Digital Medicine: Health Care in the Internet Era by Darrell M. West and Edward Alan Miller. Washington, DC: Brookings, 2009, 183pp.
Edward H. Shortliffe
When I recently moved to a new city and had to identify a primary care provider and health system, I decided to rule out any physician or provider organization that lacked the infrastructure or philosophy that would allow me to communicate with my doctor and the office staff by email, to secure online access to my lab results and other aspects of my medical record, or to make appointments electronically. Frustrated by my recent experience in another city, where my previous physician had actually changed practices in order to avoid being forced to adopt an electronic health record being implemented by colleagues and where all calls to his office were met with voicemail and promises to return my call, usually at a time that was inconvenient for me, I swore that I would never again subject myself to a healthcare environment or physician who had not adopted modern electronic means of communication, data management, and information dissemination. I recognized that I am a technophile and early adopter by nature, but as I looked at the plethora of smart phones, Facebook pages, and laptops in airport security lines that surround me every day, I suspected that I was not alone in using such “digital literacy” criteria to guide my choice of physician and healthcare system. I have subsequently been pleased to find a suitably robust, electronically sophisticated physician and healthcare environment in my new city and realize that I personally associate such capabilities with quality of care, safety, and cost containment.
But just how typical am I, and what are the trends that will increasingly determine how patients, physicians, other health professionals, and provider organizations will embrace and adopt such technologies in the years ahead? West and Miller provide some answers to such questions in a fascinating monograph that appeared in mid-2009, much of it summarizing and interpreting the results of their national e-health public opinion survey that polled by telephone 1,428 adults from across the United States in November 2005. West is a political scientist from the Brookings Institution who collaborated with Miller, a faculty member at Brown University with expertise in public policy, political science, and community health. Thus, the book is written not from the perspective of the technology per se but as an exploration of the current trends in adoption, acceptance, and pursuit of e-health solutions in the United States and abroad. Taken together, the eight chapters survey a variety of key issues that have determined the rate and degree of e-health penetration, the attitudes toward the technology and to medicine in general, and the differences among individuals based on variables such as education, economic status, access, ethnic background, age, and gender. By assessing other data from studies throughout the past decade, the authors are also able to give us a sense of the trends in many areas—trends that generally show a significant change in the rate of adoption of e-health solutions both by providers and by the public. Thus the data summarized in the volume, while often useful and sometimes surprising, beg the question of how much the situation may have changed by today, some three or four years later.
The authors begin by nicely summarizing the state of the art and the barriers to e-health innovation and adoption, providing background for their extensive study of trends in digital medicine. Their motivating argument is 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.” They then devote the rest of the volume to analyses of the key questions in this arena that arose from their own studies or are highlighted by other data available in the literature.
They start by analyzing available health web sites, seeking insights into the differences among public, nonprofit, and commercial sites in the healthcare space. Issues addressed include the presence and role of advertising, potential conflicts of interest, the quality and accuracy of the information on the sites, and barriers to utility such as narrative text that assumes reading levels above those of the general population, language barriers, cultural incompatibilities, or a failure to address the needs of individuals with disabilities (especially visual impairments).
The authors acknowledge that barriers to effective use of online information are determined not only by the nature of the information sites themselves but also by the extent to which individuals who may need such information are familiar with computers and Internet use and have regular access to the technology. Thus, one of their analyses focuses on three particular indicators of e-health use and sophistication by individuals: email communication with providers, access to web sites for information, and use of the Internet to purchase medications or other medical materials. A variety of socioeconomic and demographic barriers to increased use of health information technology are documented, among both patients and providers. As my own experience has demonstrated, the failure to use email to communicate with a physician or with office staff may not reflect reluctance on the part of the patient but refusal to provide such services on the part of the clinician. Similarly, the online purchase of medications often depends on the type of health insurance that covers a patient and the ease of submitting prescriptions to a central online resource, rather than on the patient’s desire for such access.
West and Miller also explore the relationship between e-health participation and attitudes toward the healthcare system. It is fascinating that their analysis of this topic begins with discussion of a 2002 article in The Milbank Quarterly by David Blumenthal, appointed by President Obama to be the National Coordinator for Health Information Technology (HIT) shortly after this volume had gone to press. Blumenthal is quoted as expressing concern that patient satisfaction with the quality of medical care will decline in a wired world. One wonders how his impressions may have evolved since his immersion in the HIT world. The data summarized by West and Miller, however, suggest that there are no guarantees that a wired world is going to produce positive attitudes toward the healthcare system. The mere use of electronic media does not enhance an individual’s perceptions of the health system unless it is accompanied by other indicators of quality that provide reassurance and a sense of personal empowerment and individualized attention.
Another key issue in the dissemination and adoption of e-health resources is the role of demography. It is not surprising that socioeconomic status would have an effect on one’s ability and interest in online health information, email, and prescription purchases, but the authors’ data provide useful insights about other sociodemographic determinants as well. For example, women are more likely than are men to use e-health resources, and younger people are more likely to turn to commercial web sites than public ones, perhaps reflecting privacy fears and distrust of government in the younger age groups. Racial and ethnic determinants are also striking, with Asians in the United States the most sophisticated in their use of e-health resources with substantially lower (but improving) numbers for African-Americans and Hispanics. Language issues are seen as particularly important elements in the digital disparities affecting the Hispanic community. Such issues emphasize the challenges for policymakers who are attempting to close the digital divide, both broadly and in the healthcare setting.
West and Miller also provide sobering data on how the United States compares with other parts of the world in the adoption of e-health capabilities by patients, providers, and governments. Some challenges relate to the differences in basic broadband infrastructure, which saw the United States ranked fourth in 2001 but fifteenth by 2007, a reflection of the nation’s limited national investment and its belief that the private sector will take care of the proliferation of necessary infrastructure to support e-health and other social goods. The United States has invested heavily in high-quality, government-sponsored health-related web sites, and it compares favorably with other parts of the world in this regard. In the use of such resources by the public and the overall adoption of HIT by providers and health systems, however, the United States is woefully behind most of the developed world.
The volume closes by proposing policies and activities that are necessary to advance the role and acceptance of digital medicine in the United States. Their suggestions follow logically from the earlier analyses, are persuasive, and resonate with recommendations from a variety of professional and scientific groups that bemoan the country’s relatively slow progress in advancing this field and realizing its full potential. Improved education, both of the public and of current and future health professionals, is viewed as a key element in any solution, and has been too often overlooked when others have assessed approaches to making better use of information technology in health care. The data in this volume show that we also have a significant need to boost computer literacy, despite the ubiquitous cell phones and Facebook pages to which I referred earlier. Given the economic determinants of e-health use and the digital divide, low-cost technologies and improved access through publicly available means continue to be key requirements. We also need improved public investment to create and maintain the broadband infrastructure necessary to serve the populace and maintain economic competitiveness. This is a fundamentally political issue and one that has lacked significant government support despite the data showing that the United States is falling behind other countries by relying on the private sector for such solutions. Thus, overcoming the stultifying effects of the modern political process, while also taking ethical and privacy considerations seriously, is also an important element in any long-term solution.
In summary, this volume is thought provoking and insightful, although it begs for a current update so that we can understand how the situation has changed over the past few years in this rapidly evolving area. The text is a bit dry, with copious tables and discussion of statistical results, but the summary statements and closing chapter provide an excellent sense of the issues and investments that will determine the success, acceptance, and impact of e-health as digital medicine continues to evolve in the decade ahead.
Edward H. Shortliffe (Shortliffe@amia.org) is president and CEO of the American Medical Informatics Association in Bethesda, Maryland, and a professor in the School of Health Information Sciences at the University of Texas Health Science Center in Houston, Texas.