December 4th, 2009 by Christian Seebode

But how much trust is really needed to support a patient’s individual health? Maybe this is not the right question because trust is a concept with a general image but individual consequences. What feels right and trustworthy for one person is unacceptable for another. Additionally the trust needed for a patient – physician dialogue in a face to face contact may be something different than the trust into same thing online. This seems to be the situation. The undisputable right of the patient for privacy, security and trust can’t be assessed without knowing the net effects on the same concepts of the applied technology. However blogging without some sense of imagination is close to nothing, so here we go …

What is trust in Patient Centered IT Systems?

The need for trust is motivated by some kind of risk involved in a relationship. Risk, perceived risk in particular is what influences trust (Mayer 1995). However, perceived risk may really differ from calculated risk based on real or probable incidences (Croll 2007). Anyway it dominates the importance of trust in ehealth or Patient Centered IT. This is some dilemma because the relationship of trust with perceived risks seems to be uncontrollable and out of reach of a systematic analysis. But his is not true either. The disposition to trust is influenced by some factors which are controllable and under consideration for patient-physician electronic communication (Klein 2007).

In addition to the scientific effort to investigate the meaning of trust in ehealth I try to categorize trust and mention some simple influences on trust in Patient Centered IT that are mainly biased by a pragmatic understanding and common sense.

Trust myself

A patient is in a pitiful situation. Sometimes as considered by him- or herself which has sometimes a value of its own. Patients may consider themselves vulnerable and easily offended which compromises their disposition to trust anything or anybody. Patient Centered IT, especially the Patient – Physician online portals deal with remote communications maybe without knowing communication partners personally. It is obvious that any patient in that situation needs to build some confidence and self-trust. One question that has to be answered in this context is

Would i connect with others online and share intimate information?

If the answer is yes: fine. If no: What can we do about the situation to help it? There’s evidence that the personal control in web-based communications has a positive influence on self-disclosure (Kam 2003). Applications should offer maximum control over content that is contributed by patients. An example is the possibility to change even older contributions and answers to online questions. Another important influence on self-trust is the act of writing itself. Writing in anonymity lowers thresholds for self-disclosure but this neither seems to be a necessary condition nor is it acceptable for online healthcare (Johnson 2007). But at least writing about health symptoms instead of reporting in face to face contacts could support a positive self-image. This in combination that writing supports self reflection (‘What will others think?’) gives patients the sense of more self control and hence self trust. Applications should support this by enhanced interaction possibilities. History and self description should be reviewable and versionable. Interaction with trusted parties (i.e. family members) should be possible too.

Trust others

Patients need to know the risks to communicate online with healthcare providers and the rest of the world. A remote relationship supported by electronic communication is heavily influenced by a trusted image of the healthcare provider (Andreassen 2006). Without this online communication would also not take place. But this is not enough. Applications and portals that are patient centered should be explicit about the risks and provide feedback and statistics. Any act of sharing information should be accompanied by educational material about taking the risk and how others respond in the same situation. Calculating risks and benefits of individual steps and procedures is subject of evidence based medicine. Adopting EBM as a general model in healthcare delivery is generally a good choice since EBM provides maximum transparency for patients. Visualizing healthcare delivery as a patient pathway supports the notion of steps where every step has its own calculated risk. Online communication will never be totally risk free. However the risks are manageable. Self trust together with an attitude that privacy and security is a shared asset and not always a problem helps to improve Patient Centered communication systems.

Trust the system

But how should systems consider trust as a built-in feature? Most important is that patients really do differ in their ability to trust. This should be considered in system design like having the possibility to exercise rehearsal and education with the system. Confidence levels should be explicit and changeable. A personal risk model should be offered to the patient where privacy and security levels can be selected individually for any online communication act. Furthermore system should be explicit about who is able to access the information and who really accesses it and why. This not only supports building trust but empowers patients to a more active role in healthcare delivery.


Among the three categories self-trust, trust in others, trust in systems self-trust is the most important one. It relies substantially on a positive appreciation of sharing private information. However all categories can be supported by adequate system design. This should consider giving patients maximum control over the information entered and how it is processed. Individual risk models and explicit feedback about who may access and accessed personal information is among the features that build trust. Evidence based medicine is an appropriate model to document risks of healthcare delivery in general and should be considered in system design.


Explicit feedback

Evidence based medicine


  1. Mayer(1995), An Integrative Model of Organizational Trust,The Academy of Management Review, Vol. 20, No. 3. (1995), pp. 709-734.
  2. Croll(2007), Investigating risk exposure in e-health systems, Int J Med Inform. 2007 May-Jun;76(5-6):460-5. Epub 2006 Nov 27.
  3. Klein(2007), Internet-Based Patient-Physician Electronic Communication Applications: Patient Acceptance and Trust,e-Service Journal – Volume 5, Number 2, Winter 2006, pp. 27-51
  4. Kam (2003), A Self-Disclosure Model for Personal Health Information, Proceedings of the 36th Annual Hawaii International Conference on System Sciences (HICSS’03) – Track 6 – Volume 6
  5. Andreassen(2006), Patients who use e-mediated communication with their doctor: new constructions of trust in the patient-doctor relationship, Qual Health Res. 2006 Feb;16(2):238-48.
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