E-Health and the Web 2.0
Márton Gellén
Századvég Academy of Public Administration, Budapest, Hungary
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1. E-Society and knowledge uptake in the public health sector
Generally, the health sector is one of the most knowledge-intensive sectors among all of the
public service areas. Thus in this sector, the statement that “technology is the highest
contributor of productivity growth” is more valid and more timely than in other publicly
financed territories.
Innovation is an ability of research and the capability of applying new solutions. It is obvious
that IT determines innovative capability, although innovation might stem from various fields.
It has been proven a major policy simplification that more connectivity is equal to more
knowledge uptake.
2. What do we mean by E-health?
Since the aging European societies face enormous challenges in coping with the tension
between the technologically possible and the economically affordable, IT offers significant
changes in the way we might think about public healthcare services.
We define e-health as using IT technologies in order to increase the performance of public
health systems without any respect on who the user is. Thus according to our definition, users
might be doctors, patients, family members as well as civil servants or medical university
students and teachers. The other impact of E-health is: organizational change. It is important
to state that no technology can efficiently serve workflows managed by a non-cooperative
staff.
3. Centralized E-health model
The centralized E-health model stems from the service provider – in case of public healthcare
the state, state authority, agency, social security institution – and targets the individual patient
throughout a complex mechanism of entities and regulations. The centralized model can
embrace clinical, telehealth, distributed and complied applications.i Clinical E-health
applications provide professional support for entitled workforce of hospitals and other
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practitioners. Telehealthii applications provide remote patient monitoring throughout
information networks and thus save visiting hours for both the patient and the doctor and save
the time and costs of coming the hospital personally for the patient. Distributed e-health
provides access to medical information stemming from various regions or countries (including
prescription data and health records). Complied e-health services cover training, research
projects, supply chain management and administrative activities.
4. Problems with the centralized E-health applications
Centralized E-health applications – naturally – have risks that are to be discussed.
4.1 Risks of Policy Transfer
Policy transfer is “the process by which knowledge of ideas, institutions, policies and
programmes in one time and/or place are fed into the policy making arena in the development
of policies and programmes in another time and/or place.”iiiSince E-health applications are in
many cases subjects of international policy transfer therefore many errors and public policy
failures emerge of policy transfers without precisely elaborated and implemented strategies.
Main policy transfer failure factors are as follows [Dolowitz and Marsh]:

Policy transfer framework: who transfers what to whom, from where, to what extent?

Policy complexity: the more complex the more likely to fail.

Interactive effects: past policies and other policy efforts might distort the process
compared to the original intentions.

Institutional constraints: It is not enough to implement ICT solutions, real
transformational value should be created – if possible. Paradoxically the institutional
systems that operate at the lowest performance indicators and that are mostly in need
of E-health knowledge uptake are the less receptive for such initiatives and are more
likely to fail.

Feasibility
constraints:
political,
bureaucratic,
technological
and
economic
circumstances have to serve the policy transfer.
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4.2 E-Health as a tool for increasing government control
The medical profession always had a certain independence from the central state authorities.
This relative autonomy is based on the complexity of the medical profession that is
manifested in the direct doctor-patient relationship. Historically the doctors were the most
important players in determining costs and public healthcare expenditures. “their institutional
and cultural dominance of health care institutions has given them the largest say in the
allocation of resources.”iv With certain e-health applications the service provider institutions
might make individual doctors internally transparent in terms of measuring work
performance, directly or indirectly orienting (or instructing) them about their practical
activities. Besides many benefits to the public health expenditures, these phenomena might
lead to a shift of responsibility and discretion to a higher level or at least to a chaotic state
where duties and responsibilities are not well defined.
Of course the increase over government control over the medical profession is only one side
of the coin. The even more hard-to-take challenge is the privacy issue that has to be redefined
in a global arena – especially in case of global e-health systems are being introduced.
4.3 Project management risks
It is well known – although not frequently repeated – that the failure ratio of e-government
projects is very high.v With e-health projects the situation is the same or worse.
There are certain parameters that the project design has to take into consideration in order to
minimize risks such as keeping a short timeframe, try to keep to the simplest possible
application, make sure that the project meets the needs, put organizational change first –
constantly inform the affected medical workers, do not manage multiple projects parallel,
ensure strong stakeholder support but without distorting the original project design, make sure
that the staff is aware that the e-health project is not a panacea for all of their problems. On
further project management risk assessment and risk minimalization see The UK treasury
Green Bookvi.
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5. The Web 2.0
As broadband Internet access gradually penetrated the international society and as mobile
devices became eligible of replacing computers in certain fields of services, a complex
phenomenon occurred that is called Web 2.0. It is a mixed result of the improved and
commonly accessible infrastructure and is a complex phenomenon of a new kind of culture.
The cultural dimension can be characterized by a sort of “active citizenship” as a combination
of free participation, initiative attitude, solidarity, trust and entertainment.
Without further describing the Web 2.0, a few well-known brands are to serve as examples in
order to throw light on the economic, social and intellectual power of the citizen (consumer)
network: Second Life, E-Bay, IWIW, YouTube, Wikipedia, Googlemaps etc. Although the
business segments they are in are different, it is common that all of the enlisted business
models are based on the consumer as a value holder and value contributor. They act as hubs
for the customers, who are demanding but also willing to contribute their own knowledge,
experience and personal network.
The Web 2.0 and the more critical and proactive attitude in the social patterns it involves, are
challenging for all traditional government agencies that have always been isolated in a certain
sense from the public they served. In the case of the EU as a whole and its institutions, the
isolation from the citizens has been publicly criticized and negotiated frequently but in the
new realm of Web 2.0 the democratic deficit is expected to irritate citizens even more.
6. New Element in E-Health: the Web 2.0
6.1 brief Case Study: http://www.halapenz.hu/
The case study is from Hungary. “Hálapénz translates literally as ‘gratitude money’, and it
seems to have originated many decades ago”vii. Hálapénz in Hungary is privately paid
compensation to the doctores or seldom to nurses for extra attention or to express satisfaction
with the medical services received. It does not exist outside the medical system. Although it is
generally considered as a form of corruption, it is still flourishing as a sort of social custom.
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Although being a custom, giving gratitude money is not secretive, therefore the patients or
their family members preparing to give “hálapénz” usually do not know how much to give.
Than – to the surprise of the Hungarian media and to the outrage of the medical profession – a
website appeared whereas mothers expecting babies informed each other about the “tariffs” of
certain doctors identified by their full names regarding childburth “prices” and other
gynacological service compensations.
After short, the site had to be closed down to protect the privacy of the doctors named on the
site but the phenomenon expressed the power of the individuals sharing information on the
web.
6.2 How Web 2.0 Changed E-Health?
Web 2.0 E-health applications changed the range of E-health in terms of targeted entities and
also regarding the services submitted to these entities.
E-health applications – defined in the broad sense – can be categorized according to the target
groups and to the type of service they offer. The new territories are illustrated by the charts
below.
E-health target entities
Applications for
individuals
Applications for
groups
Applications for the
service providers
Chart No. 1. E-health applications categorized by target groups
Many government projects have been undertaken to increase e-services targeting the patients
or potential patient individuals
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E-Health
outcomes
Additional
medical
information
(specific or
general)
Supporting
existing
processes
Enabling new
processes
Chart No. 2. E-Health applications categorized by the outcomes.
The following table indicates a potential logical framework of categorizing existing elements
of the composite phenomena of E-health extended by Web 2.0 applications in E-health.
Additional medical
information
Supporting existing
processes
Enabling new
processes
Applications for
Applications for
Applications for
individuals
groups
service providers
Reading medical
Registering into a
websites, newsletters. medical chatroom,
sharing information
with each other in
an electronic patient
to patient discussion.
Preparing for visiting Controlling existing
the doctor with
processes by
educated questions.
discussing them on
the web.
Distant medical
Collective action for
control. Automatic
promoting
medical data
prevention or to
collection. IT
promote policy
supported risk
decisions.
assessment.
Up-to date scientific
information. Best
practices.
Electronic patient
database screening in
order to sort out free
riders.
Distant surgery.
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6.3 E-health in the Web 2.0 era, first consequences
Although many creative ideas have been circulated within the scientific and policy circles,
most of the measurable positive experience we have are the first results of patient-patient and
patient-doctor connections enabled by the Web 2.0 culture.
How did Web 2.0 contribute to the performance of the healthcare systems?
Generally, e-health solutions decrease costs by monitoring individual condition and thus
decreasing the number of very costly emergency room visits but virtual e-health communities
enable even more.
As the access for healthcare information became easy through the Internet, it has become a
popular information source. People with Internet access browse for medical information for
themselves but mostly for other people living in their families.
Although the access to various medical information sources is practically limitless, the
understanding and applying such information is very limited since the lack of medical
education within the wide public. Since the public receptiveness of detailed and professionally
unquestionable medical information is utterly narrow, most of the publicly preferred sites
transmit simplified information. Such simplifications might contribute to understanding but
might raise questions about the correctness. If the given site is sponsored by a pharmaceutical
producer, the correctness and validity of the content might be questioned – especially if the
suggestions concerning the therapy of the illnesses discussed have a certain focus on the
product portfolio of the sponsor. In many cases one can only suspect such influence without
any concrete evidence of such influence.
Virtual e-health communities have been very helpful for patients with rare diseases viii. The
Internet has proved to serve as a powerful channel for online information exchange, social
support and personal empowerment. E-health groups are very promising phenomena of the
Web 2.0. They are expected to challenge traditional public health service workflow and
structure. They are also appropriate hubs of patient-information that are vital for proper
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diagnosis and medical control. It is easy to imagine that the e-health communities would soon
have a patient-orientation role based on consumer feedbacks and thus expressing an indirect
quality control above the healthcare institutions.
In many cases, the medical information publicly available is too complicated for people to
understand. On the other hand, the pursuit to elaborate digestible information occasionally
concluded to the creation of incorrect medical information as well. Most of the information
distortion could be interlinked with the commercial interest of the affected informationsupplier company. Although medical information correctness is not absolutely ensured in the
Web 2.0 model, permanent correcting and cross-checking is a natural, built-in function since
the participants can always correct and comment each other.
Although E-health on the Web 2.0 is not a general solution for all E-Health challenges, it is
exempt of many problematic issues of the centralized E-Health e.g. it does not burden the
central budget thus there is no public expenditure even if an application would fail.
Sharing medical information has been proved successful and efficient in territories where
anonymity is a general priority for the patients:

depression, cancer-related trauma, perceived stress

back pain

diabetes, gynecological illnesses

eating disorders and obesityix
6.4 The Risks of Web 2.0 applied for health related issues
The shortage of e-readiness of patients and medical workers has to be enhanced equally. In
certain cases, a negative attitude towards technology of the medical staff was detected.
Privacy issues within the realm of e-health are extremely important. The more participating
sites a user visits, the more detailed and interrelated becomes the personal portrait. Therefore
this territory has to be strictly regulated in the future.
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Since the Web 2.0 absorbs not relevant or not professional information as well, there are
many distortions, misinformation, mistakes etc – however, all with the opportunities of being
corrected.
7. Further potentials
The following chart (source: www.ittk.hu) indicates that the proportion of the Internet users is
45% of the 14+ age group while the percentage of the PC users. The chart indicates that the
gap between the number of PCs and Internet connected PCs is decreasing. The question that
this figure raises is whether the Internet penetration growth has considerable further reserves.
Chart No. 3 Internet users in the 14+ age group in Hungary
The most considerable source – besides the increase of internet penetration – is catching up
with the range of inequalities behind the gross figures. These inequalities contain: gender,
age, education, wealth, race aspects. It is easy to see that these social parameters are related to
health status and health needs.
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Contents
1. E-Society and knowledge uptake in the public health sector ............................................. 2
2. What do we mean by E-health?.......................................................................................... 2
3. Centralized E-health model ................................................................................................ 2
4. Problems with the centralized E-health applications ......................................................... 3
4.1 Risks of Policy Transfer ............................................................................................... 3
4.2 E-Health as a tool for increasing Government Control .................................................... 4
4.3 Project management risks................................................................................................. 4
5. The Web 2.0 ....................................................................................................................... 5
6. New Element in E-Health: the Web 2.0 ............................................................................. 5
6.1 brief Case Study: http://www.halapenz.hu/.................................................................. 5
6.2 How Web 2.0 Changed E-Health? ............................................................................... 6
6.3 E-health in the Web 2.0 era, first consequences .......................................................... 8
6.4 The Risks of Web 2.0 applied for health related issues ............................................... 9
7. Further potentials.............................................................................................................. 10
Contents ................................................................................................................................ 11
i
Tom Jones et al.: E-Health for Developing Countries: Affordable Strategies, Commonwealth Secretariat,
Geneva, Switzerland, 18 May 2008
ii
See good example: www.e-trikala.gr
iii
J. Barlow (1997), Policy transfer: the management of change in a Hungarian local authority, unpublished
paper, international conference on Public Sector Management for the Next Century, University of Manchester,
29 June – 2 July. Cited by: David P. Dolowitz and David Marsh: Policy transfer: a framework for comparative
analysis in Beyond the New Public Management – Changing Ideas and Practices in government (Minogue,
Podliano, Hulme – Editors), Edward Elgar Publishing Inc. Cheltenham, UK, 2000
iv
Michael Moran: Managing reform: controlling the medical profession in an era of austerity. In. Bovens, Hart,
Peters (Editors): Success and failure in Public Governance, Edward Elgar Publisher, 2001, Cheltenham, UK
v
See Moran’s Managing reform: controlling the medical profession in an era of austerity to see the many means
of success and failure in public policy.
vi
http://www.hm-treasury.gov.uk./media/3/F/green_book_260907.pdf
vii
http://www.economist.com/displaystory.cfm?story_id=10553357
viii
James E. Katz, Ronald E Rice, and Sophia K. Acord: E-health networks and social transformations:
expectations of centralization, experiences of decentralization In.Manuel Castells (Editor) The Network Society
– A Cross-cultural perspective. Edward Elgar Publishing Inc. Cheltenham, UK, 2004 Examples cited from p.
303.
ix
Bovens, Hart, Peters (Editors): Success and failure in Public Governance, Edward Elgar Publisher, 2001,
Cheltenham, UK
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