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Internet Use by Physiciansand Its Impact on MedicalPractice—An Exploratory StudyIk-Whan G. Kwon PhD a b & Henry Yu Xie MBA ba Consortium for Supply Chain Management Studiesb John Cook School of Busimess, Saint LouisUniversityPublished online: 22 Sep 2008.

To cite this article: Ik-Whan G. Kwon PhD & Henry Yu Xie MBA (2003) Internet Use byPhysicians and Its Impact on Medical Practice—An Exploratory Study, Health MarketingQuarterly, 21:1-2, 5-27, DOI: 10.1300/J026v21n01_02

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Internet Use by Physiciansand Its Impact on Medical Practice–

An Exploratory Study

Ik-Whan G. Kwon, PhDHenry Yu Xie, MBA

ABSTRACT. Internet use by physicians has played a vital role in medi-cal practices for many years. A number of related studies have emergedto examine the impact of Internet use on medical practice. However,there is yet to be a comprehensive study on the impact of Internet use byphysicians on their medical practice. This study examines a preliminarystep to explore the major implications of physicians’ Internet use on thetraditional areas, such as health education and learning, physician-pa-tient relationship, and medical marketing. Barriers to Internet use arealso investigated. Implication of use of the Internet in the medical prac-tice and limitations of this study are discussed as well. [Article copiesavailable for a fee from The Haworth Document Delivery Service: 1-800-HAWORTH. E-mail address: <docdelivery@haworthpress.com> Web site:<http://www.HaworthPress.com> © 2003 by The Haworth Press, Inc. Allrights reserved.]

Ik-Whan G. Kwon is Professor and Director, The Consortium for Supply ChainManagement Studies, and Henry Yu Xie is Doctoral Student, both at The John CookSchool of Busimess, Saint Louis University.

Address correspondence to: Ik-Whan G. Kwon, The Consortium for Supply ChainManagement Studies, The John Cook School of Business, Saint Louis University,3674 Lindell Boulevard, DS 109, St. Louis, MO 63143 (E-mail: kwoni@slu.edu).

This study is partially supported (non-financial) by the St. Louis Metropolitan Med-ical Society, St. Louis, Missouri.

Health Marketing Quarterly, Vol. 21(1/2) 2003http://www.haworthpress.com/web/HMQ

© 2003 by The Haworth Press, Inc. All rights reserved.Digital Object Identifier: 10.1300/J026v21n01_02 5

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KEYWORDS. Internet use, medical practice, medical marketing,health care, quality of care, physicians, patients

INTRODUCTION

In the last decade, the emergence of the Internet has been dramati-cally revolutionizing the way people access, share and communicateinformation in almost all facets of society. Although the commercialInternet bubble burst in the late 1990s, the use and application of theInternet in various business and industrial functions have seen a biggerrole ever since. In the field of medical practice by physicians, the 2002American Medical Association (AMA) Study on Physicians’ Use ofthe World Wide Web found that almost half of physicians interviewedreported that the Internet has had a major impact on the way they prac-tice medical service (Health Care Strategic Management 2002).

There have been a number of studies on the Internet’s impact on healthcare and hospital marketing strategy (Lin et al. 2001; Sanchez 2000).There are also a few studies on the growing linkage between the Internetand physicians (Kassirer 2001; Gruen 1999). However, there are not yetcomprehensive studies regarding the Internet’s impact on the physicians’medical practice. Some questions still remain: What impact does theInternet have on the medical practice of physicians? What has impededfurther Internet use in this field? How much will physicians be willing toinvest in information technology for the patient management?

Among many areas that Internet use may influence physician’spractice behavior, this study attempts to study the impact of Interneton three major areas related to physicians’ medical practice; health ed-ucation and learning, physician-patient relationship, and medical mar-keting. In addition, we also discuss the barriers to Internet use in thecontext of medical practice and the implications of this study. Limita-tions of the study are also discussed.

SAMPLING AND METHODOLOGY

Survey Instrument

A questionnaire was carefully designed with the help of Internetspecialists and medical practitioners from the St. Louis Metropoli-tan Medical Society to ensure the relevance of questions (refer to

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the Appendix for a copy of the instrument). The instrument was de-signed to capture seven (7) major areas (constructs); general infor-mation on availability of the Internet and extent of usage, areas ofInternet use, amount of investment in Internet technology, confi-dentiality and privacy issue, medical practice, barriers to use Internetand demographic variables. Each question is randomly listed in theinstrument to avoid any response bias. One thousand eight hundred(1,800) questionnaires were distributed via U.S. mail to physicians andother medical practitioners in the St. Louis, Missouri metropolitan area,under the supervision of the St. Louis Metropolitan Medical Society.

Overall Return Rate and Validation of Sample Returns

Four hundred and forty-five (445) valid responses (24.7% responserate) were obtained and analyzed. Although the return rate of 24.7% isconsidered acceptable, each valid return is sequentially numbered totest non-respondent bias. The last 45 valid returns were used to seewhether the contents of these returns were significantly (statistically)different from earlier returns. The former is considered as representa-tive of non-respondents (Amstrong and Overton 1997; Lambert andHarrington 1990; Kannan and Tan 2002). The chi-square test resultsof frequency distribution for two groups of returns do not show anystatistically significant differences.

RESULTS

Overview

Regarding the type of practice, 64.4% of the respondents aresolo/two physician practices or group practice, the rest being hospitalbased (10.3%), medical school based practice (14.8%) and other vari-ous types of practices (8.6%) as shown in Table 1. The respondents’specialties include various functions such as internal medicine, sur-gery, pathology, ER, and pediatrics, etc. Of the total returns, 360(84.1%) are from male respondents, almost 95% of the returns areU.S. educated physicians, and almost two-thirds are 50 years or older.

Several demographic variables of our returns are evaluated basedon the corresponding information of the St. Louis Metropolitanarea’s physicians population to validate the representativeness of our

Ik-Whan G. Kwon and Henry Yu Xie 7

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sample that is also shown in Table 1. All in all, the sample distributionreflects reasonably well the population information (chi-square test failsto detect significant differences between information in sample andpopulation) except that our study appears to under-sample surgeons(32% in population vs. 8.5% in sample).

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TABLE 1. Return Rates (%) by Selected Demographic Attributes BetweenPopulation and Sample

Attributes Population Sample

Gender Male 88% 84.1%

Female 12% 15.9%

Type of Practice Solo/Two MD practice 45% 33.2%

Group practice 35% 33.2%

Hospital based 10% 10.3%

Medical school 9% 14.8%

Others 1% 8.6%

Type of Specialty Family practice 5% 5.8%

Internal medicine 26% 20.2%

Surgery 32% 8.5%

Pediatrics 7% 9%

OB/GYN 11% 8.8%

Radiology 5% 5.1%

Psychiatry 7% 5.8%

Anesthesiology 5% 3.4%

Pathology 1% 0%

ER 1% 1.2%

Other 1% 32.1%

Age 40 years or younger 7% 9.6%

41-49 years old 19% 26.6%

50-59 years old 28% 32.5%

60+ years old 46% 31.3%

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Frequency of Internet Use. Our study indicates that almost 63% of therespondents currently use Web, Internet or Intranet in their practice,17.5% mentioned that they do not use the information technology, andalmost 20% of the respondents did not respond to this question as shownin Table 2. This information is in line with a national survey on this subject in2002 by the American Medical Association (AMA 2002). Of those who usethe Internet, and/or Web, 62.4% use them on a daily basis (called “heavyuser”), 29.2% 1 to 3 times a week (“moderate user”) and the rest (8.3%) 1to 3 times a month (“infrequent user”), as shown in Table 3.

Age. Internet use by physician’s age group as shown in Table 4indicates that the older physicians (age older than 59) use lessInternet (58.8%) than their counterparts (78.9% for age less than 41to 88.9% between 50 and 59 years old), as expected, as shown inTable 4 (p < 0.01). When the degree of Internet use is evaluated bythe respondent’s age, that physicians under 40 are more likely touse the Internet on an infrequent basis than any other age groups isunexpected, although such a relationship is statistically not signif-icant. It is also to some extent unexpected to see a high rate of “heavyusers” in the age 60 or older group as shown in Table 5.

Ik-Whan G. Kwon and Henry Yu Xie 9

TABLE 2. Internet Use in Medical Practice

Numbers Percent

Yes (use Internet) 280 62.9

No (do not use Internet) 78 17.5

Did not respond 87 19.6

Total 445 100

TABLE 3. Degree of Internet Use

Numbers Percent

Heavy user 171 62.4

Moderate user 80 29.2

Infrequent user 23 8.4

Total 274 100

Heavy user is defined as Internet use on daily basis; Moderate as 1-3 times a week; Infre-quent as 1-3 a month.

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Type of Information Technology. Of those who use information tech-nologies, most of them appear to use both Web (70.9%) and the Internet(73%), as shown in Table 6. Over 31% of the respondents use both tech-nologies.

Place and Hours of Use. It appears that the majority of physicians(62.5%) use this tool in their office as well as their home (Table 7).Less than half (41.2%) of them use the computer less than two hoursper day in their office. It is, however, a bit of a surprise to see over10% of the physicians using this tool for more than six hours eachday in their office (Table 8). The number of hours using the computerin their home is more evenly distributed than those in their office set-ting.

Training Process. Learning up-to-date information technologyis a challenging task to many novices, especially physicians who

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TABLE 4. Internet Use by Age of Physicians

Age 40 41-49 50-59 60 Total

Use 30 (78.9%) 87 (81.3) 112 (88.9) 50 (58.8) 279 (78.4)

Not Use 8 (21.1) 20 (18.7) 14 (11.1) 35 (41.2) 77 (21.6)

Total 38 (100) 107 (100) 126 (100) 85 (100) 356* (100)

Chi-square = 27.936 (p < 0.001).*Eighty-nine respondents did not check one or both questions (age or use of Internet).

TABLE 5. Degree of Internet Use by Age of Physicians

Age 40 41-49 50-59 60 Total

Heavy 16 (53.33%) 57 (67.9%) 67 (61.5%) 27 (61.4%) 167 (62.5%)

Moderate 10 (33.33%) 22 (26.2%) 32 (29.4%) 15 (34.1%) 79 (29.6%)

Infrequent 4 (13.34%) 5 (5.9%) 10 (9.2%) 2 (4.5%) 21 (7.9%)

Total 30 (100%) 84 (100%) 109 (100%) 44 (100%) 267 (100%)*

Chi-square = 3.975 (p = 0.68).*Eight respondents did not check this question.

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feel time pressure in their daily patient management. Almost 66%of the respondents appear to have learned the skill by themselves,which is followed by peers (15.1%) and family (10.6%). Less than10% of them participated in any organized learning settings asshown in Table 9.

IMPACT OF INTERNET USE ON MEDICAL PRACTICE

Health Education and Learning. The Internet offers a unique opportu-nity of health promotion through the use of interactive tools such as E-mailand hyperlinks. Health-related websites should be considered as instrumentsfor learning. Health information is complex, dynamic, and sometimes evencontradictory. It is argued that the Internet sometimes provides low-quality

Ik-Whan G. Kwon and Henry Yu Xie 11

TABLE 6. Types of Information Technology Used by Physicians

Place Frequency Percent of Responses Percent of Cases

Web 202 36.1 70.9

Internet 208 37.1 73.0

Intranet 61 10.9 21.4

All 89 15.9 31.2

Total 560* 100%

*Multiple responses.

TABLE 7. Place of Internet Use

Place Frequency Percent

Home 48 17.1

Office 57 20.4

Both 175 62.5

Total 280 100

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information (Costello et al. 2000). In addition, specific information on theInternet will become increasingly expensive to find, as the search cost willgrow while human attention will remain limited. The low-cost of creatinglow-quality information on the Web means that the low-quality informationmay eventually swamp high-quality resources (Coirer 2000).

These negative aspects of the increment learning process can beavoided in part by the Internet’s multimedia capability (Stout et al.2001). Increasingly, patients look for health information on the Internet.

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TABLE 8. Hours of Internet Use

Office Home

Frequency Percent Frequency Percent

1-2 hours 106 45.9 63 29.4

3-4 hours 57 24.7 65 30.4

5-6 hours 32 13.9 34 15.9

7 or more 36 15.6 53 24.2

Total 231 100 214 100

TABLE 9. Learning Settings

LearningPlaces

Frequency Percent ofResponses

Percentof Cases

Self 235 65.8 88.7

Peers 54 15.1 20.4

Family 38 10.6 14.3

Classroom 22 6.2 8.3

Profession 8 2.2 3.0

Total Counts* 357 100.0

*Multiple responses.

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By 2001, it was estimated that more than 70,000 websites carry healthinformation, while more than 50 million people seek health informationonline (Cline and Haynes 2001). According to Cline and Haynes(2001), consumers access online health information in three primaryways: searching directly for health information; participating in supportgroups; and consulting with health professionals. Medical informationis one of the most researched topics online. Many health education re-searchers and practitioners already have embraced the Internet as anarea of inquiry and application. For example, Bernhardt and Hubley(2001) argue that the variety of communication channels it provides,such as email, newsgroups, chat rooms, instant messaging, World WideWeb, and file exchange services, offers the potential to improve the ef-fectiveness, efficiency, and reach of almost all aspects of health educa-tion.

Armed with unprecedented access to health-related information viaInternet, health care customers, including patients, are increasingly de-manding more involvement in their own care, as well as access to morechoices as to how health care is organized, delivered, and paid for. TheInternet has created an interactive medium that health care consumers,providers, physicians, and patients can use to seek high quality healthinformation (Wilkins and Navarro 2001). On the other hand, health careproviders, mainly physicians, are equally pressed to search for updatedmedical information. Interactive Internet search has provided an idealvenue for many physicians, especially for those who feel pressed fortime.

According to our study, physicians rank the medical information source(83.7% cases) as the biggest usage of the Internet, followed by communi-cations with patients (73.5% cases) as the second biggest usage of theInternet. However, it becomes also apparent, according to Table 10, thatphysicians also depend on the Internet for many other non-medical,non-patient related areas such as travel information (72.4% of cases), send-ing/receiving non-patient related emails (70% cases) and news and generalinformation (68.6% cases).

Physician-Patient Relationship. In their study, Johnson and Ramaprasad(2000) hold that the patient-physician relationship in the U.S. has beenviewed as a seller-customer interaction. The power and knowledge imbal-ance between the two parties and the traditional paternalistic attitude domi-nated the relationship, resulting in a vulnerable, and even disadvantageous,position for patients. The Internet has started to affect the physician-patientrelationship, enabling the widespread availability of inexpensive information

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sources and the emphasis on sharing. As a result, the patient is empow-ered and evolved into an informed patient. Subsequently, it paves theway for an enhanced, more informative, and more satisfying relation-ship between physicians and patients. In addition, it also places morechoices in the patient’s hands. According to Hickey (2000), a prescrip-tion can be phoned, faxed, or emailed at anytime. Some doctors can eventransmit prescriptions directly to pharmacy sites. The most importantInternet-generated change in the physician-patient relationship will be thereduced need for face-to-face contact (Friedewald 2000). However, ac-cording to Friedwald (2000), active participation from physicians is imper-ative for this new dynamic to positively impact the ability to providequality care. Kerwin (2002) even asserts that the Internet gives physiciansthe opportunity to obtain and share valuable information that has the poten-tial to improve the quality of care provided to patients.

Our survey shows that patient satisfaction is one of the top three bene-fits of Internet use on the physicians’ part. Table 11 indicates the top fivebenefits the respondents cited. As expected, time management (51% ofcases) and business practice (36.9% of cases) rank the first two importantreasons that physicians use the Internet, which is followed by patient sat-isfaction (29.3% of cases).

It is encouraging to know from Table 11 that physicians recognize thevalue of Internet use for their business practice. The perceived impor-tance of the Internet in medical practice is gaining ground among physi-cians.

Marketing Practice. Traditionally, yellow page listings are the mostwidely cited form of physician advertising. Many prospective patientsconsulted the yellow pages when contacting and selecting a physician

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TABLE 10. Top Five Areas of Internet Usage by Physicians

Internet Use Number of Counts Percent of Cases

Medical information 237 83.7

Communication with patients 208 73.5

Travel information 205 72.4

Sending/receiving non-patient related e-mails 198 70.0

News and information 194 68.6

Total Counts* 1,042

*Multiple responses.

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(Butler and Abernethy 1996). Butler and Abernethy (1996) also found thatprospective patients mostly displayed information such as service offer-ing/specialty, address/location, and professional qualifications/certifica-tions, etc. A recent work by McGlone et al. (2002) indicates that factorssuch as physicians’ reputation, record, location, and qualifications are themajor dimensions of consumers’ selection of physicians. Advertising inbrochures and the yellow pages is rapidly diminishing in importance tomost patients in the physician selection process. The Internet has emergedas a new means for the marketing of medical/health care. The study by theAmerican Medical Association (AMA) in 2002 also found that one of theprimary reasons that physicians have a site on the Internet is to promote andadvertise their practice and/or provide patient education and information(Health Care Strategic Management 2002). Another study by the BostonConsulting Group (BCG) in 2001 suggests that physicians have found thatnot only has the Internet already had a considerable impact on physicianbehavior, but also the influence of the Internet is likely to increase (HealthCare Strategic Management 2002). Physicians are using the Internet forgathering medical knowledge and they are beginning to embrace onlinetools that enhance patient care. Gruen (1999) argues that physicians wouldneed to become actively involved in the Internet to survive. Kerwin (2002)maintains that physicians should be able to remain up-to-date and aware oftimely healthcare issues that affect their patients and medical practices.

As indicated in Table 6, almost 71% of the cases (respondents) havetheir own website. Table 12 shows the top five areas that physicians liston their website. Office information such as location, specialists, etc.,tops the list (94.5% of cases) which is followed by distant office sched-ule (56% of cases), link to the other medical Websites (55% of cases)and medical information for patients (51.4% of cases). It is apparent

Ik-Whan G. Kwon and Henry Yu Xie 15

TABLE 11. Top Five Areas for Benefits of Internet Use by Physicians

Benefits No. of Counts Percent of Cases

Time management 80 51.0

Business practice 58 36.9

Patient satisfaction 46 29.3

Scheduling 30 19.1

Others 30 19.1

Total Counts* 244

*Multiple responses.

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from Table 12 that the Internet has to a large extent taken up the tradi-tional roles of physicians’ marketing and promotional effort.

Investment in Information Technologies. Butler (2001) argues thatthe Internet makes a significant impression on consumers who use it tolearn about diseases and treatments, although reaching those consumersis more difficult than reaching people shopping online for other con-sumer goods. Greater patient access to online information can subse-quently lead to greater patient involvement.

Lin et al. (2001) indicate that as health care organizations becomemore sophisticated in information technology management, they willincreasingly use the Internet/Web-based technology to help gain a com-petitive advantage by implementing their Internet program strategically.Lin et al. (2001) also suggest that physicians and health care providersshould compare themselves with others to estimate the potential benefits ofoffering more effective Internet use and to measure the success of Internetimplementation.

However, use of the Internet and the Web requires a substantial in-vestment in hardware and software as well as additional training tomake it more effective. In our survey, the physicians’ mean spending onInternet marketing was $359.60 with standard deviation of $1,028.70 in2000. This mean expenditure was expected to increase to $1,278.70 inthe following year, an increase of 255%! In addition, the expenditure on in-formation technologies including computer upgrade was also expected togrow. Among the 202 respondents who own a Website (see Table 6), while al-most 32% of the respondents plan to spend less than $3,000 on informationtechnologies in the next 12 months, almost 41% of the respondents wouldspend more than $3,000 on Web construction/update. When the future ex-

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TABLE 12. Top Five Listed Information on Physicians’ Website

Listed Information No. of Counts Percent of Cases

Office information (location,specialties, etc.)

103 94.5

Office schedule 61 56.0

Link to other medical website 60 55.0

Medical information for patients 56 51.4

Link to registration form 16 14.7

Total Counts* 296

*Multiple responses.

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pected spending on information technology is crosschecked with physician’sage category, a marginally significant relationship is registered (F-value =3.362, p < 0.1). Furthermore, among those who plan spending at least $3,000on Web construction/update, over 83% are younger than 60 years old. This in-formation is indeed encouraging that the younger physicians plan to spendsubstantial resources on information technologies years to come.

Barriers to Internet Use

In spite of the growing importance of Internet use on physicians’ medicalpractice, a variety of factors have to some extent impeded the widespreadInternet use (Kerwin 2002). Our study reveals several factors that becamebarriers to Internet uses.

Time Constraint. Time constraint is regarded by many physicians inour survey as one of the major barriers for their Internet use. Almost69% for Internet users and almost 73% for non-users regard time con-straint as the major barrier to their use of the Internet in medical prac-tice, a percentage much higher than any other barrier factors as shown inTable 13.

Privacy. The collection and use of health information has been vitalto the practice of medical care. The tradition of confidentiality and trustbetween physicians and patients are an integral part of their relationship(Masys et al. 2002). According to Gostin (1997), systematic flows ofsensitive health information occur both vertically and horizontallyamong employers, hospitals, insurers, laboratories, and suppliers. Thetraditional method of exercising control over personal health informa-

Ik-Whan G. Kwon and Henry Yu Xie 17

TABLE 13. Top Five Barriers for Physicians’ Internet Use

Barriers User Non-User

No. ofCounts

Percent of Cases No. ofCounts

Percent ofCases

Time constraints 142 68.9 43 72.9

Privacy/confidentiality issues 78 37.9 24 47.5

Resources including overhead 64 31.1 28 40.7

Technical difficulty 63 30.6 19 32.2

Lost productivity 25 12.1 11 18.6

Total Counts* 372 125

*Multiple responses.

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tion through informed consent is flawed with a modern health informa-tion infrastructure that does not provide sufficient control over personalinformation to assure adequate protection of privacy. People are con-cerned about using the Internet for transmitting personal health infor-mation. A study by the California Health Care Foundation in 2000 andthe Internet Healthcare Coalition found that 75% of consumers seekinghealth information are concerned about the sites which they have regis-tered sharing their personal health information without permission(Medical Marketing & Media 2000). The same study also reports that alack of trust is also an issue among physicians who are concerned overprotecting patient privacy. In his study, Kerwin (2002) admits that pri-vacy and confidentiality issues are a primary concern that results in thereluctance of physicians and patients to completely utilize the Internet.

In our survey, according to Table 13, almost 38 percent of cases fromInternet users cited the privacy and confidentiality issue as a main bar-rier to using the Internet in their business, while almost 48% cases fromnon-users cited this issue as a main factor.

When the privacy and confidentiality issue was further addressed andanalyzed based on age of the respondents, over 70% of them were eitherunsure or do not feel that the privacy and confidentiality issue was ade-quately protected, as shown in Table 14. As expected, the older the re-spondents are, the more they are skeptical about the privacy andconfidentiality issue.

Resource Limitations. Our study reveals that resources required toimplement information technologies including Web construction andtraining are the third major reason that physicians are reluctant to oper-ate their own website for users (31.1% of the cases), while this factorappears to become more serious for non-users (almost 41% of thecases), as shown in Table 13.

Technological Difficulty and Fear of Using Technology. In many sit-uations, a lack of knowledge of the Internet and information technologyappears to be a great constraint for physicians to fully take advantage ofthe Internet. For example, a study by Shepherd and Fell (1996) of 360health care facilities shows that a lack of technical knowledge about theInternet and a clear understanding of the Internet’s potential are rankedas the greatest barrier (53%) to Internet use in health care marketing,which is followed by cost (21%), lack of trained personnel (19%) andlack of interest (7%). Kassirer (2000) also points out that many physi-cians are wary of new computer applications and may be unskilled inInternet and information search. According to Cline and Haynes (2001),

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navigational challenges (e.g., technical language, lack of permanence)and poor and inaccurate quality of online health information have hin-dered the access. As Goldsmith (2000) argues, the greatest barrier to re-alizing the networks full potential is persuading physicians to use thesetechnologies. Our survey seems to reflect such a phenomenon asshowed in Table 13. As shown in Table 9, almost 66% of the respon-dents learned information technology without attending a formal train-ing, that may have added more frustrations.

It appears that technical difficulty in the information age, along with twoother barriers, hinders the more active usage of the Internet by physicians.It is recommended for medical schools in this country to offer more vig-orous technical courses encompassing computer technology and its ap-plication in the medical field. Interaction and integration of bothup-to-date information technology and medical practice may help thephysicians overcome the technical difficulty they face in their use of theInternet. A comparable example would be that the majority of businessschools in the country have already installed information technologycourses in their curriculum, with an apparent positive impact on the ap-plication of the Internet in the business community.

CONCLUSION AND IMPLICATION

This study draws several inferences based on the sample of physiciansfrom the St. Louis, Missouri Metropolitan Area. Although not inclusive ofall factors impacted on medical practice across the profession, this studydoes give us a relatively detailed insight into the impact of Internet use onphysicians’ medical practice behavior.

Ik-Whan G. Kwon and Henry Yu Xie 19

TABLE 14. Confidentiality and Privacy Protection by Age

Age 40 41-49 50-59 60 Total

Protected 12 (40.0%) 26 (30.6%) 29 (26.4%) 13 (26.5%) 80 (29.2%)

Not protected 9 (30.0%) 24 (28.2%) 44 (40.0%) 15 (30.6%) 92 (33.6%)

Not sure 9 (30.0%) 35 (41.2%) 37 (33.6%) 21 (42.9%) 102 (37.2%)

Total 30 (100%) 85 (100%) 110 (100%) 49 (100%) 274 (100%)

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The last decade has seen a dramatic increase of Internet use in thefield of medical care. As revealed by our survey and discussion, Internetuse has inserted a considerable impact on the physicians’ medical prac-tice. Traditional areas such as health education and learning, physi-cian-patient relationship, and medical marketing have been undergoingsignificant changes amid the Information age. The Internet has greatlyexpanded the distribution of medical information to health care custom-ers and patients, and substantially enhanced health education and thelearning process. In addition, the use of the Internet has also strength-ened the physician-patient relationship with the availability of informa-tion sources and the emphasis on sharing. Finally, the Internet hasemerged as a new and alternative means for traditional marketing, pav-ing the way for a new age for medical/health care marketing.

One of the interesting findings from this study is that physicians atthe age of 41 to 59 are found to typically have a higher percentage ofInternet use and willing to spend more resources on information tech-nology. Considering the fact that physicians at this age group make upthe majority of physicians, this result reinforces our belief of the grow-ing impact of Internet use on medical practices in the future.

Although this study reveals an extensive use of Internet use by physi-cians, the Internet has NOT been used heavily in medical-patient relatedfields. As indicated, among the top five areas that physicians listedInternet use (Table 10), the bottom three areas are not medical-patientrelated fields. Important areas where the Internet can be useful, such asdrug information, continuing medical education, medical records, etc.,were not included. Furthermore, less than 40% of our sample indicatedthat they own a Website for business purposes. Of those who do notcurrently own their own Website, two-thirds (75%) of them expressedthat they never intend to create their own Website. Lin et al.’s (2001)study using 250 hospitals also reveals that hospital senior decision mak-ers are not quite satisfied with their Website uses. Perhaps continuingeducation for physicians on the benefits of Internet use is needed to seea measurable increase in health care management efficiency. In addi-tion, medical schools should seriously consider the use of the Internet inpatient management as a part of their curriculum.

On the other hand, our survey also shows that Internet use by physi-cians is still hindered by barriers such as time constraint, the privacy is-sue, and technological difficulties. These barriers should be carefullyaddressed and tackled in the interaction of Internet use and medicalpractice. It is suggested that up-to-date information technology should be

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integrated in physicians’ training/educational programs to better equipthe physicians in this information age, and a way should be explored toassure physicians that privacy and confidentiality of using the Internet isand will be protected. As discussed, more than 70% of current Internetusers are unsure of this protection; that is a major obstacle to efficient pa-tient management.

The Internet is likely to become more common in this field as well asother facets of society. There are both opportunities and challenges fac-ing physicians in their medical practice, as well as the physician-patientrelationship. As information technology advances, it is imperative forphysicians to keep up with the change and utilize a practical applicationof Internet technology in their medical practices.

This exploratory study provides a framework for further research.For future study, it is necessary to conduct more in-depth and in-breadthresearch in the related research topics and to enrich the literature on thisunique perspective of medical care.

LIMITATIONS

This study explores Internet use by physicians in their health care prac-tices using a sample from one region of this country. A similar study inother major cities of this country may be needed to validate the results fromthis study. In addition, various research studies show that Internet use andperception of information technology in patient management differs de-pending on the user’s behavior toward computers (Dosik 1993; Czaja andSharit 1998; Wigger 1996; Williams 1995; Dixon and Dixon 1994). A sim-ilar study by extensive demographic variables would provide additional in-sights to this subject. Finally, as the need for foreign trained physiciansincreases, their impact on the health care market in this country will be-come more prominent. A large sample from foreign trained physicianswould also provide a better insight of their perception and behavior to-ward this important area of health care management.

REFERENCES

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Armstrong, J.S. and T.S. Overton (1977), “Estimating Non-Response Bias in Mail Sur-veys,” Journal of Marketing Research, 14 (3), 396-402.

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Bernhardt, Jay M. and John Hubley (2001), “Health Education and the Internet: TheBeginning of a Revolution,” Health Education Research, 16 (6), 643-45.

Butler, Daniel D. and Avery M. Abernethy (1996), “Yellow Pages Advertising by Phy-sicians,” Journal of Health Care Marketing, 16 (1), 45-50.

Butler, Linda (2001), “Consumers Use Internet When Sick, and They Favor Dis-ease-Specific Websites,” Health Care Strategic Management, June, 12-13.

Cline, R.J.W. and K.M. Haynes (2001), “ Consumer Health Information Seeking onthe Internet: The State of the Art,” Health Education Research, 16 (6), 671-92.

Coiera, Enrico (2000), “Information Economics and the Internet,” Journal of Ameri-can Medical Informatics Association, 7 (3), 215-21.

Costello, Richard, Anthony Shaw, Roz Cheetham, and Robert J. Moots (2000), “TheUse of Electronic Mail in Biochemical Communication,” Journal of AmericanMedical Informatics Association, 7 (1), 103-05.

Czaja, S.J. and J. Sharit (1998), “Age Differences in Attitudes Toward Computers,”The Journal of Gerontology, 53B (5), 329-40.

Dixon, D.R. and R.J. Dixon (1994), “Adoption of Information Technology Enabled In-novation by Primary Care Physicians: Model and Questionnaire Development,”Annual Symposium on Computer Applications in Medical Care, 631-35.

Dosik, H.E. (1993), “The Consequences of Deprofessionalization in the Social Transforma-tion of Doctoring: The New Entrepreneurship in Private Practice Medicine,” ElectronicDissertation Abstracts Online, 54-08A.3211. Available: http://firstsearch.oclc.org.

Friedewald, Vincent E. (2000), “The Internet’s Influence on the Doctor-Patient Rela-tionship,” Health Management Technology, November, 79-80.

Goldsmith, Jeff (2000), “How Will the Internet Change our Health System?” HealthAffairs, 19 (1), 148-57.

Gostin, Lawrence O. (1997), “Personal Privacy in the Health Care System: Em-ployer-Sponsored Insurance, Managed Care, and Integrated Delivery Systems,”Kennedy Institute of Ethics Journal, 7 (4), 361-76.

Gruen, Jeffrey (1999), “The Physician and the Internet: Observer or Participant?”MDComputing, 16 (6), 46-48.

Health Care Strategic Management (2001), “Physicians Say the Internet Is Having BigImpact on Their Behavior; Internet’s Influence Will Increase,” December, 4.

Health Care Strategic Management (2002), “AMA Survey Finds Internet Has MajorImpact on the Way Physicians Practice Medicine,” September 2002, 10.

Hickey, Mary (2000), “The Virtual Pharmacy: Be Careful When You Click,”Businessweek, March 20, New York.

Johnson, Grace L. and Arkalgud Ramaprasad (2000), “Patient-Physician Relationshipsin the Information Age,” Marketing Health Service, 20 (1), 21-27.

Kannan, Vijay and Keah Tan (2002), “Supplier Selection and Assessment: Their Impacton Business Performance,” Journal of Supply Chain Management, 38 (4), 11-21.

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Lambert, D.M. and T.C. Harrington (1990), “Measuring Non-Response Bias in MailSurveys,” Journal of Business Logistics, 11 (2), 5-25.

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Lin, Binshan, Karen James, John Vassar, and Chris Martin (2001), “The Internet andHospital Marketing Strategy: A Survey,” Health Marketing Quarterly, 18 (3/4),27-37.

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McGlone, Teresa A., E. Sonny Butler, and Vernon L. McGlone (2002), “Factors Influ-encing Consumers’ Selection of a Primary Care,” Health Marketing Quarterly, 19(3), 21-37.

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Sanchez, Peter M. (2000), “The Potential of Hospital Website Marketing,” HealthMarketing Quarterly, 18 (1/2), 45-57.

Shepherd, C. David and Daniel Fell (1996), “Hospital Marketing and Internet,” Jour-nal of Health Care Marketing, 16 (4), 47-48.

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RECEIVED: 04/28/03REVISED: 08/26/03

ACCEPTED: 10/11/03

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APPENDIX

Survey Instrument on Physicians’ Useof World Wide Web in the St. Louis Metropolitan Region

and Its Implications on Medical Practice Behavior

1. Do you currently use a computer in your practice? ( ) YES ( ) NOIf you checked NO, skip to Question No. 25

2. Do you currently use the Web, internet, or intranet in your practice?

( ) YES ( ) NOIf you checked NO, skip to Question No. 25

3. If you answered YES to Question No. 2, which of the followingtechnologies are you currently using? (Check all appropriate boxes.)

( ) Web ( ) Internet ( ) Intranet ( ) All of the above

4. If you use the Web, how often do you use it?

( ) Use daily ( ) 1-3 time per week ( ) 1-3 time per month

5. What time of the day do you mostly use the Web?

( ) Morning ( ) Afternoon ( ) Evening

6. Where do you use the Web? (Check one box.)

( ) Home ( ) Office ( ) All Locations

7. If you are online with Web, what area(s) do you find most useful? (Check as manyboxes as applied.)

a. ( ) Use for general communicationsb. ( ) Use for communication with patientsc. ( ) Use for medical information sources (i.e., Medline)d. ( ) Use for news and informatione. ( ) Use for sports and recreationf. ( ) Use for drug informationg. ( ) Use for business practiceh. ( ) Use for patient educationi. ( ) Use for continuing medical education (CME)j. ( ) Use for telemedicinek. ( ) Use for practice marketingl. ( ) Use for sending/receiving non-patient related e-mailm.( ) Use for medical information sourcesn. ( ) Use for medical records

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Ik-Whan G. Kwon and Henry Yu Xie 25

o. ( ) Use for travel informationp. ( ) Use for professional association communicationq. ( ) Use for collecting conference informationr. ( ) Use for purchasing products/servicess. ( ) Use for shoppingt. ( ) Use for brokerage servicesu. ( ) Use for online bankingv. ( ) Use for patient prescriptionsw. ( ) Drug informationx. ( ) Use for other reasons. Specify: ______________________________

8. What medical and non-medical Web sites have you visited in the past 3 months?(Check as many boxes as applied.)

a. ( ) Medline b. ( ) Physicians Online/POLc. ( ) American Medical Association d. ( ) Center for Disease

Controle. ( ) National Institutes of Health f. ( ) Medscapeg. ( )The New England Journal of Medicine h. ( ) American Academy of

Pediatricsi. ( ) American College of Physicians j. ( ) PubMedk. ( ) American Academy of Family Practice l. ( ) Others________________

9. If you use the Web for your continuing medical education (CME), how many hours did youearn in 2000 and plan to earn in 2001?

( ) Hours in 2000 ( ) Planned hours in 2001

10. If you use the Web for practice marketing, approximately how much did youspend on marketing purpose in 2000 and expect to spend in 2001?

($ ) in 2000 ($ ) in 2001

11. How many hours in the past 2 weeks have you spent on the Web?

At Office At Home

a. ( ) 1-2 hours a. ( ) 1-2 hoursb. ( ) 3-4 hours b. ( ) 3-4 hoursc. ( ) 5-6 hours c. ( ) 5-6 hoursd. ( ) 7 or more d. ( ) 7 or moree. ( ) None e. ( ) None

12. Do you have your own practice Website? ( ) YES ( ) NO

13. If YES, approximately how much did you spend to develop the site? (Check one box)

a. ( ) None/free b. ( ) Less than $1,000 c. ( ) $1,000-$2,999d. ( ) $3,000-$5,999 e. ( ) $6,000-$10,000 f. ( ) Over $10,000

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APPENDIX (continued)

14. If you have your own site, what is some of the information listed in your Website?

(Check as many boxes as applied.)

a. ( ) Office information such as location, specialties, etc.b. ( ) Office schedulec. ( ) Fee scheduled. ( ) Medical information for your patientse. ( ) On line medical recordsf. ( ) Link to other medical Websitesg. ( ) Link to registration formh. ( ) Audio featurei. ( ) Others. Specify: ________________________________________

15. Where did you learn how to use the Web?

a. ( ) Self-taught b. ( ) From peers c. ( ) From familyd. ( ) Attended formal classes e. ( ) At professional meetingsf. ( ) Others. Specify: _________________________________________

16. If you do not own your own Web site now, do you plan to develop one in?(Select one);

a. ( ) Next month b. ( ) Next 3 months c. ( ) Next 6 monthsd. ( ) Next 12 months e. ( ) Never

17. Do you use personal digital assistance (PDA)? ( ) YES ( ) NO

18. If you use PDA, please check the following box

( ) For Personal ( ) In Practice only ( ) Both

19. If you use personal digital assistance, which operating system do you use?

( ) Palm OS ( ) Window CE ( ) Other________________

20. Do you access hospital data from home?

( ) YES ( ) NO ( ) NOT APPLICABLE

21. Do you feel that confidentiality and privacy issues on Web use are adequately protected?

( ) YES ( ) NO ( ) DON ’T KNOW

22. Do you feel Web use in your practice increases your liability? (Check one.)

a. ( ) Substantially b. ( ) Moderately c. ( ) Minimum d. ( ) Not at alle. ( ) Do not know

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23. Do you feel that the use of the Web resources helps your practice become moreefficient in? (Check as many boxes as apply.)

a. ( ) Staffing b. ( ) Scheduling c. ( ) Appointmentd. ( ) Business practice e. ( ) Patient satisfactionf. ( ) Time management g. ( ) Others: specify: ______________________

24. How much is your practice planning to spend on information technologies includingcomputer upgrade in the next 12 months?

a. ( ) None b. ( ) Less than $1,000 c. ( ) $1,000-$2,999d. ( ) $3,000-$5,999 e. ( ) $6,000-$10,000 f. ( ) Over $10,000

25. What are some of the barriers that make you use less or no Web technology in yourpractice? (Check as many boxes as appropriate.)

a. ( ) Timeb. ( ) Resources including overheadc. ( ) Privacy and confidentiality issuesd. ( ) Do not believe that the Web should be used in the medical practicee. ( ) Technical difficultyf. ( ) Lost productivityg. ( ) Other reason. Specify: _____________________________________

Demographic Information. Please check one box in each question most appropriate for your situation.

1. Gender: ( ) Female ( ) Male

2. Type of Practice: ( ) Solo/Two Physician Practice ( ) Group Practice( ) Hospital based ( ) Medical School( ) Other _________________________________________

3. Type of Specialty: ( ) Family Practice ( ) Internal Medicine( ) Surgery ( ) Pediatrics( ) OB/GYN ( ) Radiology( ) Psychiatry ( ) Anesthesiology( ) Pathology ( ) ER( ) Other: __________________________________________

4. Your age: ( ) 40 years or younger ( ) 41-49 years( ) 50-59 years ( ) 60+ years

Thank you for your cooperation. Please return this questionnaire using the self-addressed, stamped en-velope. Summary of this study will be available to you through the normal communication channel ofthe St. Louis Metropolitan Medical Society.

If you have any questions regarding this study, please contact Dr. Ik-Whan G. Kwon, Professor of Deci-sion Sciences at 314-977-7155, fax to 314-977-2068, or email to kwoni@slu.edu. Also you can view hisactivity in his Website, www.slu.edu/centers/cscms.

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