A cross-sectional study was performed to evaluate the feasibility of the eHealth intervention judged by parents and medical doctors.

A questionnaire to evaluate feasibility was developed consisting of the variable use, acceptance, and usability of the eHealth intervention.

The questionnaire was developed based on a modified Technology Acceptance Model (TAM). The TAM model, proposed by Davis in 1989, is based on the Theory of Reasoned Reaction and proposes that Perceived Ease of Use (PEU) and Perceived Usefulness (PU) predict user acceptance of information technology [10,11,13]. Technology acceptance is defined as “an individual’s psychological state with regard to his or her voluntary or intended use of a particular technology” [14]. The TAM has been tested for the prediction of adoption of telemedicine by health care professionals and can predict technology acceptance in both obligatory and voluntary usage settings [15,16]. It is suitable for both genders, various age groups, most cultures, and for individuals of all levels of information technology competency [16]. To determine the use, acceptance, and usability of our eHealth intervention, we modified the TAM by adding the dimension “attitude towards use” to the original TAM. Attitude can be defined as “the perception by an individual of the positive or negative consequences related to adopting the technology”. Behavioral intention is also determined by attitude, which is influenced by PU and PEU [17]. Questions to evaluate use, acceptance, and usability were developed following the modified TAM.

After at least one consultation with the regional doctor, both parents and doctors were sent a structured study questionnaire. The study questionnaire of the parents and doctors consisted of 38 and 29 questions respectively, grouped into 3 variables (demographic information, use, acceptance and usability) (Table 1). Acceptance and usability were subdivided by the three dimensions of the TAM (PU, PEU, and attitude). On a 3-point scale (agree-no agreement/no disagreement-disagree), we rated 22 questions for the parents and 15 for the doctor. Six and nine questions respectively of the parent and doctor questionnaire could be answered with yes or no, and with the final question, parents and doctors were asked to rate the eHealth intervention on a 0-10 scale (0=very bad, 10=excellent). Apart from the generic questions, all questions contained room to clarify the answer. At the end of the questionnaire, there was an open field for comments and suggestions. Prior to the study, it was determined that an average of 90% of the parents and doctors had to score the items positively regarding feasibility to qualify the eHealth intervention as feasible.

User statistics were recorded. The number of e-consultations, tertiary teledermatology consultations, and responding times were calculated.

Descriptive analyses were used to evaluate the use, acceptance, and usability.

A total of 31 parents and 22 regional doctors participated in the HTP and received the questionnaire; 25 parents and 15 regional doctors responded (response rate of respectively 81% and 68%). Reasons for not responding on the questionnaire are unknown. Parent and regional doctor characteristics are shown in Table 2.

At the start of treatment, all children were ≤5 months of age. All parents and doctors proved themselves experienced with use of the computer and Internet. Each regional doctor treated an average of 1.5 patients (range 1-4). The mean distance from parents’ residence to the tertiary expert center was 52 kilometers.

All parents and doctors (regional and academic doctors) used the HTP. The e-consult function of the HTP was used by all parents. The average number of e-consultations was 0.5 per parent/month. E-consultations were mostly sent to (and answered by) the academic doctor, 106/112 (95%) messages, within an average time of 2 days. All parents found that their e-consultations were answered adequately.

Eight regional doctors contacted the academic doctor. Of the 8 regional doctors, 7 (88%) found the academic doctor easily accessible for consultation and questions; 40% (6/15) of the regional doctors used tertiary teledermatology to contact the academic doctor. Others contacted the academic doctor by email or phone. Four of the 15 regional doctors (27%) used the e-consult function to communicate with parents. Some contact moments between doctors and patients were not reported in the HTP, whereas doctors did report in the hospital’s own electronic patient dossier.

The different functions of the HTP (e-consult, uploading photographs, completing questionnaires) were used by 19/25 (76%, range 32-100%) of the parents.

Many of the parents (63%, range 52-76%) agreed that treatment by the regional doctor corresponded with the information given by academic center. Parents saved time and costs because of treatment at a regional doctor in respectively 58% and 48% of the cases.

Of the regional doctors, 93% (14/15) felt informed enough to treat patients with IH.

This study describes an eHealth intervention to make the care for children with IH efficient and easily accessible using an online hemangioma treatment plan. Treatment of IH took place with regional doctors, supported by an expert at distance (academic doctor). The HTP was used to facilitate transition of treatment to regional doctors and to involve parents in the care for IH. Evaluation of the feasibility of this new way of providing care was performed by studying the small group of first patients and regional doctors who participated in this newly developed eHealth intervention.

The feasibility according to the parents ranged from 63-100% and according to the regional doctors from 47-100% (Table 3). The predetermined percentage of 90%, necessary to qualify the eHealth intervention as feasible, was not always reached. However, almost all parents thought the HTP was useful and all regional doctors had a positive attitude towards the HTP.

Although most results on feasibility are positive, only 53% of the regional doctors found the HTP easy to use. This could be influenced by the fact that 73% of them experienced technical problems and that they were mostly instructed in writing. Most technical problems experienced by both parents and doctors related to logging in and uploading of photographs. The problems were most likely caused by prematurity of the technology itself. Problems of logging in are resolved now. The problem with uploading photographs was due to low capacity of the website and will be resolved in the near future. Technical problems might also be caused by a lack of adequate computer skills to use eHealth systems. Health care providers are the key driving force in pushing eHealth initiatives [18]. IT support (verbal) might facilitate eHealth acceptance and use [19].

Furthermore, the tertiary teledermatology to consult an academic doctor of the CAVU team was seldom used by the regional doctors. Mostly they consulted the CAVU team by phone or by sending emails. Probably the regional doctors were not used to this tool for consulting a colleague, and the fact that parents could see the content of the questions of the regional doctor may have contributed. However, studies have shown that tertiary teledermatology might improve communication between regional and academic doctors and might reduce wait times [20,21]. They have advantages over telephone consultations, which require the need for both parties to be available at the same time, and email, which does not meet current privacy requirements for sharing personal health information [20,22].

Secondly, regional doctors were not positive about the e-consult with the parents. Only about half (54%, 7/13) of regional doctors considered the e-consultation useful. A possible explanation is that these doctors might expect e-consultations to be time consuming (74% of the regional doctors found the HTP worth the time investment) or that they are not used to working with e-consultations. However, it has been shown that the use of e-consultations in dermatology is feasible and the majority of e-consultations take less than 10 minutes for the medical doctor to answer [20,23,24]. It has been shown that e-consultations improve access to specialty care [25]. On the other hand, Palen et al [26] found that having online access to medical records and clinicians was associated with increased use of clinical services. However, this has been debated by others [27,28]. Further research should point out the consequences of e-consultations for time investment and usual care.

Some parents felt that the regional doctor was less experienced with IH care. However, in our opinion, this is probably only a temporary problem since studies have demonstrated that online health communities of doctors from different echelons and patients can be used to exchange medical experience and knowledge and that knowledge of participants increased and the adherence to guideline recommendations improved [29,30]. Partial transition of treatment of IH to secondary centers combined with support by an expert might have an educational value for the regional doctors. This is confirmed by the fact that 87% of the regional doctors agreed that the HTP was of educational value for them. In the long term, increased knowledge about IH treatment and treatment indications might result in better recognition and treatment of children with IH at risk for complications. In the short term, increasing the knowledge about treatment of IH among regional doctors (eg, through eLearning courses) might make them and the parents more comfortable with treatment in regional centers.

Some of the parents included in this study mentioned privacy issues. Security and privacy issues are consistently found in studies as influencing patients’ interest in digital PHRs [31]. Adequate verbal instruction to parents about (the prematurity of) the intervention and about security is important in further implementation. The implementation of the HTP requires a different way of acting and thinking from both doctor and patient. Satisfaction of eHealth interventions has rarely been studied [32]. High patient satisfaction was also seen in a Dutch eHealth intervention that includes an eczema portal combining e-consulting, monitoring, and self-management training for patients and parents of young children with atopic dermatitis [33,34]. Overall parents were positive about the eHealth intervention. From the perspective of the regional doctor, feasibility of treatment at local hospitals and system usability of the HTP should be further adapted to their needs to enhance acceptation, actual usage of the HTP, and implementation on a larger scale. It is known that medical doctors have had some reservations about moving forward in the area of eHealth and PHRs, partly because of concern that they will be bombarded with questions and that patients will have trouble interpreting their findings [35,36]. However, most of the empirical experiences suggest that these problems do not represent major issues when patients are provided with and adopt PHRs [37,38]. Solutions to reduce time investment could involve specialized nurses in the triage of e-consultations and creating a link between the patient file of the hospital and the PHR of the eHealth intervention. Nevertheless, results of this early evaluation of the HTP should be interpreted with consideration of the psychology that goes along with changes in management. Hands-on training for the set-up could be necessary for structural implementation of the e-consultation functionality [25]. Besides patient-doctor interaction, workforce items such as workload and workflow, as well as contextual factors like institutional policy regarding eHealth, influence the implementation of eHealth interventions [39]. To realize treatment of IH on a larger basis at local hospitals, clear referral policy should be made. Regional doctors should agree on how to facilitate treatment of IH on a larger scale. Academic doctors have an important role in assuring the quality of care as they are expected to recognize those patients that require treatment at the tertiary center. Hospital management of tertiary centers should incorporate e-consulting in daily practice to ensure the academic doctor can meet this important role.

The results of our study must be interpreted with caution given the small sample size of both parents and doctors and the prematurity of the intervention. Furthermore, parents had a relatively high education level and were therefore not representative of the general population.

The implementation of eHealth interventions will incur costs. However, the transition of IH treatment to secondary centers might save (in)direct health care costs. Health insurance does already reimburse the implementation of eHealth in some fields of medicine. However, there is still no funding for the care provided through the eHealth interventions. Studies have shown that eHealth, combining e-consultations, monitoring, and self-management training, could lead to cost-savings, and e-consultations could reduce the number of face-to-face consultations [20,23,24,40]. In this study, parents reported a time and cost reduction with respect to traveling due to the use of the HTP. Lower costs can be expected due to a lower number of face-to-face consultations at the tertiary academic center. There might even be situations where digital contact through the HTP replaces face-to-face contact. Wait times will shorten, and more new patients can be seen in a shorter time. Lower indirect costs can be expected due to lower work-absenteeism, as care can be received closer to home. Further studies are necessary to confirm this.

The HTP is a new care innovation that was and will be continuously improved according to user feedback. Points for improvement are resolving the technical problems, such as extending the capacity for uploading photographs, providing more detailed training for regional doctors, and taking care of organizational support. The HTP was a pilot to evaluate the feasibility of treating patients in a regional hospital with online support of the academic center and was part of the pediatric Skin House. After some improvement, this eHealth intervention could be a helpful tool for efficient and accessible care for IH and might be used to increase cooperation between different sectors of health care (primary, secondary, and tertiary care).

Our eHealth intervention to improve the efficiency and accessibility of care for children with IH shows good feasibility, especially among parents. Improvement with respect to technical problems, training of regional doctors, and achieving organizational support might be needed for successful implementation in the future.