![SciPICH Logo](https://webarchive.library.unt.edu/eot2008/20090115020317im_/http://www.health.gov/scipich/images/smscipichtrans.GIF)
![SciPICH Publications - button/link](https://webarchive.library.unt.edu/eot2008/20090115020317im_/http://www.health.gov/scipich/images/pubstinyyel.GIF)
An Evidence-Based
Approach
Introduction:
Evaluation of IHC
Consumers & IHC
Evaluation
Developers &
IHC Evaluation
Policy Issues Relevant
to IHC
Health Care
Providers, Purchasers & IHC
SciPICH Final
Report
![SciPICH home icon and link](https://webarchive.library.unt.edu/eot2008/20090115020317im_/http://www.health.gov/scipich/images/hometrans.GIF)
|
|
Wired for Health and Well-Being: The
Emergence of Interactive Health Communication
Editors: Thomas R. Eng, David H. Gustafson
Suggested Citation: Science Panel on Interactive
Communication and Health. Wired for Health and Well-Being: the Emergence of Interactive
Health Communication. Washington, DC: US Department of Health and Human
Services, US Government Printing Office, April 1999.
Download in PDF format: [Entire Document] [References]
Chapter II.
Interactive
Health Communication
The variety and sophistication of IHC applications have
increased dramatically during the last decade as a result of advances in multimedia
technology and new communication channels such as the Internet. Indeed, the substantial
increase in the number and sophistication of applications available on the World Wide Web
just during the period that this Panel has met is a prime example of the dynamic nature of
these technologies.
IHC applications are available on a wide variety of health
topics and can focus on a single health condition or target a group of conditions. These
programs range from applications designed to convey limited health information to complex
clinical decision-support tools and modules that are designed to influence health
behaviors. The degree of user interactivity can be limited and short-term (e.g., selecting
an option to obtain specific health information) or involve a series of complicated
interactions over a prolonged period of time (e.g., monitoring and managing a chronic
health condition, shared decisionmaking applications). Applications can be developed using
one medium (text) or multimedia techniques (combination of text, sound, and still graphics
and video). In addition, systems-development costs can range from minimal costs to
millions of dollars depending on complexity (GAO, 1996). There are also a plethora of
vehicles and media for disseminating IHC applications. These include stand-alone or
locally networked computers, the Internet (accessed through computers, kiosks, TV, or
other electronic devices), dial-in services, cable, satellite and other wireless modes,
and CD-ROM and DVD and other information storage and delivery technologies.
Whereas most health communication materials and programs
were developed and sponsored primarily by government agencies and nonprofit health-related
organizations in the past, there are now a growing variety of entities and individuals
that are developing, sponsoring, disseminating, and using IHC applications. These include:
individuals, families, and communities; information technology corporations (e.g.,
hardware, software, Internet, telecommunication, and mass media companies); employers and
other purchasers of health services; the health care industry (e.g., managed care
organizations and other health plans, pharmaceutical and other health care product
companies); government agencies and public policymakers; health care professionals and
professional societies; academic health centers and institutions; biomedical researchers;
private nonprofit health-related organizations; schools; publishers; venture capitalists
and investors; and commercial advertisers. A growing number of Internet companies, many of
which have substantial financial backing from large corporations, have been specifically
created to develop and market applications including "e-commerce" companies that
sell health-related products and health "portals" that seek to attract users
searching for health information and support (Fitzgibbons and Lee, 1999). A substantial
number of developers, however, are nonprofit entities. Volunteers often run online peer
support groups, one of the most commonly used IHC applications.
The background and training of developers in the health and
communication sciences vary widely. Some developers may employ a large team of
professionals with extensive experience and training in appropriate areas; other
developers may be individuals without such credentials. Although many stakeholders are
involved in application development, applications produced by large technology
corporations and start-up companies, the health care industry, well-known private
nonprofit health-related organizations, academic institutions, and government agencies are
most likely to reach the largest number of users. Because of the global reach of many
Internet-based applications, programs developed in one country may have implications for
other nations. In addition, as application development tools become easier to use and the
Internet becomes more pervasive, the number of individuals who develop health-related
applications may increase. Currently, data about the frequency to which IHC applications
are evaluated for effectiveness are not available; however, anecdotal information suggests
that such evaluations are uncommon.
Functions of IHC Applications
IHC applications use technology to further the general
goals of health communicationinform, influence, and motivate individuals,
populations, or organizations on health-related issues (NCI, 1989). Although many
applications focus exclusively on one function, an increasing number of applications
encompass multiple functions. The range of specific functions of IHC applications include
the following:
- Relay information. These are applications that
provide general or individualized health information on demand. Examples include Web
sites, online services, and telephone-based applications that use interactive voice
response and fax-back technology (Buhle et al., 1994; Wingerson et al., 1997).
- Enable informed decisionmaking. These applications
facilitate the health decisionmaking process of individuals and/or communication between
health care providers and individuals (including consumers, patients, family members,
caregivers, and others) regarding the prevention, diagnosis, or management of a health
condition (OTA, 1995; AHCPR, 1997). Some applications assist individuals with health care
decisions, such as selecting a health care professional, health plan, or nursing home
(Meyer, 1996; Firshein, 1997). More sophisticated applications assist individuals in
evaluating and selecting options that are consistent with desired health outcomes (Barry
et al., 1995; Wennberg, 1995; AHCPR, 1997; Gustafson, Hawkins et al., 1999).
- Promote healthy behaviors. These applications promote
the adoption and maintenance of positive health behaviors on both an individual and
community level. Some applications promote healthy habits by providing wellness
information and explaining associated benefits and costs. Applications also include
risk-assessment and health promotion modules typically based on theories of behavior
change (Robinson, 1989; Skinner et al., 1993; Campbell et al., 1994; Strecher et al.,
1994; Krishna et al., 1997).
- Promote peer information exchange and emotional support.
These applications represent some of the most common health-related uses of the Internet
(Ferguson, 1996; Scolamiero, 1997) and enable individuals with specific health conditions,
needs, or perspectives to communicate with each other, share information, and provide and
receive peer and emotional support (Gustafson et al., 1992; Gleason, 1995; Bluming and
Mittelman, 1996; Feenberg et al., 1996; Weinberg et al., 1996; Fernsler and Manchester,
1997; Peters and Sikorski, 1997). Online support groups exist for almost any health
condition or health-related need (White and Madara, 1998). Participants in such support
networks include consumers, patients, health professionals, and family caregivers (Brennan
et al., 1995; Ferguson, 1996).
- Promote self-care. These applications may either help
users manage health problems without direct intervention from a health care professional
or supplement existing health services by facilitating remote health monitoring and care
(Robinson, 1989; Ferguson, 1997; Shah et al., 1998). Some users may have limited access to
a health care professional or seek information on therapies that may not be available from
their health care provider.
- Manage demand for health services. These applications
provide specific information, tools, and other resources to support wellness, self-care,
and self-efficacy, to enhance utilization of effective health care services and reduce use
of unnecessary services (Robinson, 1989; Fries et al., 1993; Vickery, 1995). They are
increasingly being used by health plans and employers to manage health care costs
(Mullich, 1997). Examples include computer-assisted telephone advice systems, interactive
voice response systems, clinician-patient e-mail, and other electronic consultations with
health professionals (Balas et al., 1997; Kane and Zands, 1998).
The above functions also may extend the reach of clinical
practice and enhance productivity by increasing patient access to clinician-approved
health information without additional office visits. A continuum of clinician-patient
contact may be established ranging from face-to-face visits to autonomous information
delivery and/or exchange. In addition, reducing unnecessary or trivial visits may increase
clinician satisfaction (Mechanic, 1970) and reduce health care costs.
It is likely that consumers will increasingly use the
Internet and other networked technologies to conduct health care-related transactions to
schedule appointments, fill prescriptions, enroll in health plans, choose providers, and
purchase health-related products. Some health plans are already providing such access to
improve efficiency and service. These functions are outside of the Panels definition
of IHC, but they may be bundled or integrated with the IHC functions described above.
Factors That Impact the Adoption of IHC
Many environmental factors may influence the adoption
and use of IHC applications. Understanding the role these factors play in promoting or
hindering adoption and implementation of IHC is critical to the identification of
strategies that promote use of quality applications. Factors that promote adoption of IHC
include:
- Increasing telecommunication and computing capacity.
The exponential increase in telecommunication and computing capacity during the 1990s in
terms of data transmission speed, bandwidth capacity, computer processing power and
software design, information storage capability, and transmission options (e.g., phone
line, cable, wireless) have greatly spurred the development of IHC applications. Advances
in software authoring tools and increasing knowledge about how to design more intuitive
IHC applications also have played an important role. Without these recent technological
advancesin tandem with decreasing costsit would be virtually impossible to
deliver multimedia applications in an effective manner. In particular, the rise of global
communication networks, such as the Internet, has presented an enormous opportunity to
distribute such applications widely and inexpensively, and link and build upon multiple
applications.
- Increasing computer literacy and access. The
exponential increase in computer literacy and public access to personal computers and the
Internet are major factors for the increasing popularity of IHC applications. Computer
literacy among Americans will continue to rise as increasing numbers of people have access
to computers at work, at home, or in public access points.
- Increasing consumer demand for health information and
shared decisionmaking. Consumer demand for health information is substantial and
increasing (GAO, 1996). For example, telephone inquiries to the HHS-sponsored
clearinghouses increased an average of 209 percent from 1990 through 1994 (McGinnis et
al., 1995). Surveys show that most Americans place a high value on access to health
information (Deering, 1996), and that searching for health information is one of the most
popular reasons for using the Internet (FIND/SVP, 1997). The nature of public inquiries to
government-sponsored information clearinghouses seems to have shifted from primarily
questions about general wellness and healthy lifestyles in the 1980s to requests for
information on diagnosis and treatment of specific diseases and health conditions in the
1990s (McGinnis et al., 1995). Major reasons for the increased demand for health
information and shared decisionmaking (HCI, 1994) include: 1) growing recognition of the
complexity of medical decisions and that health choices may depend as much or more on
patient preferences as on medical science;1 2)
increasing concern about the effect of financial incentives on clinical decisions and
increasing distrust of health care institutions, which may lead people to seek independent
information and second opinions; 3) rising interest in "self-care" where people
seek to prevent, diagnose, and treat health problems with no or limited intervention from
traditional health care professionals; 4) the "aging of America," which has
resulted in a growing number of persons with chronic health conditions and/or their
caregiversboth of whom have substantial health information and support needs; 5)
growing interest in alternative approaches to established health care remedies (Eisenberg
et al., 1998); and 6) increasing investment of the pharmaceutical and other health care
companies in direct-to-consumer communication about medications and other health
interventions (Jupiter Communications, 1998).
- Increasing emphasis on primary and secondary prevention.
Because many health conditions do not have effective therapies, clinicians and health
officials are recognizing the pivotal role of primary prevention (USPSTF, 1996). IHC
applications can be used in prevention programs to promote healthy lifestyles, encourage
positive behavior change, and facilitate delivery of preventive health services. There
also is an increasing emphasis on prevention-related quality indicators [e.g., the Health
Plan Employer Data and Information Set (HEDIS) of the National Committee for Quality
Assurance]. IHC may be a mechanism to move these forward.
- Increasing trend to reduce cost of health care services.
The national trend towards managed care reflects efforts to improve the coordination of
health services and to reduce the cost of health care. A recent study estimates that US
health care expenditures will almost double from $1.1 trillion in 1998 to $2.1 trillion in
2007 (Smith et al., 1998). Some health plans, including managed care organizations, may be
likely to implement preventive health applications because they have the infrastructure to
employ these technologies. Some have a strong focus on preventive health and a financial
incentive to use potentially cost-saving technologies.
Barriers to the widespread adoption of IHC include:
- Health care provider resistance. Some health care
professionals may not be supportive of IHC applications because use of this technology may
be perceived as a threat to professional autonomy and authority. With increasing access to
specialized health information and expert knowledge systems, health professionals may be
perceived as only one of many legitimate sources of information. Some believe that
cost-conscious managers may use IHC applications to supplant rather than complement
clinician interactions with patients. In addition, some providers are concerned about
potential, professional liability issues associated with adopting IHC applications.
- Lack of financial incentives to change behavior. The
lack of financial incentives for health care providers to support or adopt IHC
applications adds to provider resistance. Without reimbursement for IHC-related services
from health plans and other payers, it is difficult to motivate behavior change. In
addition, existing capital investments by some health organizations in information systems
and applications that do not support or integrate well with new applications are
substantial disincentives to implementing new programs.
- Lack of access to infrastructure and inability to utilize
applications. Residents of rural areas, inner cities, and lower socioeconomic status
neighborhoods tend to have less access to computer and communications infrastructure than
persons in other areas (US Department of Commerce, 1995). Widespread adoption of IHC
applications will be impeded as long as a substantial proportion of the population,
including low-income, rural, and inner-city families; certain racial/ethnic groups;
disabled persons; and the elderly, lack access to technology infrastructure or lack the
ability to utilize applications because of illiteracy, language, and other factors (Eng et
al., 1998).
- Substantial implementation and maintenance costs.
Implementation and maintenance costs associated with some IHC applications may be
substantial in terms of investing in necessary software and hardware, training of program
implementation and maintenance personnel, and support costs. IHC applications with
sophisticated multimedia features, for example, may require updated computer equipment or
large bandwidth capacity to run efficiently, thus requiring substantial capital to acquire
or update equipment. This may be prohibitive to smaller corporations or health plans.
There is also a lack of understanding of how to implement and maintain IHC applications
within the context of the structure, policies, and procedures of health care institutions
or larger health care systems.
- Lack of convincing data on effectiveness. A number of
studies have demonstrated a positive impact in providing the kind of information often
included in IHC applications, but more data are needed to persuade skeptical
decisionmakers in health plans and provider organizations. Self-care books provided to
members of health maintenance organizations and to Medicare beneficiaries have been shown
to reduce office visits and specialty referrals (Vickery et al., 1988). Interventions
designed to help patients prepare for office visits have been shown to improve treatment
outcomes for chronic diseases (Greenfield and Kaplan, 1985). In addition, computer access
to support groups and decision guidance has been shown to positively impact on women with
breast cancer and patients with AIDS (Gustafson et al., 1993, 1994; McTavish et al.,
1994). Shared decisionmaking programs have been shown to improve health outcomes while
reducing the utilization of surgery and other high-cost interventions (Barry et al., 1995;
Morgan et al., 1997). For IHC to be widely adopted, additional data are needed in such
areas as effectiveness and cost-effectiveness in specific populations and health care
settings.
Benefits and Risks of IHC
Interactive media are changing the design and delivery
of health communication. Some health communication interventions using traditional media,
such as radio, television, and printed text and pictures, have been effective in improving
knowledge and promoting healthy behaviors (Flay, 1987; Flora et al., 1995), but emerging
media may have several advantages for health communication efforts. These include:
- Improved access to individualized health information.
The interactive nature of emerging technologies allow the "tailoring" of
information or support to the specific needs or characteristics of individuals or groups
of users (Harris, 1995).
- Broader choices for users. The ability to selectively
combine text, audio, and visuals enables designers to employ specific media based on the
purpose of the intervention and the learning styles of users (Harris, 1995). The ability
to easily create multiple versions of an application means that users have a wider
spectrum of products from which to choose.
- Potential improved anonymity of users. These
technologies, when used appropriately, can help protect the anonymity and privacy of
people who access sensitive information by bypassing the need for people to obtain such
information in public or face-to-face settings (GAO, 1996). Computer-based interfaces also
can improve the quality of personal health information, such as health status, health
risks, and fears and uncertainties, collected from individuals (Locke et al., 1992;
Gustafson et al., 1993). This allows health professionals to better assess and manage
those in need.
- Greater access to health information and support on
demand. These resources often can be used at any time and from numerous locations
through the Internet (Harris, 1995; GAO, 1996).
- Greater ability to promote interaction and social support
among users and between consumers and health professionals. Through the use of
networking technologies, such as e-mail and synchronous communication, barriers to direct
communication among peers and between consumers and health professionals are reduced
(Robinson et al., 1989; Harris, 1995; GAO, 1996; Pingree et al., 1996).
- Enhanced ability to provide widespread dissemination and
immediate updating of content or functions. Provided that technology infrastructure is
established, applications can be rapidly distributed to many audiences at relatively
minimal cost (GAO, 1996).
In addition, emerging technologies such as the Internet,
allow users to also become developers and active participants in the information exchange
processthey can glean what they wish from various sources and create and disseminate
new information. Thus, these users become health communicators.
Although the potential benefits of IHC are impressive,
there is the risk of harm. The proliferation of IHC applications that are available to the
public raises legitimate concerns about their potential to cause harm especially among
those who may not have the skills or background to evaluate the quality or relevance of
IHC applications (Consumers Union, 1997; Silberg et al., 1997; The Lancet, 1997). Public
use also may impact health care quality and cost, the clinician-patient relationship, and
the organization of health care systems (HCI, 1994; Kassirer, 1995; Blumenthal, 1997).
There has been minimal research about the potential risks associated with the widespread
use of IHC, and documented cases of harm are relatively rare (Weisbord et al., 1997). Use
of inappropriate or poor quality applications, however, can result in the following
potential negative outcomes:
- Inappropriate treatment or delays in care. Inaccurate
or inappropriate health information and support could result in inappropriate treatment or
cause delays in seeking appropriate health care (Goldwein and Benjamin, 1995; Saksena and
Nickelson, 1995; Keoun, 1996b; FDA, 1997; Impicciatore et al., 1997; Scolnick, 1997;
Weisbord et al., 1997). For example, misleading claims for medical products and health
care fraud are endemic on the Internet (FTC, 1997), and, in at least one documented
instance, resulted in use of a harmful product (Weisbord et al., 1997). People may be
particularly susceptible to questionable marketing practices when they have a serious
illness and are desperate for potential cures. Another possible source of inaccurate or
inappropriate information is online support groups, where such information may spread
rapidly before being corrected, or where the experiences of one or a few individuals are
inappropriately applied to others who share the condition but may differ in other
important characteristics (Bulkeley, 1995; Gray, 1998).
- Damage to the patient-provider relationship.
Inappropriate use of IHC applications can result in people losing trust in their regular
health care providers and prescribed treatments and lead them to seek inappropriate care
or care from questionable providers. Use of inappropriate applications can also lead to
unnecessary conflicts and confrontations between consumers and health care providers (Bero
and Jadad, 1997).
- Violations of privacy and confidentiality. As the
ability of IHC applications to tailor health information and support becomes increasingly
utilized, more potentially sensitive personal data will be collected through applications
based in workplaces, health care organizations, and public networks. Without adequate
safeguards, such data and information may be shared or sold to others without the
users knowledge or permission, or used for unintended or illegal purposes.
- Wasted resources and delayed innovation. Unless
adequate information about effectiveness and cost-effectiveness of specific IHC
applications is available, ineffective or inefficient applications may be adopted leading
to wasted resources and delayed innovation. As noted previously, relatively few
applications have undergone scrutiny to ensure that they produce their intended effects.
Lack of understanding of user needs also may contribute to development of inappropriate
resources.
- Unintended errors. As new software tools, such as
"agents" (discussed later in this chapter), become available, developers will
use them to create increasingly complicated programs that may employ complex algorithms
transparent to the user. Many of these applications will be developed by multiple
individuals who may not be aware of potential adverse interactions between application
components. This may lead to instances where complex IHC applications, such as shared
decision support programs, produce unintended errors that result in harm.
- Widening the technology and health gap. As IHC
applications become more pervasive and the Internet and other technologies become
essential components for delivery of health information and care, those without access to
these technologies may fall further behind in their ability to obtain information and care
(Eng et al., 1998; Hoffman and Novak, 1998; US Department of Commerce, 1998). There are
currently few initiatives that provide access to technology to underserved populations,
such as low-income populations, residents in rural areas, and those with disabilities.
Many of the concerns cited also apply to more traditional
communication media. The Panel believes that the emphasis on the potential for harm from
IHC applications, however, is justified because new and emerging media may influence
behavior and decisionmaking in ways that are more powerful than other media. For example,
research shows that people put more credibility in information from computers than
information from television and other media (Hawkins et al., 1987), and that some
individuals, especially adolescents, often prefer to provide sensitive information to a
computer rather than to a physician (Paperny et al., 1990; Lapham et al., 1991; Kinzie et
al., 1993; Turner et al., 1998).
Implications of IHC for Health
Professionals
The wide availability and use of IHC applications will
likely have major implications for health professionals who provide individual- and
population-based health services. For clinicians, the major areas of impact are likely to
include patient care, the clinician-patient relationship, and the organization of medical
systems (HCI, 1994; Kassirer, 1995; OTA, 1995; Blumenthal, 1997).
Patient Care
The premise of clinical decision-support IHC
applications is that patient care is participatory and largely patient-directed. In this
model, the health professional functions as a facilitator or partner in care rather than
as an authority. Although this may come naturally to some health professionals, others
will need to develop new strategies of communication rooted in an understanding of their
patients needs and preferred clinical outcomes, and an acceptance of the increasing
role and responsibility of patients in decisionmaking. In addition, the use of some IHC
applications, such as those that facilitate remote health monitoring and self-care, will
require clinicians to take a more proactive approach in identifying health problems and
care delivery. It should be noted, however, that regardless of information access, some
proportion of people would prefer to relate to their provider as an authority figure
rather than on an equal level. One of the challenges for clinicians will be to determine
the appropriate balance between their role as an "authority" versus their role
as a "partner" for any given patient.
The ability to translate, integrate, or link clinical
protocols to IHC applications may impact on patient expectations and provide a powerful
way to monitor quality-of-care from the patients perspective. It is possible that
the quality of patient care may be improved by telemedicine-oriented IHC applications that
assist real-time specialty consultations, increase access to information databases and
continuing education opportunities, and facilitate clinical decisionmaking (Blumenthal,
1997). In addition, these technologies are beginning to have a profound impact on the
training of health professionals in patient care both in terms of enabling innovative
methods for teaching and developing patient communication skills (Henderson, 1995;
MacKenzie and Greenes, 1997).
The Clinician-Patient Relationship
IHC applications that promote peer and emotional
support and provide health information through nontraditional channels may be perceived by
some to diminish a patients trust and confidence in, or dependence on, his or her
clinician. Information and advice from other information sources, such as online
publications reporting new research, or anecdotal sources, such as online chat groups, can
be used to challengeor "second guess"clinicians (Keoun, 1996a).
These factors, the sheer volume of biomedical information produced every day, and the
increasing ease of access to health information, create an environment in which the
publics perception about authorities for health information is changing. Physicians
and other traditional health professionals may come to be perceived as one of many sources
of authoritative medical knowledge, and clinicians may become one of several types of
professionals that individuals rely on to help solve a health problem. In some cases,
patients may have greater access to information about their conditions than their health
care providers.
The above challenges, however, can sometimes lead to
greater rather than diminished confidence in health care providers (Gustafson, Robinson et
al., 1999). Some IHC applications, such as shared decisionmaking tools and
provider-patient electronic communication applications, can enhance the clinician-patient
relationship by providing clinicians with valuable insights into patient needs and
improving their patient communication skills (Borowitz and Wyatt, 1998). It is also
possible that patient compliance with treatments may improve through increased access to
information and support. In addition, a recent survey of Californians with Internet access
showed that they considered information from their physicians and other health care
providers to be the most useful and trustworthy of all information sources, including the
Internet (NHF, 1998).
Health Care Systems
The trend to reduce health care costs will increase the
demand for IHC applications that promote self-care, enable demand management of services,
and supplement face-to-face interactions with electronically mediated ones. Many health
plans already communicate with members through e-mail and Web sites. Deployed as tools to
assist with administrative matters, such as changing an address or checking on insurance
status, IHC will increasingly be used for health care-related functions, such as remote
management of patients (Alemi, 1998). As this evolves, confidentiality and privacy
concerns regarding the transmission of personal health information beyond the traditional
medical record will be major issues.
In a fragmented health care system, IHC applications have
potential to help integrate service delivery by enhancing provider communication and
centralizing information resources. It is also possible that, as health care delivery
increasingly relies on information technology to maximize efficiencies, smaller health
plans that cannot invest as heavily on technology as the better capitalized plans will
become less price competitive. On the other hand, implementing cost-effective IHC
applications may allow smaller health organizations to be more competitive because they do
not have large physical plants to maintain and support.
As health care delivery systems look to further reduce
costs, some components of care delivery may be reassigned from relatively expensive
professionals, such as physicians, to less costly providers, such as nurses and other
health professionals. This may already be happening as new types of professionals such as
"care managers" or "health resources specialists" who have substantial
skill at finding and coordinating resources, are beginning to emerge to assist patients.
The delivery of health information and education, once under the purview of physicians,
may be delegated to expert "communication/information specialists," redefined
health educators, or interactive systems. Even if this only occurred within a small
segment of the population, the "disintermediation" of the traditional
"mediators" of health care would represent a major shift in roles and
responsibilities for many clinicians (Blumenthal, 1997).
Public Health Systems
The application of information technology to public
health systems is likely to result in profound changes because most of the core functions
of public health, such as monitoring health status, diagnosing community health problems,
and evaluating personal and population-based health services, are heavily reliant on the
collection, analysis, and dissemination of data and information (PHFSC, 1994). IHC
applications targeted for public health professionals could facilitate communication
between the health care and the public health sectors and among public health
professionals themselves. This may result in improved coordination and integration between
the health care and public health systems (The Medicine/Public Health Initiative, 1998),
but it also raises significant concerns about data quality.
IHC applications also can improve the reach and use of
public health services by increasing awareness of services and expanding community
outreach. This may be a particular benefit in rural areas where distance has been a
significant barrier to service delivery. If current trends in public demand for health
information continue, it is likely that the general public and others will want enhanced
access to health datain terms of both disease risk and health statuson a local
and national level. Currently, however, many local health departments do not have the
staff, resources, or technical capacity to collect, analyze, and disseminate community
health data and information (CDC, 1997; PHF, 1998). Smaller health departments, in
particular, may find themselves challenged by balancing the demand for more
community-tailored information with finding resources to provide and maintain it. By
implementing IHC applications collaboratively, however, local health departments may
improve operating efficiencies.
With improvements in the technical capacity of health
departments, IHC may become a central strategy for community health education, community
outreach for services, and social marketing for positive health behaviors. In fact, some
health departments are already developing applications that serve these functions (ASTHO,
1998). For example, providing access to interactive tools that assess and communicate
individual disease risk, and provide support for behavior change, can be important
initiatives to improve community health. In addition, IHC may have a particular impact on
one of the central functions of public health departmentsdisease surveillance and
monitoring of community health indicators. In the future, "disease surveillance"
may be blended into a larger system of "health surveillance," and a substantial
proportion of health information and data may be generated by routine collection of data
from many community settings rather than driven by reports from clinical encounters. This
may lead to both more accurate community health monitoring and improved detection of
disease outbreaks (OCarroll, 1997).
Technology Trends and IHC
The technologies underlying IHC are undergoing rapid change
and evolution (NAS, 1996). Developers and other stakeholders should be cognizant of how
emerging technology trends may influence future applications. Pertinent trends include:
- The ubiquitous presence of computers and the Internet in
society
- Wide availability and increasing use of computers and the
Internet for personal use in the home
- Dramatic increases in the affordability and portability of
network-capable computers and other communication devices increasing justification, given
their perceived benefit, for their purchase by the public
- The emergence of the Internet and the World Wide Web as a
means for public access to health information and support (Slack, 1997)
- The convergence of IHC technologies into a common carrier
(the Internet and World Wide Web) and decisions by both public and private sector
organizations to support a common carrier for health information (Tifflin and Rajasingham,
1995; Agnew and Kellerman, 1996)
- The imminent availability of a next-generation, broadband 2 Internet (e.g., Internet2 and the Next Generation
Internet) capable of delivering high Quality of Service (QoS) and interactive multimedia
programming, including full motion video and increasingly engaging and easy-to-use
interfaces (Henderson, 1995; Henderson, 1998; Shortliffe, 1998)
- The emergence of novel methods of information access and
analysis, including knowledge repositories (Haynes et al., 1997), intelligent and mobile
"agents," "data mining," and "expert systems" as discussed
later (Apte, 1977; Kotz et al., 1997; Maes, 1997)
The first four of these trends project an environment in
which most users will have access to network-based services, and most will be capable of
using them. The last three will have great impact on the kinds of distance learning
applications that can be provided. This makes possible learning experiences that are more
involving, effective, and efficient than before, as well as information retrieval that is
extremely easy or transparent to the user. Next-generation IHC applications may be capable
of delivering extraordinary learning experiences to individuals and organizations,
independent of time and location.
Developers, purchasers, and policymakers can help set the
direction of the application of these technologies, and derive advantage from them. This
requires an understanding of the underlying technologies and how they can be applied,
research on the current and future state of the infrastructure, and the actual application
of technologies and tools to improve infrastructure for personal and public health.
Agents, Data Mining, and Expert Systems
Agents are information-processing programs that can act
autonomously and adapt to a users needs. They are aimed at reducing
"information overload" and facilitating the information-retrieval process. For
example, agents can simplify interfaces by eliminating steps or choices that a user must
make after several encounters with a system. Agents can facilitate use of complex
databases by translating arcane database queries into user-friendly dialogs. They also can
automate tedious searches for new information by performing searches in the background
until new information is located and identified as potentially useful. In addition, mobile
agents are programs that can migrate from machine to machine. This allows complex queries
to be done at the location of a large database without downloading that database to the
users workstation over slow channels. The particular advances that allow agents to
perform such tasks are in the areas of machine learning, information retrieval, high-level
scripting languages, graphical interfaces, and generic World Wide Web technology.
The rate of growth of information content on the Web, in
the technical literature, and implicitly in electronic records may overwhelm people who
wish to use health-related information. Through use of information retrieval and Web
technology, it may be possible to build agents that can constantly monitor several
databases and other repositories of information for new material pertinent to a
providers needs and areas of expertise. When that information is identified, the
agent formats it into a natural presentation and notifies the user of its availability.
By design, agents move much of the tedium and complexity of
information gathering and correlation into the background so that a novice can easily
begin using more powerful capabilities. Developers have already demonstrated such agents
with Web "clipping" services that utilize user-friendly interfaces and e-mail
systems. Furthermore, it is possible to program agents that gradually adapt to a
users experience by creating shortcuts and anticipating actions based on prior
usage. This property of agents arises from the design of the agent system by understanding
the needs of users and building systems that amplify the users abilities without
forcing new processes onto them.
The emergence of expert systems has important implications
for IHC development. Potentially, for example, they could help users self-diagnose their
conditions and even select from a variety of available treatment options. One powerful
feature of expert systems is that they can improve themselves over time if they can
collect data on the accuracy of their earlier conclusions and recommendations. Such
systems have great potential for improving participation in health care and empowering
consumers. They also have the potential to reduce costs-of-care by allowing, over the long
term, consumers to manage their own care rather than relying on clinicians.
To date, however, expert systems have not lived up to their
promise. They frequently have not been as accurate as expected in the conclusions they
reach. Hence, such systems need to be very carefully evaluated in a wide variety of
applications before they should be made available for such important decisions as
diagnosis and treatment selection. Moreover, because they often are systems whose
underlying structure changes over time, their evaluation would need to be ongoing. Even
so, expert systems will likely be a fundamental component of IHC applications that enhance
self-care and reduce health care costs.
It is likely that some automated tools will be built into
applications to assist in the assessment of quality and maintenance of information.
Because tailoring of information in automated systems may involve complex algorithms and
databases can be automatically updated by agents, the ability of people to adequately
evaluate these IHC applications may be compromised, and research and development on this
issue are needed. This and other evaluation issues are discussed more fully in Chapter IV.
1 Shared decisionmaking is
the process in which health care professionals and patients (or other interested parties)
jointly assess and decide on treatment options.
2 "Broadband" refers
to network bandwidth that is wide enough to carry advanced services such as high quality
motion video. Quality of Service (QoS) is used here to describe the technical quality of
media services, such as full motion video, of sufficient quality to support educational
goals. Measures of QoS include video window size, frame rate, and the latencies between
selecting a video stream and its actually starting, and synchronization between video and
audio.
Return to Table of Contents
Comments: SciPICH@nhic.org
Updated: 05/01/08 |