Quality health care depends on successful communication between health professionals and patients [1
]. As the use of Web tools becomes more pervasive in health and medicine as represented by the concepts Health 2.0 [2
] and Medicine 2.0 [3
], and patients become more empowered, all parties need to adjust to a new form of participatory health care. These new environments are likely to promote more personalized health care, increased collaboration, and better health education. Expected outcomes are not only improved health but also more efficiency in the use of scarce resources, improved trust between stakeholders, and greater convenience [3
], the essence of quality health care. Prior work suggests that online communication tools such as the Web and email can play important roles in enhancing access to health care and health information, in facilitating clinical management [4
], and in increasing the effectiveness of practice administration. Such tools might even play roles in reducing health system expenditure [5
] and in increasing overall efficiency [6
]. However, a number of barriers and risks have also been identified [7
]. Evidence from recent fieldwork is mixed, probably because assessment has involved varying methodologies, settings, systems, and perspectives [5
Some studies have indicated that demand for online communication is strong among patients [20
] and that, among Internet users, willingness to pay for Web portal services does not appear to vary significantly with age [22
]. In one study of pediatric primary care, parents were particularly enthusiastic about the possibility of communicating online with their child’s physician [23
], stating that the ability to communicate online might be a reason to choose a particular pediatrician, even though the majority said they were unwilling to pay for such access [24
]. In another study, older patients responded that they would like to use email to communicate with their physicians [25
Regarding level of actual use, some studies of providers and consumers have found that online correspondence among patients and physicians, both solicited and unsolicited, has increased dramatically, while other studies have found this type of communication to be more limited. In New Zealand, for example, 68% of the 80 general practitioners interviewed in one study had never used email to communicate with their patients, and only 4% had used it regularly [26
]. An investigation conducted in the east of Scotland found similar levels of use [27
]. On the other hand, a cross-sectional study involving all physicians at the Finnish Student Health Service found that 79% of these physicians use email to communicate with patients [28
] the same level reported by other studies of email communication in similar settings [17
]. Studies involving the general population have reported much lower but also disparate levels of use. An online survey conducted in the United States in 2006, found that while only up to 4% of adults use or have access to online services for communicating with their physicians, most would like to communicate with their physicians in this way. In fact, the majority stated that the availability of online services would influence their choice of health care provider to some extent [29
]. Meanwhile, results from the Health Information National Trends Surveys, HINTS 2003 and HINTS 2005, [30
] showed that in 2003, 7% of American Internet users had used email or the Internet to communicate with a physician or a physician’s office in the past 12 months, a proportion that had increased significantly to 10% by 2005. In Europe, the World Health Organization (WHO)/European Survey on eHealth Consumer Trends (eHealth Trends) [31
] found that the estimated percentage of the population that had approached a family doctor or other known health professional through the Internet, even if only to read their website, had increased from 3.6% in 2005 to 6.9% in 2007, while the percentage of those interacting with a Web doctor or health professional they had never met increased from 8.2% to 11.1% over the same period. Results from a 2007 online survey of Dutch primary care patients with chronic complaints [32
], a relevant target group for e-consultations, revealed that 90% had had no prior experience with such a service.
By the time of the second eHealth Trends survey, European countries had established priorities and strategies for eHealth [33
]. However, the conditions reported to have been in place in the seven countries that participated in the eHealth Trends survey were very different. In Denmark, several initiatives were in place that aimed at the development of common standards, concepts, and classifications; good integration between electronic health records (EHR) and other health information systems; and the implementation of an Internet-based health care data network. The Danish public national health portal, Sundhed.dk, had been launched in 2003 [34
In Germany, the two pillars of modernization identified were the establishment of an information and communication technology (ICT) infrastructure and the implementation of a private electronic patient record. The latter, to be introduced in four stages, would allow the provision of administrative data and transmission of electronic prescriptions, among other things [35
]. With respect to a legal and regulatory framework, national legislation addressing telemedicine and eHealth service provision was in place. The German Medical Association's professional code of conduct (Berufsordnung der Ärztekammer
) restricted the exchange of health-related email between doctor and patient to situations where there had been previous face-to-face contact.
In Greece, plans for the period 2006 to 2007 aimed at strengthening standardization and communication infrastructures and preparing the path for national integration by 2015. The plan was to do this through spearheading pilot projects linked to Europe-wide efforts with health insurance cards, e-prescription, and telemedicine [36
In Latvia, development of telemedicine and provision of health care services online were two of the priorities defined, but by April 2007 the assessment of progress achieved so far was considered irrelevant given that the implementation plan was to have been ready at the end of 2006. As of 2007, there was no legal framework specific for eHealth or telemedicine practice available [37
In Norway, the implementation of a national eGovernment information portal serving all sectors, including health, that might give access to e-prescription, the implementation of eResept (for electronic communication of prescription information), and the clarification of responsibility, rules, guidelines, and costs in connection with telemedicine consultations were among future activities to be developed. Legislative research started during spring 2006 to determine ways in which existing legislation was hindering progress in eHealth [38
In Poland, development of electronic communication in health care, telemedicine services, and a central health care portal were some of the strategic targets in the national eHealth roadmap, but by 2007 much seemed to be still at the conceptual phase, and no specific legal framework for eHealth was available [39
In Portugal, the promotion of telemedicine initiatives and development of e-prescription functionalities were some of the future activities envisaged [40
]. There was no legal framework specific for eHealth or telemedicine practice, but online interaction in general involving personal data exchange and diffusion, such as eHealth services, come under very strict legislation that discourages online communication with patients in a clinical setting, especially in private and small practices.
Technical and legal differences in European countries exist together with spreading use of the Internet and email in Europe and the increased potential of these technologies to change the boundaries of communication within medical practice as well as several dimensions of the patient-physician relationship. Therefore, there is an urgent need to investigate how such services are being used, appraised, and valuated by European citizens.
For this paper, we used data of the second eHealth Trends survey that were not analyzed in previous work [31
]. We used these data to investigate in the seven participating countries use of the Internet and email to interact with known health professionals for specific online services. First, we report on current levels of use of the Internet to obtain a prescription, schedule an appointment, or to ask a particular health question. We also report on changes in Internet use and expectations about future use that have occurred over the 18 month period following the first eHealth survey administered in 2005 in the seven countries. In addition, we report the importance of the availability of email and Web services for communicating with the physician when choosing a doctor for a first-time face-to-face appointment. Finally, using the results of logistic regression analysis of the data, we draw profiles of the potential consumers of related eHealth services. The discussion focuses on implications for citizens, health care providers, policy makers, and other stakeholders across Europe.