Bard of CyberDialogue Bard of CyberDialogue Maturation of eHealth 5 Cs eCommerceeContent eConnectivity eCare eCommunity

Automated Journalism Editor Storage Referee Electronic Reader Print Author

Medical On-Line Services Full text of : JAMA, NEJM, BMJ, Lancet, Annals Int Medicine, Archives Js, othersJAMA, NEJM, BMJ, Lancet, Annals Int Medicine, Archives Js, others TextbooksTextbooks Medline from NLM

Medical On-line Services Advantages Timely, High Quality/QuantityTimely, High Quality/QuantityDisadvantages Difficult to searchDifficult to search ExpensiveExpensive

Medical CD-ROM Single journalsSingle journals Collections by topic/publisherCollections by topic/publisher Reference MaterialsReference Materials Interactive approachesInteractive approaches

Medical CD-ROM Advantages Low cost players and disksLow cost players and disks Effective for teachingEffective for teaching Multimedia capabilityMultimedia capabilityDisadvantages Slow response timeSlow response time Information not timelyInformation not timely

Medical 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 Internet Advantages Worldwide, Voluminous, PersonalWorldwide, Voluminous, PersonalDisadvantages Unregulatable, variable quality, poor securityUnregulatable, variable quality, poor security

Determinants of Human Behavior A Hierarchy Personal Morality Societal Ethics Public Law

A quality or fact of conforming to or deriving from right ideas of human conduct; goodness and uprightness of behavior

Principles of conduct governing an individual or profession; the ideals of character manifested by a people

A rule or mode of conduct or action that is formally recognized as binding by a supreme controlling authority and is made obligatory by a sanction

One of the defining features of a professional is "the voluntary self- imposition of higher than ordinary standards" "When faced with a difficult decision, the true professional will efface his own self- interests" Pellegrino The Essence of Professionalism is Self-Governance

I. A physician shall be dedicated to providing competent medical service with compassion and respect for human dignity.

Doing the right thing for individual patients and populations of patients

Seek Truth and Report It Minimize Harm Act Independently Be Accountable Society of Professional Journalists Code of Ethics -1996

11. …bad faith…fraud…bribery…public wrong 12. Controversies…voluntary agreement or impartial arbitration 13. …moral obligations of individuals… 14. Lawful cooperation…is commended 15. Business should render restrictive legislation unnecessary

The International Committee of Medical Journal Editors (The Vancouver Group) Ann Intern Med, BMJ, CMAJ, Dutch Med J, Index Medicus, JAMA, J Danish Med Assoc, Lancet, MJA, NEJM, NZMJ, J Norw Med Assoc, West J Med Ann Intern Med, BMJ, CMAJ, Dutch Med J, Index Medicus, JAMA, J Danish Med Assoc, Lancet, MJA, NEJM, NZMJ, J Norw Med Assoc, West J Med > 600 journals have agreed to participate 1999 > 600 journals have agreed to participate 1999

CME activity – Jan 1999 to Dec 2000

Ethics statement or seal15% Brand name identification 9% Brand name identification 9% Presence of leading experts44% Not certain how to judge 32% How survey responders judge the ethics of a medical web site

1. Candor 2. Honesty 3. Quality 4. Informed Consent 5. Privacy 6. Professionalism in Online Healthcare 7. Responsible Partnering 8. Accountability

1. Privacy Policies 2. Enhanced Privacy Protection for Health-Related Personal Information 3. Safeguarding Consumer Privacy in Relationships with Third Parties 4. Disclosure of Ownership and Financial Sponsorship 5. Identifying Advertising and Health Information Content Sponsored by Third Parties 6. Promotional Offers, Rebates, and Free Items or Services 7. Quality of Health Information Content

Between and Health/Medical Sites on the Internet HealthSearchers PornoSearchers >

US Adults Seeking Health Info on the WWW June million June million June million November million November million Harris Interactive Harris Interactive

On Line Health Information On Line Health Information 97 Million US Adult Users 97 Million US Adult Users Search engine or portal52% Directly to health site24% General site with health info14% Average 3.3 visits a month Harris Interactive 2001

> 50% for specific illness or diagnosis 46% after new Rx/treatment Only 20% before seeing their physicians CyberDialogue CyberDialogue Patients Visiting Health Sites 2000

On line Health Users On line Health Users 15% of MDs recommend specific sites specific sites Vitamins and nutritional supplements are bought supplements are bought Prescription drugs not bought on line on line

On line Health Users On line Health Users More women than men Typically older, married, Caucasian & college-educated Caucasian & college-educated Arrive at Doctor with print-out Leave with lower opinion of Doctor Doctor

US MDs accessing the Internet % % % % % % %

US MD Internet Use Overall 85% Medical information and news 71% and news 71% Access guidelines and protocols 50% and protocols 50% HealthTech 2001

MDs Use Internet 3 Hours/Week to: MDs Use Internet 3 Hours/Week to: Research clinical matters90% Read journal articles78% Contact colleagues61% Complete CME45% Attend conferences31% BCG 2001 BCG 2001

Average time on-line on Medical sites 2-3 hours/week Medical sites 2-3 hours/week Have looked for/at: Disease Information 94% Medical Association News 85% Medical Sites 74% University sites 67% Online CME 45% Canadian Physicians

Medical Portals most used : Medical Associations 26% Medscape 11 % MEDLINE 6 % WebMD6% Pubmed 2% University sites 2% Canadian Physicians

Expect their Internet use to increase next 12 months Accessing Disease Info 70% On Line CME 58% Access Drug Info 33 % Canadian Physicians

Agreed with the statement: The Internet is changing the way I practice medicine 43% I take fewer medical journals because the information is on the Internet37% Canadian Physicians

What do Physicians Do?

Physicians and Information SeekingGatheringInterpretingFeedbackObservingAssimilatingDispensingMonitoring

Where is the Internet Applicable? Where is the Internet Applicable? 1. Anywhere the telephone/fax machine is used 2. As a library 3. To replace hand-delivered notes 4. To replace letters/brochures/certificates/lab results results 5. Orders and results 6. Verbal communications 7. Whenever distance separates individuals or copies are needed for others copies are needed for others

Physicians Essential Internet Applications Physicians Essential Internet Applications Clinical Diagnostic reporting Electronic medical records Administrative Claims processing Eligibility authorizations Referral authorizations IT systems support HealthTech 2001 HealthTech 2001

Great for an established patient-physician relationship

Verboten for initial or sole patient-physician interaction

Values of Medicine Values of Medicine Maintain continuity of care Facilitate information flow Increase meaningful communication Reduce unnecessary appointments Increase patient responsibility Mechanic 2001 BMJ Mechanic 2001 BMJ

34 million want to Only 3 million have done so 5 million have visited any physician web site physician web site CyberDialogue CyberDialogue Patients Contacting Physicians Electronically 2000

Electronic Alerts from Physicians - 84% Lab Results on line - 83% Personalized Medical Information - 80% Charts to Monitor Chronic Conditions - 69% Conditions - 69% Will Select Physician Based on Internet Services - 43% -Harris Interactive Harris Interactive 2000 What Consumers Want

Concerned that will impact their busy schedules Only experimental methods of payment Potential loss of high-touch relationships Consider nurse or physician assistant triage Physician Fear and Resistance

MDs Use : MDs Use : with patients 26% EMR22% Electronic prescribing 11% Remote monitoring 5% BCG 2001 BCG 2001

How often do you patients? How often do you patients? Daily 9 % Few Times a Week 11 % Once a Month 15 % Never 65 % Aug 2001 Aug 2001

Medical Practice on the Internet A Watershed Time/Issue Medical Practice on the Internet A Watershed Time/Issue 1. Follow basic principles of medical ethics like Hippocrates first do no harm CEJA like Hippocrates first do no harm CEJA 2. Preserve Privacy 3. Disclose/Disclose/Disclose 4. Informed Consent Applies 5. Promote Research on Internet Medicine; Publish the good research; then let Ethics Publish the good research; then let Ethics follow Science follow Science 6. Much of this is a Risk/Benefit Ratio still to be determined for most interactions/interventions determined for most interactions/interventions

A fundamentally new medium A fundamentally new medium Exact nature still unknown Exact nature still unknown Likely to change every aspect of how we live Likely to change every aspect of how we live As electricity did As electricity did John Seely Brown John Seely Brown The World Wide Web

Physician Patient

Changing Physician Behavior Changing Physician Behavior EducationFeedback Financial rewards Financial penalties Administrative changes Physician participation Eisenberg 1981 Eisenberg 1981

Changing Physician Behavior (1) Changing Physician Behavior (1) Know the literature and have the data Convene committee of leading physicians Achieve agreement based on evidence and opinion Implement administratively Lundberg 1998

Changing Physician Behavior (2) Changing Physician Behavior (2) Add educational materials and conferences Receive complaints Ride out reactions and make adjustments Enjoy success Lundberg 1998 Lundberg 1998

Motivating Change in Clinician Behavior Motivating Change in Clinician Behavior Scientific performance data Best practice care expectations Positive financial gains or incentives Fear of losing patient access due to economic credentialing Fear of restriction of privileges Fear of public exposure Rosenstein 2000 Rosenstein 2000

Doctor Decision to Use an Internet Tool Doctor Decision to Use an Internet Tool Does it: Save time Save time Work as advertised Work as advertised Have trusted quality stamp Have trusted quality stamp Strengthen power position Strengthen power position Help meet a mandate/requirement Help meet a mandate/requirement Is it free? Forrester 2000 Is it free? Forrester 2000

Primary Care MDs Sometimes Using EMR United States17% Canada14% Australia 25% New Zealand52% United Kingdom59% HI 2000

Primary Care MDs Often Prescribing Electronically United States 9% Canada 8% Australia 44% New Zealand52% United Kingdom87% HI 2000

There are no secrets in hospitals There are no secrets in hospitals -Lundberg 2000 Privacy Issues Surrounding Health Care on the Internet

Solutions should be technology neutral Solutions should be technology neutral -Boulding Boulding 2000 Privacy Issues Surrounding Health Care on the Internet

Privacy on the Web and in Privacy on the Web and in There isn't any - There wont be any Companies should have, should post, and should follow policies Dont steal identities - Dont rip people off Informed Consent - Opt-In > Opt-Out

A New World Made Better by Information

Shared by many C ulture Shared by some Cult Shared by two Love Held by one Psychosis Delusion

Malnourished - 50 Substandard Housing - 80 Able to Read - 30 College Education - 1 Own a Computer - 1 The Worlds Population - %