Healthcare systems are increasingly moving in the direction of patient-centeredness, meaning that, in recent decades, patients are have been participating in decisions concerning their own treatment (Bundesministerium für Gesundheit, 2015). As a result of this development, patients are becoming more empowered, making the old, paternalistic models obsolete in favour of the appropriate integration of patients as equal partners in their health care. In this era of equality between patients and nurses, eHealth systems offer the potential to support the health care of individuals (Gesundheit Österreich GmbH, 2019).
eHealth and diabetes
The World Health Organization (WHO) has defined eHealth as:
‘The use of information and communications technology in support of health and health-related fields.’
eHealth systems can be understood as a collective term for all electronic applications that make healthcare services more efficient. Among other things, this implies communication transfer and the exchange of information, interdisciplinary networking (Matusiewicz et al, 2018), nursing documentation and patient management, as well as performance records of all employees (Bürki Sabbioni et al, 2010). The rationale for using eHealth systems is the ever-increasing use of modern electronic recording methods, technological advances, and greater demand for monitoring and adequate patient involvement in their own treatment by government agencies, professionals, and investors in private healthcare companies (Jensen et al, 2015).
With approximately 422 million people affected (WHO, 2020), type 2 diabetes mellitus is one of the most common diseases worldwide. The associated healthcare costs amount to $827 billion each year globally. The condition is linked with an unhealthy lifestyle and inadequate health literacy. Type 2 diabetes forms the basis for the development of other serious diseases, such as strokes, polyneuropathies and heart attacks (Hien et al, 2013; Lenzen-Schulte, 2016; WHO, 2020).
In recent years, eHealth systems (eg phone apps and virtual consultations via emails, phone calls or webcams) have been increasingly used for the care of patients with type 2 diabetes. Studies have discovered that the use of electronic patient-centered systems has a positive impact on the course of treatment (Jeffrey et al, 2019; von Storch et al, 2019). Computer-assisted decision-making, access to symptoms for nurses in real-time, and digital prescription of medication can sustainably improve care for patients (Iljaz et al, 2017). eHealth systems also represent a potential strategy to optimise diabetic patients' self-care management and help them to keep their condition stable (Redman, 2013). Only when patients have extensive knowledge about their condition, its associated symptoms and possible late complications, can they act promptly to seek professional help if their health starts to deteriorate (Sorensen et al, 2015; Gesundheit Österreich GmbH, 2019), resulting in increased competency in self-care.
Extensive knowledge about diabetes and the correct assessment of personal health-related changes reduces the risk of hypo-and hyperglycaemia (Schäfer and Abt-Zegelin, 2009). Using eHealth systems, patients have the ability to digitally report daily blood glucose levels or information about their physical and mental health from home to increase the effectiveness of their therapy through digital support. This involves electronic notifications to ensure medication intake compliance, assistance in the interpretation of health-related parameters and subsequent therapeutic decision-making (Redman, 2013). These electronics-based digital capabilities and ongoing contact with nursing staff enable patients to continue living autonomously at home and minimise long-term hospitalisation. Nurses assume an educational and organisational role in this area (Fischer and Krämer, 2016).
Aim
The aim of this study was to investigate the effects of eHealth systems on the health status of patients and the communication between patients and nurses. Furthermore, the study explored nurses' fields of activity using eHealth systems in daily practice, as well as the associated approaches and challenges in this area. The study focused on patients living with type 2 diabetes, although research and reviews of eHealth systems used with patients with other conditions were also included.
Method
The present study was based on a literature search. The search was carried out from November 2018 to February 2019 in the databases PubMed and CINAHL, using the search terms ‘eHealth system’, ‘effects’, ‘type 2 diabetes mellitus’, ‘patients’, ‘nursing care’ and ‘health status’, which were linked in different combinations with the Boolean operator ‘AND’. Due to the manageable number of results, ‘OR’ and ‘Not’ were discarded. Generated results were presented under the four headings:
Both qualitative and quantitative studies as well as literature reviews were included, published over the past 10 years. The authors deliberately avoided books, general articles and websites, as research results on the specific topic were the centre of interest. The 20 studies included are listed in Table 1.
| Authors (year) | Approach/methodology | Background |
|---|---|---|
| Albrecht et al (2010) | Qualitative approach |
Nurses' experiences of the use of eHealth systems for nursing documentation |
| Ariens et al (2017) | Mixed-methods study | Patients' and nurses' experiences of the use of eHealth systems |
| Chao et al (2019) | Quantitative approach |
Effects of an eHealth system on the health status of people with type 2 diabetes mellitus (T2DM) |
| Cui et al (2016) | Systematic review | Effects of international eHealth systems on the health status of people with T2DM |
| Flodgren et al (2015) | Systematic review | Effects of international eHealth systems on professional practice and health care outcomes |
| Graf et al (2016) | Quantitative approach |
Willingness of patients to use eHealth systems |
| Greenwood et al (2017) | Systematic review |
systems to support self-management of people with T2DM |
| Hao and Xu (2018) | Quantitative approach |
Effects of an eHealth system on the health status of people with T2DM |
| Koivunen and Saranto (2017) | Systematic review of qualitative studies | Nurses' experiences of the facilitators and barriers to the use of eHealth systems |
| Koot et al (2019) | Quantitative approach |
Effects of an eHealth system on the health status of people with T2DM |
| Kumar et al (2018) | Quantitative approach |
Effects of an eHealth system on the health status of people with T2DM |
| Munster-Segev et al (2017) | Quantitative approach |
Effects of an eHealth system on the health status of people with T2DM |
| Öberg et al (2017) | Qualitative approach |
Patients' experiences of the use of eHealth systems |
| Odnoletkova et al (2016) | Quantitative approach |
Effects of an eHealth system on the health status of people with T2DM |
| Rasmussen et al (2016) | Quantitative approach |
Effects of an eHealth system on the health status of people with T2DM |
| Sharma and Clarke (2014) | Qualitative approach |
Nurses' experiences of the use of eHealth systems |
| Sood et al (2018) | Mixed-methods study | Effects of an eHealth system on the health status of people with T2DM (quantitative approach), usability of the eHealth system (qualitative approach |
| Triller (2016) | Qualitative approach |
Barriers and solutions for nurses using eHealth systems |
| Wild et al (2016) | Quantitative approach |
Effects of an eHealth system on the health status of people with T2DM |
| Wu et al (2018) | Systematic review including meta-analysis | Effects of international eHealth systems on the health status of people with T2DM |
Results
Effects of eHealth systems on health status
The use of phone apps and virtual consultations via phone calls has a proven positive effect on the health outcomes of patients with type 2 diabetes (Cui et al, 2016; Munster-Segev et al, 2017; Kumar et al, 2018; Wu et al, 2018; Koot et al, 2019). These studies found that the number of secondary diseases and associated symptoms could be reduced by the use of eHealth systems. This primarily affected the occurrence of retinopathy (6.70% vs. 22.20% P<0.001) and nephropathy (5.90% vs. 13.70% P<0.026) (Sood et al, 2018). In addition, the glycated haemoglobin (HbA1c) value (14.60% vs. 10.60% P<0.016), blood glucose levels (17.60% vs. 13.10% P<0.015), cholesterol (07.10% vs. 06.10% P<0.044) and body weight of the subjects decreased (Rasmussen et al, 2016).
Effects of eHealth systems on communication
Patients believed that using phone apps improved communication with health staff. Exchanges about therapies, as well as experienced symptoms, were subjectively described as comprehensible and simple (Lie et al, 2018), as one patient explained:
‘Earlier follow-up has just been blood samples and other tests, and then finished and “goodbye”. I have not had time to express thoughts and emotions, and […] That was what I appreciated, that I could finally communicate with someone about it. How I experience all of it.’
According to some of the patients in the studies examined, electronically recorded health data gathered during visits by health professionals increased understanding of the impact of type 2 diabetes on everyday life (Sood et al, 2018; Chao et al, 2019). One patient said:
‘It becomes more concrete than when it is just in your head. Maybe for some people when they have written it down, I will not say that it becomes a contract, but yet more concrete than when it is just feelings and thoughts.’
In addition, health professionals can request health-related data before a hospital check-up, providing in-depth information about a patient's physical and mental health so that they are prepared for the upcoming visit. As a result, during the visit, more time can be spent on discussing the health-related feelings of the patient, patient education and the future course of therapy (Lie et al, 2018).
With electronically based systems, patients perceive communication with health professionals to be more flexible, enjoyable, and time-saving, as open questions can be digitally sent from home to health professionals to then be discussed together. In addition, the possibility of keeping a written record of their physical and mental health was evaluated very positively. By completing standardised electronic questionnaires on a daily basis or keeping a journal with no time limits, patients living with diabetes are able to record their thoughts and feelings and reflect on their health status. As a result, patients can better reflect on their self-documented health status, control changes in their health behaviour, implement preventive measures, and thus sustainably improve their own health (Hao and Xu, 2018; Lie et al, 2018).
eHealth systems in daily nursing practice
Nurses take on an educational, communicative and organisational role in this area. They inform patients about the use of phone apps and the process of electronic consultations (Odnoletkova et al, 2016). By using them correctly, patients can maintain constant contact with the nurses after they have been discharged from hospital or have left the diabetes day clinic. This is useful for raising health issues such as therapy-associated side-effects or questions. eHealth systems therefore support patient and symptom management, which are essential areas of professional health and nursing care (Greenwood et al, 2017; Lie et al, 2018).
In addition, eHealth systems can be used during patient education sessions to strengthen patients' understanding of their condition. In this case, however, the electronic patient-centered systems should only be used as an aid for the transfer of knowledge, since they are not a substitute for face-to-face consultation (Lie et al, 2018). A combination of digital and personal counselling sessions was considered particularly useful and helpful by nurses in one study (Odnoletkova et al, 2016). For example, initial knowledge transfer sessions can be produced in an electronic format for the patient to view and then followed up with a personal consultation. This strategy offers patients the opportunity to relate the information they receive to their personal life situation and gives them ample time to prepare themselves for the subsequent personal consultation with the nurse. This implies that eHealth helps the internalisation of newly acquired knowledge and with noting questions to ask health professionals (Flodgren et al, 2015; Wild et al, 2016;).
Challenges and approaches
Despite the many benefits of digital diabetes treatments, some nurses still experience mixed feelings concerning the use of technology in this area (Koivunen and Saranto, 2017). During the implementation phase, in particular, some nurses reported that introducing eHealth systems caused additional time commitments due to ambiguities in the organisational process or in their correct application. As a result, and despite an existing professional routine, nurses felt increasingly stressed and job satisfaction decreased (Sharma and Clarke, 2014). The reasons for this reaction was most often the lack of adequate support during the introductory phase of an eHealth system, as well as a lack of basic technical knowledge (Ariens et al, 2017).
Other problems reported included a lack of compatibility between eHealth systems and existing digital applications, application problems, such as frequent logins required, and too rapid implementation of new programs without sufficient lead times (Franch-Nadal et al, 2015; Lie et al, 2018; Sood et al, 2018). eHealth therefore requires an implementation phase, to take place over an appropriately long period of time, and supported by competent IT personnel who are available for questions and problem solving. Thus, adequate support is essential (Öberg et al, 2017).
Some information is difficult to communicate electronically, such as patients' feelings about their psychosocial wellbeing. Patients who perceive digitally supported written communication as unsatisfactory are less likely to communicate in this way. Hence, there is a risk that essential patient data could go unrecorded and overlooked (Sharma and Clarke, 2014). This challenge can be counteracted by eHealth systems with integrated audio or video functions, since these features enable personal conversations despite the nurse and patient being in separate locations, so that sensitive content does not have to be communicated in writing (Albrecht et al, 2010).
The potential lack of practicality of eHealth systems is a further challenge. Some patients find that eHealth applications are incompatible with their lifestyles. Consequently, there may be no positive effects on symptom and patient management. Some applications may be incompatible with other electronic systems used by nurses. Such hurdles are often due to the lack of involvement of nurses in the development process of such systems. A reduced understanding of this technology makes cooperation even more difficult. In the future, it is important to ensure systems are more user friendly and to test eHealth systems over a longer period of time so they can be adapted to practical requirements (Triller, 2016). People over the age of 65 with a fluctuating state of health and lower levels of education have been found to prefer paper-based questionnaires and disease management information (Graf et al, 2016). Hence, eHealth systems may not be suitable for this patient group. Patients should therefore be able to choose whether or not to use electronic systems for their diabetes management (Chang et al, 2017).
Summary and discussion
Type 2 diabetes is one of the most common chronic conditions worldwide. The root cause of this metabolic disease is unknown, but can be triggered by an unhealthy lifestyle, which is characterised by poor nutrition, obesity and lack of exercise and forms the basis for numerous sequelae and associated symptom burdens (Schmeisl, 2011; Jeon et al, 2016; WHO, 2020). The demand for adequate care on the part of patients and health policy is increasing. With eHealth systems, this demand can be met as they allow for continuous recording of a patient's real-time health status. As the patient's health deteriorates or as questions arise, eHealth systems enable prompt contact with nurses so that appropriate countermeasures can be taken. As a result, eHealth systems can also ensure ample involvement of patients in their own treatment. Nurses support patients in the use of these digital systems through targeted educational measures, whereby informed discussions provide information on the electronic system, its correct handling and the functions that are of interest to people with diabetes (Franch-Nadal et al, 2015; Lie et al, 2018; Sood et al, 2018;).
Integrating eHealth systems into diabetes treatment was recognised as helpful by both affected patients and health personnel in the studies reviewed. The use of digital systems generally had a positive effect on the health-related outcomes of the patients. Patients had the opportunity to view their symptoms in graph format and could add questions in their own words as comments. Such functions aim at a more intensive exchange about the illness between nurse and patients (Dobrozsi and Panepinto, 2015; Odnoletkova et al, 2016; Wild et al, 2016).
Problems with eHealth systems mainly arise during the implementation phase because of the lack of computer literacy among nurses or patients. The acceptance of eHealth systems is also influenced by the perceived ease of use of the system by the users and the state of health of the patients. Providing IT professionals and adequate training can make it easier for nursing staff to access and troubleshoot eHealth system issues.
Support and training could be provided by trained advanced nurse practitioners (ANPs) and diabetes specialist nurses (DSNs). Nurses in the UK, some other European countries including Austria and Scandinavia, and North America have been providing specialist care to patients with chronic conditions for many years and are well placed to do this (Dieplinger and Welche, 2016).
Box 1 lists some recommendations for the successful implementation of eHealth systems.
Due to necessary evaluations and further developments, nurse researchers can adopt a significant role in the field of eHealth. Through the use of eHealth systems in health care, resources can be optimised and distributed in a targeted and sensible manner. In this way, there will be a cooperation network between ANPs, DNSs and nurse researchers in order to successfully cope with the high demands of nursing patients with diabetes and the associated challenges in the future (Dieplinger and Welche, 2016).