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 - %