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Internet-Based Patient Self-Care: The Next Generation of Health Care Delivery
Internet-Based Patient Self-Care: The Next Generation of Health Care Delivery
June Forkner-Dunn, PhD, RN 1 June Forkner-Dunn, Internet Services Group, Kaiser Foundation Health Plan, Inc, 1 !! Harrison Street, 1 th Floor, "akland #$ %&'1(-)&(%, *S$, Phone+ ,1 -1! '(( ((, Fa.+ ,1 -1! '(- ( (%, /0ail+ dunn1kp2or32 Revie4ed 56 7 Ger5er and D $hern $uthor in8or0ation 9 $rticle notes 9 #op6ri3ht and :icense in8or0ation 9 ;his article has 5een cited 56 other articles in P<#2 Go to+
Abstract
;he *nited States health care s6ste0 is an outdated 0odel in need o8 8unda0ental chan3e2 $s part o8 this chan3e, the s6ste0 0ust e.plore and take advanta3e o8 the potential 5ene8its o8 the =e-revolution,= a pheno0enon that includes ever6da6 use o8 the Internet 56 the 3eneral pu5lic2 Durin3 (!!(, an esti0ated 1!! 0illion $0ericans 4ill have o5tained in8or0ation > includin3 health in8or0ation > 8ro0 the ?e5 as a 5asis 8or 0akin3 decisions2 ;he Internet is thus an in8luential 8orce@ and, as such, this 0ediu0 could have a revolutionar6 role in retoolin3 the trillion-dollar *nited States health care industr6 to i0prove patient sel8-0ana3e0ent, patient satis8action, and health outco0es2 $s a 3roup, ph6sicians use the Internet 0ore than do 0an6 other sectors o8 the 3eneral adult population2 Ho4ever, ph6sicians have not received su88icient in8or0ation to convince the0 that the6 can provide hi3her-Aualit6 care 56 usin3 the Internet@ indeed, 8e4 studies have assessed the InternetBs value 8or i0provin3 patientsB 0edical sel8-0ana3e0ent and health 5ehavior, as 4ell as their clinical outco0es and relationships 4ith health care practitioners2 Ne4 e-technolo36 8or0ats introduced to the 3ro4in3 consu0er 0ove0ent 4ill drive the ne.t 3eneration o8 sel8-care 56 allo4in3 patients to 0ana3e their o4n health convenientl6 and pro8icientl62 Key ords: #onsu0er participation, Internet, 0edical in8or0atics, patient education, ph6sician-patient relations, sel8 care, technolo36, disease 0ana3e0ent, co0puters Go to+
Introd!ction
;he land0ark Institute o8 <edicine report, =#rossin3 the Aualit6 chas0+ a ne4 health care s6ste0 8or the (1st centur6= C1D, depicts an outdated 0odel o8 health care that hosts 4orsenin3 chronic 0edical conditions, sk6rocketin3 health care e.penditures, and 8ailure to e88ectivel6 trans8or0 technical innovation into i0proved health outco0es2 ;he Internet 0a6 have a revolutionar6 role in retoolin3 the trillion-dollar health care industr6 in the *nited States2
Indeed, 56 introducin3 ne4 e-technolo36 8or0ats to the 3ro4in3 consu0er 0ove0ent, the online revolution 0a6 5eco0e the en3ine drivin3 the ne.t 3eneration o8 sel8-care, there56 allo4in3 patients to 0ana3e their o4n health convenientl6 and pro8icientl62 $lthou3h the InternetBs po4er to positivel6 a88ect care 0ana3e0ent see0s an intuitive concept, the InternetBs value 8or i0provin3 health outco0es 0ust 5e e.a0ined and docu0ented to provide a 5asis 8or 8urther advance0ent2 Go to+
a 8or0al stud62 Further research is necessar6 to understand 4hat e88ect the Internet a3e has on the patient-ph6sician relationship2 For e.a0ple, are patients 0ore co0pliant 4ith prescri5ed therap6 5ecause the6 discussed it 0ore 4ith their ph6sician or 5ecause the6 read it on the ?e5I ;he =school o8 la6 0edicine= 8ound on the Internet o88ers an i0portant opportunit6 8or patients to 5eco0e activel6 en3a3ed in their o4n care2 Durin3 the pre-Internet era, 0edical in8or0ation 4as pu5lished in 0edical te.t5ooks and Fournals onl6, 4hereas patients can no4 3ain access to citations o8 0ore than 1( 0illion 0edical articles online C'D2 Indeed, 0an6 patients are no4 helpin3 to in8or0 their ph6sicians on the latest research and treat0ents2 Ph6sicians Ger5er and /iser CJD postulate that the Internet a3e o88ers opportunities to i0prove the patient-ph6sician relationship 56 sharin3 the 5urden o8 responsi5ilit6 8or kno4led3e2 ;he6 also underline the necessit6 8or research to identi86 the e88ects on the patient-ph6sician relationship, as 4ell as the e88ects on patient and ph6sician satis8action and on health outco0es2 ;he locus o8 po4er in health care also is shi8tin3+ instead o8 the doctor actin3 as sole 0ana3er o8 patient care Kie, =the captain o8 the ship=L, a consu0erist 0odel has e0er3ed in 4hich patients and their doctors are partners in 0ana3in3 the patientBs care C D2 "n the other hand, there are 0an6 patients 4ho do not 4ish to 5e the captain o8 the ship2 Research needs to address ho4 the Internet 4ould a88ect these individuals2 Go to+
$s a 3roup, ph6sicians the0selves have constituted a 0aFor source o8 resistance to online health care2 $n article, =?h6 doctors hate the Net= C1&D, identi8ied ) speci8ic concerns o8 ph6sicians+
/-0ail 8ro0 patients 8urther 5urdens over8lo4in3 ph6sician schedules Durin3 an alread6-cro4ded o88ice visit schedule, e-savv6 patients ar0ed 4ith printouts 8ro0 the Internet 4aste precious ti0e discussin3 in8or0ation 8ro0 unkno4n or other4ise-du5ious sources <uch health-related in8or0ation posted on the Internet is unrelia5le2
<ore than a centur6 a3o, a si0ilar 5acklash in health care acco0panied introduction o8 another technolo36+ the telephone2 Soon a8ter invention o8 the telephone 56 $le.ander Graha0 7ell, 0uch cultural opposition to it 4as 3enerated 56 ph6sicians 4ho dou5ted that the telephone could add value to 0edical practice2 ;hese ph6sicians co0plained that ans4erin3 calls 4ould di0inish the ti0e availa5le 8or in-person interaction 4ith patients2 "ther ph6sicians Auestioned 4hether patients 4ould 5e 4illin3 to use the ne4 technolo362 So0e ph6sicians 4orried that the telephone 0i3ht destro6 the patient-ph6sician relationship C1-D2 $s the6 did 4ith the telephone, ho4ever, ph6sicians are 5eco0in3 less resistant to usin3 the Internet 8or deliverin3 patient care2 Recent esti0ates o8 Internet-eAuipped ph6sicians var6, 5ut these reports a3ree that ph6sician adoption o8 the Internet is increasin3 noticea5l6 C1'D, and 0ost a3ree that ph6sicians Ka 3roup so0eti0es thou3ht technopho5icL use the Internet 0ore than do 0an6 other sectors o8 the 3eneral adult population C1JD2 Ho4ever, ph6sicians have not received in8or0ation su88icient to convince the0 that the Internet can help the0 provide hi3her-Aualit6 care+ althou3h --G o8 ph6sicians surve6ed use e-0ail to co00unicate 4ith pro8essional collea3ues, onl6 1)G stated a 4illin3ness to send e-0ail to patients C1 D2 In contrast to this 8indin3, %!G o8 patients surve6ed 4ished to co00unicate 4ith their ph6sicians 56 e0ail C1%D2 In their article =?e 3ot 0ail,= <o6er et al C(!D hi3hli3ht issues such as ineAuit6 o8 e0ail access, 4orkload, 0edical-le3al concerns, as 4ell as privac6 and con8identialit62 Research is necessar6 to address these issues2 Does e-0ail 8ro0 patients reall6 5urden a ph6sicianBs scheduleI I8 so, 4ill tria3in3 56 others helpI ?hat e88ect does eco00unication have on the patient-ph6sician relationshipI #an e-0ail re0inders 8ro0 a =virtual case 0ana3er= i0prove health outco0esI #an providers 5e held lia5le i8 an unauthoriHed third part6 accesses con8idential 0edical in8or0ation sent 56 e0ailI Is e-0ail cost-e88ectiveI Go to+
Access Ga&s
$nother o5stacle to 4idel6 i0ple0entin3 online 8or0s o8 health intervention is the assu0ption that lack o8 necessar6 technolo36 56 0an6 senior, 0inorit6, and lo4erinco0e patients 4ill e.clude the0 8ro0 this intervention2 ?hile access to the Internet is less co00on in these 3roups, studies sho4 that the =di3ital divide= is narro4in32
Fro0 $u3ust (!!! throu3h Jul6 (!!1, the nu05er o8 $8rican $0ericans usin3 the Internet 3re4 nearl6 (!G C(1D2 ;he proportion o8 4ired $8rican $0ericans K&)GL, nonetheless, re0ains lo4 in co0parison 4ith the avera3e o8 online $0ericans K- GL C(1D2 Internet access a0on3 Hispanics in the *nited States increased 56 (-G 8ro0 <arch (!!! throu3h Fe5ruar6 (!!1, indicatin3 that 0ore than hal8 o8 that population is no4 online C((D2 :ike $8rican $0ericans, ho4ever, Hispanics have less access to c65erspace than their #aucasian counterparts2 In contrast, $sian $0ericans use the Internet 0ore than other 3roup+ 0ore than J-G o8 that population has access to the Internet C()D2 /cono0ics pla6 a part in access2 Studies sho4 that lo4er-inco0e people are less likel6 to 5e 4ired+ )JG o8 those 4ho are not 4ired have 8a0il6 inco0es under M)!!!!, 4hereas onl6 1 G o8 those 4ith Internet access have inco0es under M)!!!! C(&D2 Poor readin3 skills add even 0ore 5arriers to those econo0icall6 disadvanta3ed 8or accessin3 the 4orld o8 the ?e52 ;he senior population has 5een slo4er than other a3e 3roups in e05racin3 the Internet 5ut this is chan3in32 $ Pe4 report C(-D predicts that 4ith 0an6 5a56 5oo0ers approachin3 retire0ent a3e, seniorsB use o8 the Internet 4ill increase dra0aticall62 ;he health care industr6 0ust 5e prepared to acco00odate this 3ro4in3 se30ent o8 the population, 0an6 o8 4ho0 4ill 5eco0e ho0e5ound 5ut 4ill still need services, trainin3, and rein8orce0ent o8 0edical sel8-0ana3e0ent, as 4ell as continued connection to clinicians and contact 4ith other patients2 ?hile eHealth technolo3ies have the potential to reduce disparities in health care 56 pro0otin3 health and preventin3 disease, traditionall6 underserved 3roups 4ho could 5ene8it the 0ost 8ro0 eHealth initiatives, are the least likel6 to have access to such technolo3ies2 $lthou3h seniors and 0an6 0inorit6 3roups are the 8astest-3ro4in3 se30ents o8 ne4 Internet users C((,(),(-D, 4e need to 5etter understand access 5arriers2 Further0ore, /n3 et al C('D raise i0portant points re3ardin3 access issues 8or those 4ho cannot read at all, those 4ho cannot read /n3lish, and those 4ith disa5ilities2 Go to+
0ana3e0ent, health-related 5ehavior, health outco0es, and relationships 4ith health care practitioners2 Go to+
Ac/no led%'ents
$lan /shle0an, <D, and 7eth /shel0an, :#S?, revie4ed the 0anuscript2 ;he Kaiser Per0anente <edical /ditin3 Depart0ent provided editorial assistance2 Go to+
0ootnotes
#on8licts o8 Interest+ None declared2 Go to+
#eferences
12 Institute o8 <edicine, #o00ittee on Oualit6 o8 #are in $0erica, authors2 $ ne4 health care s6ste0 8or the (1st centur62 ?ashin3ton, D#+ National $cade06 Press@ (!!12 (2 ;a6lor H2 Harris Poll nu05er (1+ #65erchondriacs update2 (!!(2 <a6 1, C(!!( $u3 (%D2 http+PP4442harrisinteractive2co0PharrisQpollPinde.2aspIPIDR(%%2 )2 Fo. S, Rainie :, Horri3an J, :enhart $, Spooner ;, 7urke <, et al2 ;he online health care revolution+ ho4 the ?e5 helps $0ericans take 5etter care o8 the0selves2 ?ashin3ton, D#+ ;he Pe4 Internet E $0erican :i8e ProFect@ http+PP4442pe4internet2or3PreportsPpd8sPPIPQHealthQReport2pd82 &2 Gusta8son D H, Ha4kins R, Pin3ree S, <ctavish F, $rora N K, <endenhall J, #ella D F, Serlin R #, $pantaku F <, Ste4art J, Salner $2 /88ect o8 co0puter support on 6oun3er 4o0en 4ith 5reast cancer2 J Gen Intern <ed2 (!!1 Jul@1'KJL+&)-S&-2 doi+ 1!21!&'PF21-(--1&%J2(!!12!1'!!J&)-2.2F3i!!))( CP<# 8ree articleD CPu5<edD C#ross Re8D -2 Harris Interactive, authors2 ;he increasin3 i0pact o8 eHealth on consu0er 5ehavior2 Health #are Ne4s2 (!!1 Jun ('@1K(1L+1S%2 http+PP4442harrisinteractive2co0Pne4sPne4slettersPhealthne4sPHIQHealth#areNe4s( !!1Tol1Qiss(12pd82 '2 National :i5rar6 o8 <edicine, authors2 Pu5<ed2 C(!!) $pr )D2 http+PP4442nc5i2nl02nih23ovPPu5<edP J2 Ger5er 7 S, /iser $ R2 ;he patient ph6sician relationship in the Internet a3e+ 8uture prospects and the research a3enda2 J <ed Internet Res2 (!!1 $pr %@)K(L+e1-2 doi+ 1!2(1%'PF0ir2)2(2e1-2 http+PP4442F0ir2or3P(!!1P(Pe1-P CP<# 8ree articleD CPu5<edD C#ross Re8D
2 Reents S2 I0pacts o8 the Internet on the doctor-patient relationship+ the rise o8 the Internet health consu0er2 Ne4 Nork+ #65er Dialo3ue@ 1%%%2 http+PP4442c65erdialo3ue2co0Ppd8sP4pP4p-cch-1%%%-doctors2pd82 %2 ID/$;el KIn8or0atics 8or Dia5etes /ducation $nd ;ele0edicineL, authors FreAuentl6 asked Auestions2 C(!!) Jan ()D2 http+PP4442ideatel2co0Pin8o2ht0l2 1!2 <cka6 H G, Kin3 D, /akin / G, Seele6 J R, Glas3o4 R /2 ;he dia5etes net4ork internet-5ased ph6sical activit6 intervention+ a rando0iHed pilot stud62 Dia5etes #are2 (!!1 $u3@(&K L+1)( S)&2 http+PPcare2dia5etesFournals2or3Pc3iPcontentP8ullP(&P P1)( 2 CPu5<edD 112 Johnson K 7, Ravert R D, /verton $2 Hopkins ;een #entral+ $ssess0ent o8 an internet-5ased support s6ste0 8or children 4ith c6stic 8i5rosis2 Pediatrics2 (!!1 Fe5@1!JK(L+e(&2 doi+ 1!21-&(Ppeds21!J2(2e(&2 http+PP4442pediatrics2or3Pc3iPcontentP8ullP1!JP(Pe(&2 CPu5<edD C#ross Re8D 1(2 Feen5er3 $ :, :icht J <, Kane K P, <oran K, S0ith R $2 ;he online patient 0eetin32 J Neurol Sci2 1%%' $u3@K1)% SupplL+1(%S1)12 doi+ 1!21!1'P!!((-1!UK%'L!!!%)-J2 CPu5<edD C#ross Re8D 1)2 Dunha0 P J, Hursh0an $, :it4in /, Gusella J, /lls4orth #, Dodd P ?2 #o0puter-0ediated social support+ sin3le 6oun3 0others as a 0odel s6ste02 $0 J #o00unit6 Ps6chol2 1%% $pr@('K(L+( 1S)!'2 doi+ 1!21!()P$+1!((1)(J(!1!&2 CPu5<edD C#ross Re8D 1&2 Shact0an N2 ?h6 doctors hate the Internet2 ?ired Ne4s2 (!!!2 $pr 1!, C(!!( $u3 (%D2 http+PP44424ired2co0Pne4sPprintP!,1(%&,)--1'2!!2ht0l2 1-2 Fischer #laude S2 $0erica #allin3+ $ Social Histor6 o8 the ;elephone to 1%&!2 7erkele6, #ali8+ *niv o8 #ali8ornia Press@ 1%%(2 Sep 1, 1'2 Harris Interactive, authors2 ;he increasin3 i0pact o8 eHealth on ph6sician 5ehavior+ online in8or0ation is in8luencin3 dia3nosis, treat0ents and prescri5in32 C(!!( $u3ust (%D@Health #are Ne4s2 (!!1 Nov 1)@1K)1L+1S1)2 http+PP4442harrisinteractive2co0Pne4sPne4slettersPhealthne4sPHIQHealth#areNe4s( !!1Tol1Qiss)12pd82 1J2 $0erican <edical $ssociation, authors2 General ne4s2 Ne4 $<$ stud6 sho4s ph6siciansB use o8 Internet steadil6 risin32 C(!!( Sep 'D2 http+PP4442a0aassn2or3Pa0aPpu5PprintParticleP1'1--'&JJ2ht0l2 1 2 Harris Interactive, authors2 Ne4 data sho4 Internet, ?e5site and e0ail usa3e 56 ph6sicians all increasin3+ securit6 and privac6 concerns re0ain 5arriers to electronic trans8er o8 clinical in8or0ation2 C(!!( Sep 'D@Health #are Ne4s2 (!!1 Fe5 ('@1K L+1S )2 http+PP4442harrisinteractive2co0Pne4sPne4slettersPhealthne4sPHIQHealth#areNe4s( !!1Tol1Qiss 2pd82 1%2 N*$ Internet Surve6s, authors2 #65er$tlas+ $0ericans 4ant online access to doctors2 (!!(2 $pr 1(, C(!!( $u3 (%D2 http+PP4442nua2co0Psurve6sPinde.2c3iI 8RTSEartQidR%!-)-J &&ErelRtrue2 (!2 <o6er # $, Stern D ;, KatH S J, Fendrick $ <2 =?e 3ot 0ail=+ electronic co00unication 5et4een ph6sicians and patients2 $0 J <ana3 #are2 1%%% Dec@-K1(L+1-1)S((2 CPu5<edD (12 N*$ Internet Surve6s, authors2 Nielsen NetRatin3s+ 0ore $8rican $0ericans no4 online2 (!!12 Sep 1%, C(!!( $u3 (%D2 http+PP4442nua2co0Psurve6sPinde.2c3iI 8RTSEartQidR%!-)-J(!-ErelRtrue2 ((2 Spooner ;, Rainie :, Fo. S, Horri3an J, ?ellisch J, :enhart $, et al2 Hispanics and the Internet2 ?ashin3ton, D#+ ;he Pe4 Internet E $0erical :i8e ProFect@ (!!12 Jul (-, http+PP4442pe4internet2or3PreportsPpd8sPPIPQHispanicsQ"nlineQReport2pd82
()2 Spooner ;, Rainie :, <eredith P2 $sian-$0ericans and the Internet+ the 6oun3 and the connected2 ?ashin3ton, D#+ ;he Pe4 Internet E $0erical :i8e ProFect@ (!!12 Dec 1(, http+PP4442pe4internet2or3PreportsPpd8sPPIPQ$siansQReport2pd82 (&2 ;rackin3 online li8e+ ho4 4o0en use the Internet to cultivate relationships 4ith 8a0il6 and 8riends2 ?ashin3ton, D#+ ;he Pe4 Internet E $0erical :i8e ProFect@ (!!!2 <a6 1!, http+PP4442pe4internet2or3PreportsPpd8sPReport12pd82 (-2 Fo. S, Rainie :, :arsen /, Horri3an J, :enhart $, Spooner ;, et al2 ?ired seniors+ a 8ervent 8e4, inspired 56 8a0il6 ties2 ?ashin3ton, D#+ ;he Pe4 Internet E $0erical :i8e ProFect@ (!!12 Sep %, http+PP4442pe4internet2or3PreportsPpd8sPPIPQ?iredQSeniorsQReport2pd82 ('2 /n3 ; R, <a.8ield $, Patrick K, Deerin3 < J, RatHan S #, Gusta8son D H2 $ccess to health in8or0ation and support+ a pu5lic hi3h4a6 or a private roadI J$<$2 1%% "ct (1@( !K1-L+1)J1S-2 doi+ 1!21!!1PFa0a2( !21-21)J12Fpp !!1 CPu5<edD C#ross Re8D