e-Health involves a broad group of activities that use electronic means to deliver health related information, resources and services . The World Health Organization (WHO) has therefore defined e-health as the use of information and communication technologies (ICT) for health . e-Health has also been referred to as forms of prevention and education, diagnostics, therapy and care delivered through digital technology independently of time and place . As such e-health has the potential to improve quality of healthcare services , resulting in at least 125 developed and developing countries demonstrating continued interest in e-health uptake and use [5, 6].
Motivation to embrace e-health in developed versus developing countries will differ based on the needs and circumstances at play in a particular country classification. Adoption priorities for e-health in developing countries are likely to be influenced by significant health workforce shortages , shortage of resources (e.g. infrastructure, medical, and financial resources) as well as struggles with both communicable and non-communicable disease . In developed countries e-health focuses on applying ICT to improve the efficiency and effectiveness of healthcare delivery, while in emerging and developing countries focus is directed towards providing access to basic healthcare for people .
Even with all its promises, e-health implementations are not always successful and implementation challenges have been documented. Historically failure rates of up to 70% have been reported  and many e-health interventions have been reported to fail during clinical implementation , to sputter along , to be plagued by expensive problems , or to be regarded as spectacular  or even dangerous failures . Particular challenges associated with e-health implementation in developing countries include; lack of skilled stakeholders, inadequate infrastructures, lack of acceptance, limited resources, inadequate information communication as well as inadequate process guidance .
Case studies from developed countries are instructive, with many reasons identified as contributors to failure of an e-health project implementation [17, 14]. The UK’s National Programme for IT (NPfIT) was reported to lack both adequate end user engagement and trust, as well as lack of a phased change management approach. In addition it suffered from enforced top down decisions, and its profound scale was underestimated . In Germany, a failed e-prescription implementation had many reported failings: too technical and design focused, insufficient in focus on processes and organisational change, lacking in an overall and integrated architecture at the outset (which was not developed over time), and including no appropriate time frames for development projects. Assessments during the course of the interventions were not taken into account and governance structures were unclear and changed over time. Furthermore, the opposition of the national medical assembly was not taken seriously (the project required additional time commitments from physicians who would not profit from the service) and should not have been implemented. In addition, any benefit from nearly simultaneous starts of field test projects was unclear, there was inflexibility regarding the re-prioritisation of tasks, and insufficient time to deeply test the technology in the laboratory. Although a cost-benefit analysis was conducted, it was performed too late and not published, and showed a negative cost-benefit for five and ten year projections .
These examples emphasise that failure of an e-health implementation may have nothing to do with the e-health technology employed, but rather may be due to a lack of preparedness of the setting (healthcare institutions or communities) in which the e-health innovation is to be implemented. Reasons for lack of such preparedness in both developed and developing countries may generally be similar but may also differ based on unique circumstances present in any given country. The term e-health readiness has been used to describe the preparedness of healthcare institutions or communities for the anticipated change brought by programs related to ICT . As such it is critical to conduct an e-health readiness assessment prior to implementation of e-health innovations so as to reduce the chances of project failure. An e-health readiness assessment represents a significant step to analysing the existing setting and providing appropriate approaches to successful e-health transformation .
A previous study by the authors documented the existence of various e-health readiness assessment tools and frameworks in the literature, of which none were found entirely suitable nor adequate on their own to assess e-health readiness in the context of developing countries . Based on this work, a subsequent study developed consistency in defining e-health readiness assessment themes and e-health readiness types based upon e-health expert’s opinion and the literature. This is illustrated in Fig. 1 . This then led to conceptualisation and development of an e-health readiness assessment framework (eHRAF) suitable for use in developing countries (Fig. 2).
The definitions of each e-health readiness type are as follows ;
Organisational Readiness: The extent to which the institutional setting and culture supports and promotes awareness, implementation, and use of e-health innovations (e.g., presence of relevant policies; senior management support).
Technological / Infrastructural Readiness: The availability and affordability of ICT resources necessary to implement a proposed e-health innovation (e.g., skilled human resources, ICT support, quality ICT infrastructure, and power supply).
Government Readiness: The extent to which a country’s Government and politicians support and promote awareness, implementation, and use of e-health innovations (e.g., presence of relevant policies, and funding.
Societal Readiness: The degree of ‘interaction’ associated with a healthcare institution. Interaction is described by three parameters; interaction among members of a healthcare institution, interaction of a healthcare institution with other healthcare institutions, and interaction of a healthcare institution with its local communities.
Healthcare Provider Readiness: The influence of a healthcare provider’s personal experience; primarily their perception and receptiveness towards the use of e-health technology.
Engagement Readiness: The extent to which members of a community are exposed to the concept of e-health and are actively debating its perceived benefits as well as negative impacts. It also involves gauging the willingness of members of a community to accept training on e-health.
Core Readiness: The extent to which members of a community are dissatisfied with the current status of their healthcare service provision, see e-health as a solution, and express their need and preparedness for e-health services.
Public / Patient Readiness: The extent to which members of the public and patients are aware of, and can afford and access, e-health services. It also involves gauging the influence of their personal experiences on their perception and receptiveness towards the use of e-health technology.
The proposed e-health readiness framework for developing countries first illustrates the overarching role of ‘e-readiness’ of a setting which will inevitably impact ‘e-health readiness’ (Fig. 2). The framework then prompts assessment of e-health readiness to be conducted separately for each component of e-health (health informatics, telehealth, e-commerce, and technology enabled and enhanced teaching). In terms of actual assessment, the need for separate e-health readiness assessment tools for technical and non-technical individuals (e.g., ICT staff versus clinicians and managers) is illustrated [20, 21]. Two aspects are then identified as essential factors in determining an e-health ready setting, both of which require specific assessment; first, stakeholder engagement, and second, the presence of relevant e-health infostructure and infrastructure. Within the framework, government is at the core of stakeholder engagement.
Relevant and essential stakeholders to be engaged are; the private sector, community leaders, international partners, as well as non-governmental organisations (NGOs), humanitarian organisations, and faith based groups (Fig. 2). The need for development of a comprehensive and informed national e-health strategy as a prerequisite to e-health readiness is shown. Also highlighted are the four themes of governance (institutional and national), resources, stakeholder issues, and access. These were identified by experts in Botswana as important considerations during the development of the national e-health strategy and achieving e-health readiness. e-Health readiness assessment types (defined above) were extracted from the literature . They are included in the framework and aligned to related themes from the expert interviews (Fig. 1), and are also considered to be important during development of a national e-health strategy and towards achieving e-health readiness.
It was necessary to validate the proposed framework. Whilst the literature shows validation of various e-health readiness ‘tools’ [22, 23] there is no specific guidance for validation of e-health readiness ‘frameworks’. 'Validation' can be undertaken in several ways. Some approaches have involved psychometric assessment  or face and content validation . Others have used broad opinion gathered through social media (Facebook and LinkedIn) and either self-administration of a survey or interviews with a sample of users . In examining how to validate quality frameworks in e-learning, six approaches to validation were identified, including review of appropriate research literature, undertaking survey research, and using the knowledge of experts in the field . Overall, no specific and accepted approach to validation of e-health related frameworks has been explicitly described. Here, validation is considered the process of establishing evidence that confirms the eHRAF will be capable of consistently guiding the process it is supposed to, and that it meets the operational needs of the planned users. Considering the work of Inglis (2008) and because the literature had already been used in the design process, a survey approach to seek the opinion of international experts as well as planned users within Botswana was considered the appropriate route to validate the eHRAF. The aim of this study was, therefore, to validate the aforementioned e-health readiness assessment framework through expert survey and to determine if the framework required further refinement before empirical testing.