

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

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Policy Issues Relevant to Evaluation of Interactive
Health Communication Applications
Authors: Kevin Patrick, Thomas N. Robinson, Farrokh Alemi, and Thomas R. Eng for the Science
Panel on Interactive Communication and Health.
Citation: Policy Issues Relevant to
Evaluation of Interactive Health Communication Applications. American Journal of
Preventive Medicine, January 1999; Vol.16 No.1:35-42
Medical Subject Headings (MeSH): policy, health
communication, computers, evaluation, computer communication networks.
[PDF] [References]
Abstract
This article provides an analysis of policy-related issues
associated with the evaluation of interactive health communication (IHC) applications.
These include an assessment of the current health and technology policy environment
pertinent to public (government, education, public health) and private (medical care
providers, purchasers, consumers, IHC developers) IHC stakeholders and discussion of
issues likely to merit additional consideration by these stakeholders in the future.
Introduction
Several externalities may positively or negatively
influence the practice of Interactive Health Communications (IHC) evaluation,[1] including legal, regulatory, social, and economic processes. Some of
these processes result from the legislative efforts of federal and state governments
acting on behalf of the public interest. Others stem from the purchasing decisions of
federal, state, and local governments and of private institutions. Still others stem from
informal "policies" of private health care enterprises such as what resources
they use, and to whom they refer when their patients need health information. All of these
factors also influence the marketplace for IHC that others typically follow.
Decision-makers of all types need to understand more about
IHC technologies and applications. These individuals need a process that enables
assessment of the efficacy, effectiveness, and impact of IHC applications. Of potentially
greater importance, however, will be mechanisms by which policy-makers can understand the
"value-added" by IHC to the overall mix of public and private investment in the
promotion and protection of individual and community health, in disease prevention, and in
medical care and rehabilitation. That is, with respect to IHC, "the whole may be
greateror lessthan the sum of its parts." Knowing how IHC applications
relate to, enhance, and/or potentially detract from other determinants of individual and
community health may enable choices to be made, which promote the wisest investment in IHC
development and use.
Background
Interactive health communication is expanding at a rapid
pace. The information technology industry is now the second largest industry in the United
States, trailing closely behind personal health services. Research and development
(R&D) in information and communication technologies now represents 37% of total
R&D by U.S. companies.[2] Nonetheless, health and medical care are
prominent among those business and social sectors considered to be most underdeveloped
from an information technology perspective. Investment in information technologies is seen
by many as essential to the creation of manageable and cost-accountable medical care and
public health systems. To foster development in this area, the federal government's High
Performance Computing and Communications Program (HPCC) has targeted the health
information infrastructure for improvement.[3] However, several other
phenomenaboth inside and outside the health arenaare almost certain to
accelerate the deployment of IHC technologies and applications. These include:
- The trend away from small-scale cottage industry provision
of episodic medical care to delivery by larger integrated medical care systems that
address everything from prevention to home care to tertiary hospitalization and long-term
care. While this trend may initially hamper the growth of online communication services as
size outstrips communication capacity, the need to manage increasingly larger amounts of
information will maintain the pressure for expanding information technologies.[4]
- The change from fee-for-service and cost-reimbursed medical
care to pre-paid, capitated coverage with the concomitant shift of financial at-risk
status from the consumer/purchaser/payer to the provider. Under these funding arrangements
economic pressures will increase to provide services to consumers in the least expensive
way, including in their homes and workplaces.
- An increasing recognition of the historical imbalance
between investments in episodic and end-stage medical care versus investments in
prevention and health promotion services at both the individual and community levels.[5] Often based on behavioral, social, and environmental determinants,
disease prevention and health promotion interventions are usually "information
intensive"dependent more on information and communication strategies than on
procedures or pharmaceuticals.
- Increased access to, and reduced costs of, the
infrastructure for interactive information delivery tools and systems. This includes the
Internet, home and worksite computers, and the increasingly robust wired and wireless
communications infrastructure being developed through private and public investment.
Forty-one percent of U.S. households had a personal computer in 1997.[6]
- The increased demand for health information from consumers.
One of the most common reasons people use the Internet is to obtain health information.[7]
These phenomena raise some interesting questions for almost
everyone involved in public health and medical care. What will the future of personal
health care services look like? How will the traditional role of the health care provider
change? What new challenges will exist for those who have traditionally paid for health
care services? More specifically, as we witness the proliferation of interactive health
communication applications, how should those with an interest in health policy respond?
For example:
- What policies should be put in place to encourage the wisest
investment in IHC in either public or private settings? What objective criteria can be
used to assure that IHC purchasers are "getting what they pay for?" From the
standpoint of health outcomes, is it better to invest in IHC applications than to invest
in other health and medical care inputs? If so, how much better?
- Is a market-driven laissez-faire approach appropriate
with respect to IHC? If not, what sort of approach is necessary? Is "truth in
advertising" an issue, either with respect to core content and/or how IHC
applications are marketed as efficacious and effective?
- Will IHC technologies "naturally" evolve to
satisfactorily address issues of compelling public health importance? If not, what should
be done about it? How can IHC research, development, and use best support attainment of
the Healthy People 2000 and 2010 Health Objectives for the Nation?[8]
- Will all Americans be served by IHC? If not, should
something be done about it? Should there be an R&D agenda for IHC to ensure that
"orphan" issues or populations are served by IHC applications that may not be
addressed by applications developed solely for their commercial value? In the context of
current major telecommunications reform, are there opportunities to promote the potential
benefits of IHC to underserved populations? If so, how is this best done?
- How should privacy rights of citizens be respected in the
deployment of IHC? Under what rules for disclosure does the system operate?
- Are there unique issues related to malpractice or other
liabilities associated with assumptions or claims of efficacy, effectiveness, and use of
IHC?
In the long run, it is not merely the existence of
IHC that will be important to policymakers in the public and private sector. Rather, it is
the impact that IHC applications may have on the structure, process and outcomes of
medical care and public health. To make qualitative and quantitative judgments about these
increasingly important systems of personal and public health communication, policymakers
should become as knowledgeable as possible about them.
Policy Issues
Several areas of health information policy are already
undergoing extensive review in the context of expanded use of telecommunications and
computer technologies.[9,10] These include health data and information
standards, network security issues, and legislative actions at the federal and state
levels addressing issues such as medical information privacy, confidentiality, and
security. While each of these issues has one or more dimensions relevant to the
development and deployment of IHC, the focus of this article is on those aspects of each
pertinent to IHC. This list of policy issues is exhaustive neither in scope nor in its
description of each issue. The primary aim of this section is to present key issues
related to the evaluation and use of IHC and help policy-makers answer the following
question: What decisions made now in the broader context of health and communications
policymaking will promote optimal development, evaluation and improvement of IHC?
Privacy and Confidentiality
In virtually all assessments of consumer concerns about
communication technology-based health information and medical care, privacy and
confidentiality issues are paramount. Simply put, individuals wish to keep their health
concerns private or, if shared, shared only with a health professional with the capacity
and commitment to maintain complete confidentiality.[11,12] Many IHC
experts consider the concern about privacy and confidentiality of IHC as out of proportion
to the actual risk of disclosure, especially if appropriate safeguards are developed.[13] Nonetheless, considerable effort is being devoted to fail-safe
technologies that assure complete privacy and confidentiality both within a given health
care organization and in situations where information is shared between and among health
care entities.[14,15] This issue will become considerably more
complex as IHC applications proliferate and diversify in ownership and location. For
example, individuals now seek health information from a variety of sources on the
Internet, only a limited number of which are sponsored by mainstream professional health
organizations. The Internet enables disseminators of information to know precisely who is
seeking that information (or at least their Internet address). Many individuals access the
Internet through job-based workstations, expanding even more the potential for others
(such as employers monitoring Internet access) to discover both content sought and
information source. The implications of these electronic trails for someone seeking, for
example, potentially sensitive information on HIV/AIDS, may be profound.[16]
Policymaking now underway in the area of secure, private,
and confidential transmission of information via new communication technologies should
anticipate more than simply the electronic storage of medical records and the transmission
of this information between health care providers in medical environments. Our experience
suggests that increasing use is being made of e-mail, transmitted across the Internet, for
communication between health care providers and patients. In the future, more and more
health information obtained via interactive media will be obtained from many kinds of
health professionals in a variety of settings. Safeguards to ensure that individual health
information-seeking behavior is treated with maximum privacy and confidentiality will
become critical to the specific operationand evaluationof IHC. Policymakers
confronted with the decision to pay for or adopt a given IHC should know how well the IHC
application protects privacy and/or confidentiality. And, because standards and practices
in this arena are likely to evolve and improve, ongoing assessment of this capability
should be sought.
Perhaps one of the most complicated areas related to
confidentiality and security of health information in the future may relate to the balance
between individual rights to control the release of personal health information and the
greater community-wide and public health benefits of such things as community health
information networks or health data registries.[17-19] One of the
most common current uses of registries is to house data on immunization status of infants
and children. These data are used to assess and improve levels of immunization in defined
communities.[20,21] Use of community-wide data in this way protects
not only the health of specific individuals but that of an entire population. IHC
applications may emerge in the future that enable the aggregation and analysis of other
types of health information, including information gathered from nonclinical sources, that
can benefit an entire community. For this to occur, however, new approaches will need to
be developed for policies and procedures supporting privacy and consent for release of
personal health information.
Oversight, Regulatory, and Legal Issues
These are areas of considerable controversy at present.
While it is impossible to predict how each will evolve, some general principles can be
articulated.
Content
While first-amendment principles will likely apply to IHC,
it is also probable that the tradition of governmental regulation of certain aspects of
health care (e.g., pharmaceuticals by the Food and Drug Administration [FDA]) and
trade-related issues (e.g., some aspects of advertising by the Federal Trade Commission
[FTC]) may impact IHC. For example, consider the case of an IHC application that
facilitates the use of either a drug or a device in a disease-management program. Should
this IHC tool come under the domain of existing regulations with respect to product
labeling and information provision now required by the FDA? If it becomes
"bundled" within a larger suite of IHC applications, will the need for explicit
information about its safety and effectiveness disappear? As health-related interventions
have the potential to produce harm,[22] several leading health and
information technology organizations have outlined a proposed FDA role in the regulation
of clinical software systems, including some IHC applications.[23]
This may be more likely if private industry doesn't adopt at least a minimum standard of
self-evaluation and quality control.
The FTC is well known for penalizing entities engaged in
false and deceptive advertising. Recent examples include actions against companies
promising near-miraculous results from the use of dietary supplements for weight loss.
Developers of an IHC promising the same would change only the venue for false claims, not
the content.[24-26] In fact, the FTC is already monitoring the
Internet for false claims.[27]
Policymakers should also be familiar with the potential for
persuasion in IHC applications. As these media increase in sophistication to include
video, compelling graphics, and sound, their power to persuade may also increase. The
emotional impact of a well-produced video may be much stronger than that conveyed by
traditional print-based health information. Drawing a line between legitimate product
marketing or advertising and false and deceptive advertising may become a difficult thing
to do. This is an area that may require scrutiny from independent entities, perhaps in the
public sector.
Some oversight of IHC content will probably occur naturally
through the extension of existing mechanisms for influencing health care, such as
certification, licensure, and accreditation. For example, a Web site maintained by a
hospital may come under review by a state licensing agency if it is used to enhance
marketing or to justify community service requirements. Because of the newness of IHC
applications, and the difficulty in anticipating the kinds of safety and effectiveness
problems that might result from their use, it also seems likely that legal challenges, and
resulting case law, will influence the policy environment for IHC application development
and adoption.
Liability for Information Provider and
IHC Developers
Advances in the use of communication technology for the
provision of health information also raise some unique questions about liability. In the
context of a traditional provider-patient relationship, the provider is responsible for
the quality and timeliness of information that is provided to the patient. Although
sometimes imprecise, norms and standards of practice have evolved regarding the delivery
of health information to patients in clinical situations. Examples of these include
informed consent prior to surgical procedures, information about potential side-effects of
prescribed medications, and advice about what precautions to take to avoid risk of illness
or injury in the face of an established medical condition (e.g., coronary artery disease,
osteoporosis, diabetes).
If a health care provider is negligent in anticipating and
addressing the information needs of a patient, that provider is at risk for legal action.
What rules should apply for IHC applications? These tools may be deployed by a variety of
providers, some trained in the traditional biomedical sciences and others with different
backgrounds. This issue may become more complex as IHCs become increasingly tailored to
the specific needs of users. Interactivity may enable such systems to become influential
health counselors for individuals. Through successive use by an individual, the
accumulated wisdom that an IHC application could develop about an individual's health
status and preferences could rapidly exceed that of the health care provider, whom the
same person visits only a few times a year. Will this "wisdom" beg issues of
responsibility and, if the responsibility is not addressed by the IHC provider,
negligence?
A related issue of liability pertains uniquely to IHC
developers. IHC technologies are becoming increasingly sophisticated and are often
dependent on complex algorithms, elaborate logic, successively revised software, and
sophisticated technology. While they may become easier to use, it is likely that fewer and
fewer individuals will truly understand their inner workings. Those who deploy them, for
example, in a medical setting for patient-centered disease management, will need to accept
that they will perform as intended. In this scenario, if something goes wrong, and it can
be traced to a flaw in, for example, the IHC application logic, the developer almost
certainly will be drawn into the liability loop.
Will providers be liable for the damaging effects of a
flawed IHC application made available by their institution? Or conversely, if an effective
IHC application is available, will providers be considered negligent if they don't use it?
Finally, there are legal issues concerning the operation of
shared health record systems and data registries. Do patients need to permit providers to
add information to their record or can providers add to the publicly-held shared records
without a signed release? Patients typically need to sign for release of information to
third parties, but there are exceptions to this practice. For example, if the patient is
under the care of two clinicians, they can share information with each other without the
patient's written consent. Some releases of information require time-specific and
purpose-specific consents. Who is liable for a breach in these communication processes?
Suppose a public health information registry releases information automatically to a
provider who says he or she has the patient's consent. Who is responsible for keeping
written patient consents on file? Answers to these questions will require different
approaches and attitudes to personal health information from those now prevalent.[17] As many of these situations already exist, different practices,
varying state laws, and potentially conflicting regulations are already evolving. Clearly
the IHC field will need to participate in ongoing discussions about these issues. Given
the many unknowns in this arena, policy-makers faced with the decision to fund or use IHC
applications, or who have the responsibility to safeguard the public interest, should
develop mechanisms for assuring that IHC developers have considered these issues and have
implemented appropriate processes for quality control and evaluation.
Linking Issues: The Interconnectedness
of IHC Content
In the historically "closed" system of health
information provision, a health care provider supplies specific information to patients
from personally selected sources. Health information, usually in the form of a brochure or
similar document, is either produced in-house or purchased or licensed from a health
information provider. As interactive media and infrastructure grow, especially on the
Internet, developers and deployers of IHC applications have an ever-increasing number of
sites where information can be accessed "in real time" to add value to their own
efforts. The Internet has become an extremely dynamic environment in which sites link with
new sites, and content is revised or changed, on an almost continuous basis. Where does
the chain of responsibility begin and end with respect to the quality of that information?
It is not clear if liability for linked information will be
as much of a problem as some might think. In part, this may be dealt with by the
regulatory, licensure, and certification mechanisms for content noted previously. If norms
for appropriate content in health information provision emerge, and if intermediaries
become more savvy in their ability to create links, entire "sub-networks" of
high-quality health information may emerge as the predominant resource. However, it may
take new legislation to protect entities that direct their users to other sources of
content over which they have no ongoing control. Absent these developments, mandating
explicitly stated disclaimers about linked information might be the standard that
policy-makers deploy for IHC they fund or use, or in which they have other legitimate
interests. Examples of these disclaimers have been provided by others.[28-30]
Quality Assessment and Improvement
Several models of quality control may be relevant to this
emerging field. Placing the development and deployment of IHC applications under the
jurisdiction of an entity such as the FDA or an analogous public agency is the strongest
mechanism to assure that rigorous evaluation occurs. The FDA's tradition of assuring that
drugs and devices meet established standards of safety and efficacy has stood the test of
time. For a variety of reasons, however, this approach may not be the best for the kinds
of applications addressed in this article. These include the dynamic nature of the
underlying technologies, the changing nature of information content, and the
"porous" nature of many IHC systems as they are likely to be deployed on the
Internet and Web. Therefore, other mechanisms of quality improvement may be preferable,
including:
- Adoption of voluntary quality standards and performance
measures through an organization of IHC providers, similar to the Health Plan Employer
Data and Information Set (HEDIS) established by the National Committee on Quality
Assurance. This approach would enable IHC developers and providers to jointly develop and
apply evaluation and performance criteria on a systematic basis. As knowledge increases on
IHC efficacy and effectiveness, these criteria could be revised. In fact, it may even be
possible to build this type of functionality into the existing HEDIS program. Adoption and
effective use of IHC applications could become part of an approach to measure the level of
involvement in shared clinical decision-making and consumer satisfaction.
- Assessment of IHC by independent entities (e.g., Consumer
Reports) is another approach to quality assessment and improvement. Some of this is
already occurring for such things as health-related Web sites, but early efforts may need
to be improved.[31] The long-standing tradition of making this type
of independent consumer-oriented information available suggests that no matter what other
mechanisms are developed, this process will occur for some IHC applications.
- Development of an accreditation system for IHC developers is
another possible approach to increasing the quality of IHC applications. This approach may
be preferable to one that assesses individual IHC applications because both the underlying
technology and the content of any given application can change frequently. An
accreditation system could establish and apply accepted norms for internal quality
control; software design; participation of experts in content development; appropriate
formative, process and outcome evaluation; and ongoing evaluation after release. However,
for such a system to be effective, it too would need to be evaluated to verify that its
criteria are linked to desired outcomes for end-users.
As in other health-related areas such as medical education
or health care facilities accreditation, an IHC accrediting body could be created with
representation from both the IHC developing and IHC-consuming communities. Independently
chartered, and at arms length from entities receiving accreditation, such a group could be
supported through a combination of accreditation fees and financial support from IHC
stakeholder groups.
- Another approach might be to develop a system of
post-marketing surveillance to monitor any potential negative effects of IHC applications.
This effort could be undertaken by independent entities or required of those who develop
or deploy IHC applications.
Public Versus Private Investment for Research,
Development, and Education
With substantial current, and ever-increasing, private
R&D in the area of IHC, public policy-makers might legitimately ask whether it is
appropriate to "let the marketplace decide" about the future of these
technologies or whether they need to influence that market. Public support can take the
form of grants or contracts, specific financial incentives, tax relief, or other forms of
indirect support.
This merits attention because of the need to address health
issues for underserved individuals and populations. The issues associated with R&D of
IHC applications are different from those relating purely to access to existing tools.
Knowledge about the evaluation of IHC applications is now in its infancy. It is not yet
known if special circumstances or conditions apply to enable these tools to benefit
economically or socially disadvantaged populations. What is virtually certain, however, is
that if there isn't a viable financial market for these products in some settings, the
private capital needed to develop them will not be available. Therefore, the safety net
that federal or state governments, or philanthropic entities, can provide for IHC R&D
to serve these populations will be important.
At a more general level, the issue of public versus private
investment becomes more complicated. Many private organizations, large and small, have
already entered and abandoned IHC development. Several traditional managed care
organizations have introduced online services but have done so without changing the nature
of medical care delivery. In some settings, patients can receive modest amounts of
information online but cannot make appointments, receive reminders, contact their health
care provider, or conduct other necessary managed care services. While some types of
networked innovationssuch as online information about benefitshave proceeded,
others have not.
Is it a function of public investment to encourage
innovation in IHC development? Perhaps a reasonable role for government is to assist in
demonstrating the utility of these interventions, especially if a convincing case can be
made that IHC applications will contribute to the attainment of national health
objectives.[8] While many federal efforts focus on infrastructure
and/or technology to support application development, the real need may be for
demonstration projects to model how health care practices can be improved through the use
of IHC applications. These projects may be especially helpful in demonstrating the
potential return on investment for health plans and large employers. Also, these
technologies are accompanied by major changes in practice, for which clinicians and others
in health care may be ill-prepared.[22] The problems associated with
implementing IHC are rapidly shifting from technologic to cultural and social. Given this
environment, public-sector stimulation of case studies may be a necessary precondition of
meaningful progress in IHC development. Once these projects have been completed and their
results disseminated, market forces can then facilitate growth and development in the
field.
Payment and Reimbursement
Payment and reimbursement are important areas in which
policy-makers, public and private, can influence IHC development and evaluation. Ample
precedent exists for federal, state, and local government to require that, prior to
payment for health-related services, certain criteria are met. These can include
requirements for populations served, quality of product, evidence of safety and
effectiveness, possessing appropriate accreditation, proof of consumer input into the
system, and a host of other requirements. Given that the public share of health care
expenditures has been estimated to be 46% in 1995,[32] these
requirements can be extremely important to IHC developers.
Access
In addition to the issue of appropriateness of content
discussed previously, there is also the question of access to IHC for the economically or
geographically disadvantaged. While it is possible that low-cost devices will eventually
improve access to IHC, some of these applications are inherently biased against those who
are afraid of technology or who cannot read or write. These problems are especially
important among the poor, disabled persons and the very elderly. Market-driven
interventions are unlikely to address the needs of these relatively small groups of users.
Traditionally, it has been the role of governments and private foundations to ensure
access to services vital to individual and community health. This dimension of IHC should
be kept in mind as evaluation approaches are developed and validated.
IHC, Telemedicine, and Other Electronic Health Information
The relationship between IHC and other electronic health
information systems and processes is neither fully developed nor completely understood.
From a policy perspective this relationship is critical primarily because of the large
amount of current and projected investment in medical information systems and telemedicine
applications. Absent other input, these systems often develop along a medical-model
approach to health communication. With few current incentives to engage consumer or public
health professional input into these systems, they promise simply to replicate past and
current models of health care rather than enable future ones. For example, recent FCC
regulations stemming from telecommunications reform provide financial support for rural
medical clinics, hospitals, and public health agencies to improve their electronic
connectivity with one another and with more urban settings. Without adequate oversight,
this investment could produce systems that are not compatible with the needs of IHC users.
This problem can, in part, be remedied through the
assurance that IHC and other health information systems utilize standardized and common
languages and open platform architecture, such that they are scaleable, extensible, and
ultimately interoperable with one another. Fortunately, the platform-independent Internet
model is rapidly becoming the norm among health entities, although policymakers should
monitor potential changes in these practices.
Recommendations
As with most complex issues facing policymakers, we believe
that there will be no easy way to assure optimal outcomes for IHC-mediated individual and
community health. However, it is possible to make several broad recommendations to
policymakers that are likely to improve the climate for favorable progress in this regard.
Monitoring and Evaluation
There is a need for ongoing monitoring and evaluation of
IHC applications. As described in the other articles in this series, there is no
substitute for explicitly understanding the use, efficacy, effectiveness, and impact of
these tools on real-world conditions in actual settings. Through the consistent
application of defined evaluation criteria, the value added from these systems can be
measured and tracked, and IHC can be systematically and continuously improved in an
evidence-based manner.[22] If policymakers
wish to maximize their contributions to improved health outcomes, they should participate
in the creation and application of standards of evaluation as advocated by the articles in
this series, and in the creation of an environment that encourages and promotes such
evaluation.
Financial Support for "Orphan" Populations and Their IHC Applications
Because of the issues outlined previously, it is virtually
impossible to outline a scenario in which all will be well served by IHC applications in
the immediate future. There is too much financial uncertainty and too little financial
incentive to address noncommercially viable and/or controversial public health issues such
as prenatal care for indigent women, prevention of tuberculosis, mental health needs of
the homeless, immunization assurance for low-income refugees, HIV risk behavior change for
incarcerated individuals, and a host of other problems. Policymakers will need to support
the IHC development community in these areas and should apply the same standards of
evaluation to tools for these problems that they do for others.
Public Education and Community Awareness
Policymakers, especially those in state and federal
government and individuals associated with voluntary health organizations, are in a unique
position to promote public awareness of IHC resources that have demonstrated benefits. As
with public awareness campaigns for specific topics or issues such as heart disease,
stroke, or diabetes, the promotion of evaluated IHC media themselves may be beneficial.
Akin to promoting the use of libraries to increase general knowledge, promoting the
adoption and regular use of effective health communication tools can potentially lead to a
healthier and more self-reliant populace.
Collaboration Among Stakeholders
Policymakers in the public and private sectors will need to
collaborate with one another to assure optimal outcomes from IHC. As noted previously in
this article, most of the challenges of IHC are no longer technical, but rather social and
cultural. Community-wide demonstration projects that connect public health programs with
private health care providers may be required. New approaches to evaluation research may
be needed to assess the impact of IHC on health, functional status, and quality-of-life.
Discipline- and tradition-bound perspectives will need to give way to new ways of
cooperative R&D efforts if these systems are to realize their potential for improving
the health of individuals and communities.
Acknowledgements
Panel members and staff: Linda Adler, MPH, MA,
Kaiser Permanente, Oakland, CA; David Ansley, Consumer Reports, Yonkers, NY; Patricia
Flatley Brennan, RN, PhD, FAAN, School of Nursing and College of Engineering, University
of Wisconsin-Madison; Molly Joel Coye, MD, MPH, The Lewin Group, San Francisco, CA; Mary
Jo Deering, PhD, Office of Disease Prevention and Health Promotion, U.S. Department of
Health and Human Services; Joseph Henderson, MD, Interactive Media Laboratory, Dartmouth
Medical School, Dartmouth, NH; Holly Jimison, PhD, Oregon Health Sciences University,
Portland, OR; Albert Mulley Jr., MD, MPP, Massachusetts General Hospital, Boston, MA; John
Noell, PhD, Oregon Center for Applied Science, Inc. and Oregon Research Institute, Eugene,
OR; Thomas C. Reeves, PhD, University of Georgia, Athens, GA; and Victor Strecher, PhD,
MPH, University of Michigan Comprehensive Cancer Center, Ann Arbor, MI.
The authors are grateful to Paul Kim, Andy Maxfield, PhD,
Anne Restino, MA, and John Studach, MA, for their contributions to the panel's work, and
to Linda Friedman for assistance with copyediting. In addition, the authors thank the
liaisons to the Science Panel on Interactive Communication and Health, especially the
following persons who offered valuable suggestions for improving this manuscript: Loren
Buhle, PhD; David Cochran, MD; Connie Dresser, RN; Alex Jadad, MD; Craig Locatis, PhD; Ed
Madara; Georgia Moore; Kent Murphy, MD; Scott Ratzan, MD, MPA, MA; Helga Rippen, MD, PhD;
and Christobel Selecky.
Address correspondence to: Thomas R. Eng, Office of
Disease Prevention and Health Promotion, HHS, 200 Independence Avenue, SW, Room 738G,
Washington, DC 20201.
Address reprint requests to: Mary Jo Deering, PhD,
Office of Disease Prevention and Health Promotion, U.S. Department of Health and Human
Services, 200 Independence Avenue, SW, Room 738G, Washington, DC 20201.
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