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Bard of CyberDialogueBard of CyberDialogue
Maturation of Maturation of eHealth “5 Cs”eHealth “5 Cs”
eCommerceeCommerceeContenteContent
eConnectivityeConnectivity
eCareeCare
eCommunityeCommunity
Automated JournalismAutomated Journalism
EditorEditor
StorageStorage
RefereeReferee
ElectronicElectronicReaderReader
PrintPrint
AuthorAuthor
Medical On-Line ServicesMedical On-Line ServicesFull text of :Full text of :
• JAMA, NEJM, BMJ, JAMA, NEJM, BMJ, Lancet, Annals Int Lancet, Annals Int Medicine, Archives Js, others Medicine, Archives Js, others
• TextbooksTextbooks
Medline from NLMMedline from NLM
Medical On-line ServicesMedical On-line ServicesAdvantagesAdvantages
• Timely, High Quality/QuantityTimely, High Quality/Quantity
DisadvantagesDisadvantages
• Difficult to searchDifficult to search
• ExpensiveExpensive
Medical CD-ROMMedical CD-ROM•Single journalsSingle journals•Collections by Collections by topic/publishertopic/publisher•Reference MaterialsReference Materials•Interactive approachesInteractive approaches
Medical CD-ROMMedical CD-ROMAdvantagesAdvantages
• Low cost players and disksLow cost players and disks
• Effective for teachingEffective for teaching
• ““Multimedia” capabilityMultimedia” capability
DisadvantagesDisadvantages
• Slow response timeSlow response time
• Information not timelyInformation not timely
Medical InternetMedical Internet• Web of NetworksWeb of Networks
• Millions of participantsMillions of participants
• Research databasesResearch databases
• Interactive and personalInteractive and personal
• Widely searchableWidely searchable
• Massive information sourceMassive information source
Medical InternetMedical InternetAdvantagesAdvantages• Worldwide, Voluminous, PersonalWorldwide, Voluminous, Personal
DisadvantagesDisadvantages• Unregulatable, variable quality, Unregulatable, variable quality,
poor securitypoor security
Determinants of Determinants of Human BehaviorHuman Behavior
A HierarchyA Hierarchy
Personal MoralityPersonal Morality
Societal EthicsSocietal Ethics
Public LawPublic Law
A quality or fact of A quality or fact of conforming to or conforming to or deriving from right deriving from right ideas of human ideas of human conduct; goodness conduct; goodness and uprightness of and uprightness of behaviorbehavior
Principles of Principles of conduct governing conduct governing an individual or an individual or profession; the profession; the ideals of character ideals of character manifested by a manifested by a peoplepeople
A rule or mode of A rule or mode of conduct or action that conduct or action that is formally recognized is formally recognized as binding by a as binding by a supreme controlling supreme controlling authority and is made authority and is made obligatory by a obligatory by a sanctionsanction
One of the defining features of a professional is One of the defining features of a professional is "the voluntary self-imposition of higher than "the voluntary self-imposition of higher than ordinary standards"........"When faced with a ordinary standards"........"When faced with a difficult decision, the true professional will efface difficult decision, the true professional will efface his own self-interests"his own self-interests"
PellegrinoPellegrino
The Essence of Professionalism The Essence of Professionalism is Self-Governanceis Self-Governance
I. A physician shall be I. A physician shall be dedicated to providing dedicated to providing competent medical service competent medical service with compassion and with compassion and respect for human dignity.respect for human dignity.
Doing the right thing Doing the right thing for individual patients for individual patients
and populations of and populations of patientspatients
Seek Truth and Report ItSeek Truth and Report It
Minimize HarmMinimize Harm
Act IndependentlyAct Independently
Be AccountableBe Accountable
Society of Professional Society of Professional Journalists Journalists
Code of Ethics -1996Code of Ethics -1996
11. …bad faith…fraud…bribery…public wrong11. …bad faith…fraud…bribery…public wrong
12. Controversies…voluntary agreement or 12. Controversies…voluntary agreement or impartial arbitrationimpartial arbitration
13. …moral obligations of individuals…13. …moral obligations of individuals…
14. Lawful cooperation…is commended14. Lawful cooperation…is commended
15. Business should render restrictive legislation 15. Business should render restrictive legislation unnecessaryunnecessary
The International The International Committee of Medical Committee of Medical Journal Editors Journal Editors
(The Vancouver Group)(The Vancouver Group) Ann Intern Med, BMJ, CMAJ, Ann Intern Med, BMJ, CMAJ, Dutch Med J, Index Medicus, JAMA, Dutch Med J, Index Medicus, JAMA, J Danish Med Assoc, Lancet, MJA, J Danish Med Assoc, Lancet, MJA, NEJM, NZMJ, J Norw Med Assoc, NEJM, NZMJ, J Norw Med Assoc, West J MedWest J Med
> 600 journals have agreed to > 600 journals have agreed to participate participate 19991999
0
5000
10000
15000
20000
25000
30000
35000
40000
Q1 1999 Q2 1999 Q3 1999 Q4 1999 Q1 2000 Q2 2000 Q3 2000 Q4 2000
Per Quarter 1999 and 2000 Total Internet CME Credits Granted—124,600
CME Credits
CME activity –CME activity – Jan 1999 to Dec 2000Jan 1999 to Dec 2000
Ethics statement or “seal”Ethics statement or “seal” 15%15%
Brand name identificationBrand name identification 9%9%
Presence of leading expertsPresence of leading experts 44%44%
Not certain how to judge Not certain how to judge 32%32%
How survey responders How survey responders judge the ethics of a medical judge the ethics of a medical
web siteweb site
1. Candor1. Candor2. Honesty2. Honesty3. Quality3. Quality4. Informed Consent4. Informed Consent5. Privacy5. Privacy6. Professionalism in Online 6. Professionalism in Online HealthcareHealthcare
7. Responsible Partnering7. Responsible Partnering8. Accountability8. Accountability
1. Privacy Policies 1. Privacy Policies 2. Enhanced Privacy Protection for Health-Related 2. Enhanced Privacy Protection for Health-Related
Personal Information Personal Information 3. Safeguarding Consumer Privacy in Relationships 3. Safeguarding Consumer Privacy in Relationships
with Third Parties with Third Parties 4. Disclosure of Ownership and Financial Sponsorship 4. Disclosure of Ownership and Financial Sponsorship 5. Identifying Advertising and Health Information 5. Identifying Advertising and Health Information
Content Sponsored by Third Parties Content Sponsored by Third Parties 6. Promotional Offers, Rebates, and Free Items or 6. Promotional Offers, Rebates, and Free Items or
Services Services
7. Quality of Health Information Content7. Quality of Health Information Content
Between 20 000 and Between 20 000 and 2 000 0002 000 000
Health/Medical Sites Health/Medical Sites on the Interneton the Internet
Health Health SearchersSearchers
Porno Porno SearchersSearchers>>
US Adults Seeking US Adults Seeking Health Info on the Health Info on the
WWWWWW June 1998 54 million June 1998 54 million
June 1999 69 millionJune 1999 69 million
June 2000 98 millionJune 2000 98 million
November 2000 106 millionNovember 2000 106 million Harris InteractiveHarris Interactive
On Line Health On Line Health InformationInformation
97 Million US Adult Users97 Million US Adult UsersSearch engine or portalSearch engine or portal 52%52%Directly to health siteDirectly to health site 24%24%General site with health infoGeneral site with health info 14%14%
Average 3.3 visits a monthAverage 3.3 visits a monthHarris Interactive 2001Harris Interactive 2001
> 50% for specific illness or > 50% for specific illness or diagnosisdiagnosis
46% after new Rx/treatment46% after new Rx/treatmentOnly 20% before seeing their Only 20% before seeing their
physiciansphysicians CyberDialogueCyberDialogue
Patients Visiting Patients Visiting Health Sites 2000Health Sites 2000
On line Health UsersOn line Health Users15% of MDs recommend 15% of MDs recommend specific sitesspecific sitesVitamins and nutritional Vitamins and nutritional supplements are boughtsupplements are boughtPrescription drugs not bought Prescription drugs not bought on lineon line
On line Health UsersOn line Health UsersMore women than menMore women than menTypically older, married, Typically older, married, Caucasian Caucasian && college-educated college-educatedArrive at Doctor with print-outArrive at Doctor with print-outLeave with lower opinion of Leave with lower opinion of DoctorDoctor
US MDs accessingUS MDs accessingthe Internetthe Internet
19951995 3%3%1996 1996 15%15%1997 1997 32%32%19981998 60%60%19991999 80%80%20002000 89%89%20012001 93%93%
US MD US MD Internet UseInternet Use
Overall Overall 85%85%Medical information Medical information and news and news 71%71%Access guidelines Access guidelines and protocols and protocols 50%50%
HealthTech 2001HealthTech 2001
MDs Use Internet 3 MDs Use Internet 3 Hours/Week to:Hours/Week to:
Research clinical mattersResearch clinical matters 90%90%Read journal articlesRead journal articles 78%78%Contact colleaguesContact colleagues 61%61%Complete CMEComplete CME 45%45%Attend conferencesAttend conferences 31%31%
BCG 2001BCG 2001
Average time on-line onAverage time on-line on Medical sitesMedical sites 2-3 hours/week 2-3 hours/week
Have looked for/at:Have looked for/at:Disease Information Disease Information 94%94%Medical Association News Medical Association News 85%85%Medical Sites Medical Sites 74%74%University sites University sites 67%67%Online CME Online CME 45%45%
Canadian PhysiciansCanadian Physicians
Medical Portals most usedMedical Portals most used::Medical Associations Medical Associations 26%26%
Medscape Medscape 11 %11 %MEDLINE MEDLINE 6 %6 %WebMDWebMD 6%6%Pubmed Pubmed 2% 2% University sites University sites 2%2%
Canadian PhysiciansCanadian Physicians
Expect their Internet use to Expect their Internet use to increase next 12 monthsincrease next 12 months
Accessing Disease Info Accessing Disease Info 70%70%
On Line CME 58%On Line CME 58%
Access Drug Info 33 %Access Drug Info 33 %
Canadian PhysiciansCanadian Physicians
Agreed with the statement:Agreed with the statement:
The Internet is changing theThe Internet is changing theway I practice medicine way I practice medicine 43%43%
I take fewer medical journals because I take fewer medical journals because the information is the information is on the Interneton the Internet 37%37%
Canadian PhysiciansCanadian Physicians
What do What do Physicians Physicians
Do?Do?
Physicians and Physicians and InformationInformation
SeekingSeekingGatheringGatheringInterpretingInterpretingFeedbackFeedback
ObservingObservingAssimilatingAssimilatingDispensingDispensingMonitoringMonitoring
Where is the Internet Where is the Internet Applicable?Applicable?
1. Anywhere the telephone/fax machine is used1. Anywhere the telephone/fax machine is used2. As a library2. As a library3. To replace hand-delivered notes3. To replace hand-delivered notes4. To replace letters/brochures/certificates/lab 4. To replace letters/brochures/certificates/lab resultsresults5. Orders and results5. Orders and results6. Verbal communications6. Verbal communications7. Whenever distance separates individuals or 7. Whenever distance separates individuals or copies are needed for otherscopies are needed for others
Physicians’ “Essential” Physicians’ “Essential” Internet ApplicationsInternet Applications
Clinical Clinical Diagnostic reportingDiagnostic reportingElectronic medical recordsElectronic medical records
AdministrativeAdministrativeClaims processingClaims processingEligibility authorizationsEligibility authorizationsReferral authorizationsReferral authorizationsIT systems supportIT systems support
HealthTech 2001HealthTech 2001
Great for an Great for an established established
patient-physician patient-physician relationshiprelationship
Verboten for Verboten for initial or sole initial or sole
patient-physician patient-physician interactioninteraction
Values of e-mail Values of e-mail MedicineMedicine
Maintain continuity of careMaintain continuity of careFacilitate information flowFacilitate information flowIncrease meaningful Increase meaningful
communicationcommunicationReduce unnecessary appointmentsReduce unnecessary appointmentsIncrease patient responsibilityIncrease patient responsibility Mechanic 2001 BMJMechanic 2001 BMJ
34 million want to34 million want toOnly 3 million have done soOnly 3 million have done so5 million have visited any 5 million have visited any
physician web sitephysician web site CyberDialogueCyberDialogue
Patients Contacting Patients Contacting Physicians Electronically Physicians Electronically
20002000
Electronic Alerts from Physicians - Electronic Alerts from Physicians - 84%84%
Lab Results on line - Lab Results on line - 83%83%Personalized Medical Information - Personalized Medical Information - 80%80%
Charts to Monitor Chronic Charts to Monitor Chronic Conditions - Conditions - 69%69%Will Select Physician Based on Will Select Physician Based on Internet Services - Internet Services - 43%43%
-Harris Interactive -Harris Interactive 20002000
What Consumers WantWhat Consumers Want
Concerned that e-mail will impact their busy Concerned that e-mail will impact their busy schedulesschedules
Only experimental methods of paymentOnly experimental methods of paymentPotential loss of “high-touch” relationshipsPotential loss of “high-touch” relationshipsConsider nurse or physician assistant triageConsider nurse or physician assistant triage
Physician Fear Physician Fear and Resistanceand Resistance
MDs Use :MDs Use :
E-mail with patients E-mail with patients 26%26%EMREMR 22%22%Electronic prescribing Electronic prescribing 11%11%Remote monitoringRemote monitoring 5% 5%
BCG 2001BCG 2001
How often do you email How often do you email patients?patients?
DailyDaily 9 % 9 %Few Times a Week 11 %Few Times a Week 11 %Once a Month 15 %Once a Month 15 %Never 65 %Never 65 %
Aug 2001Aug 2001
Medical Practice on the Medical Practice on the InternetInternet
A Watershed Time/Issue A Watershed Time/Issue1. Follow basic principles of medical ethics 1. Follow basic principles of medical ethics like Hippocrates first do no harm CEJAlike Hippocrates first do no harm CEJA2. Preserve Privacy2. Preserve Privacy3. Disclose/Disclose/Disclose3. Disclose/Disclose/Disclose4. Informed Consent Applies4. Informed Consent Applies5. Promote Research on Internet Medicine; 5. Promote Research on Internet Medicine; Publish the good research; then let Ethics Publish the good research; then let Ethics follow Sciencefollow Science6. Much of this is a Risk/Benefit Ratio still to be 6. Much of this is a Risk/Benefit Ratio still to be determined for most interactions/interventionsdetermined for most interactions/interventions
A fundamentally new mediumA fundamentally new medium Exact nature still unknownExact nature still unknown Likely to change every aspect Likely to change every aspect
of how we liveof how we live As electricity didAs electricity did
John Seely BrownJohn Seely Brown
The World Wide WebThe World Wide Web
PhysicianPatient
Changing Physician Changing Physician BehaviorBehavior
Education Education FeedbackFeedbackFinancial rewardsFinancial rewardsFinancial penaltiesFinancial penaltiesAdministrative changesAdministrative changesPhysician participationPhysician participation Eisenberg 1981Eisenberg 1981
Changing Physician Changing Physician Behavior (1)Behavior (1)
Know the literature and have the Know the literature and have the datadata
Convene committee of leading Convene committee of leading physiciansphysicians
Achieve agreement based on Achieve agreement based on evidence and opinionevidence and opinion
Implement administratively Implement administratively Lundberg 1998Lundberg 1998
Changing Physician Changing Physician Behavior (2)Behavior (2)
Add educational materials and Add educational materials and conferencesconferences
Receive complaintsReceive complaintsRide out reactions and make Ride out reactions and make
adjustmentsadjustmentsEnjoy successEnjoy success
Lundberg 1998Lundberg 1998
Motivating Change in Motivating Change in Clinician BehaviorClinician Behavior
Scientific performance dataScientific performance dataBest practice care expectationsBest practice care expectationsPositive financial gains or Positive financial gains or
incentivesincentivesFear of losing patient access due to Fear of losing patient access due to
economic credentialingeconomic credentialingFear of restriction of privileges Fear of restriction of privileges Fear of public exposureFear of public exposure Rosenstein 2000Rosenstein 2000
Doctor Decision to Use Doctor Decision to Use an Internet Toolan Internet Tool
Does it:Does it: Save timeSave time Work as advertisedWork as advertised Have trusted quality stampHave trusted quality stamp Strengthen power positionStrengthen power position Help meet a mandate/requirementHelp meet a mandate/requirement Is it free?Is it free? Forrester 2000Forrester 2000
Primary Care MDs Primary Care MDs Sometimes Using EMR Sometimes Using EMR United StatesUnited States 17%17%CanadaCanada 14%14%AustraliaAustralia 25%25%New ZealandNew Zealand 52%52%United KingdomUnited Kingdom 59%59%
HI 2000HI 2000
Primary Care MDs Often Primary Care MDs Often Prescribing ElectronicallyPrescribing Electronically
United StatesUnited States 9% 9%CanadaCanada 8% 8%AustraliaAustralia 44%44%New ZealandNew Zealand 52%52%United KingdomUnited Kingdom 87%87%
HI 2000 HI 2000
““There are no secrets in There are no secrets in hospitalshospitals””
-Lundberg 2000-Lundberg 2000
Privacy Issues Privacy Issues Surrounding Health Surrounding Health Care on the InternetCare on the Internet
““Solutions should be technology Solutions should be technology neutralneutral””
-Boulding 2000-Boulding 2000
Privacy Issues Privacy Issues Surrounding Health Surrounding Health Care on the InternetCare on the Internet
Privacy on the Web Privacy on the Web and in e-mailand in e-mail
There isn't any - There won’t be anyThere isn't any - There won’t be anyCompanies should have, should post, Companies should have, should post,
and should follow policiesand should follow policiesDon’t steal identities - Don’t rip Don’t steal identities - Don’t rip
people offpeople offInformed Consent - Opt-In > Opt-Out Informed Consent - Opt-In > Opt-Out
A New World A New World Made Better by Made Better by
InformationInformation
Shared by many CShared by many Cultureulture
Shared by some Shared by some Cult Cult
Shared by two Shared by two LoveLove
Held by oneHeld by one Psychosis Psychosis
DelusionDelusion
Malnourished - 50Malnourished - 50
Substandard Housing - 80Substandard Housing - 80
Able to Read - 30Able to Read - 30
College Education - 1College Education - 1
Own a Computer - 1Own a Computer - 1
The World’s The World’s Population - %Population - %