Portuguese on line and making it readily accessible to its citizens. As a
case in point, to provide better access to governmental data, Portugal
reportedly offers free public access in some parish churches—
“eGovernment in Europe,” 2004).
However, websites such as the NHS library or MDConsult.com,
which aim to provide accurate and secure information to health-seek-
ers, suffer from readability problems (Ebenezer, 2003) and are rarely
designed for patients (Tench et al., 1998). Moreover, at least in the US
and Canadian contexts, patients are generally unaware of these high-
quality data sources (Sigouin & Jadad, 2002), so they are often not
places to which consumers are likely to turn, at least in the first part of
their attempts to seek information. Hence, health seekers tend to use
general search engines, such as Google (Boston Consulting Group,
2001, 2003). However, the more centralized and commercial websites
found in this manner generally lack customer interaction features.
Instead they provide only unidirectional information (Cudmore &
Bobrowski, 2003). For example, fewer than one out of three pharma-
ceutical company websites offer a way to respond online to consumer
requests. Fewer than half of health-supply websites respond to online
requests or questions (Pharmaceutical, 2003). Yet government health
sites are even less interactive (Rice, Peterson & Christine, 2002).
Further, these more general health sites may not provide the specific,
contextual information appropriate to the user’s needs, and may have
both identifiable and hidden commercial and other biases.
Personal websites have role
Personal, rather than commercial, educational or government, health
websites play a significant role in the construction of medical knowl-
edge online, and represent the growth of interest in ‘local’ knowledge.
In a search for rheumatoid arthritis, 34% of relevant sites were posted
by an individual, more than those posted by a non-profit organization,
and over 6 times more than those posted by an educational institution
(Suarez-Almazor et al., 2001). Yet, very little research has been done on
the ways in which health-seekers use this information source, as its exis-
tence is often overshadowed by online support groups. It is likely that
“blogs,” or web logs (which are essentially on-line diaries with an inter-
active component that encourages others to leave comments), will be
playing a growing and complementary role in these processes.
Uses of Internet and Mobile Technology in Health Systems 187
Physician websites becoming an important resource
In the US, it appears that about one-third of physicians have a Web
site, of whose development obstetrics/gynaecology and internal medi-
cine specialists have been the most prevalent (AMA, 2002). Howitt et
al. (2002) studied UK websites and found that, apart from e-mail sent
to the practice, possibilities for electronic communication were low, as
was the general quality of information. Sanchez (2002) notes that the
vast majority of physician websites focus on practice enhancement tac-
tics, rather than specific patient service. In contrast to the supply side
of the healthcare equation, Norum et al. (2003) report that cancer
patients want to see more information on hospital websites that is
directly related to the delivery of healthcare. For example, these
include waiting time before a physician is available, treatment services,
and office location information (Pastore, 2001). Services like WebMD
are providing physicians with an array of electronic support, including
websites and secure email. Patients have reported that these sites are
cumbersome, in part due to the concerns about liability and the
assumption of responsibility.
Desire for useful online information from physicians is also typical
of Spain, apparently, even though there is overall less Internet health-
seeking and more traditional ties to local providers. This desire is
reflected in a study of Catalonian patients. Panés et al. (2002) found
that 84% of Internet health-seeking patients (which represented 44%
of all patients) suffering from irritable bowel syndrome wanted a local
website from their own clinic; 65% were willing to pay for this serv-
ice. It seems that patient demand continues to exceed physician supply
of useful information both in the US and Spain.
Health kiosks: Crossing a digital divide?
Health kiosks are uncommon in the US and tend to be situated in
clinic waiting rooms (indeed the proportion seems to be declining for
reasons of inutility and cost). For example, Sciamanna et al. (2004)
experimented with a kiosk giving tailored advice on fitness and smok-
ing. Although fewer than one/third of the participants had ever used
the Internet to seek health information, over 80% found the kiosk easy
to use. However, less than half of the doctors looked at the report pro-
vided by the kiosk or discussed it with the patient. Goldschmidt and
The Network Society
Goodrich (2004) placed bilingual kiosks in clinic waiting rooms and
noted that 68% of people said they found all the information they were
looking for, and that flu shots increased by 24% following the installa-
tion. In contrast to the US (which seems to use kiosks to reduce infor-
mation demand on the physician), other countries are experimenting
with health kiosks containing pre-sorted information, to reach commu-
nities which may not have Internet access or know-how. Jones et al.
(2001) found that among an elderly Spanish population without
Internet access, 25% were interested in the kiosk idea. While in terms
of professional opinions about their utility, kiosks do not rate high,
they may yet be a significant way to disseminate medical information
to socially remote communities or in specific delivery locales.
Physician education resources
There is great potential for the Internet to help educate and update
physicians. For instance, Casebeer et al. (2003) details the positive
impact that a Web-based physician tutorial on preventative care (in
these specific case, sexually transmitted diseases) had on the knowl-
edge of the experiment group versus the control group.
Policy Concerns of Centralized Applications
Due to the decentralized, unregulated nature of the web, and even
the contested nature of what constitutes valid and quality medical
information, the accuracy and usability of online information are
extremely pressing policy problems (Berland et al., 2001; Kunst et al.,
2002; Rice, 2001; Zeng et al., 2004). As just one example, websites
that offer so-called alternative medical treatments have been described
as containing dangerously inadequate or misleading information
(Ernst & Schmidt, 2002; Hainer et al., 2000; Molassiotis & Xu, 2004).
Organizations such as HON (Health on the Net) have devised guide-
lines to rate the quality of e-health information, and some current
websites carry the HON seal of approval (Wilson, 2002). However, it
is not clear really to what degree health-seekers use general search
engines because they are not familiar with approved medical
resources, or because they are specifically looking for alternative treat-
ment ideas. As there is no way to prevent the dissemination of haz-
ardous information, the best use of resources seems to be to develop
Uses of Internet and Mobile Technology in Health Systems 189
sanctioned general web health portals and raise public awareness
about ways to look for reliable health information, especially by the
patients’ physicians. The recent success of WebMD Health (after
staggering losses in 2001) demonstrates the fruits of such policies.
In addition, it does seem as if health-seekers realize the dangers of
bad health information online and want the development of local-
medical sources such as physician websites. In responding to this need,
the biggest factors are ensuring readability, privacy, and publicity in
accurate medical sources, as well as informing patients of clinical stud-
ies for new treatments. As Seidman, Steinwachs and Rubin (2003)
point out, there still needs to be developed a robust tool, accessible to
health-seekers, to identify quality information on the Internet.
Yet these concerns should not blind us to the enormously impor-
tant role online health information is already playing. For instance,
Wagner et al. (2004) report that patients who suffer chronic diseases
(in this case diabetes) find that the information gained through online
channels help them manage their situation. Moreover, there is another
way in which quality interacts with the Internet, and this is in terms of
rating the quality of physicians and healthcare providers (especially
hospitals and insurers). Indeed, this is one area in which we could pre-
dict a revolution that will benefit the public even at the cost of some
individual or institutional reputations.
Apart from the quality or design of Internet health applications,
there are still major differences in exposure and access. It is not always
clear whether the fault or limitation inheres in the application or in
the target population. But in the USA, at least, there are consistent
“digital divides” in access to healthcare information. These include
socioeconomic status, gender, race (Houston & Allison, 2002), health
status, language (Berland et al., 2001, found Spanish-language sites
suffered from even worse quality issues), age (Meischke et al., 2005)
and physical disabilities such as elderly immobility (Katz & Aspden,
2001) or visual impairment (Davis, 2002). Most importantly, much
data support claims that higher education levels corresponds with
Internet use (Giménéz-Perez et al., 2002; Licciardone et al., 2001;
The Network Society
1 In fact, in a recent study in W
ashington State, only 7% of seniors who suffered heart
attacks and had Internet access ever looked for information on their conditions online
(Meischke et al., 2005).
Pandey et al., 2003). Kakai et al. (2003) found that people of higher
education levels prefer to get their health information through seem-
ingly objective, scientific, and updated forms, such as the Internet,
while those of lower educational levels prefer to have their informa-
tion come from mass media and other people because they say they
like the human approach. Perhaps one way to increase delivery to the
“have-nots” may be to develop health kiosks in ways that appeal to the
elderly and non-native language speakers; of course attention to loca-
tion and usability would be paramount, as well as situated teaching
campaigns to train local populations in their use.
Cultural factors are also important in understanding the policy
implications of various e-health applications (Yom, 1996). Kakai et al.
(2003) found differences in preferred information sources along ethnic
lines, as Caucasian patients preferred objective, scientific, and updated
information obtained through medical journals, research institutions,
and telephone and Internet sources, while Japanese patients preferred
media and commercial sources such as TV, magazines, books, and
other written sources. Non-Japanese Asians and Pacific Islanders
tended to favor information sources marked by person-to-person
communication, such as physicians, social groups, and other cancer
patients. In the US, black women had a 60% lower likelihood of using
computer-based resources than did white women (Nicholson et al.,
2003), and non-white people are less likely to use the Internet to look
up health information for breast cancer (Fogel et al., 2002). Social and
cultural factors of populations and communities hence appear to be
important considerations when developing targeted e-health applica-
tions (Morahan-Martin, 2004).
Thus, despite the widespread development of Internet e-health
applications, these resources do not seem to be accessible to, or at
least accessed by, large portions of US society. Nor do they often seem
recognized as a source for medical knowledge in communities and cul-
tures that are already much more familiar with face-to-face physician
interaction. The challenge remains then to create health information
systems accessible in ways that fit lifestyles and choices of under-
served groups, motivate healthcare providers to provide personal
encouragement for and information about using online resources, and
encourage these groups to develop knowledge and routes of accessi-
bility to e-health websites.
Uses of Internet and Mobile Technology in Health Systems 191
E-health applications also should not stop at merely providing uni-
directional information, although this is important. Keeping in mind
the way most non-students learn, it is important to develop on-line
possibilities for multi-directional interaction between health-seekers
and appropriately tailored information.
Bamford et al. (2003) implemented a country-wide network of
physician webcams in the UK through the implementation of double-
headed microscopes in 35 histopathology departments across the UK.
A year after installation, they found that 71% of the physicians had
not even used the networking software. All of those physicians who
had used it found it effective for diagnosis and exchanging opinions.
Bamford et al. conclude that the project did not achieve its aims to
due excessive workloads preventing physician training, IT staff reluc-
tance to render assistance, but above all, user attitudes.
Many physicians do not use email because they are not compen-
sated for the time involved to check, assess, and respond (Anderson et
al., 2003; Harris Interactive, 2001; Rice & Katz, 2006); and there are
liability and confidentiality issues that preclude using email. In con-
trast, American healthcare consumers overwhelmingly say they would
often like to be able to contact their physicians by email rather than
through office visits (CyberAtlas, 2002; Norum et al., 2003). Patients
would like to email for prescription refills, non-urgent consultations,
and to receive test results (Couchman, Forjuoh & Rascoe, 2001).
However, it is noteworthy that 75% of patient emails to physicians
included requests for medication/treatment information or actions, or
specific diseases/symptoms (Sittig, 2003). Hassol et al. (2004) found
that most patients preferred email communication and face-to-face
communication with their physicians (depending on the matter), while
US physicians preferred telephone to email communication. Of those
20-30% of physicians who do use email or electronic communication,
many see improved patient satisfaction and some note improved effi-
ciency and care (Harris Interactive, 2001).
The Network Society
In this context, it is unsurprising that researchers have attempted to
develop software that would identify terms in patients’ emails that could
be then linked to medical information to be emailed back to the patients
without the need for a physician response (Brennan & Aronson, 2003).
This system may be efficient, but it is also likely to raise some serious
concerns in the minds of the patients; it may be that patients want email
because they seek a human response, which may be paradoxically more
difficult through traditional physician-patient channels.
Sometimes it is suggested that “out-sourcing” of medical informa-
tion provisioning could help the developed countries as well as devel-
oping ones. This idea is already widespread in many technical and
consumer support fields, most notably in computer user problem res-
olution. However, there appears to be scant interest on the part of
healthcare consumers for such services at this point. For instance,
Hassol et al. (2004) evaluated interest in various ways in which off-
shore physicians could be contacted by patients. They found mild
interest in telephone contact methods among Americans, but no inter-
est whatsoever in an email service.
Health information management systems
Mendelson and Salinsky (1997) note that the early failure of many
Community Health Management Information Systems (CHMIS)
(similar to CHINS, or community health information networks) was
due to the lack of private sector support for integrated, state-wide sys-
tems. In addition, the general public distrust of state-sponsored health
care systems combined with the proprietary interests of the players
involved served to eliminate them in the majority of states (Eder &
Wise, 2001; Katz & Aspden, 2001). However, in states where health
databases exist, such as Wisconsin Health Information Networks, the
direct access to clinical and administrative data saved up to $68,000 a
year for private practices and up to $1 million for hospitals
(Mendelson & Salinsky, 1997).
Using electronic medical records in hospital databases was demon-
strated to help ensure consistent and correct coding by physicians, as
well as context-sensitive treatment in Germany, by Muller et al.
(2003). Patient-accessible health records have been found to be a valu-
able step forward, with satisfaction, rates in the 65-85% range (Hassol
Uses of Internet and Mobile Technology in Health Systems 193
et al., 2004; Joustra-Enquist & Eklund, 2004; Wang et al., 2004).
there is both resistance to them by staff due to local cultural practices
and larger concerns about privacy and security. Radio-frequency iden-
tification (RFID) systems are expected to blend database management
and mobile tracking together in extremely fruitful ways, although
problems of cost and integration remain to be solved before they can
see widespread deployment.
Outside of the US, the EU has implemented a general e-health
strategy for the years to come,
and Tachinardi (1998) describes an
ongoing project in Brazil to build a network of e-health applications
including a unified health record for the exchange of patient data, and
a virtual hospital of health information and medical journals for physi-
cians and lay patients..
Online discussion groups respond to many of the needs unfulfilled
by the centralized information providers. In some cases, these groups
extract information from professional journals (Wikgren, 2001) and
recreate it in a way to make it more applicable and understandable
among the users. Many discussion groups include physicians (Katz &
Aspden, 2001). Practically all conditions and situations have groups,
The Network Society
ang et al. (2004) developed a web-based personal health record for patients to collect
and manage their health information (medical history, past surgeries, medications, and
allergies), to request self-referrals, and to store a record of their consultations. The PHR
also includes a messaging system that can be structured into the workflow of referral man-
agement as well as allowing more general communications. A preliminary study was con-
ducted with 61 patients. Thirty-two patients completed a survey in which 85% of
respondents were satisfied with the usability and 94% were satisfied with the overall online
referral process. Joustra-Enquist and Eklund (2004) report on SUSTAINS, a web-based
health care account in which the patient can login (with a login sent to their mobile
phone) and review medical results and prescriptions and information, and exchange writ-
ten information with physicians; participants reported that it is beneficial for both parties.
According to Hassol et al. (2004), 65-85% of Americans in an experiment with electronic
health records reported them easy to use, and that they understood all the information; a
small minority reported confidentiality concerns.
3 By the end of 2005, each member state should have a national roadmap for e-health,
focusing on e-health symptoms and electronic records, and there will be an EU public
health portal. By the end of 2006, member states should have a common approach to
patient identifiers and identity-management, as well as interoperability standards for
health data message and electronic health records. By 2008, health information networks
should be commonplace (European Commission, 2004).
including those that deal with chronic conditions or embarrassing
conditions (Millard & Fintak, 2002) and rare diseases (Patsos, 2001).
Participants also report across-the-board benefits for themselves (Pew,
2000; Pew 2002) and for their loved ones (Till, 2003). They especially
seem to like the fact that use offers empathy (Preece & Ghozati,
2001), personal empowerment (Sharf, 1997), and emotional support
(Winzelberg et al., 2003). In fact, many report that symptoms seem
reduced or alleviated by membership (Lorig et al., 2002; McKay et al.,
2001; Winzelberg et al., 2003). This is not surprising in part because if
people did not perceive benefits, they would not be using the systems.
The social-psychological and emotional benefits are the qualities that
are often lacking in treatments provided by physicians and institu-
tions. Beyond the perception of psychological and emotional benefits,
however, perceptions of actual health changes and improvements may
be highly inaccurate and may even lead users to engage in treatment
practices that are harmful.
E-commerce and online bidding
MedicineOnline.com offers an auction service in which patients can
elicit physician bids for surgeries (Baur et al., 2001). It is unclear who
uses this service, however, and what impact it has. At the same time,
online “retail” e-commerce is likely to grow quickly, in part because of
the desire to reduce costs and, in many societies including the US, to
open channels of competition. This is likely to affect the cost of, and
hence demand for, many elective procedures. Cosmetic surgery and
whole-body magnetic resonance imaging (MRIs) are likely to be
among those that are going to be competitively marketed online.
Certainly there is already much promotion among dentists for both
routine and cosmetic procedures through traditional distribution
channels, and it is likely that the Internet will also become an impor-
tant method of advertising for many common procedures and for
attracting patients to under-utilized hospitals and treatment centers.
The US has experimented with web-based health interventions,
while other countries tend to focus on mobile phone text-based inter-
ventions (Curioso, 2006). For the US, one web-based diabetes care
Uses of Internet and Mobile Technology in Health Systems 195
Documents you may be interested
Documents you may be interested