Intended for healthcare professionals

Letters E-patients and healthcare

Skills and characteristics of the e-health literate patient

BMJ 2018; 361 doi: (Published 16 April 2018) Cite this as: BMJ 2018;361:k1656

‘Smart’ technologies in low resource settings: Do epatients exist in this part of the world?

There has been an ever-growing advancement in technologies in terms of devices as well as software. Smartphones and digital devices coupled with multi-functional and up to date health applications powered by the internet systems are increasing day by day. Data reports, more than 95% people living within the coverage of mobile networks and 63% of the population having access to mobile phones in Nepal as of January 2018.1 Given this context, the use of health information from electronic media and the ability of people to utilise this information to decisions is far from being known. This is supported by a 2016 study conducted among the new doctors from a leading health sciences university in Nepal, where 40% of them had never used the internet for searching health queries in past one year and more than a quarter of these doctors were unsure about the availability of useful health resources in the internet.2 The Nepal Health facility 2015 reports only 1 in 10 health facilities in Nepal have access to internet.3 Nepal has an adult literacy rate of 66% nationally.4 Only about 60% of all deliveries were conducted by skilled providers in 2016.5 Voluntary insurance schemes with a coverage ceiling of 500 USD per family is just being implemented and out of pocket expenditure (OOP) in health is still close to 50%.6
With the health system in Nepal still working on provision of basic health services to all, the government through the National eHealth Strategy 2017, encourages the use of information and communication technologies in improving quality of care and evidence based decisions regarding health care services.7 eHealth initiatives are just starting as health message dissemination and informing services through mobile/web based platforms in Nepal.7
Health literacy is used synonymously with knowledge disease or services in Nepal, and the concept is yet to be recognised as a composite concept8 encompassing the ability to access, understand, appraise health information and process this information to make health care decisions for oneself and others.9,10
In one arm access to digital media is increasing with ‘smart’ technologies, on the other arm, the basic health services are still a luxury for many due to access, affordability and knowledge/awareness issues.8
There is a dearth of evidence, health literacy of the population at large and health literacy responsiveness of the health system is not known. eHealth literacy is still remains a hidden challenge in Nepal. The internet use, especially the social media seem popular, yet the use of electronic resources for health care decision making is not known. The evidence is yet to be generated, however at this point the recent eHealth Literacy Framework11 seems to be a potent tool to generate evidence regarding the eHealth Literacy among Nepali people- epatients12 or not. eHealth Literacy of a low income country resident has a tendency to also affect the high income country in the modern era, where doctors produced in a low income country are employed in Americas, Europe and Australia and simultaneously these regions also have people from a low income country who eventually presents as patients in a high income country.
1. Telco News. Internet users in Nepal increases rapidly, penetration reaches 63 percent. Technology and Services for Internet in Nepal. Kathmandu; 2018 Jan 31;
2. Pokharel PK, Budhathoki SS, Pokharel HP. Electronic Health Literacy Skills among Medical and Dental Interns at B P Koirala Institute of Health Sciences. J Nepal Health Res Counc. 2016;14(3):159–64.
3. Ministry of Health (MOH) Nepal, New Era, NHSSP, ICF. Nepal Health Facility Survey 2015. Kathmandu; 2017.
4. Central Bureau of Statistics. National Population and Housing Census 2011(National Report). Vol. 1, Government of Nepal, National Planning Commission Secretariat, Central Bu reau of Statistics. 2012.
5. Ministry of Health. Nepal Demographic and Health Survey 2016. Kathmandu; 2016.
6. Social Health Security Development Committee. Health Insurance Board, Government of Nepal [Internet]. 2018 [cited 2018 Apr 20]. Available from:
7. Government of Nepal Ministry of Health. eHealth Initiatives in Nepal. In: eHealth Convergence & Planning Workshop. Kathmandu; 2017.
8. Budhathoki SS, Pokharel PK, Good S, Limbu S, Bhattachan M, Osborne RH. The potential of health literacy to address the health related UN sustainable development goal 3 (SDG3) in Nepal: a rapid review. BMC Health Serv Res. BMC Health Services Research; 2017;17:237.
9. Batterham RW, Hawkins M, Collins PA, Buchbinder R, Osborne RH. Health literacy: applying current concepts to improve health services and reduce health inequalities. Public Health. 2016;132:3–12.
10. Greenhalgh T. Health literacy: towards system level solutions. BMJ. 2015;1026(February):24–5.
11. Kayser L, Karnoe A, Furstrand O, Batterham R, Christensen KB, Elsworth G, et al. A Multidimensional Tool Based on the eHealth Literacy Framework: Development and Initial Validity Testing of the eHealth Literacy Questionnaire (eHLQ). J Med Internet Res. 2018;20(2):e36.
12. Riggare S. E-patients hold key to the future of health care. BMJ. 2018;360:k846.

Competing interests: No competing interests

20 April 2018
Shyam S Budhathoki
Associate Professor
School of Public Health and Community Medicine
B P Koirala Institute of Health Sciences, Ghopa-18, Dharan, Nepal