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

4. Automated Journalism Editor Storage Referee Electronic Reader Print Author

5. 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

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

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

8. 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

11. 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

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

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

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

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

16. 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

17. 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

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

19. Doing the right thing for individual patients and populations of patients

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

21. 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

22. 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

23. CME activity – Jan 1999 to Dec 2000

24. 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

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

26. 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

27. Between 20 000 and 2 000 000 Health/Medical Sites on the Internet HealthSearchers PornoSearchers >

28. US Adults Seeking Health Info on the WWW June 1998 54 million June 1999 69 million June 2000 98 million November 2000 106 million November 2000 106 million Harris Interactive Harris Interactive

29. 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

30. > 50% for specific illness or diagnosis 46% after new Rx/treatment Only 20% before seeing their physicians CyberDialogue CyberDialogue Patients Visiting Health Sites 2000

31. 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

32. 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

33. US MDs accessing the Internet 1995 3% 1996 15% 1997 32% 199860% 199980% 200089% 200193%

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

35. 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

36. 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

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

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

39. 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

40. What do Physicians Do?

41. Physicians and Information SeekingGatheringInterpretingFeedbackObservingAssimilatingDispensingMonitoring

42. 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

43. 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

44. Great for an established patient-physician relationship

45. Verboten for initial or sole patient-physician interaction

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

47. 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

48. 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 2000 -Harris Interactive 2000 What Consumers Want

49. Concerned that e-mail 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

50. MDs Use : MDs Use : E-mail with patients 26% EMR22% Electronic prescribing 11% Remote monitoring 5% BCG 2001 BCG 2001

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

52. 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

54. 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

55. Physician Patient

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

57. 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

58. 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

59. 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

60. 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

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

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

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

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

65. Privacy on the Web and in e-mail Privacy on the Web and in e-mail 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

66. A New World Made Better by Information

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

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