The analysis of the results reveals that the majority of patients could benefit from the use of health informatics tools as the Online Patient Book©. The majority who evaluated their use of the Online Patient Book©, 32 out of the 34 patient users, stated that the tool contributed positively to their feelings of security and certainty during their course of treatment and care. The two patient users who described that the tool had no effect on their feelings of security or certainty still indicated that they valued or utilized the freedom to use the tool when they needed and explained how the tool helped them maintain their overview during their course of treatment. None of the completed responses contained descriptions that pointed directly at negative effects from the use of the tool. This points to the fact that the tool in general empowered the patient users. However, it is important to consider that a higher number of the patients who valued the Online Patient Book© in their course of treatment and care responded to the invitation to evaluate the system than those who did not use or value the tool.
For the purpose of this evaluation, in combination with a population who already were familiar with this particular web environment, the Web-based survey via the Online Patient Book©
was a relevant and appropriate evaluation mechanism. Although, it is acknowledged that face-to-face interviews may potentially contribute to more in-depth insights than those depicted in written evaluations. This is due to the more cognitive demanding task of writing the answers rather than responding to verbal questions [27
]. However, from a qualitative perspective the patients indicated that the Online Patient Book©
was important. Interestingly, this was confirmed in a general hospital patient satisfaction survey conducted in 2010 by Ruby and Poulsen [31
]. Two of the Online Patient Book©
users were informants in this face-to-face interview study and the interviewer was unaware of the Online Patient Book©
. Even so the two informants spontaneously talked about the basic idea in this tool [31
It (the Online Patient Book
) has especially impressed me very much…It is really good, if you just have some questions or something you just have a little doubt about. And for me it is effective, as if I wake up at 3 a.m., I can write, and they (the healthcare professionals) can answer, when they have the time (page 38).
These external findings illustrate the potential of integrating Internet technologies, and especially utilising the online, asynchronous and written environment, in the future patient information.
The findings of this research confirm the conclusion of Pinnock et al.  in relation to their project which developed a website for men with prostate cancer in general. Using the early Internet technologies the contents were primarily readable information, by which the users were limited to passive viewing, and thereby, only could retrieve information. Though, in addition the user could submit an anonymous question to an unknown healthcare professional. The questions and answers were then displayed at the website to all users. However, the website was used passively by most users, with less than 1% of the users submitting anonymous questions. This type of online helpline does not seem to respond to the need for individualized information, as the users still expressed needs for highly individualized information. Pinnock et al.  link the lack of individualized information to the passive role and describe how unique features such as searching, sorting, and interactivity have the capacity to respond to the need for individualized information. The evaluation of the Online Patient Book© documents the importance of complementing the functionality of the static web pages by including more dynamic websites, which allow the users to interact and collaborate in a dialogue.
Furthermore, both the project by Pinnock et al.  and the Online Patient Book© support the potential of utilising the online media even when the patient groups represent patients over 50 years. Despite that the age of the patient group, the evaluation contains several comments that the patients see health informatics tools as an important and natural way of getting information from and communicating with the healthcare professionals. Some patient users directly recommended future use of online contacts both in relation to men with prostate cancer and other group of patients.
The effects of the tool must be understood in the light of the information and communication the individual patient is offered in all. This means that the Internet based dialogue between the patient and the healthcare professionals do not stand alone. The patients in this study were also provided with the standardized oral information and opportunity for dialogues in scheduled meetings at the hospitals. At the same time, the Online Patient Book© offered both monologue and dialogue-based applications, as listed in the Method section. However, this paper focuses on the patient users’ descriptions related to the asynchronous, written dialogue with the healthcare professionals at the Department of Urology.
From this research it is evident that the online dialogue in the Online Patient Book© is possible and that access to it makes a difference, but maintaining and further developing health informatics tools specifically for patients will require the ongoing use of such tools in daily clinical practice and that healthcare professionals are active users. Broom  explains how the qualitative effects for patients who use the Internet relies on the healthcare professionals being active and positive. The Internet allows the patients to act, however, this will only be the case if healthcare professionals are aware and accept the new roles that exist between a patient who is empowered through his use of the Internet and the healthcare professionals. As Broom  stresses the healthcare professionals must provide encouragement, guidance, and support to patients in relation to their Internet usage to achieve the maximum benefits. Additionally, in relation to dialogue-based web applications, such as the Online Patient Book©, the healthcare professionals also have to take an active role in the usage of the tool to support patients.
Or et al.  explain how nurses felt uncomfortable using a health informatics system, if they perceived the use of it as a burden to their patients. Therefore to be an active and positive healthcare professional user it is important that the particular health informatics system improves the quality of care and treatment. Looking at the Online Patient Book© it is therefore relevant to comment about how the healthcare professional users actually saw the importance of this tool. The healthcare professionals’ experiences, in this instance, points to how the Online Patient Book© was of great value for the patients. The Online Patient Book© therefore also became a tool for the healthcare professionals, which they indicate can contribute to increasing quality in the care and treatment of their patients, and especially in relation to meeting the needs of the individual patient. Even though these experiences were only expressed by the healthcare professionals in informal meetings, and therefore not a part of the data gathering in this evaluation, such experiences are very important to establish a positive environment around the every day use of the tool in the clinical practice. However, further evaluations are needed and planned to explore in detail the healthcare professionals’ experiences.
The relevance of dialogue-based applications, which the patients can use at home, is comparable with findings in a study by Andersen and Ruland . Messages via e-mail between patients at home and nurses were analysed using content analysis. This contributed to a picture of patients with cancer who are inadequately informed even when it comes to basic knowledge in relation to their disease, symptoms, treatment, side effects, or rehabilitation. The patients had several serious unanswered questions and concerns, which could contribute to considerable uncertainty and anxiety.
The continuously open electronic door that the dialogue-based web application offers; the online, asynchronous and written environment, appears to accommodate the patients’ need to get in contact without having the feeling of disturbing the healthcare professionals, which was a problem according to the literature survey as depicted in the Background section of this paper. The advantages and importance of the asynchronous online environment is underpinned by Clemensen  who points out the limiting aspects when using telephone, as much time is often wasted. Minimizing waiting time is important both for the patients and for the healthcare professionals and findings in the current study document the relevance in the usage of web application of asynchronous, written contacts for that purpose.
Based on their preliminary results Ruland et al.  consider that online communication with nurses is important in order to reduce the patients’ unplanned consultations with doctors, as these are often the result of the unanswered questions and concerns based on insufficient information.
From the evaluation of the Online Patient Book© it is not possible to conclude whether there has been any reduction in relation to readmission or telephone consultations in the first year of implementation, as the clinical practice has also been influenced by other factors such as the reduction of admission time and changed techniques and procedures in relation to anaesthesia, surgery, and so on. However, it is intended that future study will explore whether quantitative effects are also present.
Both Andersen and Ruland  and Moore and Sherwin  point out the initial fears the healthcare professionals have for inappropriate use, or an overwhelming amount, of online messages from patients. Their findings are based on analysis of the content in e-mails, however both studies initially reject these concerns. Based on the data from the patients’ evaluation of the Online Patient Book©, the current study confirms this rejection. The expressions in the evaluation contribute to a picture of patients who use the online contact because they need it in their difficult and insecure situation. The asynchronous environment contributes to a kind of freedom, an open door, which the patient can use when he needs. However, it is also evident that the patients act as respectful partners in a dialogue, including paying attention to the other participants’ time, for example by trying to avoid disturbing the healthcare professionals. This is consistent with the findings in an interview study by Dickerson et al. . They describe how men who used the Internet have a more proactive attitude including a collaborative approach to patient care. The Internet helps the men to stay in control, to be an active partner and problem solver in their own course of treatment. These men seek an open communication with the healthcare professionals and will come to their consultations prepared, organizing their questions efficiently, as they realize that they need to respect the healthcare professionals time .
In dialogues the presence of at least two partners is a prerequisite, however, it is possible to be present despite physical separation, as presence does not depend solely on physical attendance. Instead the important aspects are to be aware of, listening to, and respond to the other party [22, 39, 40]. In relation to the online environment this means to be aware of, listen to, and respond to the written contributions. Thus, in online asynchronous and written environments, as utilized in this intervention study, reciprocity is significant. All postings have to be responded to as it signals presence and awareness. In the evaluation of the Online Patient Book© the patient users were asked directly whether they experienced any periods when they did not receive an answer within 24 hours. Three patient users responded with an affirmative answer. One patient user contacted the helpdesk following a weekend when he did not get an answer. Whether this neglect was due to workload or oversight is not clear, however, the healthcare professionals still experienced the 24 hours as significant and so, their daily use was supported by an action card placed at a central point in the departments.
There were a number of limitations to the current study. Of the eligible participants 59 percent responded to the invitation to evaluate. It is possible that the patients who valued the Online Patient Book© were more likely to undertake the evaluation. However, none of the patient users stated that the tool had a negative effect on their contact with the healthcare professionals. As the Online Patient Book© is still a part of the standard care in clinical practice it is both possible and relevant to supplement the current evaluation with face-to-face interviews, content analysis of the dialogues generated, and quantitative methods to document reduced resource consumption and with other groups of responders.
The Internet application for online dialogue between the individual patient and healthcare professionals involved in his care is integrated in the health informatics tool: The Online Patient Book©. It is a tool that is designed to be the patients’ health informatics tool, however with a focus particularly on men with prostate cancer treated with prostatectomy surgery. The tool, in its current version, is therefore only relevant in this specified context and for this specific group of patients. However, the Online Patient Book©, as a model, has gain interest in other contexts in Denmark both in relation to other patient groups and other hospital settings. The future use of online contacts, both in relation to men with prostate cancer and other group of patients, is underpinned by the direct recommendation from patient users in the current study. However, further development of the Online Patient Book© to other patient groups or hospital settings will require involvement of patients and healthcare professionals in these contexts. Only through the involvement of these new groups of users, can a relevant patients’ health informatics tool for other patient groups be developed.
In addition to these aspects both structural and cultural issues must be considered in relation to future use of systems as the Online Patient Book© internationally. The development of the Online Patient Book© took place in Denmark influenced by structural components  and cultural issues [42, 43] present in this nation. As with any other health information systems these issues should be taken into account when considering technology transfer. In the case of the Online Patient Book© the basic premise is a sufficient and established infrastructure. The patients and the hospitals must be online with reliable access to the Internet, but the staff should also be granted the possibility to communicate with the patients within a given timeframe. In some health systems each individual service is subject to payment, and in these cases the service delivered by online communication with patients must be considered.
In Denmark personalized online registries have existed for many years, as the unique personal identifier was introduced in 1968. Furthermore, all the necessary legislation has long been in place clearing the way for secure log-on and secure transmission of sensitive communications. These issues should also be considered when transferring the system to another environment.
Issues of liability may also vary from country to country, but the alteration from traditional synchronous audio telephone communication to asynchronous written communication should not pose any further complications. As when the healthcare professionals recognise any ambiguities in their contact with the patients, for example in the telephone contact, they will always ask to see the patient in person at the hospital.
Reflecting these limitation, the Online Patient Book© represents an example of a health informatics system that primarily aimed to meet the information and communication needs of the patients and could therefore be a basis-model for future design processes of patients’ health informatics tools.