Internet and Medicine Medicine on the Internet



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Internet and Medicine

Medicine on the Internet

  • Consumers
  • Providers
  • Companies

Consumers

  • 40-50% of Internet users look for healthcare info on the net – 70% of them feel the info affects their decision making
  • Goals
    • Specific disease info
    • Educational services
    • Medications
      • Info, purchasing
    • Fitness
    • Alternative medicine

Consumers

  • Disease info
    • 2/3 don’t receive info about their or their child’s disease(s) when in the MD’s office
  • Medications
    • Most don’t receive info about medications they are prescribed
  • Alternative medicine
    • Increased interest in alternative medicine (45%)
    • Many consider alternative medicine to be equal to traditional medicine

Providers

  • Provider education
    • Literature,
  • Provider-provider communication
    • Provider groups
    • Teleconsultation
  • Patient information
    • Lab and radiology results
  • Provider-patient communication

Companies

  • Consumer education (marketing)
  • B-B
    • Supply chain management

Healthcare info on the net

  • Provider sites
    • MayoClinic Home - MayoClinic.com
  • Special interest sites
    • JAMA Migraine Information Center
    • The Migraine Relief Center
    • Migraine Awareness Group MAGNUM
    • Natural Migraine Treatment FAQ

Healthcare info on net

Healthcare quality on the internet

  • California hospitals
    • Web sites difficult to locate
    • Underdeveloped content
    • 93% provided basic contact info, mission statements
    • 48% insurance information
    • 21% accreditation info
    • 36% quality measures
    • 11% patient appointments online
    • 5% allow on-line health profiles

Healthcare info quality

  • JAMA study
    • Study of accessibility, quality, readability
    • 14 search engines
    • 25 web sites
    • Evaluated by MD’s

Accessibility or relevant content

  • 10 English language and 4 Spanish language search engines
    • Ranking methods used: location and frequency of key words, cross-linking, payment from sites, human editing
  • Search terms
    • Breast cancer
    • Childhood asthma
    • Depression
    • Obesity

Accessibility of content

  • Links considered relevant if the search term itself or key terms (e.g. inhaler, gastric bypass surgery) present in the link itself or surrounding text
  • Relevant links followed to determine whether they led to relevant content
  • Pages assessed for content, promotional content and explicit advertisements

Accessibility

  • 34% of discovered links were relevant with significant variation by search engine
  • 74% of relevant links led to relevant content within ten clicks
  • English: 56% contained explicit content and 44% contained promotional material
  • Spanish: 36% explicit ads and 21% promotional material

Quality of content

  • Web sites selected for ranking, reputation and the absence of a need for subscription or payment (open sites)
  • Panel developed condition-related questions that one would expect to be answered by a site
    • “When should I start having regular mammograms?”
  • Panel developed clinical elements (recommendations/statements that should be included)
    • “most breast cancers occur in women without a family history of the disease”

Quality

  • Web sites retrieved and abstracted after having been stripped of identifying info
  • Abstracted material evaluated by MD’s and rated re: clinical elements
    • Not addressed
    • Minimally addressed
    • More than minimally addressed
  • Abstracts also rated for accuracy and conflicting info

Percentage of “required clinical elements not covered”

  • English
    • Breast 16%
    • Asthma 27%
    • Depression 20%
    • Obesity 35%
  • Spanish
    • Breast 49%
    • Asthma 33%
    • Depression 61%
    • Obesity 69%

Quality

  • Material not covered
    • Alternatives to medical and surgical rx for breast Ca
    • Evaluation of depression
    • Safety and effectiveness of dietary supplements

Accuracy (correctness of presented material)

  • English
    • Breast 91%
    • Asthma 84%
    • Depression 75%
    • Obesity 86%
  • Spanish
    • Breast 96%
    • Asthma 53%
    • Depression 63%
    • Obesity 68%

Inaccurate info

  • Omega-3 fatty acid deficiencies causes major depression
  • Cockroaches are the leading cause of childhood asthma

Conflicting info

  • About half of English language sites had one or more conflicts re:
    • Treatment 35%
    • Diagnosis 13%
    • Definitions 7%
    • Adverse effects 5%
    • Etiology/Risk factors 5%
    • Incidence/Prevalence 4%
  • Example
    • One point in web site says inhaled steroids do and another don’t stunt growth

Reading grade level

  • English
    • Collegiate
  • Spanish
    • 10th grade

Conclusions

  • Consumers may have trouble finding complete and accurate information regarding a health problem
  • Consumers relying on the Internet to make treatment decisions, deficiencies in information might negatively affect decisions

Conclusions

  • Reading level is “quite high”
    • 48% of the overall population and
    • 75% of current welfare recipients have “low or very low” reading skills

Conclusions

  • Study limitations
    • Internet is a moving target
    • Small set of search engines
    • Simple search terms
    • Not a “natural experiment” with real people, real problems
    • Use of medical terms (rather than lay terms) in search strategy may have skewed results
    • Searchers may have missed important material

Recommendations

  • Variation among search engines suggest that overall search efficiency could be improved
  • Lack of critical information can be fixed
  • Information should be accurate and free of conflict of interest
  • Uniform rating scale would be of use
  • Information needs to more “readable” or reader friendly”

Consumer kids

  • Study similar to that in JAMA but for kids
    • Reading level 12th grade
    • No self-evaluation of reading level

Consumer teens

  • ¾ teens and young adults have used the Internet to find health info
    • Topics include
      • Depression, mental illness, drugs and alcohol (25%)
      • Birth control, sexually transmitted diseases (44%)
    • Plus: Internet can be a resource for education parents can’t provide
  • 39% changed their personal behavior as a result of the info found online, 14% had seen an MD as a result of the info

Lab result education

  • News and info about a variety of tests
  • Sponsored by six clinical lab groups
  • Lab Tests Online: Welcome!

Medical web site accreditation

  • American Accreditation Healthcare Commission
    • Disclosure and linking
    • Health content and service delivery
    • Privacy and security
    • Quality oversight
    • Standards

Drug purchase

  • “Rx-running seniors saving money online
  • “Black market” drugs bought online from outside the US

Fraud

  • FTC, FDA anti-scam efforts
    • Devices, herbal products, dietary supplements
    • Treat or cure cancer, HIV, arthritis, hepatitis, diabetes etc.

Providers

  • Professional organizations
    • ASCCA, ACCP, AMA
  • Continuing medical education
    • PACEP
  • Provider-patient contact
    • Usenet
    • Email
  • Patient data

Usenet

  • Unmoderated groups

Usenet

  • Moderated groups

Email

  • There are potential efficiencies in provider-patient communication
  • Providers have been slow to adopt
  • Issues to be resolved re: what’s OK, what are the laws, storage, turnaround etc.
  • Consider the following email

Email

  • Strange medium
  • May be characterized by
    • Disinhibition
    • Abnormal behavior/communication patterns
    • Mutual misunderstanding

Questions re: sample email

  • Is it analogous to a phone message?
  • Should it be included in the patient’s record?
  • Does the content carry the weight of a medical emergency?
  • Would the same statement have the same weight if it were a voice message, a letter?
  • Should this be regarded as a confidential communication by you? By the carrier?
  • What are the provider’s legal responsibilities
  • Is the time devoted to email reimbursable?

Email recommendations

  • AMIA
  • AMA
  • AAFP

Email issues

  • Patient provider email defined as
    • Computer based communication between clinicians and patients within a contractual relationship in which the health care provider has taken on an explicit measure of responsibility for the client’s care
  • Provider-provider
  • Provider “client” without contractual relationship
    • Provider takes on an advice giving role with a disclaimer

Email advantages

  • Advantages
    • Asynchronous
    • Less formal than a letter, more so than a phone message
    • Good format for follow-up communication, reinforcement, provision of supplemental information (educational material, lab/radiology results)
    • Readily stored to create a paper trail

Email disadvantages

  • Disadvantages
    • Informality and lack of verbal cues make email susceptible to miscues
      • “take that with a grain of salt”
      • Sarcasm and wit misinterpreted
      • emoticons

Email emotions

  • One can expect anger or frustration from patients
  • Should respond dispassionately
  • Document trail

Encryption techniques

  • Encryption techniques can be used to “guarantee” important components of correspondence
    • Authenticity of the sender
    • Privacy/confidentiality of the communication
    • Tamper-proofing
    • Time stamping
    • Non-repudiation

Email communication guidelines

Telemedicine

  • Patient care
    • Consultations, monitoring, triage from home
  • Professional education
    • CME, online info, individual mentoring
  • Patient education
  • Research
    • Aggregated databases
  • Public health
    • Access, poison centers, disease reporting
  • Health care administration
    • Video conferencing, quality monitoring

Classifying telemedicine

  • Initial urgent evaluation of patients
  • Supervision of primary care
  • One-time provision of specialty care
  • Consultation/second opinions
  • Monitioring or tracking of a patient
  • Use of remote sources to guide concurrent patient care

Telemedicine history

  • 1924
    • Cover of Radio News magazine “The Radio Doctor”
  • 1950’s
    • Teleradiology systems using phone
  • 1961
    • Radio telemetry of vital signs

Current sorts of telemedicine applications

  • Teleradiology, telepathology
  • Telemonitoring
    • ICUSA
  • Telesurgery
  • Emergency systems
  • Telemedicine for prisoners
  • Telepsychiatry
  • Teleconsultation
    • Managed care

Technological challenges

  • Rapid pace of change
  • Variety of hardware and software
  • Lack of standards for integration
  • Space, training and support requirements
  • Diversity of needs and requirements
  • Need to accommodate diverse types of communication links

Key information technologies

  • HCI
    • Hand-held computing
    • Handwriting and speech recognition
    • PDA’s
    • Biometrics
    • Automated data collection
    • Structured data entry

Key technologies

  • Storage and processing
    • CPR’s
    • Magnetic stripe cards, smart cards
    • Picture archiving, medical imaging
    • Optical storage
    • Image compression
    • Digital signal processing
    • Object oriented software

Key technologies

  • Connectivity
    • CIS’s
    • Cabled, optical and wireless networking
    • Internet and email
    • Messaging standards
    • Security, encryption standards
    • Fault tolerance and redundancy
    • Bandwidth

Key technologies

  • Data distillation
    • DSS
    • Pattern recognition
    • AI
      • Knowwledge based systems, discovery
    • Relational databases
    • Natural language processing

Human factors

  • Requirement for dedicated training, people to make computer systems work in medical environment
  • Equipment issues
    • Problems with convenience, reliability
    • Training time
    • Equipment decisions wrong-headed
    • Lack of flexibility/too much flexibility with proprietary systems

Human factors

  • Incorporating telemedicine into current practice
    • System already strained
  • Analogous to telephones in the early days
    • Few phones
    • Inefficient networking

Human factors

  • Current units are fixed desktop systems
  • Email, fax, voice mail not yet integrated into systems
  • Lack of CPR’s

Cultural issues

  • Telemedicine may alter referral relationships
  • Lack of documented benefits from telemedicine
  • Lack of payment
  • Medicine undergoing restructuring – will new players (managed care) embrace telemedicine

Policy context

  • Telemedicine crossing state borders
  • Federal vs. state role
  • Licensure
  • Malpractice issues
    • Defined as a deviation from accepted standard of care that causes harm to a patient for whom the physician has responsibility
  • Privacy, confidentiality, security
  • Payment policies
    • Fee for service barriers (compare government)
  • Device regulation: devices used in telemedicine

Case example

  • ICUSA
    • Technology
    • Issues pertaining to above licensure, malpractice coverage/suits, devices, resistance, outcomes and payments

Evaluation of telemedicine

  • Does telemedine improve quality of care compared to alternatives
  • Does telemedicine improve outcomes
  • Does telemedicine improve access to care
  • Does telemedicine decrease costs
  • Is telemedicine acceptable to users

Findings from national working group

  • Limited adoption to date
    • Question of benefit
    • Inadequate assessment of practitioner and community needs
    • Practical difficulties integrating telemedicine into practice
    • Limited familiarity on the part of clinicians with telemedicine and telecommunications
    • Fears about telemedicine (what will it do to me)

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