Ehealth and mhealth development in Spain: Promise or reality?

International Journal of Environmental Research and Public Health Article eHealth and mHealth Development in Spain: Promise or Reality? XoséMahou 1, Bran Barral 2,Ángela Fernández 1, Ramón Bouzas-Lorenzo 2and Andrés Cernadas 2,*   Citation: Mahou, X.; Barral, B.; Fernández, Á.; Bouzas-Lorenzo, R.; Cernadas, A. eHealth and mHealth Development in Spain: Promise or Reality?. Int. J. Environ. Res. Public Health 2021,18, 13055. https:// doi.org/10.3390/ijerph182413055 Academic Editors: George Crooks and Paul B. Tchounwou Received: 29 October 2021 Accepted: 8 December 2021 Published: 10 December 2021 Publisher’s Note: MDPI stays neutral with regard to jurisdictional claims in published maps and institutional affiliations. Copyright: © 2021 by the authors. Licensee MDPI, Basel, Switzerland. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license (https:// creativecommons.org/licenses/by/ 4.0/). 1Department of Political Science and Sociology, Faculty of Social Sciences and Communication, University of Vigo, 36005 Pontevedra, Spain; [email protected] (X.M.); [email protected] (Á.F.) 2 Department of Political Science and Sociology, Faculty of Political and Social Sciences, University of Santiago de Compostela, 15782 Santiago de Compostela, Spain; [email protected] (B.B.); [email protected] (R.B.-L.) *Correspondence: andr[email protected] Abstract: In the last decades, the use of Information and Communication Technologies (ICTs) has progressively spread to society and public administration. Health is one of the areas in which the use of ICTs has more intensively developed through what is now known as eHealth. That area has recently included mHealth. Spanish health system has stood out as one of the benchmarks of this technological revolution. The development of ICTs applied to health, especially since the outbreak of the pandemic caused by SARS Cov-2, has increased the range of health services delivered through smartphones and the development of subsequent specialized apps. Based on the data of a Survey on Use and Attitudes regarding eHealth in Spain, the aim of this research was to conduct a comparative analysis of the different eHealth and mHealth user profiles. The results show that the user profile of eHealth an mHealth services in Spain is not in a majority. Weaknesses are detected both in the knowledge and use of eHealth services among the general population and in the usability or development of their mobile version. Smartphones can be a democratizing vector, as for now, access to eHealth services is only available to wealthy people, widening inequality. Keywords: eHealth; mHealth; telemedicine; Spanish national health system; health policy; health equity; public policy; healthcare disparities 1. Introduction 1.1. How the National Health System Works In the late 1970s, healthcare in Spain transitioned from a social insurance system that imitated those of central European countries such as Germany or Belgium to a national health system (NHS) that was universal in nature and funded exclusively through state taxes. In tandem with this, the Constitution of 1978 decentralized the Spanish state into 17 Autonomous Communities (ACs). These were endowed with numerous competences, including management of healthcare services, while the state retained competence over non-domestic healthcare and general coordination of the healthcare system. The new system materialized in 1986 with the Ley General de Sanidad (LGS, General Health Law), which expressed the political will to make the right to health protection effective, as recognized in Article 43 of the Constitution of 1978. The law established two fundamental principles: (1) that “All Spaniards and foreign citizens with residence established in the national territory have the right to health protection and medical attention” (Art. 1.2. LGS); and (2) that access to healthcare will occur in conditions of effective equality, and that this policy will be oriented towards overcoming social imbalances (Art. 3.2 and 3.3 LGS), according to the maxim of “equal access for equal need” [1]. 1.2. eHealth In recent years, Spain has been consolidating the application of new information and communication technologies (ICTs) to public administration. Many services understood as Int. J. Environ. Res. Public Health 2021,18, 13055. https://doi.org/10.3390/ijerph182413055 https://www.mdpi.com/journal/ijerph Int. J. Environ. Res. Public Health 2021,18, 13055 2 of 17 basic citizen rights have been digitalized through eGovernment programs. Healthcare was one of the first services to introduce ICTs. Though reducing costs was the initial motivation, with ICTs administrative processes having been automated, attempts have been made to improve quality of service, to ensure professionals and users enjoy greater security, and to ensure that the system can be accessed using the internet [ 2 ]. However, investment has stagnated in Spain, in contrast with efforts of other European countries, to apply ICTs to public services and administration [3]. The integration of ICTs into health services and their use in diverse tasks related to healthcare and lifestyle management is known as digital health or eHealth. Recent research has introduced elements into the definition of eHealth that include the potential of ICTs for improving access to healthcare; increasing efficiency, efficacy, and the quality of clinical processes; and improving management for all actors involved [4–6]. Accessing the internet for information, along with new forms of communication, devices and applications that allow users greater control and monitoring of their health has been reported to contribute significantly to their empowerment [ 7 ]. These possibilities motivate users to take greater interest in their health [ 8 ], giving rise to ePatients: more proactive and informed individuals who seek to participate in decisions that affect their health [9]. Some eHealth services offered in Spain have been well received and are completely established, such as the use of electronic prescriptions, making appointments using the internet, or accessing Electronic Medical Records (EMRs) [ 10 ]. However, services such as telemedicine or activities related to digital imaging exhibit the need for greater investment and development to attain satisfactory levels of use. Several pilot programs [ 11 – 13 ] have offered positive preliminary results (reduced costs through tele-assistance or telecare) but lack sufficient continuity to become established. In relation to eHealth, both the state as coordinator of the NHS, and the regional AC health services are adapting their web portals to facilitate access to services via mobile phones. To keep pace with the growing use of these devices, apps are being developed that allow users to interact with medical personnel or monitor activities or behaviors. This provision of health services via smartphones is commonly known as mHealth. Some authors have indicated [ 14 , 15 ] that it could give a significant impulse to eHealth in general and telemedicine in particular [14,15]. 1.3. mHealth The term mHealth can be defined as “medical or public health practices that use mobile devices such as smartphones, personal digital assistants (PDAs), tablets and wearables” [ 15 ]. The use of these devices is linked to specific technical requirements and functionalities that include voice or text messaging, third, fourth, or fifth generation mobile telecommunications (3G, 4G, 5G), and Bluetooth or global positioning systems (GPS). Health apps are on the rise. A study by Research2guidance reported more than 300,000 of them, mainly for the two great operating systems, Apple and Android [ 16 ]. Most of these are oriented to fitness or general wellbeing. The Institute for Healthcare Informatics [ 17 ] provides concurring data, indicating that the majority of such apps center on lifestyle (diet, physical exercise, stress, and way of life), followed by those that address specific aspects of health such as pregnancy, mental health, diabetes, or medication [18]. Similarly, a review of the relevant literature demonstrates that mHealth is mainly used in preventative health. The most frequently addressed topics are family planning, pregnancy, AIDS prevention, diagnosis, information about addictions or treatment, and follow-up of medications and pathologies [ 19 , 20 ]. Being a good tool [ 21 , 22 ], it is believed that mHealth could also have great potential for monitoring patients and chronic illnesses or conditions such as asthma, chronic pulmonary diseases, heart failure symptoms, blood sugar levels, and blood pressure. This approach is also highly useful for promoting health and gathering data to improve medical assistance and the system itself [23]. Int. J. Environ. Res. Public Health 2021,18, 13055 3 of 17 Though there is consensus about the convenience and ease of these technologies for professionals [ 24 ] and users, each of these actors has their own set of expectations and concerns. Healthcare professionals value mHealth very positively and are concerned with the stability of the programs, the potential usefulness of mHealth for their professional activity, and the security or reliability of data and internet connections [ 25 , 26 ]. Patients are concerned with usability and medical attention, the ongoing failure of devices to carry out many of the actions required for digital interaction to date, and app incompatibilities. They also express lack of confidence in security measures. Both groups clearly consider mHealth to be a good tool, but there are discrepancies about how specific utilities, such as access to digital medical records, should be developed [27]. The literature review revealed that research has centered mainly around studying— but very little on achieving—data usability, accessibility, and quality [ 28 , 29 ]. Significant interoperability issues derived from the incompatibility of gathered data are believed to persist [ 30 ]; the worldwide web is still considered insecure and lacking in investment [ 31 ]; institutional barriers have been detected [ 32 ]; and the lack of first-language information on the internet is accompanied by information reliability issues [ 33 ]. All these issues together create an important obstacle to the development of mHealth. Studies seem to indicate that eHealth and mHealth do not generate social and health changes directly. Moreover, given that the technology incorporates forms of power, interests, and relationships between actors that are not always concordant [ 34 ], healthcare systems also require adaptation. In this area, the outbreak of the SARS-CoV-2 virus that unleashed the global COVID-19 pandemic in 2020 has enlivened the debate about the potential of eHealth and mHealth as useful tools for controlling pandemics [ 35 – 37 ]. How users interact with healthcare professionals has changed significantly, as circumstances have accelerated the adoption of digital tools such as telemedicine and virtual care [32,38–42]. 1.4. Objectives This work provides an analysis of the use and recent evolution of eHealth in Spain, and mHealth in particular, based on the results of a survey involving a statistically significant sample of the population. The scientific literature was also reviewed, and relevant secondary sources were consulted from organisms that evaluate eHealth access and use, including the reports of the Observatorio Nacional de Tecnología y Sociedad de la Información (ONTSI, National Observatory on Technology and the Information Society) or the Instituto Nacional de Estadística (INE, National Statistics Institute), both official research Spanish institutions. Motivated by the gap in the literature concerning the definition of an mHealth user profile [ 43 – 45 ], this work attempts to describe the levels of mHealth use and acceptance in Spain along with future perspectives. Specifically, the idea was to contrast users who opt to manage and consult health-related issues from a mobile device (mHealth) and those who access eHealth through other devices. The study of individuals who use their mobile device (hereafter MobU) as an access point for eHealth services and those who use other devices, mainly computers, (hereafter WebU) to access the same services provides a reference for detecting similarities and differences in access and use of the online healthcare system and determining the degree of Health and mHealth penetration. Accordingly, the results were configured and compared based on device use for each user profile (MobU, WebU) and ratings and opinions from both groups. In addition to the comparative aspect, the various survey question blocks made it possible to compile a panoramic picture of the state of eHealth services in 2018. It provides much more detail about uses and use profiles than what is offered in other secondary data sources. Int. J. Environ. Res. Public Health 2021,18, 13055 4 of 17 2. Materials and Methods Up-to-date information on the use of eHealth and mHealth services was gathered from the Encuesta de Uso y Actitudes ante la eSalud en España (Survey on Use and Attitudes regarding eHealth in Spain), hereafter referred to as the eHealth Survey. 2.1. Design of the eHealth Survey This survey was conducted by means of telephone calls and Computer-Assisted Telephone Interviews (CATI). During the survey, opinions were requested about questions related to the accessibility for the main services offered on AC health web portals: scheduling a medical appointment, accessing digital medical records, managing electronic prescriptions, digital imaging, and telemedicine. Other items were included concerning use of devices, the perceived potential of new technologies, priorities for services, means of accessing internet, and perceived priorities about eHealth and mHealth services. The average duration of the interview was 9.0 min, with a range of 5.7 to 12.3 min. The amplitude of the range was conditioned by filter questions, on the basis of which not all informants had to respond to the entire survey. The fieldwork was done from 24 May 2018 to 21 June 2018 throughout the entire Spanish territory, with the exception of the autonomous African cities of Ceuta and Melilla. 2.2. Population A sample of 1695 adults legally residing in Spain were interviewed. Phone calls were randomly generated from the Infobel telephone directory at different times of day and days of the week. To guarantee adequate representativeness, sociodemographic profile features were included in the case selection process. Quotas were established for sex, age, and habitat, with a confidence level of 95% and a margin of error of 2.45 for the entire sample. 2.3. Analysis and Interpretation The information gathered was stored in a codified data base according to the survey design and objectives. The preliminary results were corrected, standardized, and recodified into variables to facilitate statistical treatment. Weighting was applied with attention to the quotas mentioned earlier, to ensure representativeness at the national level. Finally, the data were thoroughly analyzed using SPSSTM and STATATM software packs. From these, general opinions were extracted and categorized for the set of informants, whose contribution to the research objectives was then assessed. The analysis has been carried out with the aim of contrasting user profiles according to their use of health web portals on computer or mobile platforms. Health web portals have been the main or only gateway to eHealth services in Spain, and therefore, this centralized all access to them. Based on this first selection of cases, a profile for each typology was created with the aim of determining the main differences and similarities between them. In addition, some indicators were built with the purpose of weighing and estimating the average use of services, thus defining the priorities of each profile. The operations carried out to perform these analyses are described along with the results in order to ease its understanding. This treatment provided us with a description of the general situation of eHealth in Spain and made it possible to contrast the habits and expectations of two user profiles: MobU, indicating those who use a mobile device to access services, and WebU, indicating those who use computers or any other device for the same purpose. 3. Results 3.1. Dimension of Each Profile As part of the WebU profile, the MobU contingent represented 24.4% of all those who interacted with eHealth services. Int. J. Environ. Res. Public Health 2021,18, 13055 5 of 17 WebU comprised 49.91% of the Spanish population. This indicates that although the number of people who access eHealth services is considerable at nearly 50%, that use of eHealth is by no means generalized. With this in mind, the two profiles as well as their use and expectations of eHealth and mHealth in Spain are described in the following sections. 3.2. Health Status and Frequency of Medical Visits Mobile users (MobU) generally made greater use of in-person health services than web users (WebU). Although 59.4% of WebU went to the doctor between 0 and 3 times per year compared to 52.3% of MobU, the inverse situation was observed for the response category of 4 or more visits per year. In total, 47.7% of MobU made in-person visits compared to 40.6% of WebU. Thus, MobU used healthcare services more frequently than WebU. Is this because the health status of MobU is worse or does it simply manifest their greater concern for their health? The following data on health status and the presence of chronic illnesses will help to clarify this question. MobU and WebU self-assessed their health status almost identically (means and medians were extremely similar and hovered around 2, “Good”). MobU cases were higher at both ends of the distribution (especially in the “Very good” category but also in “Bad” or “Very bad”), but not notably higher than WebU (less than 2%). For chronicity, the similarity continued: 35.7% of WebU declared a chronic condition compared to 33.3% of MobU. 3.3. Use of Internet (General and Specific to the Medical Context) When asked about how they connected to the internet, MobU indicated that their main device was the mobile phone: 85.6% used it every day and 93.2% used it frequently. After that, and to a much lesser degree, other devices named included desktop computers, laptops, and tablets, which 20% reported using daily and 30–45% reported using frequently. The WebU group also used their mobile phones as their main tool for accessing the internet, but the numbers were lower than MobU; in fact, about 10% less of WebU reported frequent use (83.8%). Desktops and laptops filled the gap in similar numbers, though slightly higher for desktops: over 30% indicated daily use and nearly 50% reported frequent use. Use of tablets to access the internet was almost identical between profiles, with nearly 20% reporting daily use and slightly more than 30% reporting frequent use. Finally, 34% of both user profiles accessed the internet with their television to some degree, with over 10% indicating that they go online daily with this device. These figures differentiate the access profiles of the two groups through infrastructural or technological means . When asked about the physical space or location from which they usually connected to the internet, the MobU group was less restricted to a specific location. Nearly one-third of MobU connected from anywhere, and nowhere in particular, compared to 18% of WebU. In that group, domestic/home spaces emerged as clearly predominant places of internet connection in 70% of the cases, compared to 62.1% of MobU. Finally, the third most relevant option of connecting from the workplace was reported by 10.6% of WebU and 7.6% of MobU. Despite the differences, connection from home remained predominant. This may be associated with consumption and free-time habits, despite the significant numbers for “free” access (no preference for a specific location), especially among people who access the internet from their mobile phones. For general online activities, both profiles displayed the same priorities and order in frequency of use, but with clear differences in the intensity of task completion. As the following graph illustrates (Figure 1), MobU persistently tended toward more frequent use, while WebU displayed more diversified use and lacked use or knowledge of several items. Int. J. Environ. Res. Public Health 2021,18, 13055 6 of 17 Int. J. Environ. Res. Public Health 2021, 18, 13055 6 of 17 “free” access (no preference for a specific location), especially among people who access the internet from their mobile phones. For general online activities, both profiles displayed the same priorities and order in frequency of use, but with clear differences in the intensity of task completion. As the following graph illustrates (Figure 1), MobU persistently tended toward more frequent use, while WebU displayed more diversified use and lacked use or knowledge of several items. Figure 1. Basic online activities (by user profile). In the area of healthcare, when informants were asked about search criteria and priorities for online health queries, a similar behavior pattern emerged. Table 1 shows that although consultation sources and priority of access to them were equal, MobU had higher consultation intensity and frequency. Table 1. Frequency of accessing health information sources (by user profile). When You Look For Information about Health, How Often to You Go to the Following Websites? Frequency of Access Every Day Frequently Occasionally Almost Never Never User Profile WebU MobU WebU MobU WebU MobU WebU MobU WebU Mob U My Autonomous Community’s public health service 0.92 0.00 11.58 18.94 43.20 39.39 19.49 18.18 23.48 24.82 Another institution such as the World Health Organization or the Ministry of Health 0.18 0.00 3.31 6.82 19.12 18.18 17.65 18.94 56.06 59.74 Businesses that provide healthcare services (insurance companies or workplace mutuals) 0.00 0.00 2.94 3.03 17.28 17.42 14.89 12.88 66.67 64.89 Patient associations 0.18 0.00 2.21 3.82 11.23 6.87 15.47 16.79 72.52 70.90 Health blogs or forums 0.37 0.76 4.97 8.40 23.57 23.66 19.71 19.08 48.09 51.38 Source: authors’ own data. Highest and lowest frequencies/scores are showed in different colors. 5.30 4.25 58.33 55.54 75.00 66.48 58.33 58.56 26.52 23.20 0.00 0.18 25.76 21.81 34.85 34.87 15.91 15.10 24.24 21.73 19.70 20.26 21.97 16.21 52.27 50.65 6.06 8.49 5.30 7.37 13.64 14.00 35.61 29.65 46.21 47.33 9.09 10.72 0.76 0.37 1.52 3.50 2.27 3.31 6.82 11.42 12.12 12.89 7.58 12.57 0.00 0.74 2.27 7.55 1.52 2.39 11.36 15.47 19.70 23.39 0.0 20.0 40.0 60.0 80.0 100.0 MobU-Online administrative procedures (with Public Administrations or businesses) WebU-Online administrative procedures (with Public Administrations or businesses) MobU-Look for information on search engines WebU-Look for information on search engines MobU-Use social media WebU-Use social media MobU-Use eMail WebU-Use eMail MobU-Watch, listen to, download or share files WebU-Watch, listen to, download or share files MobU-Buy products or services WebU-Buy products or services Every day Frequently Occasionally Almost never Never Figure 1. Basic online activities (by user profile). In the area of healthcare, when informants were asked about search criteria and priorities for online health queries, a similar behavior pattern emerged. Table 1shows that although consultation sources and priority of access to them were equal, MobU had higher consultation intensity and frequency. Table 1. Frequency of accessing health information sources (by user profile). When You Look For Information about Health, How Often to You Go to the Following Websites? Frequency of Access Every Day Frequently Occasionally Almost Never Never User Profile WebU MobU WebU MobU WebU MobU WebU MobU WebU MobU My Autonomous Community’s public health service 0.92 0.00 11.58 18.94 43.20 39.39 19.49 18.18 23.48 24.82 Another institution such as the World Health Organization or the Ministry of Health 0.18 0.00 3.31 6.82 19.12 18.18 17.65 18.94 56.06 59.74 Businesses that provide healthcare services (insurance companies or workplace mutuals) 0.00 0.00 2.94 3.03 17.28 17.42 14.89 12.88 66.67 64.89 Patient associations 0.18 0.00 2.21 3.82 11.23 6.87 15.47 16.79 72.52 70.90 Health blogs or forums 0.37 0.76 4.97 8.40 23.57 23.66 19.71 19.08 48.09 51.38 Source: authors’ own data. Highest and lowest frequencies/scores are showed in different colors. 3.4. Value and Use of Autonomous Community Websites The first item to address in assessing the AC health services websites was how users accessed knowledge of their existence. The great difference between the two profiles resided in how they knew about the existence of these websites. In the WebU group, 37.2% reported that this information was provided by the AC public health system, its personnel, or another administration ( e.g., municipal ), compared to 31.8% in the MobU group. For MobU, the most common way of accessing this knowledge was by internet search (38.6%), while for WebU, the Int. J. Environ. Res. Public Health 2021,18, 13055 7 of 17 percentage was lower (31.2%). This strikes a contrast between a more institutional and traditional access profile and a more informal and up-do-date one. Turning the spotlight to frequency of access, we found that MobU accessed health websites considerably more often: 52.7% declared to have accessed such a site “in the last month” compared to 36.1% of WebU. The latter group also presented more sporadic access by declaring higher frequency of access superior to 3 months. Levels of satisfaction with websites showed the greatest differences at “moderate” and “high” levels. Among WebU, 44.1% reported moderate satisfaction, compared to 36.4% of MobU. In contrast, 54.5% of MobU indicated “high” satisfaction, while only 48.4% of WebU declared the same. A general reading, thus, confirms a medium-high level of satisfaction in both profiles that is slightly higher among mobile users. Concerning accomplishing the objectives for which they accessed the websites, there were no great differences: more than 9 out of 10 (92.4% of MobU and 90.8% of WebU) declared to have fulfilled the intended purpose of their visit. The data compiled about the type of consultations on healthcare websites indicate that the information most commonly sought by both user groups was “locating medical centers, opening hours and contact information”. However, differences appeared for other types of information: MobU searched for “prevention programs” (vaccinations, advice on healthy habits . . . ) and “Information on the AC public health system” more frequently than WebU. Differences for other types of information, such as “Illnesses, therapies and medications”, were smaller. As for frequency, MobU used the websites more (there were fewer “never” responses) and more intensively (more frequent than occasional) than WebU. For eHealth services, the pattern became more accentuated. First of all, the most frequent service accessed—by 83.3% of MobU and 72.5% of WebU—was online scheduling (changing, canceling) of appointments. The service most often accessed after that, though to a lesser extent (34.1% MobU, 28.0% WebU), was management of the medical identification card. More specifically, differences found in the frequency of seeking online services indicate that 33% of MobU used the services mentioned on some occasion, compared to 28.8% of WebU. There was a difference of 10.9% between the two groups for online scheduling of appointments (16.7% of MobU had never used this service, compared to 27.5% of WebU). Apart from these two services, MobU reported using an average of 21.6% of available eHealth services (range 15–23%) and WebU used an average of 18% (range 13–20%). Again, there were no great differences in the importance attributed to each eHealth service, although MobU tended to assign them more value and importance. There were fewer in that group who responded that these services had “No importance” (7.3% compared to 10.1% for WebU) and 66.2% of MobU considered all the services “very important”, compared to 63.2% of WebU. Figure 2shows the main differences among eHealth services and the prominence of services related to scheduling appointments and consulting/receiving medical reports or results. Regarding ease of use of eHealth services, hardly any differences appeared, and both profiles considered them easy to use (88.3% of MobU; 88.1% of WebU). When asked for a general opinion of the AC websites, the opinions of both profiles were recorded along with MobU responses to a specific question about using those websites from a mobile device. Table 2shows the comparison of opinions regarding AC public health websites by user profile. Int. J. Environ. Res. Public Health 2021,18, 13055 8 of 17 Int. J. Environ. Res. Public Health 2021, 18, 13055 8 of 17 Figure 2. Ranking of the importance of health services (by user profile). Regarding ease of use of eHealth services, hardly any differences appeared, and both profiles considered them easy to use (88.3% of MobU; 88.1% of WebU). When asked for a general opinion of the AC websites, the opinions of both profiles were recorded along with MobU responses to a specific question about using those websites from a mobile device. Table 2 shows the comparison of opinions regarding AC public health websites by user profile. To better understand the balance between categories, a visual indicator was created. Multipliers were used for each percentage of cases marked in the response categories (Very bad = *0; Bad = *1; Unremarkable = *2; Good = *3; Very good = *4). The maximum accumulated value of 400 points became a denominator that made it possible to standardize scores in a range of 0 (Very bad) to 1 (Very good). This indicator was applied to other questions in the same way, multiplying the scores by “n (number of categories)-1”. Table 2. Opinions of Autonomous Community health websites (by user profile). Frequency Score Rating of AC Websites Rating of Mobile Version of AC Websites Rating of AC Websites Rating of Mobile Version of AC Websites WebU MobU MobU WebU MobU MobU Very bad 0.4 0.8 3.1 0 0 0 Bad 2.5 3.9 1.5 2.46 3.88 1.53 Unremarkable 19.3 15.5 22.9 38.64 31.01 45.80 Good 66.7 65.9 55.7 200.00 197.67 167.18 Very good 11.2 14.0 16.8 44.70 55.81 67.18 Score (0–1) 0.7145 0.7209 0.7042 Source: authors’ own data. 0.0 20.0 40.0 60.0 80.0 100.0 MobU-Request, change or cancel an appointment with my general practitioner, a medical specialist or other healthcare professional WebU-Request, change or cancel an appointment with my general practitioner, a medical specialist or other healthcare professional MobU-Access my medical records WebU-Access my medical records MobU-Access or receive medical test results WebU-Access or receive medical test results MobU-Communicate with a healthcare professional WebU-Communicate with a healthcare professional MobU-Request change of doctor WebU-Request change of doctor MobU-Manage my medical identification card (request new card, change information … ) WebU-Manage my medical identification card (request new card, change information … ) Percent of total MobU vs WebU ranking of importance of eHealth services Very Somewhat Not very Not important Figure 2. Ranking of the importance of health services (by user profile). Table 2. Opinions of Autonomous Community health websites (by user profile). Frequency Score Rating of AC Websites Rating of Mobile Version of AC Websites Rating of AC Websites Rating of Mobile Version of AC Websites WebU MobU MobU WebU MobU MobU Very bad 0.4 0.8 3.1 0 0 0 Bad 2.5 3.9 1.5 2.46 3.88 1.53 Unremarkable 19.3 15.5 22.9 38.64 31.01 45.80 Good 66.7 65.9 55.7 200.00 197.67 167.18 Very good 11.2 14.0 16.8 44.70 55.81 67.18 Score (0–1) 0.7145 0.7209 0.7042 Source: authors’ own data. To better understand the balance between categories, a visual indicator was created. Multipliers were used for each percentage of cases marked in the response categories (Very bad = *0; Bad = *1; Unremarkable = *2; Good = *3; Very good = *4). The maximum accumulated value of 400 points became a denominator that made it possible to standardize scores in a range of 0 (Very bad) to 1 (Very good). This indicator was applied to other questions in the same way, multiplying the scores by “n(number of categories)-1”. As is apparent, there were no great differences between MobU and WebU ratings of AC websites, although the generally favorable opinions of MobU were somewhat attenuated when it came to evaluating the mobile versions of those websites. Table 3presents the results for other eHealth services based on the same calculation pattern . Int. J. Environ. Res. Public Health 2021,18, 13055 9 of 17 Table 3. Frequency and importance of eHealth services (by user profile). Scores Regarding Frequency of Use of eHealth Services Scores Regarding Importance of eHealth Services WebU MobU Dif WebU-MobU WebU MobU Dif WebU-MobU Request a second medical opinion 0.0523 0.0811 −0.0288 0.7509 0.7519 −0.0010 Register a complaint 0.0607 0.0848 −0.0241 0.7857 0.8010 −0.0154 Access medical test results 0.1444 0.3077 −0.1632 0.7563 0.7667 −0.0104 Receive medical test results 0.1202 0.2564 −0.1362 0.7706 0.8333 −0.0627 Check an appointment or position on a waiting list 0.1948 0.2701 −0.0753 0.8362 0.8640 −0.0278 Check prescriptions or medications 0.1236 0.1411 −0.0176 0.7259 0.7275 −0.0016 Request reimbursement of expenses 0.0486 0.0751 −0.0265 0.7031 0.7025 0.0007 Receive information on preventative health campaigns 0.1118 0.1042 0.0077 0.7519 0.7743 −0.0224 Consult with a healthcare professional online by videoconference 0.0117 0.0061 0.0056 0.7392 0.7813 −0.0420 Monitor health using remote measuring devices (glucose, blood pressure . .. ) 0.0760 0.0841 −0.0081 0.7500 0.7787 −0.0287 Compile data about individual physical activity (smartwatches, pulsometers) 0.1566 0.1976 −0.0411 0.6509 0.6432 0.0077 Ability to send health-related photos or files to a professional 0.0513 0.0685 −0.0171 0.7012 0.7442 −0.0430 Average 0.0960 0.1397 −0.0437 0.7435 0.7640 −0.0206 Source: authors’ own data. Highest and lowest frequencies/scores are showed in different colors. For this, Tables 3–5, which have the same layout, the explanation of the colors is as follows: in columns WebU and MobU, the scores obtained are shown from lowest (red) to highest (green); intermediate values are shown in orange and yellow. In the Dif WebUMobU columns, the differences in favor of MobU are highlighted in red; those features in which WebU scores higher are in green. Table 4. Importance of measures to foster access to eHealth (by user profile). WebU MobU Dif WebU-MobU Improve internet speed 0.8579 0.8590 −0.0011 Improve coverage and access in all of Spain 0.9002 0.9033 −0.0031 Reduce internet costs 0.8956 0.9192 −0.0236 Reduce costs of devices (mobile phones, computers, tablets) 0.8625 0.8687 −0.0062 Improve citizen education in new technologies 0.9233 0.9116 0.0116 Increase security and privacy of personal data 0.9331 0.9338 −0.0008 Make known and simplify the use of digital certificates and national ID cards 0.8887 0.9000 −0.0113 More encouragement from medical professionals to patients to make greater use of these technologies 0.8278 0.8244 0.0034 Publicize and inform more about health websites and apps 0.8520 0.8564 −0.0044 Better coordination among medical centers, hospitals, pharmacies and professionals 0.9501 0.9495 0.0006 Int. J. Environ. Res. Public Health 2021,18, 13055 16 of 17 rollo e Innovación Orientada a los Retos de la Sociedad, Convocatoria 2014). This fact does not imply the existence of any type of conflict of interest either due to such funding or for other reasons. Institutional Review Board Statement: Not applicable. Informed Consent Statement: Informed consent was obtained from all subjects involved in the study. Data Availability Statement: The survey will be available in this public repository: http://www. arces.cis.es/jEstudios.jsp. Conflicts of Interest: The authors declare no conflict of interest. The funders had no role in the design of the study; in the collection, analyses, or interpretation of data; in the writing of the manuscript, or in the decision to publish the results. References 1. De Maeseneer, J. European Expert Panel on effective ways of investing in Health: Opinion on primary care. Prim. Health Care Res. Dev. 2015,16, 109–110. [CrossRef] 2. Criado Grande, J.I. Entre Sueños Utópicos y Visiones Pesimistas; INAP: Madrid, Spain, 2009. 3. Naciones Unidas. 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