This paper represents a personal viewpoint based on a nonsystematic review of the literature and the experience of observing and participating in the design, evaluation, and analysis of health informatics interventions. It originated as a briefing document for members of a multidisciplinary team of clinicians, researchers, and software designers, which was designed to foster shared understanding and plan a program of formative and evaluative work. The paper draws on existing literature advocating interdisciplinary methods in medical informatics but focuses on generating a dialogue between software developers and researchers working in this area.

The article begins by considering the increasing heterogeneity of the field, the need for multiple research perspectives, and the implications of scientific subcultures; it discusses the importance of research for ensuring that new eHealth technologies are adopted and effective; it highlights common concepts and methods in software design and health services research; and it then considers the benefits, challenges, and facilitators to interdisciplinary collaboration.

For the purposes of this paper, the term eHealth is used broadly as a synonym for health informatics or medical informatics and health services research for health technology assessment and health systems research.

Not so long ago, medical informatics was largely the preserve of computing professionals and managers due to its focus on aspects of information technology “hidden” beneath the surface of health care organizations, such as operating systems, architectures, and databases. While epidemiologists were quick to harness the potential of electronic patient records for research and disease surveillance, it was the growth in practice-based computing during the 1990s that increased awareness of information technologies among clinical stakeholders and saw their gradual integration into the processes of care. Among the general public, awareness of eHealth, as the field is becoming known [1], has burgeoned since the turn of the 21st century, paralleling access to the Internet and the proliferation of Web-based health and lifestyle resources. This is reflected at the policy level, where governments have become increasingly interested in the potential of information and communications technologies to improve the organization and delivery of health services and to support patient empowerment for self-care [2]. In the United Kingdom, for example, the National Health Service (NHS) National Programme for Information Technology is gradually bringing the health service into people’s homes via initiatives such as NHSDirectOnline and NHSHealthSpace, which offer not only information but also opportunities for electronic consulting and personal health care organization (eg, records, appointments) [3].

Reflecting this societal trend, academic involvement in medical informatics has become ever more interdisciplinary, with growing participation by the social, economic, and legal sciences (eg, around managing change, ethics, and cost-effectiveness) and the emergence of translational fields such as bioinformatics that promise to challenge existing medical models. At the same time, the boundaries between scientific, policy, and commercial areas of research and development are becoming grayer, as academia and industry respond to government funding opportunities and the policy community responds to emerging evidence and new technologies.

Growing use of the term health informatics, in preference to medical informatics, also reflects a shift toward inclusiveness. Figure 1 represents this shifting landscape in terms of the stakeholders, technical focus, disciplinary drivers, and objectives of medical informatics practice and research. It is not intended as a comprehensive chronological account of the field’s evolution, although the domains reflect observations from previous analyses of the literature [1]. A key change has been the increasing breadth and complexity of the field not only in terms of new technologies but also the perspectives that are being brought to bear in planning, understanding, and evaluating these technologies.

Figure 1

The increasing breadth and complexity of eHealth in terms of the stakeholders, technologies, objectives and disciplines involved

The increasing heterogeneity of the eHealth field raises challenges for interdisciplinary working and the translation of research to policy and practice. These challenges have to do with the management of nonshared concepts and languages and the values ascribed to different forms of scientific and technological endeavor, within what may be termed the knowledge economy of eHealth.

Despite popular stereotypes about “the” scientific paradigm, different disciplines have evolved uniquely over time and have their own theoretical or applied stance, criteria for appraising quality, and their own ways of working. Although we agree on basic principles of objectivity and methodological adherence, the way in which we see the world and approach new research problems is affected by a host of contextual and historical factors that are specific to individual disciplines, making truly interdisciplinary working difficult to achieve [4].

Unpicking all these factors is beyond the scope of a single paper; however, a useful guide is to be found in the comparison of two important areas of activity that are central to modern eHealth—namely, software design and health services research (HSR). The reason for concentrating on these is that managing their relationship is fundamental to ensuring that eHealth innovations achieve their potential to improve the quality, efficiency, and safety of patient care. This paper focuses on the software development process, with particular reference to user-centered design methods. Its origins lie in the author’s growing appreciation of the nature, value, and limitations of evaluation methods used in the software engineering community and the lack of awareness of these among health services researchers evaluating eHealth resources. While several high-profile documents have explored potential synergies between HSR and the broad field of medical informatics, and these have undoubtedly contributed to quality improvements in some areas, their potential impact across the wider eHealth landscape is far from being realized [5-12]. In practice, many eHealth software developments, and the HSR projects associated with them, take place in the context of short contractual episodes, where neither developers nor health services researchers have the time or incentive to engage in cross-disciplinary learning. As a result, developers and researchers of eHealth regularly work in parallel universes, each regarding the other’s domain of activity as separate and neglecting the potential for useful interaction.

Although developing technical solutions remains central to medical informatics, recent years have seen a growing emphasis on identifying and resolving barriers to implementation. Particular attention has been devoted to understanding so-called people and organizational factors, such as stakeholder resistance to change and the appropriate integration of new technologies into work patterns [13,14]. Two key themes have emerged from this discourse, which have direct relevance for the potential effectiveness of eHealth innovations:

To consider the first theme, while there is general consensus among software designers on the importance of engaging users in software design and testing, commercial drivers and a historical focus on product development have meant that this has often been inadequate in the past, resulting in top-down developments whose problems may only emerge after rollout. The health care sector has been particularly prone to such problems in recent years, and there are numerous examples of potentially useful systems that have failed or been abandoned due to unanticipated technical, human, or organizational issues [15-17]. Design flaws can affect the ease of use and reliability of systems and may even be dangerous, creating ill-feeling and reducing clinicians’ willingness to use emerging systems, software, and hardware in practice [18,19]. Even seemingly minor problems with usability or conceptual fit can destabilize the implementation of otherwise highly engineered and valid technologies. The discussion that follows illustrates how developers are rising to this challenge.

To consider the second theme of eHealth technologies being unproven, while research in this area is burgeoning, it remains a fact that there is little reliable evidence to demonstrate the measurable impact, risks, or cost-effectiveness of eHealth innovations, except in a modest number of application areas [20-22]. This creates uncertainty and hence a reluctance on the part of clinicians and policy makers to implement such technologies. Where rigorous research designs have been employed, this has often been in the context of academic studies in which the future sustainability or generalizability of the products being evaluated cannot be assured. Indeed, a recent systematic review of health information technologies demonstrated that of 257 published evaluations, a staggering one quarter emanated from four academic institutions that implemented internally developed systems, while only nine reported on commercially developed systems [22].

Tackling these problems requires the application of joint thinking between practitioners in the two fields so as to ensure high-quality, user-informed products of demonstrated effectiveness. However, cultural divides between the traditional software developer and health researcher communities have inhibited this process.

Software development represents an application of computer science, a field rooted in engineering and mathematics. Although it has drawn on philosophy (eg, semantics, logic) and social science (eg, human-computer interface research, social technology studies), its historical focus has been on building machines and the software they require, albeit with ever more complex digital innovations such as the Internet and intelligent agents. This focus on product development has led to a close alliance with the business and service sectors, and, although basic science is highly valued, there has been an understandable emphasis on applied research and development within university curricula. Within the workforce itself, economic drivers prioritize the production of resources that meet key functionality criteria and client-defined requirements within commercially viable time frames. Evaluation often takes a lower priority, and rapid application development using small convenience samples of users is common [23].

HSR is an interdisciplinary field concerned with the scientific study of the structure, processes, and effects of health services, technologies, and policies. This harnesses traditionally medical research approaches from epidemiology and clinical science, alongside the social and economic sciences, utilizing a mixture of quantitative and qualitative methodologies appropriate for the specific problem under investigation. It is closely allied to the evidence-based medicine movement, which holds that clinical practice should be driven by evidence of what interventions work best and for whom. As well as measuring impacts, such research is also about enquiry. For example, it may explore the needs of particular stakeholder groups or demographic patterns of health and health care utilization in order to identify the place of a potential new intervention or examine the reasons why an intervention is more easily adopted or more effective in different contexts. A defining characteristic of this field is the strong emphasis on methodological rigor. From randomized controlled trials to qualitative case studies, the focus is on detailed planning and recording of procedures and on transparent, theoretically informed participant sampling and data analysis. This area is less influenced by commercial drivers, although there is a strong emphasis on research that addresses health service policy needs.

Thus, software design is mainly concerned with developing interventions, and HSR, with evaluating them. But look closer and the reality is not so clear cut. In fact, much of HSR is geared toward informing the design of new interventions, including eHealth technologies, while rigorous software design encompasses evaluation processes that would be very familiar to health services researchers.

However, within these two communities there has been a mutual lack of awareness of each others’ theoretical stance, motives, and modus operandi, exacerbated by differences in language, epistemologies, and the representation of concepts. This reflects the origins of the two disciplines and the funding environment, which place different expectations on eHealth design and research projects.

While various academic approaches have been applied to the study of software design and diffusion (eg, in the management literature), in the context of this paper the compatibilities between process models of software development and HSR are particularly relevant. These compatibilities illustrate the importance of exploration and evaluation for informing developments and quality improvements in both domains, the value of user engagement in this process, and the natural progression to assessment of the effects.

Designing effective eHealth systems and services requires the application of expertise from diverse fields and will benefit from interdisciplinary collaboration. This may be eased by increasing familiarity with each others’ terminologies, theoretical bases, and research methods, with the ultimate objective of achieving transdisciplinary working. There is sufficient overlap in the techniques and concepts employed within the software design and HSR communities to make this a reality, but realizing this requires the development of mutual trust and respect for each others’ aims, epistemologies, and contextual drivers, as well as a willingness to step outside traditional working boundaries. New funding strategies that recognize the value of alternative methodologies and of joint working between developers and evaluators are also called for.

This paper has merely scratched the surface of a wider debate on the value of interdisciplinarity for improving the quality and effectiveness of eHealth, although it is hoped that by highlighting the potential synergies between HSR and software development it will help to provoke constructive dialogue between these two communities. Maximizing the potential of eHealth also requires the involvement of a wider constituency of disciplinary experts, including social, management, and legal scientists, all of whom have a stake in the field. Interdisciplinary networks, such as the one managed by the author, offer one means of addressing this need.