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Significant investment in eHealth solutions is being made in nearly every country of the world. How do we know that these investments and the foregone opportunity costs are the correct ones? Absent, poor, or vague eHealth strategy is a significant barrier to effective investment in, and implementation of, sustainable eHealth solutions and establishment of an eHealth favorable policy environment. Strategy is the driving force, the first essential ingredient, that can place countries in charge of their own eHealth destiny and inform them of the policy necessary to achieve it. In the last 2 years, there has been renewed interest in eHealth strategy from the World Health Organization (WHO), International Telecommunications Union (ITU), Pan American Health Organization (PAHO), the African Union, and the Commonwealth; yet overall, the literature lacks clear guidance to inform countries why and how to develop their own complementary but locally specific eHealth strategy. To address this gap, this paper further develops an eHealth Strategy Development Framework, basing it upon a conceptual framework and relevant theories of strategy and complex system analysis available from the literature. We present here the rationale, theories, and final eHealth strategy development framework by which a systematic and methodical approach can be applied by institutions, subnational regions, and countries to create holistic, needs- and evidence-based, and defensible eHealth strategy and to ensure wise investment in eHealth.
Many definitions of eHealth have been developed or adopted, but perhaps the bottom-line message is that eHealth can be anything we want it to be. It is simply the application of information and communications technologies (ICTs) to the health sector [
As a consequence, entities will often emulate or adapt practice from elsewhere. While emulation or adaptation is common, these approaches are inappropriate: “emulation” because solutions and approaches must be context specific, and “adaptation” because, although a compromise, it remains suboptimal. A sustainable eHealth solution is best designed and developed organically and interactively with stakeholders within the context and setting in which it will be applied, and in alignment with the existing health, education, and technology enterprises.
According to Mintzberg and Lampel [
Growing expectations, changing demographics, and resource limitations require wise investment in eHealth solutions that address major health needs. Of even greater import, eHealth activities implemented now will establish the practice and technology infrastructure for decades to come. Sustainable eHealth solutions require development of a sound, evidence-based, and defensible eHealth strategy. Application of the enhanced eHealth strategy development tool presented here is recommended as a key initial step and presents health care institutions, subnational regions, or countries with a viable model.
A desire exists to believe policy making is rational and based upon best available empirical evidence. Marmot [
Some authors have taken a cautious, even cynical, view of evidence-based policy making and practice while others, however, point more optimistically to recent changes in attitude. For example, Fafard [
It would seem that careful research is still required to make choices between an array of possible policy instruments and program interventions. This is particularly so in complex fields such as health, health care, and eHealth. The approach described in this paper ensures the evidence is provided and current context is thoroughly understood (including underlying values and value conflicts), and it therefore supports evidence-
Many developed countries (eg, Australia, EU countries) have established a variety of documents termed, or akin to, “eHealth strategy” [
eHealth in its largest sense has been practiced for many decades now—from basic telephony, through transmission of ECGs and images, to comprehensive e-records and even remote surgery. But despite this experience, there are few sustained eHealth implementations of demonstrated success and sustainability as evidenced through rigorous evaluation. The ITU [
A similar circumstance exists for large-scale electronic record initiatives, with large health informatics applications in developed countries failing to prove as successful as desired. For example, Electronic Health Records (EHRs) have been, or continue to be, introduced in many developed countries such as England, Scotland, France, Canada, Australia, and the USA—and at significant cost and risk. Originally budgeted at £2.3 billion, the United Kingdom is estimated to have spent between £6.2 billion [
In regard to developing countries, Fernandez and Oveido [
It would seem clear that our current approach to eHealth implementation does not work, and an alternate approach is needed.
The potential of eHealth to address growing health system concerns and health care needs is often identified in the literature, but clear evidence of its value remains uncertain. With these perspectives in mind, it is reasonable to ask “is eHealth a viable solution for developing countries?”
Despite the lack of success described above, there is some evidence from the developed world that HISs address health concerns and may lead to cost savings. But, even then, are the health concerns addressed by HISs in developed countries (eg, reduced adverse drug reactions) the most relevant to the developing world? Furthermore, the European Commission [
The WHO’s Report of the Commission on Macroeconomics and Health [
So, is eHealth a solution for developing countries? Perhaps, but the solutions and approaches are unlikely to be those pursued in developed countries and must be aligned with the specific health system and health needs of the entity (institution, subnational region, country) and culture involved [
There are also synergistic effects. Once a national eHealth strategy is in place, it encourages (perhaps requires) facility-level eHealth strategy development, which aligns with and supports the national-level approach. Similarly, within a geographic or trading “region”, countries can align their own approaches to develop a regional eHealth strategy. Several benefits are inherent in such an approach. Countries and regions take ownership of their own eHealth destiny and can guide (or decline) opportunities presented by external agencies. Furthermore, the shared experience allows more rapid accomplishment of sustainable eHealth implementations (see
Synergistic benefits derived from an eHealth strategy.
Originally a military concept, strategy development became common in the private/business sector during the 1950s and 1960s. Since that time, overt strategy development has faded; some reasons cited include failure to differentiate and treat separately “direction-giving/leadership” and “managing”, “irrational exuberance” of the markets, lack of respect for “direction-giving/leadership” as a profession, and failure to take seriously the need for “strategic thinking” and subsequent implementation in any learning organization [
Strategy in its simplest sense can be considered clarity around
What approach to strategy development is most appropriate for the complexity and continuously developing eHealth setting? Boisot [
eHealth is recognized to be a constantly evolving field, but the turbulence that existed in the early days has passed. Similarly, sufficient research and application has taken place that sound lessons and good “understandability” exists of where and how to apply eHealth. Thus, within Boisot’s typology, “strategic planning” lies at the intersection of high understandability and low environmental turbulence and is the appropriate strategic option to pursue.
Boisot’s typology of strategy options.
What makes a setting complex? Often it is the presence of a large number of interconnected parts whose interaction is not merely additive (a “simple” setting), but synergistic where the combinations and permutations are large and the outcomes not always obvious considering the properties of individual components. Complexity can be disorganized or organized [
How can such complex settings be assessed? Traditionally, we strive to reduce complex systems to simpler subparts and analyze those. However, in doing so, it can be argued that the “real-life” context and relevance of any analysis is lost. Other approaches are required. One approach is to examine settings in a holistic manner, which (according to the Oxford dictionary) is “characterized by comprehending the parts of something as intimately interconnected and explicable only by reference to the whole”. Holistic analysis is typically interdisciplinary, concerned with the behavior of complex systems and respects occurrence of “feedback” (ie, when information about an event in the past will influence an occurrence (or occurrences) of that same or related event in the present or future).
Another approach is to mimic something we do innately (eg, when driving) to understand complex and dynamic settings, that is, create “situation awareness” (defined as “the perception of elements in the environment within a volume of time and space, the comprehension of their meaning, and the projection of their status in the near future” [
Combining the approaches of holistic review and situational assessment, performance of a “holistic situation assessment” is recommended and is embedded within the enhanced eHealth strategy development framework described below.
Relationship among several cognitive processes.
Before considering development of institutional, regional, or national eHealth strategy and policy, there are some fundamental principles that need be adopted. These are outlined below.
Experience gleaned from the literature shows the process of integrating eHealth as a routine health care tool faces many challenges, is very complex, and requires significant time. However, by establishing a sound and evidence-based eHealth strategy, it is possible to reduce the impact of such realities. The process is most effective when undertaken by a local (institutional, regional, country) team, as it builds local capacity, is designed by those most intimately knowledgeable about the setting, and establishes pride and commitment of ownership for the undertaking and product.
The goal of the strategy is to find an optimal solution to the most pressing (existing or anticipated) health-related problems. In other words; the approach is very focused, very health or health care “needs-based”, and strongly “evidence-informed”, but not overly researched (see Step 1 in the Process section below). This requires an understanding of pressing health care needs and alignment with, or creation of, a clear eHealth strategy to address them.
Networking provides opportunities to spread the cost of infrastructure and “infostructure” development between the government, business, agriculture, education, and health sectors. For example, the ICT network supports all these sectors, not just one, and therefore the cost burden should not be borne by just one sector.
Four primary components of eHealth exist [
Solutions to specific health issues may require a predominance of one component over others, but it is likely any sustainable and comprehensive solution will require elements of each.
eHealth solutions that are identified for implementation should be technologically appropriate and culturally sensitive.
Appropriate technology can be defined as the most benign technological solution that achieves the desired purpose within the confines of current social, cultural, environmental, and economic conditions of the setting in which it is to be applied and that promotes self-sufficiency on the part of those using it in that setting. Described in this fashion, an appropriate technology would typically be simple to adopt and require fewer resources to operate and maintain (making it more likely to be sustainable and environmentally friendly).
Cultural sensitivity requires solutions to respect local traditions, expectations of the health care system, beliefs about health and disease, and patterns of usage of available health care services. Ignoring local health culture, such as traditional medicines or influential shamans, may undermine efforts to introduce eHealth initiatives. Or insufficient local resources may lead to abuse of modern medicines, such as using reduced doses of antibiotics, which may permit development of resistant strains capable of global spread. Solid experience and knowledge of cultural limitations must guide the design and implementation of eHealth solutions [
A clear, broadly accepted vision is required to guide the process, and garner sustained support from diverse stakeholders (eg, “eHealth facilitated health care by 2020”; “Integrated eHealth-care in 5 years”).
Enunciating a specific goal that people can embrace helps build and maintain momentum, for example, “To establish a needs-based, evidence informed, and national 5-year eHealth strategic plan that adopts technologically appropriate and culturally sensitive eHealth solutions and guides eHealth policy development”.
Developed originally as a Telehealth Strategy Development Framework [
To be effective, the eHealth strategy must address those specific health issues of most importance to the entity developing its eHealth strategy. Information regarding this will already be available in country/institution, NGO, or international agency reports (eg, WHO’s annual country health status reports), local or regional planning documents, administrative databases, as well as through literature review. The available information can be interrogated to reveal insight regarding what the issues are; what the causes and/or contributing factors are to each issue; how serious (size, scope) each issue is; who is impacted by each issue and where they are located; how many are impacted by each issue; what community/population characteristics may be related to each issue; what has been done in the past to address each issue; and why the interventions succeeded or failed.
In this way, the reports/literature (the evidence) will have identified the specific health issues (the needs) that must be addressed and allowed some analysis of any linkages between sociodemographic features, and health indicators, health risks, and service use. The process may also have revealed information gaps that may require addressing. This evidence gathering and situation assessment step establishes a sound foundation and baseline that is defensible to critics and also provides a preliminary list of areas where an eHealth application
At this point, holistic situation assessment begins. It is necessary to examine many factors beyond just health needs to see if they guide decisions in a certain direction or identify potential barriers to some presumed solutions (this holistic approach has been used in other settings [
Although not an exhaustive list, information regarding each of the following examples will impact eHealth-related decisions.
eHealth is considered by some as a tool for increasing equity of access to health care; mapping where poor and other vulnerable populations are located in relation to available health care facilities aids understanding of where implementation of eHealth solutions may be most beneficial [
ICT innovation continues to evolve, with new applications impacting all aspects of our economies and societies. Some reports suggest the public sector can begin large, expensive ICT projects without a clear understanding of goals, required resources, or risks. Understanding if and how government investment and policy formulation impacts ICT innovation, including eHealth, is essential [
eHealth is recognized to remove or at least mitigate the barriers of time and space that physical geography imposes; however, technological solutions may also be limited by geography. Thus, solutions suitable for open expanses (eg, coastal areas, deserts) may not be suitable for extremely mountainous areas, highlighting the potential need for investment in different communication and technological eHealth solutions in different regions [
Available experience with e-government, and the strength of the local supportive setting for eHealth will influence the acceptability and implementation of eHealth solutions. Furthermore, long-term vision, planning, and continuity in implementation despite political change is critical to success [
Culture influences health care in several ways, including preferences for different treatments, individual health beliefs, and attitudes toward disclosure of medical information; eHealth solutions must be culturally appropriate if they are to be adopted and sustained [
Factors such as geography, economics, and demography influence the politics, especially the foreign policy, of a country, which can influence intra- and interjurisdictional eHealth (eg, could neighboring countries support/share eHealth infrastructure or initiatives?)
Availability and skill set of the current cadre of health care (and eHealth) providers must be built to a critical point if countries are to “build the capacity to build their own capacity” [
Readiness to succeed in adoption, implementation, and use of any technology solutions is critical. The same is so for eHealth and the level of readiness of the public, health care providers, and the government must be thoroughly assessed (reassessed) to reveal gaps requiring intervention [
NGOs or other agencies have become indispensable in the delivery of health in many developing countries [
Fulmer [
In contrast to the “physical components”, infostructure can be described as those human resources, organizational and administrative structures, policies, regulations, and incentives that facilitate fully integrated and sustainable use of innovative ICTs and services to improve health care in an organized response to health and health care needs, issues, and challenges (ie, eHealth). Once again, completing an eHealth Strategy will also inform discussion around each of these issues.
The holistic review must also consider distant or unpredictable events (eg, climate change, humanitarian disasters, natural disasters), so that implemented solutions have sustainability and flexibility. Climate change remains debated, but whether natural or iatrogenic, some locations are predicted to turn from lakes into deserts or erase low-lying islands or traditional residential regions in estuaries, which will impact population movement and perhaps distribution of diseases. Humanitarian disasters (drought, war) can cause mass migration of populations across borders, stretching still further already stretched health care systems. Finally, natural disasters such as floods or earthquakes can cause extensive damage or destroy ICT infrastructure, and such considerations should impact the type and location of ICT infrastructure adopted during the strategy development process.
Individually and collectively, each of these factors has a bearing on the type of solution (and eHealth solution) that might be most appropriate and most sustainable for any identified health need and population. “Mind mapping” software (which creates diagrams of relationships between concepts, ideas or other pieces of information) is a valuable tool to assist in this process.
This holistic situation assessment step is crucial but is not typically or overtly undertaken. Absence of such a sound review undermines the credibility of any subsequent eHealth strategy, questions fiscal responsibility, and will adversely affect the sustainability of proposed applications.
This is a tool taught to physicians during their training: “a systematic method of diagnosing a disorder that explains presenting signs and symptoms of a patient”. But what happens if 2 patients appear with similar signs and symptoms? Do they have the same disease? Maybe, but not necessarily. The signs and symptoms of 2 or more patients may be similar, but the actual diagnosis can be different and differential diagnosis allows this to be resolved. Because the diagnoses for the 2 patients are different, so too will be the
Using the data, information, and analysis garnered in Steps 1 and 2, it is possible to look at groupings at the next level down (eg, subnational entities for a national eHealth strategy, districts/wards for a regional eHealth strategy, and communities for an institutional eHealth strategy) and to reveal differing needs of distinct locales or populations. These should be highlighted for later consideration.
Given resource limitations, not every option can be pursued; trade-offs are essential and enforcing choice purposefully limits the options. But how do you choose? Priorities in health needs are traditionally viewed only in terms of disease morbidity and mortality. While intended for setting research priorities, the explicit and rational approach of the Combined Approach Matrix [
At this point in the process, the evidence-informed, and needs-based, health issues of the institution, region, or country are known and have been prioritized. In addition, the internal and external influences that the current and future setting may bring to bear are also understood. It is now possible to consider a variety of solutions to address these identified health issues. But it is essential that expansive thought be employed. These solutions need
This stage is the point at which to engage a broad selection of local (institution, region, or country) stakeholders, including government, private sector, and academic participants with diverse experience and expertise in health, education, and business to become an eHealth strategy advisory team. The group must be briefed using the material gathered and analyzed in Steps 1-4, thereby creating a well-informed and up-to-date team. Their task is to assess the identified and prioritized health needs, consider the political context, leverage existing (or recommend potential) partnerships, and develop innovative solutions to the top 20% of the prioritized health needs (note that innovation is often considered synonymous with the use of sophisticated technological solutions—this is
Only at this stage is the possible application of eHealth interventions considered. This process is best undertaken with the assistance of local or (if insufficient in number or expertise) external eHealth experts (telehealth, health informatics, e-learning, and e-commerce), who then become a part of the local working group and are briefed on both the prior material (Steps 1-4) and the process and solutions identified in Step 5. Again, expansive thinking is essential; many eHealth solutions are available but each may be optimal for only specific settings. It is recommended that attention still be focused on the top 20%; eHealth solutions may well be feasible for the remaining 80%, but if they are not highly prioritized then funding such initiatives may not be the wisest investment.
Options must be limited to a small number, and for each proposed eHealth application a brief but structured review (essentially a summary “business case”) must be prepared. This will help to assess the feasibility of each solution for the given institution, region, or country; not all of the proposed eHealth applications will be technologically appropriate, culturally sensitive, or financially feasible.
Almost invariably more than one eHealth solution is available for any specific need (eg, applying different technologies such as videoconferencing versus podcasts for CME of clinicians), and more than one need can be addressed using eHealth (eg, telehealth consultation services to remote communities versus introduction of a public health surveillance tool). Decisions must be made. The business case analysis will have provided insight regarding potential cost, complexity of implementation, likely readiness to implement, and proportion of the population impacted—these features can be used to rank options as described earlier. In the absence of sufficient data to permit objective prioritization, then a more subjective approach will have to be taken. Here, each potential solution can be classified into applications that are considered
To create the institution, region, or country “eHealth strategy”, the findings from Steps 1-7 are synthesized, and the recommended priority needs and selected eHealth solutions described. This eHealth strategy document then informs further action. It will guide the building of the necessary enterprise architecture, ICT infrastructure, processes, and policy environment, as well as the subsequent design, readiness assessment, implementation plan, change management plan, evaluation study, and sustainability program for the selected eHealth applications.
There is continued debate about strategy versus policy. While there may be no clear cut answer to “what comes first—the chicken or the egg?”, logically it follows that poor inputs to designing an eHealth favorable policy environment will ultimately result in poor outputs, poor outcomes, and undesirable impacts. Consequently, this paper is intended to encourage development of a sound and evidence-based eHealth strategy for any entity (region, country, subnational jurisdiction, or health care facility) as the
Approaching eHealth policy development in this way ensures that important issues requiring policy solutions (new, revised, or rescinded policy) are identified. Attention can then be given to considering what specific eHealth policy is required to encourage and or manage the strategy, including expected growth in implementation and evaluation of eHealth solutions and sustainability. Such policy must be developed through an iterative, collaborative, and participatory process if support is to be engendered from all stakeholders. Further, it must be remembered that eHealth specific policy is only developed where it is not possible to achieve the desired result through revision/amendment of existing health, education, or ICT policy. In the end, eHealth should become just another tool by which to provide health-related information, education, and services—to do so it must become integral to the existing health care system, not separate from it.
In our culture of constant growth, more and more governments and decision makers (eg, senior managers of health care facilities) are being called to task to demonstrate the value of the decisions they make. Health seemingly consumes a greater and greater proportion of available funds in an attempt to address the complex health care issues that plague all countries as we continue the global transition from infectious to noninfectious and chronic disease and old age. eHealth—a relatively new approach available to decision and policy makers in the developing world—has been hailed by many as a solution to these woes. Yet attempts to date in the developed world have shown relatively little success or return on investment despite significant outlay. A better and more reasoned means of understanding where and how to apply eHealth solutions is necessary. An evidence- and needs-based, transparent, and defensible eHealth strategy is required by each region, country, and facility.
Only recently has some guidance for eHealth strategy development become available. In 2011, the Commonwealth provided many templates and a structure to use in initiating a series of workshops intended to lead towards development of an eHealth strategy [
While both these documents contribute significantly to the debate, neither provides conceptual background or theoretical support to the need for, and development of, eHealth strategy, nor do they focus on development of an eHealth strategy as a distinct and primary undertaking. Instead, both intermingle many other issues (eg, interoperability, standards, confidentiality, security, policy, architecture, implementation, change management, investment, benefits realization), which serves only to distract from the primary intended goal of eHealth strategy development. All of these aforementioned topics are certainly of relevance but should be addressed only once a clear understanding has been developed of “where you want to go” and “why you want to go there”, that is, having established the eHealth strategy.
Perhaps the greatest contribution of the eHealth Strategy Development Framework is its clear focus on establishing an evidence-based eHealth strategy and providing the conceptual understanding and tools required by which to achieve that. To be effective, an eHealth strategy must be solidly grounded in an understanding of the broader context within the setting (region, country, facility), and the challenges and opportunities that exist. It must provide clarity around the health need(s) that must be addressed and the solutions (particularly eHealth solutions) it is intended to apply.
The eHealth Strategy should not be so detailed and unwieldy that it cannot be used as a functional and guiding document. Therefore, it does not provide details of specific undertakings; those needs are addressed through next steps, including design of an enterprise architecture plan, business plan, readiness assessment plan, implementation plan, change management plan, evaluation plan, and operational plan. Once established, the eHealth Strategy acts as a pole star, that is, a “constant” to which all can refer as they work to achieve identified goals and navigate the defined path.
Growing expectations, changing demographics and disease patterns, and resource limitations require wise investment in eHealth solutions that address major health needs in any given setting. Solutions that are designed and implemented now must form the foundation (practice and technology infrastructure) for decades to come. Such sustainable eHealth solutions first require development of a sound, evidence-based, transparent, and defensible eHealth strategy, which then informs subsequent development of a sound and viable policy environment, enterprise architecture, and so forth. This paper describes the conceptual understanding and practical steps required for any facility, country, or region to develop its own eHealth strategy.
Canadian International Development Agency
continuing medical education
electrocardiograph
European Union
gross domestic product
health information system
health information technology
information and communications technologies
International Development Research Centre
International Red Cross
International Telecommunications Union
knowledge transfer/translation
Ministry of Health and Long-Term Care
non-governmental organization
National Health Service
Organization for Economic Co-operation and Development
Pan American Health Organization
product of value approach
socioeconomic return
Swedish International Development Cooperation Agency
sum of ranking approach
United States Agency for International Development
World Health Organization
RES conceptualized the framework. Both authors were responsible for the literature review and analysis. Both authors were involved in writing and reviewing the manuscript.
None declared.