Table 5.

An eHealth User's Guide: 10 Key eHealth Questions

Question	Answers, options and considerations
1. Which eHealth modality and clinical target is best for us?	eHealth modalities are only clinical tools or modes of care extension—their use is not a goal in and of itself, even though they can be seductively attractive. Actively consider the answers to five subquestions:
	a. What is the clinical or behavioral problem or target that needs to be addressed?
	b. What patient population(s) is of interest?
	c. What aspects of clinic staffing, culture, patient flow, and competing demands need to be considered?
	d. How will expected costs and potential reimbursement drive goal attainment and return on investment?
	e. How to get input from all stakeholders regarding which eHealth modality and clinical/behavioral targets best address the issues raised by questions “a” through “d” above?
2. What are the major benefits of a particular eHealth programs that make it attractive for use in clinical care?	The major benefits of eHealth systems include their potential to reach geographically dispersed, underserved patients, those struggling to meet clinical goals with routine visit frequency, and those who find it difficult to come for care (especially post-COVID). They also can provide effective strategies for patient education, self-management training, peer support, live and algorithm-based, real-time feedback, and assistance for day-to-day disease management and problem solving-for patients and HCTs.
3. Can I apply the published eHealth efficacy data to my clinic population to justify its use?	Whatever the reported research data, they may not apply to your clinic! Because most outcome data are generated from white, educated adults from high income countries, in highly controlled research studies, they may not generalize to your clinic and patient population. Use existing outcomes (or effectiveness) data as a starting point, but then anticipate that the eHealth system will have to be customized for your specific, targeted patient groups, accounting their diversity, literacy, numeracy, beliefs, skills, social determinants challenges, and values.
4. How much improvement in clinical and behavioral targets can I expect when applying an eHealth system?	Support for the effectiveness of eHealth systems is generally good, but there are many exceptions and qualifications to consider. Although statistically significant improvements in clinical targets with eHealth systems have been documented, it is important to decide whether or not the reported statistical improvements are sufficiently clinically meaningful and equitable across different targeted patient groups in your setting.
5. How much HCT and staff involvement, should be included to maximize benefits?	eHealth systems linked to HCTs generally show higher levels of usability and effectiveness than free-standing systems not linked to HCTs. Generally, there appears to be a positive association between the number of contacts between HCTs and users, use of the eHealth system and change in outcomes, although majority of these data are correlational, not experimental.
6. How much training and support will patients and staff require?	Evaluate training needs carefully. Patient access and training for eHealth systems and the availability of real-time technical support are crucial, especially when the eHealth system includes multiple modalities or targets. Training needs depend on the complexity of the system and the preferences and needs of the targeted patient population.
7. What kinds of clinical and behavioral problems or issues are best targeted for change using eHealth systems?	Best are short- or intermediate-term, highly specific behavioral targets, like medication taking, carbohydrates consumed, or steps completed. Long-term targets, such as HbA1C, number of comorbidities/complications, or hospital days are affected by many additional causative factors and may take a far longer time to assess accurately, thus increasing costs and allowing for the input of other complicating factors.
8. How should I consider costs, benefits, and potential reimbursements when deciding upon an eHealth program?	▪ Be realistic: eHealth programs often have good cost-value ratios, but few actually save money by switching existing in-clinic services to eHealth methods. Rapidly emerging and changing reimbursement options are providing more opportunity by offsetting the costs of eHealth programs, but these vary considerably based on the staff involved, the patient's payment system and the content of the action taken.
	▪ Definitive cost analyses are difficult to do accurately as they depend upon quality data for the time spent implementing and sustaining programs, and clear specification of which stakeholder perspectives are included.
	▪ Clearly articulate the system's business case for the modalities, clinical and behavioral targets and patient populations that will be targeted.
	▪ Make sure to fully estimate costs for staff training, patient recruitment and training, integration with existing information technology, program oversight, ongoing support and supervision, disruptions to patient flow, ongoing technical assistance, credentialing, opportunity costs, and potential liability, in addition to the costs incurred by either developing or purchasing an existing system.
	▪ Be sure to consider the time frame being used to estimate costs, benefits, and reimbursements.
9. How do I make sure that my patients will actually use the eHealth system we use?	Consider explicitly: what is the right information needed at the right time for the right user? Have patients test it out in a pilot phase and ask for their suggestions for the eHealth program's design and implementation. Assume you will need to use initially collected data to adapt the program to changing context. Typical reasons for poor use include: user lack of technological savvy, low literacy or numeracy, too many bells and whistles (keep it focused), lack of contact/feedback from HCTs, goals not commensurate with patients' needs (do they see the eHealth target as a problem), values and interests, real-time tech. support., etc.
10. What do I need to consider for the successful adoption, implementation and maintenance of an eHealth system within the clinical setting?	Clinics and health care systems rarely consider the staff time and the investment required to gain and maintain stakeholder support and engagement. Factors that need to be determined up-front by health systems include:
	▪ Regarding staff: “who does what” for the full workflow of eHealth data collection, response, documentation, etc.
	▪ How much initial training and ongoing supervision will these staff need
	▪ How will eHealth data be integrated with existing technical infrastructure
	▪ HCT information sharing
	▪ Address issues of data privacy and security
	▪ Integration with clinic culture and mission
	▪ System maintenance and periodic upgrades
	Useful eHealth systems require full integration within the structures, culture and processes of clinic operations; and ideally coordination and collaboration with other community and public health resources.