Digital Medicine

HEALTH CARE IN THE INTERNET ERABy Darrell M. West Edward Alan Miller

BROOKINGS INSTITUTION PRESS

Copyright © 2009 THE BROOKINGS INSTITUTION
All right reserved.
ISBN: 978-0-8157-0276-4

Contents

Preface…………………………………………………………………………………..ix1 The E-Health Revolution…………………………………………………………………..12 Online Content and Sponsorship Status………………………………………………………193 Use of Technology………………………………………………………………………..424 Relationship between Use of Digital Technology and Attitudes toward Health Care…………………595 Digital Disparities………………………………………………………………………746 Information Acquisition…………………………………………………………………..867 International Comparisons…………………………………………………………………978 Improving Digital Medicine………………………………………………………………..118A National E-Health Public Opinion Survey…………………………………………………….135B American Health Websites………………………………………………………………….139C Government Health Department Websites around the World……………………………………….143D Content Analysis Protocol for Health Care Websites…………………………………………..146Notes…………………………………………………………………………………….153Index…………………………………………………………………………………….175

Chapter One

The E-Health Revolution

Websites such as WebMD.com, MedlinePlus.gov, MerckSource.com, HealthFinder.gov, and MayoClinic.com answer health-related questions and provide links to discussion groups about particular illnesses. In states such as Massachusetts, California, New York, and Michigan, consumers can visit state health department sites and compare performance data on the quality of care. The U.S. government has a website that evaluates 2,500 hospitals on mortality rates, room cleanliness, and call button response and on how their patients judge the quality of the care that they provide. Some physicians encourage patients to use e-mail or web messaging instead of telephone calls or in-office visits for simple issues such as appointments, prescription renewals, referrals, or brief consultations. And digital diagnostic systems, decision-support software for health care providers, telemedicine (medical care provided by televideo or telephone), and computer-aided self-help tools also are available.

Despite the wealth of digital medicine applications available through e-mail, the Internet, and mobile devices, not many physicians or patients are taking advantage of the potential of electronic communications. Only 15 percent of the 560,000 doctors in the United States use the Internet to order medication for their patients. Industry advocates claim that a move to electronic prescriptions could save $29 billion over the next decade. According to health experts, digital technology would save money and “make transactions more efficient, reduce medication errors, and entice doctors to prescribe less expensive drugs.”

Some observers, however, worry that these types of electronic consultations will depersonalize health care. Social medicine expert Helen Hughes Evans, for example, argues that “technology has stripped medicine of its humanistic qualities” and that doctors rely too heavily on high-tech instruments. She feels that rather than advancing the quality of patient care, digital medicine has undermined the intimacy of clinician-patient relations among those who rely on electronic devices and therefore has contributed to the loss of the personal touch in the provision of health care.

In a review of research on telemedicine, though, Edward Alan Miller finds that 80 percent of medical studies showed a favorable impact of digitally mediated contact on provider-patient relations. Digital technologies facilitate access to health care for some individuals and expand the network of available health care providers. Digital communications allow people with rare diseases to find others who suffer from the same disorders and to learn from their experiences. Moreover, digital systems allow patients to take advantage of specialists in other states and even other countries. Although technology often appears to be “dehumanizing,” studies suggest that it can increase resources for self-care, enhance emotional support through electronic support groups, and improve knowledge regarding special medical problems.

In this book, we examine the revolution in information technology that is taking place in health care, the presumed benefits of electronic or digital health care, and barriers to technological innovation. We argue that in order to achieve the promise of health information technology, digital medicine must overcome the barriers created by political divisions, fragmented jurisdiction, the digital divide, the cost of technology, ethical conflicts, and privacy concerns. The desired cost savings and service improvements in health care cannot be achieved without addressing those matters.

USE OF ONLINE INFORMATION

Since the mid-1990s, there has been a dramatic increase in overall Internet use in the United States. According to figures compiled by the Pew Internet and American Life Project, 73 percent of respondents in 2006 said that they used the Internet, up from 14 percent in 1995. As shown in figure 1-1, Internet usage in the United States has risen steadily in recent years. In 2006, 66 percent of respondents said that they were Internet users, indicating a 7 percentage-point gain from 2005 to 2006.

Patients face a dizzying variety of new ways to communicate with medical providers and gain information about health care problems. They can search websites devoted to medical ailments, e-mail health care professionals, buy medicines and health care products online, and engage in interactive communication with medical providers. Such options offer people more control over their health care while also improving the quality and affordability of treatments.

However, few Americans are taking advantage of health information technologies. In a Wall Street Journal Online/Harris Interactive HealthCare Poll of 2,624 adults across the nation, only a small number of respondents indicated that they used electronic technologies to communicate with health care providers. Four percent got reminders through email from their doctor when they were due for a visit, 4 percent used e-mail to communicate directly with their doctor, 3 percent scheduled appointments through the Internet, 2 percent received the results of diagnostic tests through e-mail, 2 percent had access to electronic medical records, and 2 percent relied on home monitoring devices that allowed them to e-mail blood pressure readings directly to their doctor’s office.

When asked whether they would like to employ such technologies, large majorities indicated that they would do so if they had the opportunity. The survey shows that respondents would like the following options:

—to get an e-mail reminder when they are due for an appointment (77 percent)

—to use e-mail to communicate directly with their doctor (74 percent)

—to receive the results of diagnostic tests through e-mail (67 percent)

—to schedule an appointment through the Internet (75 percent)

—to have an electronic medical record (64 percent)

—to use a home monitoring device that allows them to e-mail blood pressure readings to their doctor’s office (57 percent).

Those who went online for medical information most commonly searched for information on specific diseases. As shown in table 1-1, of those who went online, 64 percent said that they searched for information on particular illnesses, 51 percent for information on certain medical treatments, 49 percent for information on diet and nutrition, and 44 percent for information on exercise; 37 percent sought advice on medical drugs, and 29 percent looked for particular doctors or hospitals. The number of people searching online for medical information increased in most categories during the 2002–06 period covered by the surveys.

Of those who went online for health or medical information, 58 percent indicated that the information affected their health care decisions, 55 percent said that it changed their approach to health care, and 54 percent reported that it prompted them to ask new questions of their medical providers. When asked how the information made them feel, 74 percent said that they felt reassured and 56 percent felt more confident, but 25 percent indicated that they were overwhelmed by the amount of online information, 18 percent were confused by the information, and 10 percent were frightened by information.

From those findings, it is clear that some people have positive experiences that help them learn more about illnesses and treatments but that others have difficulty dealing with the new world of online information. They do not feel comfortable searching for information online, and they get confused or overwhelmed by what they find at medical websites. Although the positive views outweigh the negative, significant segments of the population still feel queasy about employing digital medicine to meet their own health care needs.

BENEFITS OF ELECTRONIC HEALTH

Concerns about health care quality, affordability, and accessibility have led policymakers in recent years to see more widespread adoption of health information technology as a way to improve the efficiency and effectiveness of health care and to cut costs. Through Internet websites, broadband access, e-mail communications, online procurement, and electronic record keeping, national leaders see digital technology as a valuable tool for bringing U.S. health care into the twenty-first century.

The United States spends $2 trillion a year on health care, which is around 16 percent of the gross domestic product. That is twice the amount spent in 1995, when spending topped $1 trillion for the first time. With health care spending increasing at 6.7 percent a year, expenditures are projected to rise to 20 percent of GDP by 2015. Medicaid spending has increased by more than 45 percent, to $311 billion, since 2000. Medicare spending has risen by 38 percent and now exceeds $400 billion. Health insurance premiums have shown double-digit increases in recent years, well above the rate of inflation.

Rising costs have placed enormous pressures on public and private health care systems. Although individual consumers typically report a high level of satisfaction with their personal care, the United States performs poorly on a variety of aggregate health indicators. Forty-five million Americans (about 17 percent) lack access to health insurance. U.S. life expectancy trails that of other industrialized countries.

In such circumstances, many people worry whether they are receiving adequate care and treatment, especially in light of widespread reporting of adverse drug events and other problems. Around 98,000 Americans die each year because of medical errors. Others distrust managed care and the incentives it offers health providers to control costs by restricting treatment.

To deal with competing demands for economy, efficiency, and effectiveness, expenditures on health information technology are rising rapidly. In 2000, the United States spent around $19 billion in this area; according to the American Hospital Association, the figure jumped to $31 billion in 2006. The typical health care organization devotes a modest 2.5 percent of its annual budget to information technology, about the same as public sector organizations in other policy areas. Much of that investment is designed to deliver services while keeping expenses at reasonable levels.

In 2004, President George W. Bush signed an executive order creating the Office of the National Coordinator for Health Information Technology, which is charged with devising medical policies that use technology to improve health care quality, reduce costs, and coordinate medical care among different medical professionals. The goal is to use new technologies to facilitate a variety of functions, including diagnostic support, computerized physician order entry and verification, electronic claims processing and eligibility checking, secure communications, alternative information gathering, and electronic reminders.

Former U.S. House Speaker Newt Gingrich sees information technology as a panacea for service problems and rising health care costs. Gingrich believes that patients can be empowered and errors in patient records reduced through electronic medical records and digital communications with doctors. Rather than allowing medical costs to continue to spiral out of control, health care professionals can use these new tools to cut costs while giving consumers more control over health care information.

During her presidential campaign, Senator Hillary Clinton placed health information technology at the center of her American Health Choices Plan, which called for universal coverage that would cost around $110 billion to implement. Half of the money to finance coverage would come from “public savings generated from Senator Clinton’s broader agenda to modernize the health systems and reduce wasteful health spending.” The savings would include money recouped from the use of electronic health records and other forms of digital medical accounting systems.

In 2008, then senator Barack Obama argued that electronic technology could improve health care quality, affordability, and efficiency. He proposed investing $10 billion annually over the next five years “to move the U.S. health care system to broad adoption of standards-based electronic health information systems, including electronic health records.” Obama claimed that if the nation committed sufficient funds, it would save up to $77 billion each year “through improvements such as reduced hospital stays, avoidance of duplicative and unnecessary testing, more appropriate drug utilization, and other efficiencies.”

Medical experts estimate that effective implementation of electronic medical records could save $81 billion a year by improving health care efficiency and safety. Financial savings could grow to twice that amount by facilitating the prevention and management of chronic disease through health information technology. A study of eighty controlled clinical trials to evaluate the efficacy of distance-technology supplements to conventional clinical practice found a strong association between positive health outcomes and use of computerized and telephone communications for follow-up, counseling, reminders, screening, after-hours access, and touch-tone interactive systems. Sixty-three percent of the studies reviewed found improved performance or other significant benefits.

In a separate randomized controlled trial, patients using an Internet portal through which they could send secure messages directly to their physicians as well as request appointments, prescription refills, and referrals demonstrated increased satisfaction with communication, convenience, and overall care. Another study of national health care quality indicators found that adoption of health information technology reduced medication errors and improved productivity. Such results suggest that health information technology offers great hope for the future to individual consumers.

Some parts of the U.S. health care system, notably Veterans Administration (VA) hospitals, already have embraced digital technology. Whereas only 15 percent of U.S. physicians employ computer order entry, 94 percent of veterans’ outpatient prescriptions are ordered electronically, as are nearly all inpatient medications. A comparison of VA and non-VA facilities in twelve communities found that VA patient care “scored higher on care quality, chronic disease care, and preventive care.”

Ordinary Americans believe that health information technology will improve medical care. In a 2006 Wall Street Journal Online/Harris Interactive Health-Care Poll, 68 percent of those polled in a national study indicated that the use of electronic medical records would improve the quality of care that patients receive by reducing the number of redundant or unnecessary tests and procedures; 60 percent thought that electronic medical records could significantly reduce health care costs; and 55 percent believed that such records could significantly decrease the frequency of medical errors. Those figures demonstrate that the potential for improvements in health care treatment through digital medicine is quite high.

BARRIERS TO INNOVATION IN TECHNOLOGY

Technology offers great hope for the future, but a number of barriers remain to successful implementation in the health care arena. The real problem in health care is not technology per se but political, social, and economic challenges that complicate the adoption of digital technologies. Ordinary people have been slow to embrace technology in managing their personal health care. Consumers worry about the confidentiality of medical records, and professionals fear that the costs of technology will outweigh the benefits.

Research suggests that patients worry that the emergence of digital medicine will lower health care quality and lead to unmet health care needs. Work by Sciamanna and colleagues, for example, suggests that patients like to be able to schedule appointments online but worry about the quality of care provided online; some patients in primary care practices were concerned, for example, that they would not receive all the tests and treatments that they might require if they relied on Internet consultations.

Such obstacles have made it very difficult to gain the benefits of health information technology for the system as a whole. Individual applications often sound very promising at first. Consumers like the convenience and efficiency of digital medical resources, but unless patients, insurers, health care professionals, and public officials are able to overcome the major barriers, the electronic revolution in health care will be quite limited. As discussed below, a variety of factors have slowed the adoption of health information technology in the United States.

Political Divisions

Health care is a highly politicized policy issue that has aroused intense conflict between the major political parties and among powerful interest groups, ordinary consumers, hospitals, insurers, pharmaceutical companies, and the different levels of government. Change is difficult because most of the major actors are suspicious of the motives and aims of their adversaries. Given the intense partisanship and divisive conflict surrounding health care, it is difficult for technology advocates to convince policymakers, health officials, or ordinary folks to incorporate new information technologies into service delivery.

President Bill Clinton attempted to reform the U.S. health care system in 1993–94 but failed to get Congress to take even a single vote on his plan. Although Democrats held the presidency, Senate, and House, they were unable to reach consensus on key aspects of a new system. Opponents successfully attacked the proposal as “big government” and “inefficient bureaucracy.” Support for the proposed plan for health care reform started out strong but faded over time as people learned more about it.

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Excerpted from Digital Medicineby Darrell M. West Edward Alan Miller Copyright © 2009 by THE BROOKINGS INSTITUTION. Excerpted by permission of BROOKINGS INSTITUTION PRESS. All rights reserved. No part of this excerpt may be reproduced or reprinted without permission in writing from the publisher.
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