Expanding the Reach and Impact of
|Table of Contents|
|Executive Summary (Stand-Alone)|
|Preface: A Vision of e-Health Benefits for All|
|Chapter 1. Introduction|
|Chapter 2. Mapping Diversity to Understand Users’ Requirements for e-Health Tools|
|Chapter 3. Assessing the Evidence Base for e-Health Tools for Diverse Users|
|Chapter 4. Strategic Factors in Realizing the Potential of e-Health|
|Chapter 5. Partnerships for Meaningful Access|
|Appendix 1. Environmental Scan of 40 e-HealthTools|
|Appendix 2. Project Interviewees, Experts Consulted, and Reviewers|
|Appendix 3. Chapter 3 Literature Review Summary|
|Appendix 4. A Comparison of Internet Use and Health Status of Populations That Experience Health Disparities|
Chapter 4. Strategic Factors in Realizing the Potential of e-Health (Part 1)
This chapter looks at the forces that are connecting consumers and e-health tools and creating a dynamic e-health marketplace. It depicts an e-health arena that is evolving in response to cultural and technological trends, market and health system forces, and policy initiatives. It also identifies the limits of the current e-health market to coordinate e-health tool development, evaluation, and dissemination; generate sustainable business models for e-health tools; and provide strong privacy protections and quality assurance to nurture public trust. These activities are generally beyond the market’s capacity to address on its own because they require changes and investments for which there is no immediate or direct return on investment for individual stakeholders. Given the public interest in and policy commitment to universal access to broadband technologies and electronic health records noted in Chapter 1, the public sector has the ultimate responsibility for ensuring these limitations are addressed.
Government coordination of efforts to realize the public health potential of e-health tools could be synergistic with existing public-sector programs and could help advance a number of important policy goals, including eliminating health disparities and supporting consumers in taking more responsibility for their health. Government cannot achieve these changes alone, however; it needs to join forces with the many stakeholders profiled in this chapter to design and carry out strategies from which every participant can derive appropriate benefits.
Signs of Dynamism
Consumer e-health is part of the broad cultural shift toward Internet and technology use, such as portable music devices, cell phones, instant messaging, and interactive voice-response systems, as a normal part of everyday life. At the end of 2004, approximately 70 million Americans used the Internet on a typical day for activities as varied as banking, shopping, real estate transactions, research, entertainment, self-expression, and voting; the Internet is “the new normal” (Rainie and Horrigan, 2005).
The same information and communication technologies that enable these other activities offer opportunities in the health arena as well. For example, hardware is becoming smaller, more powerful, cheaper, and more portable. Software is evolving to permit the storage and integration of ever-greater volumes of information. Search engines are proliferating and becoming more robust. Communication technology is enabling greater speed, the use of multimedia, and increasing mobility. All these factors can be conducive to wider dissemination of e-health tools, provided ubiquitous broadband access can be achieved.
There are many signs of the dynamism of the e-health environment, as demonstrated in the following examples.
The growing diversity of the e-health market is itself an important sign of its dynamism. The momentum toward e-health now affects nearly every segment of society, albeit to a different extent. For example, the 5 to 7 million enrollees in the My HealtheVet program of the U.S. Department of Veteran Affairs (VA) can view parts of their health records and carry out health-related functions through personally controlled electronic health records (www.myhealth.va.gov). Significantly, so can the 1,500 migrant farmworkers enrolled in the California program MiVIA (profiled in the Preface). And every month, more than a third of the 300,000 subsidized housing residents in the United States who use the Beehive (www.thebeehive.org), a Web site designed for persons with low literacy, visit its health section—consistently the most trafficked section of the site (S. Brachle, personal communication, March 2005).
Just a few years ago, the “typical e-health consumer” was described as “educated, middle- or upper-income, and an assertive and empowered buyer” (eHealth Institute, 2002, p. 16). Citing 1999 findings of Cyber Dialogue, Inc., Cain, Sarasohn-Kahn, and Wayne reported that “online health consumers behave in ways typical of New Consumers (individuals with a certain amount of discretionary income, experience with computers at work and/or at home, and the equivalent of at least 1 year of college education)” (2000, p. 14).
Although younger, better-off consumers continue to predominate in this market, the e-health consumer profile is slowly growing more multidimensional as new channels to e-health tools open and the number and type of stakeholders, intermediaries, and dissemination agents expand. Persistent disparities and the digital divide still require policy attention, but usage trends in the U.S. population are moving toward greater inclusiveness. Today’s Internet users, for example, include more seniors, especially the cohort aging into that category (Kaiser Family Foundation, 2005); more Hispanics (Hispanic Market Weekly, 2006; Spooner, Rainie, Fox, et al., 2001); more African Americans (Spooner and Rainie, 2000); and more low-income Americans (Cain et al., 2000). In addition, evidence suggests that some traditionally underserved groups, such as seniors, Hispanics, and African Americans, are even more likely than others to seek health information online (Gustafson, Hawkins, Pingree, et al., 2001; Zarcodoolas, Blanco, Boyer, et al., 2002).
Research also suggests that health status is a complex aspect of consumer interest in e-health. One survey classified online e-health users based on health status and found that “the well” comprised 60 percent of all e-health users, “the newly diagnosed” were only 5 percent, and “the chronically ill and their caregivers” were 35 percent (Cain et al., 2000). The researchers report that the “well . . . search for preventive medicine and wellness information in the same way they look for news, stock quotes, and products,” whereas the “newly diagnosed . . . search frenetically and cover a lot of ground in the first few weeks following their diagnosis,” but do not necessarily become consistent users. The authors call particular attention to the third group—the chronically ill and their caregivers, who “have the greatest potential to affect and be affected by Internet healthcare provision” because they have incorporated chronic illness management into their daily lives and “turn to the Internet for help” (quotations are from p. 1).
Using data from the Pew Internet & American Life Project, Houston and Allison analyzed health status for Internet users who go online for health information (2002). They found that those who rated their health either as fair or poor were newer users of the Internet but tended to use the Internet more frequently and were more likely to use information from online chats.
Consumers also vary in the stimuli causing them to seek out e-health resources. Some do so after learning about them from healthcare practitioners, media advertisements, or friends. Many health educators and healthcare practitioners, rather than producing their own educational materials, refer patients to Web-based resources or download and provide the information.
The concept of “information therapy,” the prescribing of targeted information as part of a clinical encounter, has taken hold in healthcare organizations, such as Kaiser Permanente, and information providers, such as the National Library of Medicine. (See Center for Information Therapy [www.informationtherapy.org] for one perspective on the information therapy concept.) A significant percentage of e-health end users do not use the technology themselves, but rather come to the resources indirectly through relatives, friends, or other intermediaries (“infomediaries”) who serve as caregivers or information sources. Manhattan Research estimated in 2003 that the “zone of influence” surrounding what was then 82 million e-health users extended to 135 million Americans (as reported in the eHealth Institute Summary Report, 2004, p. 13).
Another stream of e-health consumers comes to these tools initially not through personal initiative but in response to organizational programs. This source of momentum is significant in understanding the forces at work in the e-health market. The organizations in question engage their constituents in using e-health tools (developed, purchased, or leased by the organizations) as part of strategies to enhance services, reduce costs, or achieve other program objectives. The dissemination and marketing strategies used by such organizations may provide useful models for future efforts to widen access to and use of e-health tools.
Diverse Interests and Stakeholders
The following sketches illustrate the variety of settings in which consumers encounter and use e-health tools, the factors influencing their e-health practices, and the range of e-health functions available. These characters are fictitious and in many ways idealized because many tools in the market do not have the multifunctionality, interoperability, reliability, and quality of the tools described below. The sketches are useful, however, to illustrate key points about e-health activities and the many purposes they could serve for funders, suppliers, intermediaries, and end users. The hypothetical value propositions involved are summarized in Table 4.
As these sketches illustrate, individuals, groups, and organizations have a broad range of interests related to consumer e-health. Healthcare organizations and health plans are major drivers. A growing number of them, and especially large health plans, offer their enrollees portals that afford access to electronic health records, communication, and administrative functions within the institution as well as ancillary health management functions. For these organizations, patient portals can be both an attractive member benefit and a means of reducing administrative costs.
Some healthcare organizations and purchasers offer their enrollees disease management tools to improve care and possibly reduce costs. Disease management tools are an important facet of the Chronic Care Improvement Program of the Centers for Medicare & Medicaid Services (CMS), which will be responsible for nearly half of all healthcare spending by 2014 (Heffler, Smith, Keehan, et al., 2005). CMS also is pilot-testing the Medicare Beneficiary Portal, an example of the kind of portal being offered to enrollees with information on health benefits, clinical content, and clinical transactions. If the CMS pilot is successful, the number and diversity of Americans with access to such portals will increase significantly.
The above sketches also illustrate that healthcare providers and purchasers are not the only public- and private-sector stakeholders in the e-health arena. For example, some large employers offer employees e-health tools as part of strategies to control healthcare costs and enhance employee health. Local, state, and national public health programs offer online prevention and behavior change programs and resources. Some schools encourage students to use e-health tools to help them deal with behavioral and health problems.
Table 4 summarizes the types of stakeholders in the e-health market and some of the interests motivating them. Nonconsumer stakeholders are particularly important for strategies to extend the reach and impact of e-health tools. Alliances and strategies formed around the vision articulated in the Preface should recognize the value propositions for every participant. It is possible that the relative benefits will vary for different stakeholders under different conditions. For example, the potential public health benefits may justify Government investment in e-health tool research, development, and dissemination for underserved populations even if an uncertain return on investment makes commercial interests reluctant to take the risk.
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