Hans van den Heuvel

DISCUSSION Principal findings By providing this overview of the literature, we aimed to assess the applicability, advantages and limitations of the use of e-health in perinatal care. This review showed that e-health interventions have a very broad, multilevel field of application focused on perinatal care in all its aspects. Most of the reviewed 71 articles were published after 2013, suggesting this novel type of care is an important topic of clinical and scientific relevance. Women of reproductive age seem to be interested in e-health as shown by their frequent use of smartphone, internet and apps and searches for pregnancy information. Most health outcomes for perinatal e-health interventions were generally positive, either resulting in positive effects (lifestyle, mental health) or providing multiple advantages while health outcomes were found equal (diabetes care). The implementation of telemonitoring was not studied extensively but research provided important effects and advantages on facilitation of new care models. Patient and care provider satisfaction with e-health interventions rates are generally good with rates up to 95%. Additional considerations Despite the promising preliminary results as reviewed above, research in e-health has progressed much slower than developments in the health technology industry. A great amount of the reviewed articles on this subject addressed more than health outcomes or satisfaction rates alone. Advances in (implementation of) apps and devices and patient- generated data are retained by legal and financial concerns. Possible privacy risks involve a lack of control to collection of data and the use by third parties afterwards. In the United States, e-health legislation, secured in the Fair Information Practice principles (part of the Health Insurance Portability and Accountability Act), is lacking protection for endpoint users: the patients. End-to-end data encryption can be used to protect the useful patient data. Combined with authentication and access control mechanisms for patients as well as care providers, e-health technologies can further enhance final security control. 106 The development of TELE-MED Act (2015), may accelerate the removal of barriers and limitations regarding use of telehealth between different states in the US. 107 In the framework of European law, e-health is simultaneously a healthcare service and an information service with corresponding legislation 108. E-health developers have to mind general legislation regarding privacy protection (Dir 95/46/EC, Arts. 8-12), electronic identification services, e-Commerce directive (e.g. online contracting), safety requirements of medical devices and general product safety and liability requirements. In answer to the inter-state developments in e-health care, the Cross Border Directive was initiated in 2011 in the European Union. The objective of the initiatives within this directive is to turn telemedicine into a standard medical service, accessible to every European patient and fully CHAPTER 2 28