The impact of eHealth technologies is sometimes questioned because of a mismatch between the postulated benefits and actual outcomes. A lack of evidence about the distinct effects of eHealth technologies on health and health care is apparent [1
]. Health care professionals are often skeptical and show little support for eHealth because technology does not seem to work for them or the benefit of their patients [5
]. As a result, eHealth technologies often face adoption problems.
What could explain this mismatch? We know from research and the literature [1
] that inadequate reimbursement and legislation can slow down the pace of innovation. Investors need to have trust before they can finance eHealth projects [2
]. Apart from economic trust, a complex innovation needs coordination and communication [6
], especially in the case of chronic disease management, where a variety of stakeholders are involved. Introducing eHealth technologies into the health care system requires careful coordination and communication among health care professionals, patients, informal caregivers, end users, and others. This is exactly what seems so hard to realize in practice. The same goes for project management; the precise definition of scope and objectives of the eHealth technology, the casting of participants, and the timely allocation of well-defined powers (eg, recourses and opinion leaders) and responsibilities are often not well defined beforehand. In day-to-day health care practice, these components are often present only on a superficial level, or not at all. In this situation, a lack of coordination and management deeply affects the outcomes from eHealth technologies research. Conversely, post hoc analysis does not, or cannot, account for the clouding of possible effects due to these important factors.
Another cause for the supposed low impact of eHealth technologies is the peripheral position of the users. eHealth technologies are often developed with only a marginal level of engagement from the (end) user. This lack of human centeredness explains the incidence of usability problems [7
], or high attrition rates [10
]. People simply stop using technologies that do not correspond in any way with their daily lives, habits, or rituals. In the end, the use of new technologies appears to be time consuming and frustrating for all those involved. In this way, technology-driven approaches result in “high tech-with-a-low impact” eHealth technologies [19
All these confounding factors are not inextricably tied up with technology. Rather, avoiding them would reveal the real impact of eHealth technologies. The way in which technology is being designed to improve health care needs rethinking. The approaches that are being used to develop eHealth technologies are not productive enough to create technologies that are meaningful, manageable, and sustainable.
The development of eHealth technologies involves more than simply designing a product or service, and includes more than merely procuring stand-alone medical devices. We recognize the social dynamic and significance of eHealth technologies and their potential for improving health care. Creating a new technology often forces us to clarify how the process of health care delivery actually runs—for example, who the key stakeholders are and how payment is organized. It also illustrates the interdependencies between technology, people, their sociocultural environment, and the infrastructural organization of health care. Ideally, all stakeholders should be aware of these complex relationships [23
In the wake of health 2.0 and medicine 2.0 initiatives [24
], a growing number of studies have emphasized the importance of a participatory development process involving (end) users—and other stakeholders such as payers, decision makers, insurers, and government officials—to increase the uptake of eHealth technologies [24
]. Yet, in current perspectives on and definitions of health 2.0 [25
], the role of stakeholders is not often addressed, nor is the potential of eHealth technologies to create infrastructures for better, cheaper, and easier-to-get health care services.
As long as the need to create a better fit between technological, human, and contextual factors continues to go unaddressed, the uptake and impact of eHealth technologies will remain at the very least poor, and at best undecided [4
]. Therefore, we believe that a holistic
approach is needed. Holistic means that we emphasize the importance of the whole and the interdependence of its parts, and avoid separate analysis of its parts. Such an approach would account for the issues of finance, management and technology when designing, implementing, and evaluating eHealth technologies. It constructs a productive fit through the integration of persuasive and human-centered design principles and business modeling. The urgent need for a holistic perspective to overcome the obstacles that stand in the way of the uptake of eHealth technologies has already been recognized [6
The aim of this viewpoint paper is to boost the uptake and impact of eHealth technologies by advocating a holistic development approach. To this end, we undertook a critical appraisal of existing eHealth frameworks. First, we tried to identify the constituent elements of the framework: the target groups, the goals related to the development, implementation, and evaluation of eHealth technologies, the theoretical backgrounds, the visions on eHealth, and strategies or principles to increase the uptake and impact of eHealth technologies. In particular, we evaluated the extent to which the frameworks aim to realize a fit between human, organizational, and technological factors. Second, based on the outcomes of the review and supported by current knowledge on eHealth technologies development, we present the working principles for the holistic development process of eHealth technologies. And third, we build these principles into a holistic framework for developers, researchers, and decision makers. This holistic framework intends to guide the development of eHealth technologies. It already does so in three of our case studies in infection management, dermatology, and diabetes. The roadmap represents our current view on the development of eHealth technologies. It is a dynamic framework and we also publish it as a wiki for collaborative use (http://ehealthwiki.org).