerns have been raised regarding data security and safety issues as well as acceptance of various interest groups, stakeholders have to appreciate their societal duty to minimize risks and optimize benefits of technical innovations. The presented data found evidence that medical professionals, patient advocates, and administrative personnel were highly aware of ongoing trends towards digitalization and surveillance society. The rapid progress in future demands of health care requires for intensified co-operation and networking of stakeholders at a quite early stage of planning of Public Health strategies and implementation of health promotion-related ICT tools.
Author contributions The first author provided strategy for data analyses and drafted the manuscript. The second author was responsible for software programming and data collection. All co-authors contributed with comments and revised the manuscript.
Conflict of interest None declared.
Funding None declared.
Acknowledgements The authors are grateful to the participants of the preliminary survey for their helpful and valuable detailed comments and suggestions. The authors also express their sincere appreciation to all members of the expert panel.
Summary points What was known before the study: • Nowadays, ICT applications are widely accepted. • ICT-based health solutions facilitate health promotion and disease prevention. • The challenges of ageing societies have to be addressed by technological innovations. What the study has added to the body of knowledge: • We developed an online survey tool for aggregating data of a two-round online Delphi survey. • The present study provides so far missing empirical data into experts’ perception of future ICT solutions in Austria. • Differences in the expected risks and advantages require closely meshed communication and cooperations between involved stakeholders.
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