Pediatric eHealth Interventions: Common Challenges
Pediatric eHealth Interventions: Common Challenges
Sustainability of an eHealth intervention refers to its "shelf life" and comprises the technical, financial, scientific, and other infrastructure necessary to maintain the implementation of the eHealth program over time. Sustainability is often overlooked during development or is relegated to an afterthought following an efficacy trial. This may be due, in part, to the field's commitment to being evidence-based and thus deferring implementation planning until efficacy is established. The unfortunate consequence is that eHealth interventions are frequently abandoned or ignored once a grant project is completed (van Limburg et al., 2011). Widespread adoption of pediatric eHealth interventions will not automatically result from positive results from randomized trials (Curry, 2007; van Limburg et al., 2011). Building on recent calls to create more efficient systems that accelerate the speed of research and thus lead to more sustainable treatments and programs (Riley et al., 2013), sustainability planning should be considered a critical part of pediatric eHealth intervention development to help maintain viability of evidence-based interventions over time (Table I).
A unique sustainability challenge for eHealth interventions is that technologies, how they are used and by whom, are all subject to fairly rapid change—a particular technology medium used to deliver a pediatric eHealth intervention may be obsolete by the point at which the intervention moves to an effectiveness trial or dissemination. Rapid changes in technological "glitz" may result in children becoming bored with and thereby nonadherent to "outdated" programs even if the science behind the intervention is robust. There may also be a "digital divide" within the intended pediatric population such that certain technologies may not be as sustainable in certain segments (e.g., low income or low literacy; Jackson et al., 2008). Technology compatibility can further impede sustainability; eHealth interventions may not be accessible to children that use a different platform (e.g., iPhone vs. Android SmartPhone) or browser (e.g., Safari vs. Internet Explorer) on which the intervention was developed. Initial planning in regards to how children will access the intervention and discussions with the technical support team about their ability to develop the application across platforms can avert subsequent issues or delays during dissemination (Table I).
There are a number of strategies to ensure the sustainability of eHealth programs. At the very least, understanding behavior pertaining to technology adoption (Chiu & Eysenbach, 2010) and how technology is used in a target population helps structure the design of interventions for optimal sustainability. The Pew Internet and American Life Project (http://www.pewinternet.org/) is a valuable resource that provides data on trends in technology use among demographic groups including children and teens. Sustainability can also be maximized by using iterative codevelopment with key stakeholders, as mentioned earlier (Pagliari, 2007; Stinson et al., 2013; van Limburg et al., 2011). Such an iterative process requires modifications to conventional trial methodology and reporting (Eysenbach, 2011). For example, initial stages of eHealth development may be better suited for adaptations of quality improvement methodologies, rather than the traditional model of randomized controlled trials where interventions should not change over the course of the trial. Attention to the cost-effectiveness of eHealth interventions is also particularly important in the current climate of health-care delivery and focus on cost offsets (Tate, Finkelstein, Khavjou, & Gustafson, 2009). Specifically, adoption of eHealth programs on a broader scale will likely be predicated on demonstrations that their efficacy compares favorably with in-person interventions and leads to reduced cost (even after development costs) across the health-care system (Table I).
Dissemination of pediatric eHealth applications can require prudent "business modeling" (Curry, 2007; van Gemert-Pijnen et al., 2011; van Limburg et al., 2011). Building a business case for an eHealth program includes articulating what the intervention is intended to accomplish and the monetary and nonmonetary value of the intervention for all relevant parties (van Linburg et al., 2011). Templates for eHealth business modeling are available and can be a useful resource (e.g., http://www.fp.ucalgary.ca/telehealth/publications/e-Health%20Business%20Case%20template%20v1.4.doc). Options for collaborating with professionals to develop a business case can range from formal collaborations through SBIR/STTR grants, philanthropic collaborations from regional or national business leaders, partnerships with organizations aligned with the population of interest, and collaborations with an institution's Office of Technology Transfer/Intellectual Property (Table I).
Formalizing collaborations between a commercial entity and an academic institution can help ensure mutual benefit while pre-empting some of the potential conflicting interests pertaining to intervention dissemination. In particular, conflicts can arise based on philosophical differences between academic pursuits and business. Research on a pediatric psychology intervention aspires to be scientifically rigorous (often at the expense of time) and to be transparent about limitations of an intervention; commercial enterprises often maintain a competitive edge through rapid execution of ideas, limiting access to proprietary information, and focusing on return on investment (Eng, 2002). As long as investigator input can be maintained (e.g., as a consultant or board member for the collaborating business entity), leveraging business expertise can be invaluable for optimizing eHealth intervention dissemination. An example of a formal approach to dissemination of eHealth interventions is technology transfer. Technology transfer refers to the process of transferring knowledge and technologies (i.e., inventions, software, or tangible research products) typically from academic institutions to commercial entities to allow for further novel development and dissemination. An institution's Office of Technology Transfer can be an asset in the dissemination of eHealth interventions by promoting the intervention, gauging commercial interest, identifying potential avenues for licensing out the program to suitable companies, and ensuring researchers receive appropriate credit for the associated intellectual property. As a potential disadvantage, however, investigators may lose influence over what happens to the eHealth intervention if it is licensed to a commercial enterprise. Additionally, the process of technology transfer often requires restrictions on public disclosure about the eHealth intervention (e.g., limiting what information can be presented at conferences) at least until a copyright or patent is filed.
There are additional options for eHealth intervention dissemination beyond collaborations with business and commercialization. Integrating eHealth interventions within existing Health System Information Technology may be viable for certain types of behavior modification interventions that incorporate decision making or other clinical tools for clinicians (Curry, 2007). Direct "marketing" to clinicians at medical conferences or via practitioner organizations can facilitate dissemination to children and families (Table I). Clinician support is often critical for adoption by children and families and is maximized by highlighting the value of the eHealth intervention to patient care and associated savings in time and/or cost (Curry, 2007). However, there are many potential barriers to practitioner adoption of eHealth tools that must first be identified and overcome, such as concerns about privacy for Web-based applications, potential depersonalization of clinical care, and lack of funding for eHealth tool implementation (Anderson, 2007; Curry, 2007).
Dissemination and Sustainability of the eHealth Program
Sustainability of an eHealth intervention refers to its "shelf life" and comprises the technical, financial, scientific, and other infrastructure necessary to maintain the implementation of the eHealth program over time. Sustainability is often overlooked during development or is relegated to an afterthought following an efficacy trial. This may be due, in part, to the field's commitment to being evidence-based and thus deferring implementation planning until efficacy is established. The unfortunate consequence is that eHealth interventions are frequently abandoned or ignored once a grant project is completed (van Limburg et al., 2011). Widespread adoption of pediatric eHealth interventions will not automatically result from positive results from randomized trials (Curry, 2007; van Limburg et al., 2011). Building on recent calls to create more efficient systems that accelerate the speed of research and thus lead to more sustainable treatments and programs (Riley et al., 2013), sustainability planning should be considered a critical part of pediatric eHealth intervention development to help maintain viability of evidence-based interventions over time (Table I).
A unique sustainability challenge for eHealth interventions is that technologies, how they are used and by whom, are all subject to fairly rapid change—a particular technology medium used to deliver a pediatric eHealth intervention may be obsolete by the point at which the intervention moves to an effectiveness trial or dissemination. Rapid changes in technological "glitz" may result in children becoming bored with and thereby nonadherent to "outdated" programs even if the science behind the intervention is robust. There may also be a "digital divide" within the intended pediatric population such that certain technologies may not be as sustainable in certain segments (e.g., low income or low literacy; Jackson et al., 2008). Technology compatibility can further impede sustainability; eHealth interventions may not be accessible to children that use a different platform (e.g., iPhone vs. Android SmartPhone) or browser (e.g., Safari vs. Internet Explorer) on which the intervention was developed. Initial planning in regards to how children will access the intervention and discussions with the technical support team about their ability to develop the application across platforms can avert subsequent issues or delays during dissemination (Table I).
There are a number of strategies to ensure the sustainability of eHealth programs. At the very least, understanding behavior pertaining to technology adoption (Chiu & Eysenbach, 2010) and how technology is used in a target population helps structure the design of interventions for optimal sustainability. The Pew Internet and American Life Project (http://www.pewinternet.org/) is a valuable resource that provides data on trends in technology use among demographic groups including children and teens. Sustainability can also be maximized by using iterative codevelopment with key stakeholders, as mentioned earlier (Pagliari, 2007; Stinson et al., 2013; van Limburg et al., 2011). Such an iterative process requires modifications to conventional trial methodology and reporting (Eysenbach, 2011). For example, initial stages of eHealth development may be better suited for adaptations of quality improvement methodologies, rather than the traditional model of randomized controlled trials where interventions should not change over the course of the trial. Attention to the cost-effectiveness of eHealth interventions is also particularly important in the current climate of health-care delivery and focus on cost offsets (Tate, Finkelstein, Khavjou, & Gustafson, 2009). Specifically, adoption of eHealth programs on a broader scale will likely be predicated on demonstrations that their efficacy compares favorably with in-person interventions and leads to reduced cost (even after development costs) across the health-care system (Table I).
Dissemination of pediatric eHealth applications can require prudent "business modeling" (Curry, 2007; van Gemert-Pijnen et al., 2011; van Limburg et al., 2011). Building a business case for an eHealth program includes articulating what the intervention is intended to accomplish and the monetary and nonmonetary value of the intervention for all relevant parties (van Linburg et al., 2011). Templates for eHealth business modeling are available and can be a useful resource (e.g., http://www.fp.ucalgary.ca/telehealth/publications/e-Health%20Business%20Case%20template%20v1.4.doc). Options for collaborating with professionals to develop a business case can range from formal collaborations through SBIR/STTR grants, philanthropic collaborations from regional or national business leaders, partnerships with organizations aligned with the population of interest, and collaborations with an institution's Office of Technology Transfer/Intellectual Property (Table I).
Formalizing collaborations between a commercial entity and an academic institution can help ensure mutual benefit while pre-empting some of the potential conflicting interests pertaining to intervention dissemination. In particular, conflicts can arise based on philosophical differences between academic pursuits and business. Research on a pediatric psychology intervention aspires to be scientifically rigorous (often at the expense of time) and to be transparent about limitations of an intervention; commercial enterprises often maintain a competitive edge through rapid execution of ideas, limiting access to proprietary information, and focusing on return on investment (Eng, 2002). As long as investigator input can be maintained (e.g., as a consultant or board member for the collaborating business entity), leveraging business expertise can be invaluable for optimizing eHealth intervention dissemination. An example of a formal approach to dissemination of eHealth interventions is technology transfer. Technology transfer refers to the process of transferring knowledge and technologies (i.e., inventions, software, or tangible research products) typically from academic institutions to commercial entities to allow for further novel development and dissemination. An institution's Office of Technology Transfer can be an asset in the dissemination of eHealth interventions by promoting the intervention, gauging commercial interest, identifying potential avenues for licensing out the program to suitable companies, and ensuring researchers receive appropriate credit for the associated intellectual property. As a potential disadvantage, however, investigators may lose influence over what happens to the eHealth intervention if it is licensed to a commercial enterprise. Additionally, the process of technology transfer often requires restrictions on public disclosure about the eHealth intervention (e.g., limiting what information can be presented at conferences) at least until a copyright or patent is filed.
There are additional options for eHealth intervention dissemination beyond collaborations with business and commercialization. Integrating eHealth interventions within existing Health System Information Technology may be viable for certain types of behavior modification interventions that incorporate decision making or other clinical tools for clinicians (Curry, 2007). Direct "marketing" to clinicians at medical conferences or via practitioner organizations can facilitate dissemination to children and families (Table I). Clinician support is often critical for adoption by children and families and is maximized by highlighting the value of the eHealth intervention to patient care and associated savings in time and/or cost (Curry, 2007). However, there are many potential barriers to practitioner adoption of eHealth tools that must first be identified and overcome, such as concerns about privacy for Web-based applications, potential depersonalization of clinical care, and lack of funding for eHealth tool implementation (Anderson, 2007; Curry, 2007).
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