The Role of eHealth in Patient Engagement and Quality Improvement

  • David Ahern
  • Judith M. Phalen
  • Charles B. Eaton

Despite accounting for 16% of annual Gross Domestic Product (Anderson, Frogner, Johns, & Reinhardt, 2006), the $1.88 trillion American healthcare system does not rank among the top nations of the world on several key dimensions with respect to healthcare quality, including infant mortality and healthy life expectancy (Schoen, Davis, How, & Schoenbaum, 2006; The Commonwealth Fund Commission on a High Performance Health System, 2006). Although a recent report from the National Committee on Quality Assurance (NCQA) describes improvements in preventive services and treatments known to enhance chronic disease management for people enrolled in health plans (National Committee for Quality Assurance, 2006), consistent evidence indicates that for most health conditions for which there are established evidence-based standards of care, Americans receive those treatments only about 50% of the time (Asch et al., 2006; McGlynn et al., 2003). Recently, Wennberg, Fisher, Sharp, McAndrew, and Bronner (2006) demonstrated the substantial regional variation in practice patterns and outcomes with respect to quality of care for Medicare recipients. Notably, the quality of care observed in regions with excess capacity of hospital and provider resources, and which were perceived as exemplary, was no better than regions with lesser capacity or reputation, and in some cases for certain conditions, worse. Hence, consumers increasingly are becoming worried about the relentless growth in healthcare costs year-to-year and about quality and safety issues (ABC News/USA TODAY/Kaiser Family Foundation health care poll, 2006). However, their primary concern is reducing the cost of their health insurance premiums (ABC News/USA TODAY/ Kaiser Family Foundation health care poll; Harris Interactive, 2005a).


Medical Informatics Chronic Disease Management Patient Engagement Personal Health Record Protect Health Information 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.


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  1. ABC News/USA TODAY/Kaiser Family Foundation health care poll. (2006). USA Today.Google Scholar
  2. Adler, K. (2006). Web portals in primary care: An evaluation of patient readiness and willingness to pay for online services. Journal of Medical Internet Research, 8(4), e26.CrossRefPubMedGoogle Scholar
  3. Agency for Healthcare Research and Quality. (2005). National Healthcare Disparities Report, 2005 (p. 188). Rockville, MD: Agency for Healthcare Research and Quality.Google Scholar
  4. Anderson, G. F., Frogner, B. K., Johns, R. A., & Reinhardt, U. E. (2006). Health care spending and use of information technology in OECD countries. Health Affairs, 25(3), 819–831.CrossRefPubMedGoogle Scholar
  5. Asch, S. M., Kerr, E. A., Keesey, J., Adams, J. L., Setodji, C. M., Malik, S., et alet al. (2006). Who is at greatest risk for receiving poor-quality health care? The New England Journal of Medicine, 354(11), 1147–1156.CrossRefPubMedGoogle Scholar
  6. Ault, A. (2002). Health web site users find information credible, but want content regulated. Reuters Medical News.Google Scholar
  7. Baker, G. B. (2002). Integrating technology and disease management – The challenges. Healthplan Magazine, 43(5), 60–62, 64–66.Google Scholar
  8. Baldwin, F. (2002). The doctor is in with physician–patient messaging, via web portals everyone is better served. Healthcare Informatics, 10, 44–48.Google Scholar
  9. Baranowski, T., Baranowski, J., Cullen, K. W., Marsh, T., Islam, N., Zakeri, I., et alet al. (2003). Squire’s quest!: Dietary outcome evaluation of a multimedia game. American Journal of Preventive Medicine, 24(1), 52–61.CrossRefPubMedGoogle Scholar
  10. Bates, D., Ebell, M., Gotlieb, E., Zapp, J., & Mullins, H. C. (2003). A proposal for electronic medical records in U.S. primary care. Journal of the American Medical Informatics Association, 10(1), 1–10.CrossRefPubMedGoogle Scholar
  11. Baur, C., & Kanaan, S. (2006). Expanding the reach and impact of consumer e-Health tools. Rockville, MD: US Department of Health and Human Services; The Office of Disease Prevention and Health Promotion (ODPHP).Google Scholar
  12. Beun, J. (2003). Electronic healthcare record: A way to empower the patient. International Journal of Medical Informatics, 69(2–3), 191–196.CrossRefPubMedGoogle Scholar
  13. Boehm, E. W., Holmes, B. J., & Yuen, E. H. (2003). How to fix health plan member service: Part one. Forrester Research.
  14. Bowling, J. M., Rimer, B. K., Lyons, E. J., Golin, C. E., Frydman, G., & Ribisl, K. M. (2006). Methodologic challenges of eHealth research. Evaluation and Program Planning, 29(4), 390–396.CrossRefGoogle Scholar
  15. Briggs, B. (2003). The main event: Best-of-breed vs. single-source. Health Data Management, 11(6), 41–48.PubMedGoogle Scholar
  16. Buntin, M., Damberg, C., Haviland, A., Kapur, K., Lurie, N., McDevitt, R., et alet al. (2006). Consumer-directed health care: Early evidence about effects on cost and quality. Health Affairs, 25(6), w516–w530.CrossRefPubMedGoogle Scholar
  17. Chang, B. L., Bakken, S., Brown, S., Houston, T. K., Kreps, G. L., Kukafka, R., et alet al. (2004). Bridging the digital divide: Reaching vulnerable populations. Journal of the American Medical Informatics Association, 11(6), 448–457.CrossRefPubMedGoogle Scholar
  18. Chase, H. P., Pearson, J. A., Wightman, C., Roberts, M., Oderberg, A. D., & Garg, S. K. (2003). Modem transmission of glucose values reduces the costs and need for clinic visits. Diabetes Care, 26(5), 1475–1479.CrossRefPubMedGoogle Scholar
  19. Cimino, J., Patel, V., & Kushniruk, A. (2002). The patient clinical information system (PatCIS): Technical solutions for and experience with giving patients access to their electronic medical records. International Journal of Medical Informatics, 68, 113–127.CrossRefPubMedGoogle Scholar
  20. Cobb, N., Graham, A., Bock, B., Papandonatos, G., & Abrams, D. (2005). Initial evaluation of a real-world Internet smoking cessation system. Nicotine & Tobacco Research, 7(2), 207–216.CrossRefGoogle Scholar
  21. Connecting for health – A public–private collaborative (pp. 1–7). (2003). New York: The Markle Foundation.Google Scholar
  22. Connecting for health: The personal health working group final report (p. 55). (2003). New York: The Markle Foundation.Google Scholar
  23. Eaton, C., Goldman, R., Parker, D., & Cover, R. (2003). HeartAge – A patient activation tool for cholesterol management. In: Scientific proceeding of North American primary care research group, Banff, Alberta, Canada.Google Scholar
  24. Elberg, P. (2001). Electronic patient records and innovation in health care services. International Journal of Medical Informatics, 64(2–3), 201–205.CrossRefPubMedGoogle Scholar
  25. Eng, T. R. (2001). The eHealth landscape: A terrain map of emerging information and communication technologies in health and health care (pp. 1–137). Princeton, NJ: The Robert Wood Johnson Foundation.Google Scholar
  26. Etter, J. (2005). Comparing the efficacy of two internet-based, computer-tailored smoking cessation programs: A randomized trial. Journal of Medical Internet Research, 7(1), e2.CrossRefPubMedGoogle Scholar
  27. Field, M., & Grigsby, J. (2002). Telemedicine and remote patient monitoring. Journal of the American Medical Association, 288(4), 423–425.CrossRefPubMedGoogle Scholar
  28. Fox, S. (2005). Health information online. Washington, DC: Pew Internet & American Life Project.Google Scholar
  29. Fox, S. (2006). Online health search 2006: Most internet users start at a search engine when looking for health information online. Very few check the source and date of the information they find (p. 15). Washington, DC: Pew Internet & American Life Project.Google Scholar
  30. Fox, S., & Fallows, D. (2003). Internet health resources: Health searches and email have become commonplace, but there is room for improvement in searches and overall Internet access (p. 35). Washington, DC: Pew Internet & American Life Project.Google Scholar
  31. Glasgow, R. E., Boles, S. M., McKay, H. G., Feil, E. G., & Barrera, M. (2003). The D-Net diabetes self-management program: Long-term implementation, outcomes, and generalization results. Preventive Medicine, 36(4), 410–419.CrossRefPubMedGoogle Scholar
  32. Glasgow, R. E., Ory, M. G., Kleges, L. M., Cifuentes, M., Fernald, D. H., & Green, L. A. (2005). Practical and relevant self-report measures of patient health behaviors for primary care research. Annals of Family Medicine, 3(1), 73–81.CrossRefPubMedGoogle Scholar
  33. Goldman, R., Parker, D., Eaton, C., Borkan, J., Gramling, R., Cover, R., et alet al. (2006). Patients’ perceptions of cholesterol, cardiovascular disease risk, and risk communication strategies. Annals of Family Medicine, 4(3), 205–212.CrossRefPubMedGoogle Scholar
  34. Goldstein, M. G., Whitlock, E., & DePue, J. (2004). Multiple health risk behavior interventions in primary care: Summary of research evidence. American Journal of Preventive Medicine, 27(Suppl. 1), 61–79.CrossRefPubMedGoogle Scholar
  35. Grimson, J. (2001). Delivering the electronic healthcare record for the 21st century. International Journal of Medical Informatics, 64(2–3), 111–127.CrossRefPubMedGoogle Scholar
  36. Grundy, S. M., Cleeman, J. I., Merz, C. N. B., Brewer, H. B., Clark, L. T., Hunninghake, D. B., et al. (2004). Implications of recent clinical trials for the National Cholesterol Education Program Adult Treatment Panel III Guidelines. Circulation, 110, 227–239.CrossRefPubMedGoogle Scholar
  37. Gustafson, D. H., Hawkins, R. P., Boberg, E. W., McTavish, F., Owens, B., Wise, M., et alet al. (2002). CHESS: 10 years of research and development in consumer health informatics for broad populations, including the underserved. International Journal of Medical Informatics, 65, 169–177.CrossRefPubMedGoogle Scholar
  38. Harris Interactive. (2005a). Public interest in the use of quality metrics in healthcare is mixed – Unless it allows them to reduce their health insurance costs (p. 6). Rochester, NY: Harris Interactive.Google Scholar
  39. Harris Interactive. (2005b). Many nationwide believe in the potential benefits of electronic medical records and are interested in online communications with physicians (p. 5). Rochester, NY: Harris Interactive.Google Scholar
  40. Harris Interactive. (2005c). New poll shows US adults strongly favor and value new medical technologies in their doctor’s office (p. 6). Rochester, NY: Harris Interactive.Google Scholar
  41. Harris Interactive. (2006a). Number of “Cyberchondriacs” – Adults who have ever gone online for health information – Increases to an estimated 136 million nationwide (p. 5). Rochester, NY: Harris Interactive.Google Scholar
  42. Harris Interactive. (2006b). Few patients use or have access to online services for communicating with their doctors, but most would like to (p. 7). Rochester, NY: Harris Interactive.Google Scholar
  43. Horrigan, J. B., & Rainie, L. (2002). Counting on the Internet: Most expect to find key information online; most find the information they seek; many now turn to the internet first (p. 17). Washington, DC: Pew Internet & American Life Project.Google Scholar
  44. Iakovidis, I. (1998). Towards personal health record: Current situation, obstacles, and trends in implementation of electronic healthcare record in Europe. International Journal of Medical Informatics, 52, 105–115.CrossRefPubMedGoogle Scholar
  45. Kenny, S., Kongstvedt, P., & Shaman, H. (2002). A survey of Payor web sites: How health plans are using the Internet to reach consumers (p. 14). McLean, VA: Cap, Gemini, Ernst and Young.Google Scholar
  46. Kilbridge, P. (2002). Crossing the chasm with information technology: Bridging the quality gap in health care (p. 32). Oakland, CA: California HealthCare Foundation.Google Scholar
  47. Kim, M., & Johnson, K. (2002). Personal health records: Evaluation of functionality and utility. Journal of the American Medical Informatics Association, 9(2), 171–180.CrossRefPubMedGoogle Scholar
  48. Lenert, L., Munoz, R. F., Stoddard, J., Delucchi, K., Bansod, A., Skoczen, S., et alet al. (2003). Design and pilot evaluation of an internet smoking cessation program. Journal of the American Medical Informatics Association, 10, 16–20.CrossRefPubMedGoogle Scholar
  49. Lesnick, B. (2003). Taking it to the next level: Georgia specialty practice provides greater care by improving efficiency with EMR system. Health Management Technology.
  50. Liss, H., Glueckauf, R., & Ecklund-Johnson, E. (2002). Research on telehealth and chronic medical conditions: Critical review, key issues, and future directions. Rehabilitation Psychology, 47(1), 8–30.CrossRefGoogle Scholar
  51. Liu, J. H., Zingmond, D. S., McGory, M. L., SooHoo, N. F., Ettner, S. L., Brook, R. H., et alet al. (2006). Disparities in the utilization of high-volume hospitals for complex surgery. Journal of the American Medical Association, 296(16), 1973–1980.CrossRefPubMedGoogle Scholar
  52. Lorig, K. R., Ritter, P. L., Laurent, D. D., & Plant, K. (2006). Internet-based chronic disease self-management: A randomized trial. Medical Care, 44(11), 964–971.CrossRefPubMedGoogle Scholar
  53. McGlynn, E., Asch, S., Adams, J., Keesey, J., Hicks, J., DeCristofaro, A., et alet al. (2003). The quality of health care delivered to adults in the United States. The New England Journal of Medicine, 348(26), 2635–3077.CrossRefPubMedGoogle Scholar
  54. Moody, R. (2003). Patient e-mails: Time pit or newest profit center? The Business Journal of Portland, e2.Google Scholar
  55. My HealtheVet. (2006). United States Department of Veteran’s Affairs.Google Scholar
  56. National Committee for Quality Assurance. (2006). The state of health care quality 2006 (p. 84). Washington, DC: National Committee for Quality Assurance.Google Scholar
  57. O’Dell, S., & Hansen, J. (2003). The next-generation health plan: Not if, but when and how. Healthplan, March–April, 54–58.Google Scholar
  58. Oenema, A., Brug, J., & Lechner, L. (2001). Web-based tailored nutrition education: Results of a randomized controlled trial. Health Education Research, 16(6), 647–660.CrossRefPubMedGoogle Scholar
  59. Parker, D. R., Gramling, R., Goldman, R. E., Eaton, C. B., Ahern, D. K., Cover, R. T., et al. (in press) Clinical practice guidelines: The complex journey from guideline dissemination to guideline adoption in the primary care setting. Annals of Family Medicine.Google Scholar
  60. Patt, M., Houston, T. K., Jenckes, M. W., Sands, D. Z., & Ford, D. E. (2003). Doctors who are using e-mail with their patients: A qualitative exploration. Journal of Medical Internet Research, 5(2), e9.CrossRefPubMedGoogle Scholar
  61. Rothert, K., Strecher V. J., Doyle, L., Caplan, W., Joyce, J., Jimison, H., et al. (2006). Web-based weight management programs in an integrated health care setting: A randomized, controlled trial. Obesity Research, 14(2), 266–272.CrossRefGoogle Scholar
  62. Rothman, A. A., & Wagner, E. H. (2003). Chronic illness management: What is the role of primary care? Annals of Internal Medicine, 138(3), 256–261.PubMedGoogle Scholar
  63. Rotich, J. K., Hannan, T. J., Smith, F. E., Bii, J., Odero, W. W., Vu, N., et alet al. (2003). Installing and implementing a computer-based patient record system in Sub-Saharan Africa: The Mosoriot Medical Record System. Journal of the American Medical Informatics Association, 10(4), 295–303.CrossRefPubMedGoogle Scholar
  64. Ruland, C., White, T., Stevens, M., Fanciullo, G., & Khilani, S. M. (2003). Effects of a computerized system to support shared decision making in symptom management of cancer patients: Preliminary results. Journal of the American Medical Informatics Association, 10(6), 573–579.CrossRefPubMedGoogle Scholar
  65. Sands, D. (2000). Using e-mail in clinical care: A practical approach combining the best of high tech and high touch. The Informatics Review (
  66. Sands, D., Tang, P., Sittig, D., & Christopherson, G. (2003). Sharing electronic medical record information with patients via the internet (p. 2). Boston: Medical Records Institute.Google Scholar
  67. Schoen, C., Davis, K., How, S. K. H., & Schoenbaum, S. C. (2006) US health system performance: A national scorecard. Health Affairs, 25, w457–w475.CrossRefPubMedGoogle Scholar
  68. Sittig, D. F. (2002). Personal health records on the internet: A snapshot of the pioneers at the end of the 20th century. International Journal of Medical Informatics, 65(1), 1–6.CrossRefPubMedGoogle Scholar
  69. Sittig, D. F., Blackford, M., & Hazlehurst, B. (1999). Personalized health care record information on the web. In: Quality Healthcare Information on the ‘Net ‘99 Conference.Google Scholar
  70. Sittig, D. F., King, S., & Hazlehurst, B. (2000). Provider attitudes toward patient-related email. The Informatics Review.
  71. Sittig, D. F., King, S., & Hazlehurst, B. (2001). A survey of patient–provider e-mail communication: What do patients think? International Journal of Medical Informatics, 61(1), 71–80.CrossRefPubMedGoogle Scholar
  72. Slater, M. D., & Zimmerman, D. E. (2002). Characteristics of health-related web sites identified by common internet portals. Journal of the American Medical Association, 288(3), 316–317.CrossRefPubMedGoogle Scholar
  73. Smith, M., Cox, E., & Bartell, J. (2006). Overprescribing of lipid lowering agents. Quality and Safety in Health Care, 15, 251–257.CrossRefPubMedGoogle Scholar
  74. Stange, K. C., Woolf, S. H., & Gjeltema, K. (2002). One minute for prevention: The power of leveraging to fulfill promise of health behavior counseling. American Journal of Preventive Medicine, 22(4), 320–323.CrossRefPubMedGoogle Scholar
  75. Taylor, H. (2002). 4-Country survey finds most cyberchondriacs believe online health care information is trustworthy, easy to find and understand (pp. 1–3). Rochester, NY: Harris Interactive.Google Scholar
  76. The Commonwealth Fund Commission on a High Performance Health System. (2006). Framework for a high performance health system for the United States (p. 20). New York: The Commonwealth Fund.Google Scholar
  77. The RelayHealth webVisit Study: Final report (p. 8). (2003). Emeryville, CA: RelayHealth Corporation.Google Scholar
  78. Trivedi, A. N., Zaslavsky, A. M., Schneider, E. C., & Ayanian, J. Z. (2006). Relationship between quality of care and racial disparities in medicare health plans. Journal of the American Medical Association, 296(16), 1998–2004.CrossRefPubMedGoogle Scholar
  79. Ueckert, F., Goerz, M., Ataian, M., Tessmann, S., & Prokosch, H. (2003). Empowerment of patients and communication with health care professionals through an electronic health record. International Journal of Medical Informatics, 70(2–3), 99–108.CrossRefPubMedGoogle Scholar
  80. Umefjord, G., Petersson, G., & Hamberg. K. (2003). Reasons for consulting a doctor on the internet: Web survey of users of an Ask the Doctor Service. Journal of Medical Internet Research, 5(4).Google Scholar
  81. United States Department of Veterans Affairs. (2006). Department of Veterans Affairs Statement announcing the loss of veterans’ personal information: May 22, 2006. United States Department of Veterans Affairs.Google Scholar
  82. United States Government Accountability Office. (2006). Privacy: Domestic and offshore outsourcing of personal information in medicare, medicaid, and TRICARE (p. 35). Washington, DC: United States Government Accountability Office.Google Scholar
  83. Vandelanotte, C., De Bourdeandhuij, I., Sallis, J. F., Spittaels, H., & Brug, J. (2005). Efficacy of sequential or simultaneous interactive computer-tailored interventions for increasing physical activity and decreasing fat intake. Annals of Behavioral Medicine, 29(2), 138–146.CrossRefPubMedGoogle Scholar
  84. Von Knoop, C., Lovich, D., Silverstein, M. B., & Tutty, M. (2003). Vital signs e-Health in the United States (pp. 1–40). Boston: The Boston Consulting Group.Google Scholar
  85. Wajli, M., Sagaram, S., Sagaram, D., Meric-Bernstam, F., Johnson, C., Mirza, N. Q., et alet al. (2004). Efficacy of quality criteria to identify potentially harmful information: A cross-sectional survey of complementary and alternative medicine web sites. Journal of Medical Internet Research, 6(2), e21.CrossRefGoogle Scholar
  86. Wennberg, J. E., Fisher, E. S., Sharp, S. M., McAndrew, M., & Bronner, K. K. (2006). The care of patients with severe chronic illness: An online report on the medicare program by the Dartmouth Atlas Project (p. 108). Hanover, NH: Dartmouth Medical School, The Center for the Evaluative Clinical Sciences.Google Scholar
  87. Whitlock, E. (2002). Evaluating primary care behavioral counseling interventions. American Journal of Preventive Medicine, 22(4), 267–284.CrossRefPubMedGoogle Scholar
  88. Wilensky, G. (2006). Consumer-driven health plans: Early evidence and potential impact on hospitals. Health Affairs, 25(1), 174–185.CrossRefPubMedGoogle Scholar
  89. Wise, M., Gustafson, D. H., Sorkness, C. A., Molfenter, T., Staresinic, A., Meis, T., et alet al. (2007). Internet telehealth for pediatric asthma case management: Integrating computerized and case manager features for tailoring a web-based asthma education program. Health Promotion Practice, 8(3), 282–291.CrossRefPubMedGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC 2008

Authors and Affiliations

  • David Ahern
    • 1
  • Judith M. Phalen
    • 2
  • Charles B. Eaton
    • 3
  1. 1.Health e-Technologies Initiative, Brigham and Women's HospitalHarvard Medical SchoolBostonUSA
  2. 2.Health e-Technologies InitiativeBrigham and Women's HospitalBostonUSA
  3. 3.The Warren Alpert Medical School of Brown UniversityCenter for Primary Care and Prevention, Memorial Hospital of Rhode IslandPawtucketUSA

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