Introduction
This article provides an overview of the trend in Internet usage; in particular, the trend that relates particularly to health-information-seeking behavior. It discusses a paradigm shift in patient-doctor relationships that has resulted from social changes; that is, lack of consultation time, thirst for medical knowledge, mass-media medical information and an explosion in the number of health Web sites. The Internet has become an important medium for bridging the gap in the patient-doctor relationship.
Issues of Internet quality are explored. While the Internet can help consumers by providing immediate feedback as far as treatment and medication are concerned, without proper standards and quality assurance it can give rise to diabolical consequences (Crocco, Villasis-Keever, & Jadad, 2002). Ciolek describes information on the Internet as mediocre and argues that health information on the Internet is subject to “Multi Media Mediocrity” (MMM) (Ciolek, 1997).
General Trends of using Internet for Health Advice
The Internet has become a vital tool for individuals, families, the health profession and the health industry. One Web site reports that there are more than 10,000 health sites on the Internet, and others report more than 100,000 health-related Web sites (Eysenbach, Sa, & Diepgen, 1999). No one knows theexact number, but what is clear is that there are numerous health sites available.
Health sites vary, from academic sites to health-provider institutions and government sites. Recently, there have been an increasing number of pharmaceutical companies disseminating information or selling products and services in a variety of ways on Web sites luring consumers (Risk & Dzenowagis, 2001).
Since the emergence of the Internet in 1991, the Internet use has grown exponentially. A recent survey shows that 86% of the 168 million American adults have visited health Web sites, compared with 55% of the 60 million in Germany. Ninety percent of American primary-care physicians have used the Internet (Risk & Dzenowagis, 2001). According to Harris Interactive consulting firm, health Internet users grew steadily from 50 million in 1998 to 69 million in 1999, 97 million in 2001 and 110 million in 2002 (Harris Interactive, 2000).
Demographical Difference
No significant difference in information-seeking habits between different age groups were found (Brodie, Flournay, Altman, Blendon, Benson, & Rosenbaum, 2000) Also, there is a direct correlation between computer usage and access to health information:
Once people gain access to the Internet, its use at home to get health information is similar across income, education, race and age. Therefore, the number of persons using the Internet to access health information should rise along with computer use. (Brodie, 2000, p.262)
According to Brodie’s report, gender, age and background do not make much difference in Internet search behavior.
A significant difference between countries is noted in research results from a questionnaire survey among the users of a dermatology atlas Web site. Pictures were used to minimize language barriers between countries (Eysenbach et al., 1999). The survey was conducted over seven months, from July 1998 to February 1999, and was answered by 6,441 users from all over the world.
Figure 1 shows the distribution of the 4,605 users who completed survey from the eight countries that showed the highest absolute numbers of users. Of those eight, Canada shows the highest percentage of users, followed by the United States (U.S.) and United Kingdom (UK), with Brazil the lowest.
There was a high proportion of general practitioners in Canada, UK, Spain and Sweden, and a high proportion of specialists in Brazil, France, Germany, Spain and U.S.
Figure 1. User profile of dermatology atlas Web site intended for health professional
A high proportion of hospital specialists were noted in Spain, Sweden, France and Brazil compared to a large number of specialists in private practice in Brazil, France and Germany. This is a reflection of the actual ratio of specialists in private practice compared with the public sector in the respective countries.
Looking at the percentage of nurses visiting the Internet, the highest percentage was noted in the U.S., Canada, UK and Sweden, as opposed to almost none in other countries, probably reflecting the differing roles and levels of responsibility nurses have in those countries.
While these data have been gathered in a specialist setting; that is, dermatology, and may be prone to self-selection bias and thus not representative of the whole, nevertheless, they tell us that there are significant differences between countries in Internet use. These differences are not only technological ones, but they also reflect differences in the health system as well as other cultural, sociological factors and economic fac-tors—for example, capacity to afford Internet facilities (Eysenbach et al., 1999).
What causes the behavioral shift in consumers towards the Internet over traditional face-to-face contact with doctors?
changing Medical practices
In the field of information technology, doctors still seem to be lagging behind other professionals.
In many industrialized nations, consumers have taken a leading role in retrieving and exchanging health information (Eysenbach et al., 1999). While telemedicine (diagnostic and curative medicine) is influenced by “technological push,” cybermedicine (preventive medicine and public health) is influenced by “consumer pull”; the traditional family doctor-patient relationship has to change to meet the demands of these social changes (Eysenbach et al., 1999).
consumer Empowerment
The availability of the Internet has provided consumers with easy access to information. “The empowered, computer-literate public is exerting tremendous influence on healthcare delivery” (Ball & Lillis, 2001, p. 2). Consumers are actively seeking health information using the Internet as a major tool. Users get access to as many of the resources and databases as physicians do, although some databases are specifically available for physicians. This empowers consumers to make informed decisions and reduces their dependency on the physician. The Internet is, thus, a motor for evidence-based medicine for both physicians and consumers. It gives “increasing consumer involvement in health care decision making and increasing the pressure on caregivers to deliver high quality health services” (Eysenbach et al., 1999, p.2).
Figure 2. Positive feedback loop (Eysenbach et al., 1999)
As can be seen in Figure 2, consumers’ access to health information on the Internet has increased tremendously; they have access to physicians’ Web pages and databases and retrieve a wealth of knowledge on medical conditions and treatments. As computer-literate consumers become empowered, they can become involved in decision making in evidence-based medicine (Eysenbach et al., 1999).
This transformation driven by the Internet can be a challenge to physicians, as users are better informed than before (Ball & Lillis, 2001). Whether consumers are capable of making quality decisions is yet to be determined, as they can become “cyberchondriac” with more access to information on health problems. However, many consumers can challenge physicians with evidence-based information from the Internet (Eysenbach et al., 1999). The speed at which information is delivered on the Internet can cause mis-communication; for example, in Britain there was a government warning about oral contraceptives on the Internet. Some consumers found the information before physicians did (Coiera, 1996). There is a pressing need for better communication among doctors regarding information technology. Equipped with the right information, physicians can improve the quality of treatment by fostering closer partnerships with consumers.
This paradigm shift is a challenge to the doctor-patient relationship, as can be seen next.
Doctor-patient Relationship
The term “patients” is slowly being replaced by “consumers” (Coiera, 1996). Sir William Osler (1849-1919) was a pre-eminent physician of the century whose work was based on trust and confidence, fostering a personal relationship. With the recent explosion of the Internet, the art of Osler’s medical practice, which has been a fundamental to medicine, is under threat (Wheeler, 1990), as consumers challenge physicians with a “stew” of medical information they have retrieved from the Internet, and arrive at their appointments with meters of printouts challenging their knowledge (Coiera, 1996).
There is a common scenario where patients spend long hours searching for information on the Internet and bring pages of printouts to the doctor and ask questions. Such discussion can be exhausting. Some doctors have suggested, “Whatever you do, don’t go on the Internet” (Ferguson, 2002, p.555). Also, the information available could be too abstruse or complex for most consumers. This health illiteracy could pose significant concerns for consumers, as they do not necessarily have sufficient medical knowledge to make informed decisions about their medical conditions (Oer-mann & Wilson, 2000; Wyatt, 1997).
In addition, there is an increase in litigation against doctors. The Internet transforms the traditional autocratic doctor-patient relationship into a balanced power play (Ball & Lillis, 2001).
What is very important is that, while information obtained on the Internet does support users, it cannot “replace the patient-physician relationship” (McLellan, 1998). The availability of resources to both physicians and patients could mean that consumers can get the same access to resources as the physicians. But it is often questionable whether the information is accurate or complete, which could lead to misdiagnosis and misunderstanding (Helwig, Lovelle, Guse, & Gottlieb, 1999).
National Medical portal: opportunities and Threats
A portal is a concept widely used within the Web. It is “a gateway or a door that provides users a single gateway to personalized information needed to make informed business decisions” (Quirk, 2001, p.2). The word “portal” has been used largely in the last two to three years and is often confused with Web sites. The difference between Web sites and portals is that the former is static and the latter is dynamic. Portals are Web-based; have dynamic links to information resources, effective information and document managers; and connect people with information (Moon & Burstein, 2004).
Medical portals provide information such as causes of diseases, medications, treatments, alternative therapies and lists of consultants. Medical portals can be either general or specific. General medical portals provide general medical information; for example, Better Health or Health Insite. Disease-specific portals provide information specific to particular disease; for example, cancer portal, breast cancer portal.
Moon and Burstein (2004) described five functional components necessary for a model of medical portal: community, personalization, quality, health services and gateway. The functional components relating to community are discussed in detail next, as it is pertinent to this article (p. 277):
• Share medical information: Can be done via e-mail, or by “chatting” or any other facilities such as MUD (multi-user device—through role play)
• Promote interaction: With doctors for receiving medical help or sharing personal experiences with other people
• Bulletin board/newsletter: From various stake holders can inform users of changes in the organization, such as change of member of the boards, or changes to portal sites for updates and so forth
• Alert to new information: With personalized settings, users can be alerted to new drugs or new research findings to a particular aspect of medical conditions
• Multimedia access via video streaming, or Web cam facilities to facilitate meetings or discussions.
opportunities
The opportunities for users that give better empowerment are as follows:
• Better access to medical information
• New form of communication between users and care providers
• Opportunity to meet other users
• Saves time from visiting doctors
• Cheaper than visiting the doctor, as the connection fee is fairly inexpensive compared to the cost of visiting general practioners or consultants
• Not time dependent— can look for information anytime
• No geographical barrier—can find information anywhere
• New opportunity for therapy (e-therapy)
• Reduces barrier between care providers and users for second opinion
• A new medium for those who are embarrassed to see doctors for personal reasons and can find answers anonymously.
All of the above and more that can be listed add value to users and empower them to make informed decisions about their health (van Melick, Hakkenberg van Gaasbeek, & Pennings, 2001).
Threats
The Internet is anarchic in nature; that is to say that it is formless and boundless. Anyone, anywhere can write content and publish it anywhere, provided they have the software to do so. The question is not how to retrieve health information but how to retrieve relevant and accurate information (Risk & Dzenowagis, 2001). The easy access to an avalanche of health information can be an enormous threat to users if they are not properly guided.
Following is a list of some adverse effects the Internet could bring if the information is not managed with proper knowledge:
• It is not always easy to see the origin of the information, and users could be making decisions on the basis of a source that might not be quality assured
• Users are not equipped to make judgments on the basis of particular scenarios, they need to see health holistically
• Could harm users if they follow treatments that are location-specific
• Risk of making a wrong diagnosis
• Risk of taking ill advice if the discussant is not properly qualified
• Risk of Internet addiction
• Could be lured by pharmaceutical companies’ advertisements
• Avalanche of information can be time-consuming and confusing.
All of the above and more add value to the users and empowers them to make informed decisions about their health (van Melick, Hakkenberg van Gaasbeek, & Pennings, 2001).
The following paragraphs discuss Internet health tools available to give guidance to consumers about the breath, depth and insightfulness of medical portals.
internet Quality Tools
Health care information has potential benefits for many Internet users (Coiera, 1996) if they are properly educated and if the developers take quality criteria into consideration (Policy Paper, 2002). How do consumers know if a site is worthy? Many tools are available to assess the quality of content on the Internet. Wilson (2002) and Risk and Dzenowagis (2001) provide tools to classify Web sites, assisting developers to produce quality sites. They are as follows:
• Code of conduct: to ensure that the developers adhere to quality criteria.
• Quality labels: a logo or a symbol is displayed on the screen.
The most common ones are Health On the Net Foundation and Hi-Ethics code. Both of these are used on more than 3,000 Web sites.
Figure 3.
Figure 4.
Hon- code does not rate the quality of information, but it provides users the origin information and the purpose of data they are reading. It also provides ethical standards to Web site developers.
Hi-Ethics code produces quality levels for commercial sites. The uses of Hi-Ethics are: American Specialty, Health Networks, America Online HEALTH vision.
• User guides: provide user guidance to assess if a site meets the criteria. Web sites such as DISCERN allow users to validate the quality of written information on treatments; QUICK gives step-by-step guidance to children; NETSCORING gives guidance on all health-related topics.
• Filters: filter information according to a set of criteria; OMNI provides gateways to evaluate resources.
• Third-party certification: a seal or logo accredited by a third party, assuring consumers the site meets accepted standards for health sites. Third-party accreditors are MEDCERTAIN and TNOQMIC.
However, Wilson fails to discuss the size of the burden placed on provders, the lack of provision for educating consumers, the cost of developing and maintaining quality and the needs of developing countries. Wilson’s article concentrates mostly on English-speaking countries.
Future Trends
There is no turning back to the past. Twenty-first-century medicine has changed traditional medicine to Internet-empowered, patient-driven online support, with users controlling and managing their health (Ferguson, 2002). As more and more consumers are using the computer, it would be impossible to unwire the information. While the Internet can pose the threat of unreliable information (Oermann & Wilson, 2000), with users lured by many commercial sectors (Risk & Dzenowagis, 2001), nevertheless, it is satisfying many consumers’ needs (Ferguson, 2002).
Doctors who do not recognize this trend would be losing patients to those who do understand the changes in the doctor-patient relationship. What is important is that there should be a synergy between doctors and patients (Yellowlees, 2000). The way to ensure this synergy exists, and to build trust between doctors and patients, is to make sure Web site content is reliable and that the Internet is serviceable (accessible both technically and design-wise). Doctors also need to understand consumers’ needs and provide them with quality information. Given that doctors are under pressure to see more patients in a given time, leading to shorter consultation time, the Internet is an alternative for consumers to educate themselves on their health concerns.
One of the ways to ensure that consumers educate themselves is to educate the developers of portals’ search engines, encouraging them to design portals that are ethical and compliant with quality standards. It is also vital to educate consumers to be cautious with the material they access on the Internet. Thus, consumers can “access health information critically” (Wilson, 2002, p.600).
Conclusion
The Internet presents a powerful mechanism for helping users to improve their health-care decision making by providing easy and rapid access to, and exchange and dissemination of, enormous amounts of health information. Yet, users must be aware of the potential for misinformation and recognize the critical need to assess the quality of the information provided. Content providers must be encouraged to develop and publish high-quality information, and policy makers and health-care professionals must be educated on this important health issue (Risk & Petersen, 2002).
Despite the perils of predicting the future of our health-care system, it is hard to ignore the evidence that the health system will undergo a revolution. The rapid growth of computer-based electronic communication and the fact that the new generations are comfortable with electronic transfer of health information leads to an increase of patient health management; that is, patients are taking an active role in the decision-making process (Kassirer, 1995). This trend is likely to grow and will have a substantial and hopefully positive impact (lowering the cost) on the health economy and on the well-being of consumers.
key terms
Consumer Empowerment: The users are well informed of the information thus making an informed decision.
Cyberchondriac: Those users of the Internet who are obsessively persuing the Internet in search of information.
Cybermedicine: The Internet-driven practice of medicine where patients communicate with doctors via electronic medium.
Evidence-Based Medicine: Evidence-based medicine is a new paradigm that replaces old paradigm of traditional medicine based on authority. It is based on clinical research which uses current best evidence in making decisions about the care of individual patients.
Health Portals: Includes any information on the Internet relating to health, including medical information as well as products and information that are related to well being, i.e., shampoo, diets, medicine, and alternative medicine.
