Skills and Competencies for the Future of eHealth

Anastasia
Constantelou and Vasiliki
Karounou, National Technical University of Athens,
Greece

Issue: An important prerequisite for
the widespread introduction of new technologies in the heath sector is the
acquisition of new types of skills by citizens, patients, doctors, nurses and
other healthcare professionals. These skills translate to new abilities,
competencies and, above all, mindsets and attitudes to new ways of working that
are more responsive to the needs of citizens.

Relevance: Human
resource development through appropriate education and training is a key factor
in coordinating efforts by stakeholders, introducing new working methods and
gradually transforming traditional healthcare service providers into agencies
that provide a wide range of eHealth services. This is particularly relevant
considering the under-investment in training and education that is endemic in
the health sector and which create blockages in the ways knowledge is
shared.

Introduction

eHealth is an umbrella term encompassing
a broad range of ICT-driven activities that are transforming the delivery of
healthcare. Such activities normally involve the use of digital data that is
transmitted, stored, and retrieved electronically for clinical, educational and
administrative purposes, whether at a fixed location or remotely. The important
implications of eHealth are becoming more and more apparent to patients, health
workers, administrators, and practitioners as new applications allow the
provision of medical support remotely at any point in time and facilitate access
to, and exchange of, pertinent health information on demand.

eHealth is an umbrella term encompassing a broad
range of ICT-driven activities that are transforming the delivery of
healthcare

The introduction and effective delivery of
eHealth concerns all players in the healthcare sector. These include hospitals
and other healthcare facilities, public and private insurance firms,
organizations developing and applying technological solutions, as well as a
variety of user groups - citizens, patients and their environment, doctors,
nurses and allied healthcare professionals. The growing body of literature on
eHealth has extensively dealt with the rise of new technologies and the
bottlenecks and challenges facing eHealth strategies in the 21st century. Less
attention has been given to ways of increasing awareness and general
understanding and utilization of ICT-driven activities among all the parties
directly involved. For this, it is important to recognize that technology alone
cannot guarantee optimal results. New types of skills, competencies and, above
all, mindsets and attitudes to novel ways of working are required for the
ubiquitous introduction and effective exploitation of ICTs in healthcare.

New types of skills, and changed attitudes to
novel ways of working are required for the ubiquitous introduction and effective
exploitation of ICTs in healthcare

ICTs and the changing nature of skills in healthcare delivery

For over two decades now, ICTs have been
gradually introduced into the healthcare system creating turbulence in its
traditional structure and organization and requiring all those working in the
area to keep pace with new technologies. As early as 1990, the European Council
issued Recommendation No R(90)21 which alerted governments of member states to
"…ensure that, as soon as possible, those staff involved in healthcare receive
appropriate, multidisciplinary training, both theoretical and practical, for
health information systems within an overall public context" (Grimson,
et. al., 2000). At that time, the predominant ways in which ICTs were introduced
and applied within the healthcare system related mainly to administrative,
managerial and financial functions. The integration of some of the ‘back office’
components of the healthcare system that was made possible with ICTs required
health practitioners to transcend the strict boundaries of their profession and
acquire a new set of skills that may have been unnecessary a few years ago.
These were mainly leadership competencies - such as strategic and tactical
planning, persuasive communication, negotiating skills, financial
decision-making, team building, conflict resolution and interviewing - as well
as some basic ICT-related technical skills (Schwartz,
R., 2000). Even at that time the need for increased information technology
‘upskilling’ created an additional burden on the already demanding schedule of
healthcare professionals. The latter viewed ICT training as peripheral to their
activities, or at worst, as an unnecessary burden which consumed valuable time
(Grimson,
et. al., 2000).

The need to equip health-care professionals with
better ICT skills has been on the agenda for over a decade

The current widespread use of ICTs in the health sector has
important implications not only for the support of administrative and functional
tasks but also for the actual delivery of healthcare. eHealth applications offer
the potential to cut costs, increase the efficiency with which care is provided,
deliver healthcare services remotely, simplify diagnostic and therapeutic
processes, and enable better care to be provided in the patient’s personal
environment. At the same time, they can increase patients’ levels of awareness
and understanding about their own health and encourage a degree of
self-care.

The modernization of public service provision
with the use of ICTs is a challenge to existing forms of organization in the
health sector and implies some kind of organizational change

The modernization of public service provision with the use of
ICTs is a challenge to existing forms of organization in the health sector and
implies some kind of organizational change. In fact, technical innovation to a
large extent depends on organizational innovation in order to achieve real
improvements in efficiency and quality of service. On the other hand, the
translation and implementation of new modes of service provision into practice
is always a serious challenge to management. Still, the potential of eHealth may
fall flat without the active involvement of healthcare professionals and
citizens in the choice, deployment, and assessment of relevant technologies. For
these user groups to participate in a meaningful way in these procedures they
have to be empowered and informed about the benefits ICTs can bring to
healthcare delivery.

Appropriate education and training is a key
factor in introducing new methods of work for healthcare service providers and
in empowering citizens to use ICTs to obtain medical
information

Human resource development through appropriate education and
training is a key factor in introducing new methods of work for healthcare
service providers and in empowering citizens to use ICTs to obtain medical
information. The nurturing of competencies and skills and the introduction of
new working methods have become key factors in the successful re-engineering of
service suppliers as they transform into agencies providing eHealth services.
Changes to strategies, structures and methods of service delivery are dependent
upon a creative and innovative workforce. The latter needs to adapt its skills,
competencies and, above all, mindsets and attitudes to new ways of working that
are more responsive to the needs of citizens.

Although technical skills are necessary to set up
eHealth applications, the delivery of these applications to citizens also
requires strong inter-personal and managerial skills

The availability of an appropriate mix of
competencies and skills is central to the wider diffusion and take up of
e-health. The care provided by specialized professionals requires adherence to
evidence-based clinical protocols, nursing processes, clinical judgement, and
skills/experience in communications, technology, and computers. Thus, although
technical skills are necessary to set up eHealth applications, the delivery of
these applications to citizens also requires strong inter-personal and
managerial skills since quite often providers are required to manage people over
the network. While the technical skills are concerned with the communication
technologies used and the clinical processes enabled by those technologies, the
interpersonal skills are concerned with relationships between system personnel,
providers and patients, and the way in which those relationships are
organized.

Furthermore, the notion of ‘civil servant’ in the health sector
needs updating to meet the requirements and opportunities of the Information
Society. The public service ethic remains vital in the sector. However, in the
eHealth era it should incorporate customer relations’ management approaches,
efficiency measures, and modern management techniques.

For citizens/patients, the ability to benefit
from developments in eHealth critically depends on their familiarity with
technology, their interest in ICTs, andin the Internet in
particular

Similarly, for citizens/patients, the ability to benefit from
developments in eHealth critically depends on their familiarity with technology,
their interest in ICTs, and in the Internet in particular. People with no
experience and no interest in computers and electronic devices are unlikely to
be able or willing to seek medical information from Internet sites or receive
care and support at a distance. By contrast, people who already use computers or
are keen on learning about technology and wish to gain some basic computer
skills are more likely to have a positive attitude towards eHealth applications
and benefit from their wider deployment.

Box 1. What competencies and skills are needed for eHealth?
Evidence from survey findings

Skills and competencies in new healthcare
delivery models and new professional roles have been identified as being crucial
to the delivery of even the simplest eHealth services. A number of surveys have
looked into the particular types of competencies and skills that are considered
as being central to the diffusion and take-up of eHealth. Some of the key
findings of these studies concerning healthcare professionals and citizens are
highlighted below.

In the US, the Michigan telepsychiatry research
project identified confidence building to senior administrative staff regarding
capabilities and use of technologies as an important issue in providing eHealth
services (Whitten,
P. & Rowe-Adjibogoun,
J., 2002).

In the UK, a survey on Primary Care Staff's use of the
Internet in Scotland found that time constraints and concerns that they lack the
necessary skills were highlighted as the most common reasons for not accessing
the Internet (Wilson,
1999).

A survey on nurses’ responses to telemedicine found that nurses
need to obtain technical skills, on how to install, calibrate and operate
equipment, as well as to recognize and fix technical problems. Also, they need
training in team building so that project nurses are able to build and develop
problem-solving skills as a group (Dansky
et al.,1999). Furthermore, awareness on a nurse’s new role as "e-nurse" needs to
be built among senior management and key nursing managers in order for them to
gain good appreciation and true understanding of what nurses are doing over the
telephone and accept their new role (Larson-Dahn
2002). The care provided by the nurse requires adherence to evidence-based
clinical protocols, nursing process, clinical judgement, and skills/experience
in communications, technology, and computers (Richardson,
R.J., Schug,
S., Bywater,
M., Williams,
D.L. 2002).

Leadership skills are also recognized as being very
important, since the role of a "champion" is considered critical for getting a
new eHealth project off the ground and sustaining interest among participants
when problems occur. (Larson-Dahn
2002, Norris 2001). Survey findings suggest that the development of people-based
skills such as cooperation, leadership, and creative thinking are just as
important as - if not more so - than actual technology developments (Ball
& Lillis,
2000; Silber
2003).

In Europe, the SeniorWatch1
survey took into account information gathered about computer usage, skills’
self-assessment and attitudes towards new technologies and came up with a
typology of citizens’ computer involvement. According to this typology the
majority of older citizens (over the age of 50) (69.7%) have either advanced IT
skills or are familiar with the use of computers, or they are keen to learn
about technology, whereas 31.3% do not use a computer or are not keen on
familiarizing themselves with this technology. The proportion of users drops
with age and so does the proportion of computer-literate individuals.

The
evidence from the Flash Eurobarometer survey (2003) shows that among computer
users only a small proportion (23.1%) of people within the European Union use
the Internet to get information about health. A positive attitude about the
Internet is a given amongst young people in contrast to older people (55.7% in
the 15-24 age group vs 26% of people over 55).

Towards a typology of eHealth competencies and skills

The findings of the survey alluded to above suggest that the
required skills and competencies for eHealth can be grouped into the following
broad categories:

Basic computer skills: these skills include use of computers, use of
web technologies for accessing portals and for using personalized services,
together with eHealth applications for delivering simple telecare
services.

Organizational and managerial skills: including the so-called ‘soft’
type of skills similar to the leadership competencies identified earlier in
the paper, which are necessary for the effective development and delivery of
eHealth services. These skills are necessary for dealing with new
organizational structures, new service delivery models, changes in working
methods, new job roles, etc.

In-depth understanding of the functional capabilities of eHealth
technologies and applications: this encompasses the ability to have a
thorough understanding of how eHealth applications such as integrated
patient management and electronic health records, epidemiological networks,
telecare and independent living devices and services, etc., fit into, and are
an integral part of, the formal healthcare delivery system.

In-depth understanding of legal, ethical, and economic issues surrounding
eHealth: this refers to the necessary knowledge and capabilities that need
to be acquired in order to manage the relations between the different
stakeholders in an eHealth environment, such as identifying their rights and
obligations, defining service level agreements, understanding the problems
surrounding the security and confidentiality of personal and health data, ways
of preventing and/or dealing with malpractice, etc.

Note that the proposed grouping intentionally does not include
advanced technical skills such as information management, health informatics,
software design, etc. These skills can be obtained formally and nowadays are the
subject of specific postgraduate courses designed specifically for the needs of
healthcare professionals.

The above grouping places particular emphasis on the ‘soft’
types of skills required as opposed to the more formal ‘hard’ type of advanced
computer and technical skills. This is because, as often demonstrated in surveys
and case studies, the former are often accountable for the weak communication
links and information flows among actors within the system. In addition, the
above categorization of skills and competencies suggests that some types of
skills, such as basic computer skills, the understanding of complementarities of
eHealth and traditional healthcare practice, and their legal and ethical
implications, should be generic for all user groups, while other types are more
specific to individual application areas of eHealth.

eHealth competencies and skills are particularly
necessary in relation to four major eHealth application areas: public health
policy, information services, patient management and telecare/ independent
living services

eHealth competencies and skills are particularly necessary in
relation to four major eHealth application areas (including their application
sub-areas):

Public Health Policy & Prevention: this refers to the collection of
healthcare event, environmental, and socio economic information that enables
data mining for healthcare strategy planning. Essential skills for healthcare
professionals involved in this area include the ability to understand the
functional design and use of personalized web services as well as the ability
to understand the structure and information needs of Public Health Policy and
Prevention in order to come up with new algorithms to fit in new types of
data.

Information services to citizens: these encompass activities providing
information to citizens on issues such as good health and lifestyle advice and
empowering them to know when professional help is required, and where and how
to obtain it. Essential skills for healthcare professionals involved in this
area include the ability to contribute to the structuring and updating of
citizen information services and to the functional design and use of
personalized web services.

Integrated Patient Management & patient health records: these concern
activities surrounding the efficient and secure sharing of information between
health and social care professionals and the establishment of an environment
to provide support for integrated client case management. Essential skills for
healthcare professionals involved in this area include the design and use of
evidence-based eHealth clinical protocols, the ability to understand the
structure and functional capabilities of integrated patient management systems
and patient health records, the operation, updating and maintenance of
Integrated Health records, and the efficient management of personal and health
information security and confidentiality.

Telecare & Independent living services. These comprise
tele-consultations, telehomecare, vital signs monitoring, and services for the
elderly and disabled that support independent living. Essential skills for
healthcare professionals involved in this area include basic technical
knowledge on how to operate telecare and independent living services, ability
to form telecare and independent living Service Level Agreements with third
parties, ability to evaluate the equipment and services delivered, and also
the management of personal and health information security and
confidentiality.

The way forward: Recommendations for the future of eHealth
education

One of the principal barriers to the adoption of telecare is
the resistance of health professionals - primarily doctors - to the use of new
technologies in their daily practice. Survey findings confirm that the inability
of healthcare staff and healthcare professionals to accept and manage change is
seen as a major blockage in implementing eHealth (Richardson,
et al., 2002). Health professionals in general are averse to using high
technology equipment when treating patients, especially if treatment takes place
from a distance. Often, they perceive the implementation of the service as a
threat to their authority. From another perspective, health professionals find
that education and training in ICTs do not fit in with their busy schedule and
could in no way substitute for the personal relationships they develop with
patients. In the UK, for example, doctors argue that in the fourth and fifth
years of their medical training and in their first years as junior hospital
doctors there is no time for training in ICTs because priority is given to
clinical work and it is in practice very difficult to fit in training on ‘fancy
ICT systems’ (Mansell
and Curry,
2002).

One of the primary barriers to the adoption of
telecare is the resistance of health professionals the use of new technologies
in their daily practice

For many years, the inclusion of IT skills in the training of
healthcare professionals has been a low priority in most countries. This
approach has caused significant discrepancies in the health system since the
on-going under-investment in professional education and training has been
occurring in an environment characterized by rapid technological and
organizational change. Today, the introduction of medical informatics onto the
curricula of medical schools at both undergraduate and postgraduate levels is
gaining more and more ground, as it is becoming widely recognized that the
ability of physicians to use ICTs is vital for the effective management of
medical information. Courses in this area are designed to equip medical students
and other health professionals with the necessary formal informatics
competencies that will allow them to function as users and producers of medical
data. Internet technology is often used in medical training and in the teaching
of health informatics as it allows better communication between participants and
better support for students. The primary goals of such courses include (Parry
et al., 2001):

Raising health-care professionals’ understanding of health informatics and
computer technology, including the effective use of common software,
communication tools, and some of the concepts underlying the use of computers
in healthcare.

Providing academic recognition of informatics skills by awarding a
diploma.

Developing a network of expertise, and

Reaching people working in relatively remote environmental
settings.

However, ‘soft’ types of skills are equally, if not more,
important for the transformation of the healthcare system into an eHealth
system. Therefore, an important prerequisite for engaging more and more
professionals in formal training in health informatics is first to raise their
awareness of the potential of ICTs and adjust existing mindsets and attitudes to
the transforming norms and practices in healthcare delivery. In other words,
apart from basic computer skills, health professionals need to be provided with
the necessary education and training that will allow them to understand the
functional capabilities of eHealth technologies and applications as well as
their legal, ethical, and economic implications in order to have at least some
input into technology choice and assessment. Furthermore, people-based skills,
such as co-operation, leadership, and creative thinking are critical for
inspiring participants and sustaining their interest at turbulent times.

An important prerequisite for engaging more and
more professionals in formal training in health informatics is first to raise
their awareness of the potential of ICTs and adjust existing
mindsets

Continuing medical education activities need to endorse this
approach. In the same way as other professionals (e.g. engineers,
industrialists) deliberately enrol in postgraduate training in order to develop
the key technical, organizational, and administrative competencies that they
need in order to be able to deliver value-added services to customers, health
professionals also need to empower themselves with the necessary knowledge of
health informatics as well as with an essential understanding of the broader
functional, legal, ethical, and economic implications of eHealth. More training
programmes addressed to all groups of health professionals - doctors, nurses,
allied healthcare professionals- should be designed along these lines. The
importance of eHealth and the variety of eHealth services need to be explained
through concrete examples so that the full benefits are appreciated and key
messages are delivered to multi professional groups. Multimedia and web-based
technologies can effectively support the delivery of such training schemes and
establish a user friendly interoperable systems infrastructure for eHealth
education.

Keywords

E-health,
skills,
competencies,
education,
training,
patients,
healthcare
professionals

Acknowledgements

This paper is based on research funded by the IPTS/ESTO Project on
‘Prospecting eHealth in the context of a European Ageing Society. Quantifying
and qualifying needs’.

We would like to thank our project partners for their informative input and
advice.

Note

1. The SeniorWatch project launched a pan European survey of elderly people
in Europe relating to eHealth and telemedicine issues. Fieldwork was carried out
by national organizations in all European Union Member States. Geographically
and socio-demographically stratified random sampling was used, with
computer-assisted telephone interviews. The interviews were conducted in June
and July 2001. Altogether 9661 interviews were performed. The cases were
weighted according to the share of the population the respective age groups
represent of the older population in each European country.

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Contacts

Anastasia Constantelou, University of the Aegean, Chios, Greece

Tel.: +30 227 10 354 61, e-mail: [email-masked]

Vasiliki Karounou, National Technical University of Athens, Greece

Tel.: + 30 (210) 77 214 50, e-mail: [email-masked]

Marcelino Cabrera, IPTS

Tel.: +34 95 448 83 62, fax: +34 95 448 83 39, e-mail: [email-masked]

About the authors

Dr Anastasia Constantelou holds a PhD in Science and Technology
Policy Studies from SPRU, University of Sussex. She has been consultant to the
OECD and Research Fellow at the Institute for Computer and Communication
Systems (ICCS), National Technical University of Athens. She has recently been
appointed as Assistant Professor of Innovation Management at the University of
the Aegean. Her research interests focus on the economics of science and
technology, innovation policy, and the socio-economic implications of the
information society.

Vasiliki Karounou has degrees in Business Administration, Applied
Statistics and Systems Analysis. She has been actively involved in
various projects and has held job positions with responsibilities in
information systems development in the private and the public sector. Since
1992, she is working in the area of health informatics as a research associate
at the National Technical University of Athens. Currently she is working as
independent consultant on e-health issues for the Greek Ministry of Health,
the Healthcare Region of Ionian Island and the Hellenic Infectious Diseases
Control.

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