Student name: Romy Amber Spronk
Student number: S2919168
Email: r.a.spronk@student.rug.nl
MSC BA HEALTH – FACULTY OF ECONOMICS AND BUSINESS – UNIVERSITY OF GRONINGEN
Effects of eHealth services on patient
empowerment: a systematic
literature review
MASTER THESIS BA HEALTH
First supervisor: dr. M.A.G. van Offenbeek
Second supervisor: dr. E.I. Metting
Date: 12-7-2020
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Abstract
Healthcare systems are increasingly shifting from paternalistic to patient-centered care, leading to a higher degree of patient empowerment. Patient empowerment could maximize both an individual’s potential for health and wellness and enable a higher degree of cost-effectiveness in healthcare, the latter being necessary due to the rising care costs faced in an ageing society. However, paternalistic
approaches are still frequently encountered in health care, impeding proper adoption of patient empowerment. Implementation of eHealth services might address this problem, as these have the potential to facilitate patient empowerment. However, mechanisms underlying the supposed relationship between eHealth services and patient empowerment remain unclear from recent
3 Table of contents Abstract... 2 Table of contents ... 3 1. Introduction ... 4 2. Background ... 6 2.1. Patient empowerment ... 6 2.2 eHealth services ... 7 2.3 Patient-physician interaction ... 8 3. Methods ... 9
3.1 Design and search strategy ... 9
3.2 Article selection ... 9
3.3 Article quality assessment ... 10
4. Results ... 13
4.1 Conceptualization and operationalization of patient empowerment ... 13
4.2 Functionalities in eHealth research examined for their effect on patient empowerment .. 18
4.3 Direct effects of eHealth services on patient empowerment ... 19
4.4 Indirect effects of eHealth services on patient empowerment ... 25
5. Discussion ... 28
Acknowledgements ... 35
References... 36
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1. Introduction
Patient-centered care has gained popularity during the last decades, resulting in a shift from a paternalist to a more patient-centered health system (Risling et al., 2019). Corresponding policy changes contributed to a growing amount of patient empowerment in health care services (Bravo et al., 2015). Patient empowerment is a
frequently used term to describe situations where patients are actively involved in and partly take control over their own care process (Alpay et al., 2010). However, paternalistic practices are still frequently encountered, impeding proper adoption of patient empowerment in daily practice (Risling et al., 2017.). Adoption might be enhanced by the implementation of electronic health (eHealth) services, as these services are expected to facilitate patient empowerment and are occupying a growing proportion of modern healthcare therapies (Alpay et al., 2010). However, current literature is inconsistent and inconclusive about the mechanisms underlying this supposed relationship between eHealth services and patient empowerment (Alpay et al., 2010). Moreover, there is no consensus in current literature on the conceptualization and operationalization of patient empowerment, impeding quality of evidence of experimental research studies (Risling et al., 2017). The research question of this systematic literature review therefore constitutes: What are the effects of eHealth services on patient
empowerment?
The digital revolution has had a dynamic and growing impact on health care since the early 1950’s worldwide (Garg et al., 2018). Initially, digital health integration was seen as a potential mechanism to solve inefficiencies and address growing costs in health care, as well as to increase quality of, improve access to, and support personalization of care (Garg et al., 2018). Over the years, the term eHealth emerged, referring to the use of interactive technologies to enable health improvement and health care services (Ahern et al., 2006). The two main problems that eHealth initiatives try to address are the limited capacity of health systems to provide health behavior change and the management of chronic diseases (Murray et al., 2011). Due to our ageing population, chronic diseases became more prevalent and subsequently increased the demand for and expenditures of health care (Murray et al., 2011)(Muka et al., 2015). Prevention is an important factor in reducing mortality and
morbidity, indicating that changing risk behavior could be an effective tool in chronic disease management (Murray et al., 2011). However, activities required for establishing effective prevention, like counseling and monitoring, are time-consuming and costly (Murray et al., 2011). From this perspective, eHealth services could enhance the capacity of current health care systems and provide a means to establish health behavior change at relatively low costs (Murray et al., 2011). In conclusion, the main potential advantages of eHealth services are enhanced reach of patient populations, relatively low costs, high time efficiency and its capacity to personalize treatments (Murray et al., 2011). Also, Alpay et al. (2010) suggest that eHealth services could contribute to a higher degree of patient empowerment, due to their focus on patient-centered care.
Patient empowerment is defined as ‘promotion of autonomous self-regulation so that the individual’s
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therapy goals and outcomes to their own norms, values and personal situation (Alpay et al., 2010). Alpay et al. (2010) created a list of requirements for patient empowerment, and subsequently grouped these requirements into four empowerment areas which are related to eHealth: (1) insight into one’s own health condition, (2) making informed choices, (3) engaging self-care activities and developing self-care habits, and (4) living independently. eHealth services contribute to improvement of patient empowerment when these requirements are met (Alpay et al., 2010). A major component of the functionalities of eHealth services is the interaction between health care professionals and patients (Smahel et al., 2019). This interaction could positively contribute to the first two empowerment areas by Alpay et al. (2010), namely insight into one’s own health condition and making informed choices . However, little research is performed on the effects of patient-physician interaction on patient
empowerment (Petrič et al., 2017). Besides the direct effect of eHealth services on patient empowerment, it would thus be interesting to explore the indirect effects as well, focusing specifically on the role of patient-physician interaction.
A recent review by Ammenwerth et al. (2019) examining the direct effects of eHealth services on patient empowerment did not find clear evidence of substantial and consistent positive effects. They included mainly studies published in 2012 and before, while much research on this topic was performed in the last decade. In addition, eHealth services are increasingly applied, developed and sophisticated during the last decade. To provide a recent update on this topic, this literature review searches for studies published during the last decade only. Previous articles investigating patient empowerment in an eHealth context also highlighted challenges in achieving consensus on how best to operationalize and conceptualize patient empowerment (Risling et al., 2017). A systematic literature review by Risling et al. (2017) emphasized a lack of conceptual clarity in patient empowerment research. They concluded that interchangeable use or conflation of terms such as patient empowerment, patient acceptance, patient engagement, and patient activation complicated the feasibility of developing conceptual measures (Risling et al., 2017). Only from 2012 onwards, specific patient empowerment measures were found in the methods of experimental research articles. Still, these measures varied significantly in their use of conceptual elements (Risling et al., 2017). Consensus on the conceptualization and operationalization of patient empowerment is required in order to increase the quality of evidence of future patient empowerment studies. This is a necessary step to eventually enable proper adoption of patient empowerment in future health care services (Castro et al., 2016).
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services and patient empowerment, which leads to insights enabling a higher degree of patient empowerment in daily practice.
2. Background
2.1. Patient empowerment
Patient empowerment involves informing and educating patients about their own illness, aiming to promote autonomous self-regulation in order to maximize an individual’s potential for health and wellness (Lau, 2002).
This relatively new phenomenon gained prominence as the healthcare system started to move away from a paternalist system to a more patient-centered system (Risling et al., 2017). Patient empowerment is positively valued by patients as it enables them to be more involved in and take control of their own care process (Alpay et al., 2010). A study performed by Bravo et al. (2015) provided a conceptual map of patient empowerment. It included the following rights and responsibilities of patients: (1) autonomy, (2) self-determination, (3) power within the healthcare relationship and (4) optimizing healthcare service. These were claimed to contribute to the level of patient empowerment, moderated by provider characteristics and local conditions. Furthermore, indicators of patient empowerment were provided, including on a patient level the degree of (1) self-efficacy, (2) knowledge, skills, attitudes and self-awareness necessary to influence their own health behavior, (3) perceived personal control over health and healthcare, (4) sense of meaning and coherence, (5) health literacy and (6) feeling respected (Bravo et al., 2015).
Despite clear theoretical foundation of patient empowerment, realization in practice turns out to be difficult. eHealth services could solve this problem as they are thought to positively influence patient
empowerment. Alpay et al. (2010) appoint eHealth services as a means to potentially enable the empowerment process for patients. However, they say this ability depends on the design of the services, and subsequently proposed directions for effective designs of E-health. As already mentioned in the introduction, Alpay et al. (2010) provided four aspects of patient empowerment. eHealth services should meet these aspects in order to
contribute to the realization of patient empowerment in daily practice.
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operationalization, and will proceed with the conceptualization by Alpay et al. (2010) in this literature review.
2.2 eHealth services
eHealth services are thus seen as a means to accomplish a higher degree of patient empowerment. As mentioned in the introduction, eHealth services are initially developed to deal with the challenges that the health care system is currently facing, in particular with respect to our ageing population and the resulting increased demand for health care services (Murray et al., 2011),(Stroetmann et al., 2006). Stroetmann et al. (2006) provided three benefit categories of eHealth services: quality, access and efficiency. First, they stated that eHealth services contribute to a higher quality of care by enabling better informing of patients and carers. By information provision healthcare processes can in turn be better streamlined, care can be provided at the right time, risks can be reduced, and healthcare can be organized more effectively. Second, care access is improved as information provision ensures better availability and accessibility at set standards to all patients who demand it. And third, efficiency of care is improved as eHealth services enable improvement of productivity, avoidance of waste, optimization of resource utilization and cost containment to budgets (Stroetmann et al., 2006).
However, benefits of eHealth services might differ as eHealth services encompass a broad range of functionalities. These functionalities could in turn have different effects on patient-specific outcomes, such as patient empowerment. Functionalities of eHealth services can be summarized in the following three categories: (1) socializing functions, (2) health monitoring, and (3) planning and monitoring of goals (Smahel et al.,2019). They can individually act upon the supposed relationship between eHealth services and patient empowerment. With patient empowerment in mind as a dependent variable in this systematic literature review, it is interesting to further examine which functionalities are most frequently encountered and how these are related to the effects of eHealth services on patient empowerment.
The most commonly encountered eHealth service is the patient portal. Patient portals include ‘patient-
accessible electronic personal health records that directly link to an electronic health record (EHR)’ (Irizarry et al., 2017). EHRs are in the literature defined as ‘a repository of patient data stored in a digital format’ (Ben-Assuli, 2015). In other words, patient portals are accessible forms of EHRs for patients, whereas
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contained in EHRs is stored in a secure way and is only accessible to authorized people. Compared to prior paper-based methods of information storage, EHRs also have the advantage to increase continuity of care.
2.3 Patient-physician interaction
In order to benefit from eHealth systems, it is necessary to understand the communication and interaction between physicians and patients as this is a central component of most eHealth systems (Weiner, 2012)(Smahel et al., 2019). Ong et al. (1995) provided an overview of three different purposes of patient-provider communication: (1) creating a good inter-personal relationship, (2) exchanging information and (3) making treatment-related decisions. Healthcare provider communication styles can influence certain patient-related outcomes, such as satisfaction, compliance and adherence to treatment, recall and understanding of information and health status (Ong et al., 1995). Applied to the eHealth context, a broad range of eHealth services with different functionalities exists, all differing in their degree of patient-physician interaction (Baker et al., 2011). It remains to be examined how these services individually aim at serving the three purposes of patient-provider communication as provided by Ong et al., and consequently how patient empowerment is affected by patient-physician interaction.
The three variables described above, patient empowerment, eHealth and patient-physician interaction, are expected to relate to each other as graphically shown in Figure 1. Functionalities of eHealth services, purposes of patient-physician interaction and indicators of patient empowerment are also shown (Smahel et al., 2019)(Ong et al., 1995)(Bravo et al., 2015). A direct relationship between eHealth services and patient empowerment is assumed. This relationship is mediated by a third variable, which is patient-physician interaction. This variable influences the interaction between eHealth services and patient empowerment. In conclusion, patient empowerment is expected to be directly influenced by eHealth services, and indirectly by patient-physician interaction. The positions of our four sub questions within this hypothesized model are shown in Figure 1. In this figure, the numbers 1, 2, 3 and 4, correspond to sub questions 1, 2, 3 and 4, respectively.
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3. Methods
3.1 Design and search strategy
Guidelines adopted from the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) were followed, together with the five-stage grounded theory method (Moher et al., 2009)(Wolfswinkel et al. , 2013), In line with the grounded theory methods, articles discussing effects of eHealth services on patient empowerment were systematically reviewed (Wolfswinkel et al., 2013). First, the fields of research, appropriate sources and specific search terms were defined. Second, the actual searching process through all identified
sources was performed (Wolfswinkel et al., 2013). The following electronic databases were assessed suitable for retrieval of the articles: PubMed, Web of Science and Business Source Premier. This assessment was based on the persuasion that databases from different research fields need to be included to acquire a broad range of articles. Additional records were identified through an additional manual retrieval, using Google Scholar. This was performed to identify potentially useful articles that might be missed otherwise. Search terms were composed, including possible combinations of important keywords and synonyms with respect to eHealth and patient empowerment. Search terms were confined to articles published from 2010 onwards, because this field of research is rapidly developing and the majority of research has been performed in the past decade. The exact search terms are specified in Figure 2. ‘Patient empowerment’ was the central search term, as it constitutes the dependent variable in this literature review. By including ‘patient portals’ and ‘blended treatment’, concepts related to eHealth and synonyms were searched for as well. ‘Communication’ and ‘patient-physician relationship’ were added to search for useful articles on the patient-physician relationship within eHealth services.
3.2 Article selection
In Figure 3, a flow chart visualizing the systematic literature review process in line with the PRISMA guidelines is shown (Moher et al., 2009). The total amount of papers eventually selected for the review (n=28) was analyzed by a second reviewer to limit the possibility of bias. Figure 4 schematically shows the selection procedure used to
Search terms
- Patient empowerment and eHealth - Patient empowerment and patient portals - Patient empowerment and eHealth and review - Patient empowerment and eHealth and case review - Patient empowerment and eHealth and meta-analysis - Patient centered and eHealth
- Patient and physician and interaction and eHealth - Patient empowerment and eHealth and contact - Patient empowerment and eHealth and
communication
- Patient empowerment and eHealth and patient-physician relationship
- Patient empowerment and blended treatment
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assess which articles meet the inclusion and exclusion criteria of this review, in line with the third phase of grounded theory methods (Wolfswinkel et al., 2013). Three major inclusion criteria were the applied: (1) articles need to be peer-reviewed, (2) the dependent variable needs to be patient-empowerment, and (3) the
independent variable needs to be eHealth services. As concepts related to eHealth and synonyms were searched for as well, the following three minor inclusion criteria were applied as well: (1) electronic health record (EHR) or data access through patient portals need to be present, (2) EHR’s and patient portals need to be accessed by patients, and (3) patient empowerment needs to be addressed in depth. An overview of the final article selection for this systematic literature review is provided in Appendix A.
3.3 Article quality assessment
The quality of evidence of the selected articles was measured as recommended by Guyatt et al., (2009), using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system. The main advantages of GRADE over other quality assessment systems include its ‘’explicit, comprehensive criteria for downgrading and upgrading quality of evidence ratings’’ and its ‘’clear separation between quality of evidence and strength of recommendations’’ (Guyatt et al., 2009). As this systematic literature review describes only a fraction of the total field of literature on eHealth and patient empowerment, the quality assessment score (QAS) provided here represents a relative score instead of an absolute score. A 3 point-scale instead of a 5 point-scale was used to minimize the bias of subjectivity.
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Figure 4: Flow chart of the article selection process
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Article number
Author(s) Limitations Consistency Directness Precision Publication bias potential Total 1 Alpay et al. 1 2 2 2 2 1.8 2 Ammenwerth et al. 2 1 3 3 2 2.2 3 Demiris 1 2 3 1 2 1.8 4 Koch 1 2 3 1 2 1.8 5 Peris et al. 3 3 1 3 2 2.4 6 Risling et al. 3 3 3 2 2 2.6 7 Samoocha et al. 3 3 2 3 3 2.8 8 Shang et al. 3 3 3 3 2 2.8 9 Showell et al. 1 1 1 2 3 1.6 10 Vedel et al. 2 2 2 3 2 2.2 11 Carrol et al. 3 2 1 3 3 2.4 12 Catan et al. 1 2 1 1 1 1.2 13 Doering et al. 3 2 2 2 2 2.2 14* Fiscella et al. 1 2 1 3 2 2.0 15 Greenwood et al. 3 2 2 3 2 2.4 16 Grünloh 3 2 2 2 2 2.2 17 Holderried et al. 2 2 2 2 1 1.8 18 Jhamb et al. 3 2 2 3 3 2.6 19 Lemire 1 2 2 1 3 1.8 20 McAlearny et al. 2 2 3 2 2 2.2 21 Moll et al. 3 3 2 3 2 2.6 23 Nazi et al. 3 3 2 2 2 2.4 23 Neurohr et al. 2 3 2 2 1 2.0 24 Sicotte et al. 3 2 3 3 2 2.6
25 Van den Berg et al. 3 2 2 2 3 2.6
26 Van den Heuvel et al. 2 2 2 1 2 1.8
27 Van der Vaart et al. 2 2 2 2 2 2.0
28 Zarcadoolas et al. 3 2 2 2 2 2.2
Total 2.25 2.18 2.07 2.21 2.11 2.18
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4. Results
Our analysis is presented in four steps, following our four sub questions. In each step, both our selected review (n=10) and research (n=18) articles are examined. First, we investigated how patient empowerment is
conceptualized and operationalized in eHealth research. Second, we discuss which functionalities are examined for their effect on patient empowerment in eHealth research. Third, the direct effects of eHealth services of patient empowerment will be discussed. A fourth and final step involves discussion of the indirect effects of eHealth services, in terms of patient-physician interaction, on patient empowerment. Among the research articles were eight papers (n=8) with an experimental study design. Table 2 provides an overview of these articles, characterizing their study design, patient population, duration of follow-up, intervention, comparison treatment, outcome measures and the effect of the intervention on the interaction between patient and physician,
respectively. Among the interventions in these studies were eHealth services as diverse as electronic health records, patient portals and remote telemonitoring systems. The patient empowerment measures were highly variable. All outcomes resulting from our research article analysis will be compared to the outcomes from the review article analysis. Eventually, a critical synthesis of all selected articles led to the construction of a unique model of eHealth-enabled patient empowerment.
4.1 Conceptualization and operationalization of patient empowerment
First, the review articles were searched for information on the conceptualization and
operationalization of patient empowerment. This issue was discussed in three review papers. First, Koch (2012) discussed three dimensions according to which the patient empowerment process should be measured: (1) disease and treatment-related indicators, (2) patient-physician interaction-related indicators, and (3) psychosocial and life-interaction-related indicators. In addition, three important goals to achieve patient empowerment were mentioned: (1) independence, (2) continuity and (3)
participation. These dimensions and goals cover the aspects of patient empowerment as provided by Alpay et al. (2010) and provide additional characteristics such as disease and treatment-related indicators and patient-physician interaction-related indicators. Due to these additional characteristics we decided to use the broader terminology by Koch (2012) in addition to the terminology by Alpay et al. (2010) in our analysis.
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achieving a consensus on the measurement and operationalization of patient empowerment. Interchangeable use of the terms patient empowerment, patient engagement and patient activation complicates the challenge to develop a distinct measurement for patient empowerment (Risling et al., 2017). The Patient Activation Measure (PAM) turned out to be the most frequently used outcome measurement, while it actually measures patient knowledge, patient skills and confidence for self-care. These concepts are in our opinion not necessarily related to and not part of patient
empowerment (Risling et al., 2017). Four out of nineteen (4/19) empirical studies in this review actually did use a scale to specifically measure patient empowerment, such as the Healthcare Empowerment Inventory (HCEI) and the Composite Empowerment Scale (CES)(Risling et al., 2017). However, not all scales examined the components and goals of outcome measures for patient empowerment as stated by Koch (2012). A third review, by Samoocha et al. (2010), mentioned difficulties in the definition and measurement of patient empowerment. Outcome measures frequently used to measure patient empowerment mainly aim at measuring self-efficacy, mastery and control. These concepts could be closely related to empowerment, but the question remains what is ‘closely enough’. However, three studies examined by Samoocha et al. (2010) used patient empowerment specific scales, such as the Diabetes Empowerment Scale (DES), disease-specific self-efficacy scales and the Pearlin Mastery Scale (PMS). In conclusion, all three reviews investigating the
conceptualization and operationalization of patient empowerment encountered a range of concepts related to patient empowerment, and consequently a broad range of outcome measurements, which are from our perspective not merely specific for patient empowerment. Moreover, these reviews all conclude that a more thorough investigation is necessary in order to optimize the effectiveness of eHealth services.
Second, our research articles were studied on conceptualization and operationalization of patient empowerment. In Table 2, the outcome measures of studies with an experimental research design are provided. Among these studies, the following outcome measures were encountered for patient empowerment: patient activation measure (PAM)(Carroll et al., 2019)(Neurohr et al., 2015), diabetes empowerment scale short form (DES-SF) (Greenwood et al., 2015), cancer empowerment questionnaire (CEQ)(van den Berg et al., 2015), Dutch questionnaire on patient empowerment (NEL)(van den Heuvel et al., 2018), perceived involvement in care scale (PICS)(Carroll et al.,
15 engagement and patient activation (Risling et al., 2017).
This variable use of scales leads to difficulties in drawing reliable conclusions. For example, Carroll et al. (2019) used the decision self-efficacy (DSES) and perceived involvement in care scale (PICS). They mentioned in their discussion section that their eHealth service of interest directly influenced patient activation, and improved domains related to patient empowerment. As we decided not to view related concepts as part of patient empowerment, no conclusions on the relationship between the eHealth services and patient empowerment can actually be drawn from this study. Consequently, we confirm the statement from Alpay et al. (2010) that proper operationalization of patient empowerment and corresponding correct outcome measurements are necessary in order to study patient empowerment in a reliable and consistent way.
We also observed that specific patient empowerment questionnaires exist for some diseases and conditions, like diabetes and cancer, while there is no general outcome measurement that covers all patient populations in our research article selection. However, we did encounter general scales for patient empowerment in previous reviews. These include the Healthcare Empowerment Inventory (HCEI) and the Composite
Empowerment Scale (CES)(Risling et al., 2017). We next decided to examine whether these two scales actually met the patient empowerment areas and goals as stated by Koch et al. (2012). The first scale, HCEI, entails an 8-item inventory and examines the following five facets of the Empowerment Model from Johnson et al. (2012) from the patient perspective: engagement, information, collaboration, commitment to treatment and the tolerance of uncertainties of outcomes (Risling et al., 2017). In this model,
indicators of depression, provider relationships, treatment adherence and indicators of clinical status are provided. The model was initially developed and evaluated for HIV patients, but was also
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information on the continuity of the care process is lacking in this scale.
In conclusion, previous review articles encountered a wide variety in outcome measurements for patient empowerment. Conceptualization of patient empowerment was broad since concepts such as patient acceptance were frequently used interchangeably with patient empowerment. Moreover, related outcome measurements such as PAM were frequently used to measure patient empowerment. This is contradictory to our own perspective on conceptualization of patient empowerment, and we consequently decided not to include outcomes by Carrol et al. (2019) in our
final conclusions on the effects of eHealth services on patient empowerment. Two general scales to
Table 2: Overview of experimental research papers
*Functionalities of eHealth services (Smahel et al., 2019); 1 = socializing functions; 2 = access to health information; 3 = access to health-related planning and monitoring functions
**PLWH = persons living with HIV; PAM = patient activation measure; eHEALS = eHealth literacy; DSES = decision self-efficacy; PICS = perceived involvement in care scale; SF-12 = health; VL = viral load; IDPCS = instrument on doctor patient communication skills; A1x = glycated hemoglobin; DKT = diabetes knowledge test; SDSCA = summary of diabetes self-care activities; DES-SF = diabetes empowerment scale short form; BP = blood pressure; TAM = technology acceptance model; CBI-B-G = cancer behavior inventory-brief version; CPS = control preferences scale; DT = distress thermometer; SUS = system usability scale; MOS-SF12 = medical outcome study-short form 12 items; CEQ = cancer empowerment questionnaire; SQL-90 = symptom checklist-90; QBO-NL = questionnaire for bipolar illness; OQ-45.2 = 45-item outcome questionnaire; ASRM = altman self-rating mania scale; IDS-SR = inventory of depressive symptomatology self-rating scale; MANSA = Manchester short assessment of quality of life; NEL = Dutch questionnaire on patient empowerment
*** NA = not addressed
Author(s) Study design Population/ setting (n) Duration of
follow-up
Intervention Functionalities* Comparison treatment Outcome measures Effect of the
intervention on the Interaction between patient and physician
Carroll et al. (2019)
RCT PLWH, >18 years (360) 12 months A customized ePHR for PLWH 1, 2, 3 Usual care PAM, eHEALS, DSES, PICS, SF-12, VL, IDPCS No significant effect Doering et al. (2018) Mixed-methods study Gastro-intestinal cancer patients, >18 years (17); Physicians (3)
3 months 2 web-based portals (patient portal and professional portal)
1, 2, 3 Care before intervention (baseline characteristics)
CBI-B-G, CPS, DT, PICS, SUS,
Positive effect of EHR on efficiency of face-to-face meetings. Greenwood
et al. (2015)
RCT Diabetes type 2 patients, 30-70 years (78)
6 months Telehealth remote monitoring intervention (using paired glucose testing )
1, 2 Usual care A1c, DKT, SDSCA,
DES-SF
NA
Jhamb et al. (2015)
Case study Nephrology patients, >18 years (2803)
36 months EHR portal 1, 2, 3 Nonusers Portal adoption, BP NA Neurohr et
al. (2015)
Case study Radiology patients (230), radiology healthcare professionals (44)
18 months eXray-Record 1, 2 Care before intervention (baseline characteristics) PAM, TAM NA Sicotte et al. (2011) Quasi-experimental retro- and prospective Chronic obstructive pulmonary disease patients (46)
10 months Home telemonitoring 2, 3 Matched control group MOS-SF12 NA Van den Berg et al. (2015) RCT (multicenter, parallel-group)
Breast cancer patients (128) 10 months Web-based self-management intervention (to support psychological adjustment)
2, 3 Usual care CEQ, SC-90 NA
Van den Heuvel et al. (2018) Mixed-methods study
Bipolar disorder patients 12 months Online personal health record 1, 2, 3 Baseline levels (no controls)
QBP-NL, OQ-45.2, ASRM, IDS-SR, MANSA, NEL
4.2 Functionalities in eHealth research examined for their effect on patient empowerment
We investigated which functionalities are examined for their effect on patient empowerment in eHealth research in our experimental research article selection (n=8), which is outlined in Table 2. We used the terminology provided by Smahel et al. (2019). This provides us with the following three functionalities in eHealth research: (1) socializing functions, (2) access to health information, and (3) access to health-related planning and monitoring functions. Table 2 provides information on the availability of these functionalities in each research article. The results will be discussed more detailed for each study below.
First, Carroll et al. (2019) implemented an electronic personal health record (ePHR), which enabled patients to communicate with their physician, to view their laboratory test results, to set reminders for appointments or to repeat medicinal prescriptions. This ePHR therefore covered all three functionalities as outlined by Smahel et al. (2019). Doering et al. (2018) examined a patient portal which provided patients with access management and copies of treatment documents, as well as a communication platform. Therefore, this portal also covered all three functionalities. Next, Greenwood et al. (2015) implemented a telehealth remote monitoring system for diabetes type 2 patients that enabled self-blood-glucose-monitoring by the patient and active communication between physician and patient. The intervention therefore covered functionalities 1 and 2. The EHR examined by Jhamb et al. (2015) enabled secure messaging between physician and patient, provided patients with information on their health status and enabled patients to review, cancel, confirm or schedule appointments. This intervention therefore covered all three functionalities. Next, Neurohr et al. (2015) evaluated a patient portal that provided patients with additional information on personal radiological exposure, in order to enable informed decision-making, therefore covering functionalities 1 and 2. Sicotte et al. (2011) examined a home telemonitoring system for patients with chronic obstructive pulmonary disease. The system enabled these patients to keep track of their health status and to understand and monitor relations between their personal habits and their health condition. No direct communication with physician was possible, and therefore only functionalities 2 and 3 were covered. Furthermore, van den Berg et al. (2015) examined a self-management intervention for breast cancer survivor patients. The intervention provided patients with health-related
information and health monitoring by means of self-tests. No therapist contact was involved, leading to coverage of functionalities 2 and 3. Finally, van den Heuvel et al. (2018) examined an EHR that enabled patients to access their medical record, to communicate with their physician and to map their current daily mood and treatment plan. Therefore, this EHR covered all three functionalities.
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4.3 Direct effects of eHealth services on patient empowerment
First, the selected review articles were searched for their findings on the direct effects of eHealth services on patient empowerment. Alpay et al. (2010) mentioned four empowerment areas that are relevant to an eHealth context: (1) insight into one’s own health condition, (2) making informed choices, (3) engaging in self-care activities and (4) living independently. They also discussed four studies investigating the effects of evidence-based eHealth services on patient empowerment. The first study reviewed patient health records (PHRs) for diabetic patients. It turned out that patients hardly used the PHRs, mainly due to the absence of information exchange possibilities with
physicians. The second study concluded that patients live with the assumption that eHealth services are not successful. The main reasons for this assumption include that patients are not informed about the possibilities of the services, that their needs are not addressed by the services and that false expectations exist about financial arrangements around the services. The third study concluded that the examined patient portal remained unknown by patients. The fourth study supported this finding by listing barriers that need to be addressed for eHealth services to get past the pilot phase. Alpay et al. (2010) concluded that information about the relationship between eHealth services and patient empowerment is scarce, due to little use in practice of the eHealth services at that time. Another review by Ammenwerth et al. (2015) also did not find clear evidence of effects of eHealth services, mainly patient portals, on patient empowerment. However, they mentioned that the majority of their examined studies were published in 2012 and before, and suggested that more recent studies could provide other insights. Demiris (2015) provided an overview of the major milestones in health informatics, during the past 25 years. PHRs turned out to support patient engagement and patient empowerment, as patients reported ‘greater control over their health and medication adherence’ due to this eHealth service. From this review it became clear that access to
information is a necessary feature of eHealth services in order to support patient empowerment.
However, related challenged involve the varying degrees of health literacy among patients, the varying ability of patients to understand the provided information on their health, and the need for valid, reliable and effective representation of data sets. This review also made a prediction about the next 25 years in this field of research, and concluded that precision medicine will become more important in order to address individual variability among patients. Moreover, the concern was shared that eHealth services might widen the gap between advantaged and disadvantaged individuals, the latter referring to patients who have a limited health literacy and access to digital devices. In this way, eHealth services might stimulate patient empowerment for advantaged patients, but widen the gap with disadvantaged patients, eventually leading to more disparities in patient empowerment. Koch (2012) outlined three mandatory steps of the process towards patient
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action’. eHealth services thus should support these three steps by providing patients access to their personal health data, validating the provided information, and stimulating patients towards an informed decision making process, respectively. However, concerns were expressed about the access to and interaction with personal health data in situations where patients receive care from multiple care providers. This is a bottleneck that could hinder patient empowerment, mainly because the continuity and patient-centeredness of the care process would be impeded. Patients would be impeded to follow their own care pathway, which negatively influences the three mandatory steps of the process towards patient empowerment (Koch, 2012). Peris et al. (2015) examined the use of eHealth services for patients with inflammatory bowel disease (IBD). They concluded that use of telemonitoring and teleconsulting increased patient acceptance, which they linked to an increase in patient empowerment. Although patient empowerment itself was not examined, a positive
relationship with patient acceptance was described. However, we argued in the background section that patient acceptance is not part of our conceptualization of patient empowerment. Risling et al. (2017) examined the effect of patient portals on patient empowerment. They found small changes in levels of patient empowerment, but did not statistically analyze their results. Samoocha et al. (2010) and Shang et al. (2019) also found small positive effects in patient empowerment levels due to implementation of eHealth services. Another review by Showell et al. (2017) focused on the effect of eHealth services on disadvantaged patients and identified 21 barriers for these patients to benefit from the services. More specifically, eHealth services would strengthen the gap between advantaged and disadvantaged patients, resulting in situations where the patients who are most in need of the potentially beneficial effects of eHealth services cannot be reached. Finally, a review by Vedel et al. (2013) found positive effects of eHealth services on patient empowerment in 80% of the studies they examined. In conclusion, eight out of ten (8/10) of the selected review articles described positive effects of eHealth services on patient empowerment, as shown in Table 3. When applying our own conceptualization on patient empowerment, excluding closely related concepts such as patient acceptance, we are left with seven out of nine (7/9) articles.
We next examined our own new selection of research on the direct effects of eHealth services on patient empowerment. These studies include randomized controlled trials (RCTs), case studies, mixed methods studies and qualitative studies. Table 4 provides an overview of the
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1Effects are shown as either not significant positive, (direct) positive, or small positive (in case no details on significance were
mentioned)
2Patient acceptance was measured instead of patient empowerment
First, Carroll et al. (2019) examined the effects of an EHR on patient activation and related domains of empowerment. Patients living with HIV were studied for this purpose. They observed a significant rise in patient activation due to the implementation of the EHR. Also, the EHR improved eHealth literacy and patient perceptions of involvement in care. However, we decided not include these results in our analysis as patient activation was used as the main outcome measurement. Second, a study by Catan et al. (2015) showed positive effects of eHealth services on patient empowerment, mainly due to improved patient-physician relationships and access to health information by patients. Third, a study by Doering et al. (2018) examined the effects of an EHR on patients’ self-efficacy. We decided to include self-efficacy as part of the concept of patient empowerment, based on the conceptualization by Bravo et al. (2015). In this study a non-randomized controlled trial was performed, examining perceptions of patients with colorectal cancer at baseline (T0) and after 12 weeks of EHR usage (T1). Due to the EHR, patients have access to their own personal health record and can give others access to a selection or all of their treatment-related data. Results showed that patients felt more involved and empowered by disease-specific knowledge, as well as more confident to judge health-related information in an objective manner. Moreover, a higher degree of self-efficacy was found among patients after EHR usage. On the contrary, a study by Grünloh et al. (2018), examining the effects of a remote monitoring intervention for type 2 Diabetes Mellitus patients, did
Author(s) Effect of eHealth services on patient empowerment1
Alpay et al. (2010) No significant positive effect
Ammenwerth et al. (2019) No significant positive effect
Demiris (2015) Positive effect
Koch (2012) Positive effect
Peris et al. (2015) Positive effect2
Risling et al. (2017) Small positive effect
Samoocha et al. (2010) Small positive effect
Shang et al. (2019) Small positive effect
Showel et al. (2017) Positive effect
Vedel et al. (2013) Positive effect
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not find any improvements in patient empowerment due to the intervention. Moreover, Grünloh et al. (2018) stated that although physicians say they are in favor of patient participation and
empowerment, paternalistic practices are still common. An interesting discussion was introduced about the concept of patient empowerment, suggesting that this concept triggers an interpretation of power as zero-sum. In other words, a gain of power for one side ensures a loss of power for the other side. The concept of patient empowerment could consequently harm the maintenance of the relationship between patient and physician. Their conclusion on the benefits of patient
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COPD patients, did not find any substantial effects on patient empowerment. Results from two other studies by van den Berg et al. (2012) and van den Heuvel et al. (2018) supported this finding. The former examined the effects of an online follow-up care program on patient empowerment, but did not find any effect. The latter examined an EHR for its effects on both clinical outcomes and patient empowerment, but also found no effects. However, qualitative analysis by van den Heuvel et al. (2018) showed that patients gained insight into the course of their illness, and experienced an increased perceived control due to EHR usage. Furthermore, a qualitative study by van der Vaart et al. (2013) identified consequences of EHRs from a physician’s perspective. The records were
expected to be beneficial for patients in particular, rather than for physicians themselves. Moreover, most disadvantages were against the benefits of the physicians. A common benefit for both
stakeholders was improved patient-physician communication. Physicians expected patients to benefit from EHRs in terms of patient empowerment, but this was not examined from a patient perspective in this study. Finally, a study by Zarcadoolas et al. (2013) contributed to the previously mentioned discussion on the different benefits of patient empowerment for disadvantages and advantaged patients. They found that patient portals led to a higher degree of patient
empowerment, mainly due to increased access to health information. This allowed patients to be more proactive and to take better care of their own health. Patients could get more out of a doctor’s visit in this way, resulting in a higher efficiency of face-to-face meetings. Again, it was mentioned that eHealth services would widen the gap between strong and vulnerable patient groups, and thus contribute to inequalities in patient empowerment levels.
In conclusion, we see inconsistent effects of eHealth services on patient empowerment and inconsistent presence of the aspects of patient empowerment by Alpay et al. (2010) in the above discussed articles. Seven out of thirteen (7/13) research articles examining the effect of eHealth services on patient empowerment found positive effects. When applying our own conceptualization on patient empowerment, we exclude results from Carrol et al. (2019) and are left with six out of twelve (6/12) articles. We arrived at an average of 2.6 aspects of patient empowerment per study. The direct relationship between eHealth services and patient empowerment is represented by number three in Figure 1. We do not change our hypothesized relationship in Figure 1 as half of the articles still found positive results of the direct effect of eHealth services on patient empowerment. However, our analysis provides us with three possible explanations for the inconsistencies in our observation. First, the eHealth services might differ in their use of functionalities, as described in section 4.2. Second, the patient characteristics and care environment differ. For example, the ratio of advantaged and disadvantaged patients and the degree of patient-centeredness in the care
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1Effects are shown as either not significant positive, small positive or positive 2Type(s) of eHealth service examined per study are shown
3Presence of the four aspects of patient empowerment by Alpay et al. (2010) in these studies are shown by corresponding
numbers 1-4: (1) insight into one’s own health condition, (2) making informed choices, (3) engaging self-care activities and developing self-care habits, and (4) living independently
4 Patient acceptance was measured instead of patient empowerment
Author(s) Effect on patient
empowerment1
eHealth service2 Aspects of patient
empowerment included (Alpay et al., 2010)3
Carrol et al. (2019) Small positive effect4 EHR 1,2,3
Catan et al. (2015) Positive effect Not specified (ICT
in general in health care)
1,2
Doering et al. (2018) Positive effect EHR 1,2
Greenwood et al. (2015) No significant positive effect
Remote monitoring system
1,2,3, 4
Grünloh et al. (2018) No significant positive effect
EHR 1
Jhamb et al. (2015) No significant positive
effect
EHR 1,2,3
Lemire (2010) Positive effect EHR 1,2
McAlearney et al. (2020) Positive effect Patient portal 1,2
Neurohr et al. (2015) Positive effect EHR 1,2
Sicotte et al. (2011) No significant positive effect
Remote monitoring 1,2,3
Van den Berg et al. (2015) No significant positive effect
Web-bases self-management intervention
1,2,3,4
van den Heuvel et al. (2018)
No significant positive effect
EHR 1,2,3
Zarcadoolas et al. (2013) Positive effect Patient portal 1,2,3
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4.4 Indirect effects of eHealth services on patient empowerment
First, our selection of review articles was searched for information on the indirect effects of eHealth services, in terms of patient-physician interaction, on patient empowerment. Three articles examined this potential relationship. According to Alpay et al. (2010), the patient-physician interaction is an important feature as communication channels between patients and physician are necessary to exchange information and knowledge. This exchange is in turn necessary to achieve patient
empowerment, as Koch (2012) mentioned patient-physician interaction as an important dimension of patient empowerment measurement. Shang et al. (2019) provide antecedents of patient-physician online interaction. From the patient perspective, they mention easier access to physicians, a higher degree of self-management and unmet needs as the three main factors triggering patients to online interact with their physician (Shang et al., 2019). Consequences of this interaction include patient empowerment, health promotion and a rise in the amount of questions among patients on their health status. With respect to patient empowerment, patients experienced the following empowerment outcomes due to online interaction with their physician: reinforced capacity to manage their physical conditions, increased acceptance of their disease, enhanced self-efficacy and enhanced quality of the interaction with their physician. Moreover, online patient-physician
interaction turned out to lead to higher communication efficiency in face-to-face meetings (Shang et al., 2019).
Second, we examined our own research article selection. The patient perspective on the effect of patient-physician interaction was discussed in quantitative studies by Carroll et al., (2019), Poss-Doering et al., (2018) and van den Heuvel et al., (2018). Carrol et al. (2019) examined this relationship in a RCT, where an EHR was implemented for persons living with HIV. They used the
Instrument on Doctor Patient Communication Skills (IDPCS) as an outcome measure, which
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interpreted the EHR of interest as a medium that could enhance quality and time-efficiency of face-to-face meetings following online interaction. Another mixed-methods study by Van den Heuvel et al. (2018) examined an EHR for bipolar disorder patients and showed an improvement in
communication between patient and physician. Patients mentioned that communication with their physician was more efficient due to the EHR.
Furthermore, some studies qualitatively discussed patient perspectives on communication with physicians. Catan et al. (2015) found that patients value face-to-face communication as it reduces anxiety. eHealth services could provide remote communication in a more accessible and faster way, and therefore is viewed as a great resource to reduce potential fears. Moll et al. (2018) stated that a large majority of patients (86%) confirmed the positive influence of patient portals on the communication between them and medical staff. The fact that the patient portal positively influenced the communication between patient and physician was stated as one of the four major reasons mentioned by patients for seeing access to patient portals as a valuable opportunity. Holderried et al. (2018) also showed that patients value remote communication with their physician, but only as a replacement until the next face-to-face meeting. The effect of a specific type of
communication, secure messaging, within an EHR was investigated by Nazi (2013). Results showed that patients felt more rapidly connected with their physician. Moreover, secure messaging led to a number of differences in both the communication content and the communication patterns, due to asynchronicity of communication. First, patients communicated more frequently with their
physicians between face-to-face meetings. Second, patients experienced a lower threshold to initiate a conversation with their physician. And third, both patients and physicians could send and respond to messages whenever they felt it was a convenient moment, which they both experienced as a very positive change. An additional major benefit of this change is the fact that both parties could express themselves more thoughtful, leading to a higher quality treatment (Nazi, 2013). Finally, Zarcadoolas et al. (2013) found an almost unanimously positive view of patients on communication with their physician due to patient portals. According to these patients, the common short length of a doctor’s visit was experienced negatively. These short visits led to increased stress levels when patients did not fully understand matters during the visit and needed time to start thinking about and reflecting on absorbed information. Also, they were less able to obtain useful information in this way. From a patient’s perspective, the patient portal solved the problems outlined above. As patients’ access to health information was increased, they developed a more proactive attitude towards their own health. They could easier approach their physician to ask questions, without the time pressure that previously would have hindered them in face-to-face meetings. This phenomenon increases the efficiency of face-to-face meetings.
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between patient and physician to broaden our view. Grunloh et al. (2018) conclude in their study that a paternalistic approach, with a minor degree of patient participation, is still common in daily practice. However, physicians say that they are actually in favor of patient-centered care.
Paternalistic practices clash with eHealth services, as they impede the communication between patient and physician. More specifically, an equal communicative relationship between patient and physician is counteracted by paternalism. As mentioned above, van den Heuvel et al. (2018) showed that a majority of patients experienced more efficient communication with their physician. However, only a third of the physicians (32.1%) experienced an improved and more efficient communication with their patients. Views of patients and physicians thus differ. This is in line with the findings from a study by van der Vaart et al. (2013), who showed that EHR’s were expected to be mostly beneficial for patients, from a physician perspective. Consequently, physicians experienced less improvements in patient-physician communication when compared to patients. However, it could be that physicians were biased in their opinion on communication change due to implementation of the EHR, because it provides them with a higher workload. Patients can for example experience problems with the interpretation of their treatment data, and therefore approach and interrogate their physician more frequently. Also, as patients get more informed about their treatment plan, consultations with their physician could become more in-depth, leading to a change in consultation content. Patients could experience this positively, while physicians also experience a negative side from the change in communication between them and their patients due to an increased workload.
In conclusion, positive indirect effects of eHealth services, with respect to patient-physician interaction,
on patient empowerment were found in previous review articles. We therefore do not change our
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5. Discussion
By studying the relationship between eHealth services and patient empowerment, this study attempted to answer the research question how eHealth services affect patient empowerment. In this section, a brief summary of our findings is provided, together with separated and integrated answers to our four sub questions and to our main research question. Also, practical and theoretical implications and suggestions for future research are provided. Finally, limitations of this study are discussed and a general conclusion is drawn.
Conceptualization and operationalization of patient empowerment - Previous review
articles investigating the conceptualization and operationalization of patient empowerment all agreed that no general outcome measurement for patient empowerment is currently widely used in practice and that more research is needed. PAM appeared to be the most frequently used outcome measurement for patient empowerment, while this outcome measurement examines patient
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process. Also, future research should investigate why the difficulty in operationalization of patient empowerment persists to exist and clarify why a lot of recent papers still use PAM instead of patient empowerment specific outcome measures.
Functionalities in eHealth research examined for their effect on patient empowerment – It
appeared that all three functionalities of eHealth services provided by Smahel et al. (2019) were covered in our article selection. More specifically, the second functionality, access to health information, was covered by all articles examined (n=8). The first and third functionality, socializing functions and access to health-related planning and monitoring functions, respectively, were covered by six out of eight (6/8) articles. Our second sub research question stated: Which functionalities are examined for their effect on patient
empowerment in eHealth research? We showed that all three functionalities of eHealth services were examined in our article selection. We encountered a broad range of characteristics that could be applied to each
functionality. Access to health-related planning and monitoring functions were for example manifested in multiple ways, such as appointment and medical prescriptions reminders and requests, and health status tracking. It appeared to be difficult to recognize and classify functionalities in currently described categories. It would therefore be interesting for future studies to further extend and specify the functionalities of eHealth services, especially since current terminology by Smahel et al. (2019) appeared to be very broad and subsequently hard to apply to patient portals and EHRs.
Direct effects of eHealth services on patient empowerment – Both previous reviews and our
selected research articles found positive direct effects of eHealth services on patient empowerment. Six out of twelve research articles examining the effect of eHealth services on patient empowerment found positive effects. The remaining studies did not find any substantial effect. Findings are thus
inconsistent, which is in line with findings from previous review articles. The research articles that
found a positive effect mainly attributed this finding to improved patient-provider communication
and interaction, and to increased access to health information. Furthermore, it was interesting to
see the differences in the presence of patient empowerment aspects, as provided by Alpay et al. (2010). The four aspects, (1) insight into one’s own health condition, (2) making informed choices, (3) engaging self-care activities and developing self-care habits, and (4) living independently, were present in thirteen, ten, seven and two articles, respectively. It was remarkable that only two studies discussed the effect of eHealth services on patient’s ability to live independently. These two studies involved a remote monitoring and a self-management intervention, respectively. A possible explanation could be that patients requiring these types of interventions can substitute care provider visits by this eHealth service, thereby creating a higher degree of independency. Furthermore, the potential gap in degree of patient empowerment between
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eHealth services could lead to a higher inequality in patient empowerment between advantaged and disadvantaged patients, mainly due to their differences in health literacy and access to technological resources (Demiris, 2016). Jhamb et al. (2015) confirmed this inequality in patient empowerment in their research study, despite intensive involvement and assistance of office staff members. These interventions appeared to be insufficient to minimize inequalities. Therefore, future research should focus on alternative ways to increase the chance of disadvantaged patients to benefit from eHealth services, in order to minimize inequalities between advantaged and disadvantaged patients in their degree of patient empowerment. Referring to our third sub question, we can eventually conclude that eHealth services have inconsistent effects on patient empowerment, which can be explained by three factors. Differences between studies might have occurred with respect to (1) eHealth
functionalities, (2) patient and care environment characteristics, and (3) operationalization of patient empowerment.
Indirect effects of eHealth services, with respect to patient-physician interaction, on patient empowerment – In section 4.4 we investigated the indirect effect of eHealth services, with
respect to patient-physician interaction, on patient empowerment. Prior reviews showed that patient-physician interaction had a positive influence on patient empowerment. Our research article selection showed an overall positive effect as well. As mentioned in Figure 1, Ong et al. (1995) outlined three different purposes of patient-provider communication: 1) creating a good inter-personal relationship, (2) exchanging information and (3) making treatment-related decisions. According to our findings, eHealth services met all three purposes. More specifically, patients using eHealth services were able to create a better relationship with their physician, to exchange information and to be more proactive towards making treatment-related decisions since they were more informed about their treatment and health conditions. Overall, a convincing evidence for a positive effect of patient-physician interaction within eHealth services on patient empowerment was found in our research article selection. When comparing these outcomes to the ones resulting from our review articles, we see many similarities. From a patient perspective, these similarities include a higher quality relationship with their physicians and a higher degree of self-management and self-efficacy. These outcomes were higher for advantaged patients compared to disadvantaged patients. Therefore, future research could aim to analyze underlying reasons for these differences. It would for example be interesting to examine why advantaged patients perceive a higher quality relationship with their physician. These results could contribute to the design of future eHealth services, in order to minimize differences between the two patient groups. Looking back at our fourth sub question, we can conclude that eHealth services have an indirect positive effect, through patient-physician interaction, on patient empowerment.
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(2015) and van den Heuvel et al. (2018) all covered the three functionalities of eHealth services as provided by Smahel et al. (2019). In addition, these studies covered three, two, three and three aspects of patient empowerment as provided by Alpay et al. (2010), respectively (Table 4). However, we decided to exclude results from Carrol et al. (2019) as PAM was used as an outcome
measurement in this study. Among the remaining three studies was one study that found positive effects, and two that did not find any significant positive effects on patient empowerment.
Moreover, these studies covered on average 2.7 aspects of patient empowerment. As this average was 2.6 for our total research article selection, we do not see a substantial difference the two. We thus conclude that the presence of all functionalities of eHealth services as provided by Smahel et al. (2019) does not lead to increased presence on aspects of patient empowerment as provided by Alpay et al. (2010), nor to improved effects on patient empowerment. We therefore withdraw our prior explanation that different functionalities within eHealth services contribute to differences in patient empowerment levels. We are consequently left with two explanations: variabilities in (1) patient and care environment characteristics and (2) operationalization of patient empowerment.
Model - Building on our previous analyses, we developed a model of eHealth-enabled patient
empowerment, which is shown in Figure 5. Our analyses showed that eHealth services improved patient-physician interaction due to asynchronicity, a specific sub feature of secure messaging, which in turn fosters patient empowerment (Nazi, 2013). This asynchronicity implies that time frames within patient-physician interaction are more variable compared to face-to-face interaction.
Asynchronicity therefore constitutes a variable with a higher value in terms of time, compared to its counterpart, synchronicity. Another variable within this figure constitutes bidirectional
communication tools, which proved to enable patient empowerment (Nazi, 2013). Furthermore, the relationship between eHealth services and patient empowerment is influenced by two factors. First, the degree of patient-centeredness in the care environment. A patient-centered care environment stimulates patient-physician communication more than a paternalistic care environment. In addition, Grunloh et al. (2018) outlined paternalism as a negative influence on patient physician interaction. As a consequence, the relationship between eHealth services and online patient-physician
communication is more positively influenced by a patient-centered care environment compared to a paternalistic care environment. Second, advantaged patients benefit to a greater extent from eHealth services than disadvantaged patients (Demiris, 2015)(Zarcadoolas et al., 2013). The relationship of interest is consequently more positively influenced when it involves advantaged patients compared to disadvantaged patients. The availability of the three functionalities of eHealth services by Smahel et al. (2019) did not influence the effect of eHealth services on patient
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empowerment and therefore decided to include this one functionality of eHealth services in our model as a variable (Smahel et al., 2019)(Koch, 2012)(Neurohr et al., 2015)(Demiris, 2015)(Lemire, 2010)(Zarcadoolas et al,. 2013)(Shang et al., 2019). Within this model we also included the three purposes of patient empowerment as outlined by Ong et al. (1995), which should be supported by eHealth services in order to enable patient empowerment. Online patient-physician interaction should thus first lead to an improvement in (1) the interpersonal patient-physician relationship, (2) the information exchange and (3) treatment-related decision-making process by patients (Ong et al., 1995). Using this model, we can answer our main research question. The direct and indirect effects of eHealth services on patient empowerment turned out to be inconsistent and positive,
respectively. Three factors were eventually identified to influence the direct and indirect effects of eHealth services on patient empowerment (1) patient and care environment characteristics, (2) conceptualization of patient empowerment, and (3) access to health information.
Theoretical implications – We made the following four suggestions for future research. First
of all, future research could examine underlying reasons for the observed differences between advantaged and disadvantaged patients, with respect to their potential to benefit from eHealth services. Second, future research should investigate why the difficulty in conceptualization and operationalization of patient empowerment persists to exist and clarify why a lot of recent papers still use PAM instead of patient empowerment specific outcome measures, the latter covering the actual concept of patient empowerment. Third, it could be studied how functionalities as provided by Smahel et al. (2019) can be elaborated and specified, and whether these functionalities contribute to different effects of eHealth services on patient empowerment in a larger article selection. And fourth, future research should investigate how patient empowerment specific outcome
measurement like HCEI an CES can cover the remaining goal of patient empowerment from Koch (2012). Achievement of this goal, continuity in patient empowerment areas, might lead a higher degree of patient empowerment in daily practice. Overall, when the above suggestions for future research are examined, future eHealth services could eventually be adapted to support equal benefits from eHealth services for both advantaged and disadvantaged patients in terms of patient empowerment and lead to overall increased levels of patient empowerment in daily practice.
Practical implications - We showed a direct inconsistent effect and an indirect positive effect with
