An Evidence-Based Approach

Introduction: Evaluation of IHC

Consumers & IHC Evaluation

Developers & IHC Evaluation

Policy Issues Relevant to IHC

Health Care Providers, Purchasers & IHC

SciPICH Final Report

Wired for Health and Well-Being: The Emergence of Interactive Health Communication

Editors: Thomas R. Eng, David H. Gustafson

Suggested Citation: Science Panel on Interactive Communication and Health. Wired for Health and Well-Being: the Emergence of Interactive Health Communication.  Washington, DC: US Department of Health and Human Services, US Government Printing Office, April 1999.

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Interactive Health Communication

The variety and sophistication of IHC applications have increased dramatically during the last decade as a result of advances in multimedia technology and new communication channels such as the Internet. Indeed, the substantial increase in the number and sophistication of applications available on the World Wide Web just during the period that this Panel has met is a prime example of the dynamic nature of these technologies.

IHC applications are available on a wide variety of health topics and can focus on a single health condition or target a group of conditions. These programs range from applications designed to convey limited health information to complex clinical decision-support tools and modules that are designed to influence health behaviors. The degree of user interactivity can be limited and short-term (e.g., selecting an option to obtain specific health information) or involve a series of complicated interactions over a prolonged period of time (e.g., monitoring and managing a chronic health condition, shared decisionmaking applications). Applications can be developed using one medium (text) or multimedia techniques (combination of text, sound, and still graphics and video). In addition, systems-development costs can range from minimal costs to millions of dollars depending on complexity (GAO, 1996). There are also a plethora of vehicles and media for disseminating IHC applications. These include stand-alone or locally networked computers, the Internet (accessed through computers, kiosks, TV, or other electronic devices), dial-in services, cable, satellite and other wireless modes, and CD-ROM and DVD and other information storage and delivery technologies.

Whereas most health communication materials and programs were developed and sponsored primarily by government agencies and nonprofit health-related organizations in the past, there are now a growing variety of entities and individuals that are developing, sponsoring, disseminating, and using IHC applications. These include: individuals, families, and communities; information technology corporations (e.g., hardware, software, Internet, telecommunication, and mass media companies); employers and other purchasers of health services; the health care industry (e.g., managed care organizations and other health plans, pharmaceutical and other health care product companies); government agencies and public policymakers; health care professionals and professional societies; academic health centers and institutions; biomedical researchers; private nonprofit health-related organizations; schools; publishers; venture capitalists and investors; and commercial advertisers. A growing number of Internet companies, many of which have substantial financial backing from large corporations, have been specifically created to develop and market applications including "e-commerce" companies that sell health-related products and health "portals" that seek to attract users searching for health information and support (Fitzgibbons and Lee, 1999). A substantial number of developers, however, are nonprofit entities. Volunteers often run online peer support groups, one of the most commonly used IHC applications.

The background and training of developers in the health and communication sciences vary widely. Some developers may employ a large team of professionals with extensive experience and training in appropriate areas; other developers may be individuals without such credentials. Although many stakeholders are involved in application development, applications produced by large technology corporations and start-up companies, the health care industry, well-known private nonprofit health-related organizations, academic institutions, and government agencies are most likely to reach the largest number of users. Because of the global reach of many Internet-based applications, programs developed in one country may have implications for other nations. In addition, as application development tools become easier to use and the Internet becomes more pervasive, the number of individuals who develop health-related applications may increase. Currently, data about the frequency to which IHC applications are evaluated for effectiveness are not available; however, anecdotal information suggests that such evaluations are uncommon.

IHC applications use technology to further the general goals of health communication—inform, influence, and motivate individuals, populations, or organizations on health-related issues (NCI, 1989). Although many applications focus exclusively on one function, an increasing number of applications encompass multiple functions. The range of specific functions of IHC applications include the following:

1. Relay information. These are applications that provide general or individualized health information on demand. Examples include Web sites, online services, and telephone-based applications that use interactive voice response and fax-back technology (Buhle et al., 1994; Wingerson et al., 1997).
2. Enable informed decisionmaking. These applications facilitate the health decisionmaking process of individuals and/or communication between health care providers and individuals (including consumers, patients, family members, caregivers, and others) regarding the prevention, diagnosis, or management of a health condition (OTA, 1995; AHCPR, 1997). Some applications assist individuals with health care decisions, such as selecting a health care professional, health plan, or nursing home (Meyer, 1996; Firshein, 1997). More sophisticated applications assist individuals in evaluating and selecting options that are consistent with desired health outcomes (Barry et al., 1995; Wennberg, 1995; AHCPR, 1997; Gustafson, Hawkins et al., 1999).
3. Promote healthy behaviors. These applications promote the adoption and maintenance of positive health behaviors on both an individual and community level. Some applications promote healthy habits by providing wellness information and explaining associated benefits and costs. Applications also include risk-assessment and health promotion modules typically based on theories of behavior change (Robinson, 1989; Skinner et al., 1993; Campbell et al., 1994; Strecher et al., 1994; Krishna et al., 1997).
4. Promote peer information exchange and emotional support. These applications represent some of the most common health-related uses of the Internet (Ferguson, 1996; Scolamiero, 1997) and enable individuals with specific health conditions, needs, or perspectives to communicate with each other, share information, and provide and receive peer and emotional support (Gustafson et al., 1992; Gleason, 1995; Bluming and Mittelman, 1996; Feenberg et al., 1996; Weinberg et al., 1996; Fernsler and Manchester, 1997; Peters and Sikorski, 1997). Online support groups exist for almost any health condition or health-related need (White and Madara, 1998). Participants in such support networks include consumers, patients, health professionals, and family caregivers (Brennan et al., 1995; Ferguson, 1996).
5. Promote self-care. These applications may either help users manage health problems without direct intervention from a health care professional or supplement existing health services by facilitating remote health monitoring and care (Robinson, 1989; Ferguson, 1997; Shah et al., 1998). Some users may have limited access to a health care professional or seek information on therapies that may not be available from their health care provider.
6. Manage demand for health services. These applications provide specific information, tools, and other resources to support wellness, self-care, and self-efficacy, to enhance utilization of effective health care services and reduce use of unnecessary services (Robinson, 1989; Fries et al., 1993; Vickery, 1995). They are increasingly being used by health plans and employers to manage health care costs (Mullich, 1997). Examples include computer-assisted telephone advice systems, interactive voice response systems, clinician-patient e-mail, and other electronic consultations with health professionals (Balas et al., 1997; Kane and Zands, 1998).

The above functions also may extend the reach of clinical practice and enhance productivity by increasing patient access to clinician-approved health information without additional office visits. A continuum of clinician-patient contact may be established ranging from face-to-face visits to autonomous information delivery and/or exchange. In addition, reducing unnecessary or trivial visits may increase clinician satisfaction (Mechanic, 1970) and reduce health care costs.

It is likely that consumers will increasingly use the Internet and other networked technologies to conduct health care-related transactions to schedule appointments, fill prescriptions, enroll in health plans, choose providers, and purchase health-related products. Some health plans are already providing such access to improve efficiency and service. These functions are outside of the Panel’s definition of IHC, but they may be bundled or integrated with the IHC functions described above.

Many environmental factors may influence the adoption and use of IHC applications. Understanding the role these factors play in promoting or hindering adoption and implementation of IHC is critical to the identification of strategies that promote use of quality applications. Factors that promote adoption of IHC include:

1. Increasing telecommunication and computing capacity. The exponential increase in telecommunication and computing capacity during the 1990s in terms of data transmission speed, bandwidth capacity, computer processing power and software design, information storage capability, and transmission options (e.g., phone line, cable, wireless) have greatly spurred the development of IHC applications. Advances in software authoring tools and increasing knowledge about how to design more intuitive IHC applications also have played an important role. Without these recent technological advances—in tandem with decreasing costs—it would be virtually impossible to deliver multimedia applications in an effective manner. In particular, the rise of global communication networks, such as the Internet, has presented an enormous opportunity to distribute such applications widely and inexpensively, and link and build upon multiple applications.
2. Increasing computer literacy and access. The exponential increase in computer literacy and public access to personal computers and the Internet are major factors for the increasing popularity of IHC applications. Computer literacy among Americans will continue to rise as increasing numbers of people have access to computers at work, at home, or in public access points.
3. Increasing consumer demand for health information and shared decisionmaking. Consumer demand for health information is substantial and increasing (GAO, 1996). For example, telephone inquiries to the HHS-sponsored clearinghouses increased an average of 209 percent from 1990 through 1994 (McGinnis et al., 1995). Surveys show that most Americans place a high value on access to health information (Deering, 1996), and that searching for health information is one of the most popular reasons for using the Internet (FIND/SVP, 1997). The nature of public inquiries to government-sponsored information clearinghouses seems to have shifted from primarily questions about general wellness and healthy lifestyles in the 1980s to requests for information on diagnosis and treatment of specific diseases and health conditions in the 1990s (McGinnis et al., 1995). Major reasons for the increased demand for health information and shared decisionmaking (HCI, 1994) include: 1) growing recognition of the complexity of medical decisions and that health choices may depend as much or more on patient preferences as on medical science;¹ 2) increasing concern about the effect of financial incentives on clinical decisions and increasing distrust of health care institutions, which may lead people to seek independent information and second opinions; 3) rising interest in "self-care" where people seek to prevent, diagnose, and treat health problems with no or limited intervention from traditional health care professionals; 4) the "aging of America," which has resulted in a growing number of persons with chronic health conditions and/or their caregivers—both of whom have substantial health information and support needs; 5) growing interest in alternative approaches to established health care remedies (Eisenberg et al., 1998); and 6) increasing investment of the pharmaceutical and other health care companies in direct-to-consumer communication about medications and other health interventions (Jupiter Communications, 1998).
4. Increasing emphasis on primary and secondary prevention. Because many health conditions do not have effective therapies, clinicians and health officials are recognizing the pivotal role of primary prevention (USPSTF, 1996). IHC applications can be used in prevention programs to promote healthy lifestyles, encourage positive behavior change, and facilitate delivery of preventive health services. There also is an increasing emphasis on prevention-related quality indicators [e.g., the Health Plan Employer Data and Information Set (HEDIS) of the National Committee for Quality Assurance]. IHC may be a mechanism to move these forward.
5. Increasing trend to reduce cost of health care services. The national trend towards managed care reflects efforts to improve the coordination of health services and to reduce the cost of health care. A recent study estimates that US health care expenditures will almost double from $1.1 trillion in 1998 to $2.1 trillion in 2007 (Smith et al., 1998). Some health plans, including managed care organizations, may be likely to implement preventive health applications because they have the infrastructure to employ these technologies. Some have a strong focus on preventive health and a financial incentive to use potentially cost-saving technologies.

Barriers to the widespread adoption of IHC include:

1. Health care provider resistance. Some health care professionals may not be supportive of IHC applications because use of this technology may be perceived as a threat to professional autonomy and authority. With increasing access to specialized health information and expert knowledge systems, health professionals may be perceived as only one of many legitimate sources of information. Some believe that cost-conscious managers may use IHC applications to supplant rather than complement clinician interactions with patients. In addition, some providers are concerned about potential, professional liability issues associated with adopting IHC applications.
2. Lack of financial incentives to change behavior. The lack of financial incentives for health care providers to support or adopt IHC applications adds to provider resistance. Without reimbursement for IHC-related services from health plans and other payers, it is difficult to motivate behavior change. In addition, existing capital investments by some health organizations in information systems and applications that do not support or integrate well with new applications are substantial disincentives to implementing new programs.
3. Lack of access to infrastructure and inability to utilize applications. Residents of rural areas, inner cities, and lower socioeconomic status neighborhoods tend to have less access to computer and communications infrastructure than persons in other areas (US Department of Commerce, 1995). Widespread adoption of IHC applications will be impeded as long as a substantial proportion of the population, including low-income, rural, and inner-city families; certain racial/ethnic groups; disabled persons; and the elderly, lack access to technology infrastructure or lack the ability to utilize applications because of illiteracy, language, and other factors (Eng et al., 1998).
4. Substantial implementation and maintenance costs. Implementation and maintenance costs associated with some IHC applications may be substantial in terms of investing in necessary software and hardware, training of program implementation and maintenance personnel, and support costs. IHC applications with sophisticated multimedia features, for example, may require updated computer equipment or large bandwidth capacity to run efficiently, thus requiring substantial capital to acquire or update equipment. This may be prohibitive to smaller corporations or health plans. There is also a lack of understanding of how to implement and maintain IHC applications within the context of the structure, policies, and procedures of health care institutions or larger health care systems.
5. Lack of convincing data on effectiveness. A number of studies have demonstrated a positive impact in providing the kind of information often included in IHC applications, but more data are needed to persuade skeptical decisionmakers in health plans and provider organizations. Self-care books provided to members of health maintenance organizations and to Medicare beneficiaries have been shown to reduce office visits and specialty referrals (Vickery et al., 1988). Interventions designed to help patients prepare for office visits have been shown to improve treatment outcomes for chronic diseases (Greenfield and Kaplan, 1985). In addition, computer access to support groups and decision guidance has been shown to positively impact on women with breast cancer and patients with AIDS (Gustafson et al., 1993, 1994; McTavish et al., 1994). Shared decisionmaking programs have been shown to improve health outcomes while reducing the utilization of surgery and other high-cost interventions (Barry et al., 1995; Morgan et al., 1997). For IHC to be widely adopted, additional data are needed in such areas as effectiveness and cost-effectiveness in specific populations and health care settings.

Interactive media are changing the design and delivery of health communication. Some health communication interventions using traditional media, such as radio, television, and printed text and pictures, have been effective in improving knowledge and promoting healthy behaviors (Flay, 1987; Flora et al., 1995), but emerging media may have several advantages for health communication efforts. These include:

1. Improved access to individualized health information. The interactive nature of emerging technologies allow the "tailoring" of information or support to the specific needs or characteristics of individuals or groups of users (Harris, 1995).
2. Broader choices for users. The ability to selectively combine text, audio, and visuals enables designers to employ specific media based on the purpose of the intervention and the learning styles of users (Harris, 1995). The ability to easily create multiple versions of an application means that users have a wider spectrum of products from which to choose.
3. Potential improved anonymity of users. These technologies, when used appropriately, can help protect the anonymity and privacy of people who access sensitive information by bypassing the need for people to obtain such information in public or face-to-face settings (GAO, 1996). Computer-based interfaces also can improve the quality of personal health information, such as health status, health risks, and fears and uncertainties, collected from individuals (Locke et al., 1992; Gustafson et al., 1993). This allows health professionals to better assess and manage those in need.
4. Greater access to health information and support on demand. These resources often can be used at any time and from numerous locations through the Internet (Harris, 1995; GAO, 1996).
5. Greater ability to promote interaction and social support among users and between consumers and health professionals. Through the use of networking technologies, such as e-mail and synchronous communication, barriers to direct communication among peers and between consumers and health professionals are reduced (Robinson et al., 1989; Harris, 1995; GAO, 1996; Pingree et al., 1996).
6. Enhanced ability to provide widespread dissemination and immediate updating of content or functions. Provided that technology infrastructure is established, applications can be rapidly distributed to many audiences at relatively minimal cost (GAO, 1996).

In addition, emerging technologies such as the Internet, allow users to also become developers and active participants in the information exchange process—they can glean what they wish from various sources and create and disseminate new information. Thus, these users become health communicators.

Although the potential benefits of IHC are impressive, there is the risk of harm. The proliferation of IHC applications that are available to the public raises legitimate concerns about their potential to cause harm especially among those who may not have the skills or background to evaluate the quality or relevance of IHC applications (Consumers Union, 1997; Silberg et al., 1997; The Lancet, 1997). Public use also may impact health care quality and cost, the clinician-patient relationship, and the organization of health care systems (HCI, 1994; Kassirer, 1995; Blumenthal, 1997). There has been minimal research about the potential risks associated with the widespread use of IHC, and documented cases of harm are relatively rare (Weisbord et al., 1997). Use of inappropriate or poor quality applications, however, can result in the following potential negative outcomes:

1. Inappropriate treatment or delays in care. Inaccurate or inappropriate health information and support could result in inappropriate treatment or cause delays in seeking appropriate health care (Goldwein and Benjamin, 1995; Saksena and Nickelson, 1995; Keoun, 1996b; FDA, 1997; Impicciatore et al., 1997; Scolnick, 1997; Weisbord et al., 1997). For example, misleading claims for medical products and health care fraud are endemic on the Internet (FTC, 1997), and, in at least one documented instance, resulted in use of a harmful product (Weisbord et al., 1997). People may be particularly susceptible to questionable marketing practices when they have a serious illness and are desperate for potential cures. Another possible source of inaccurate or inappropriate information is online support groups, where such information may spread rapidly before being corrected, or where the experiences of one or a few individuals are inappropriately applied to others who share the condition but may differ in other important characteristics (Bulkeley, 1995; Gray, 1998).
2. Damage to the patient-provider relationship. Inappropriate use of IHC applications can result in people losing trust in their regular health care providers and prescribed treatments and lead them to seek inappropriate care or care from questionable providers. Use of inappropriate applications can also lead to unnecessary conflicts and confrontations between consumers and health care providers (Bero and Jadad, 1997).
3. Violations of privacy and confidentiality. As the ability of IHC applications to tailor health information and support becomes increasingly utilized, more potentially sensitive personal data will be collected through applications based in workplaces, health care organizations, and public networks. Without adequate safeguards, such data and information may be shared or sold to others without the user’s knowledge or permission, or used for unintended or illegal purposes.
4. Wasted resources and delayed innovation. Unless adequate information about effectiveness and cost-effectiveness of specific IHC applications is available, ineffective or inefficient applications may be adopted leading to wasted resources and delayed innovation. As noted previously, relatively few applications have undergone scrutiny to ensure that they produce their intended effects. Lack of understanding of user needs also may contribute to development of inappropriate resources.
5. Unintended errors. As new software tools, such as "agents" (discussed later in this chapter), become available, developers will use them to create increasingly complicated programs that may employ complex algorithms transparent to the user. Many of these applications will be developed by multiple individuals who may not be aware of potential adverse interactions between application components. This may lead to instances where complex IHC applications, such as shared decision support programs, produce unintended errors that result in harm.
6. Widening the technology and health gap. As IHC applications become more pervasive and the Internet and other technologies become essential components for delivery of health information and care, those without access to these technologies may fall further behind in their ability to obtain information and care (Eng et al., 1998; Hoffman and Novak, 1998; US Department of Commerce, 1998). There are currently few initiatives that provide access to technology to underserved populations, such as low-income populations, residents in rural areas, and those with disabilities.

Many of the concerns cited also apply to more traditional communication media. The Panel believes that the emphasis on the potential for harm from IHC applications, however, is justified because new and emerging media may influence behavior and decisionmaking in ways that are more powerful than other media. For example, research shows that people put more credibility in information from computers than information from television and other media (Hawkins et al., 1987), and that some individuals, especially adolescents, often prefer to provide sensitive information to a computer rather than to a physician (Paperny et al., 1990; Lapham et al., 1991; Kinzie et al., 1993; Turner et al., 1998).

The wide availability and use of IHC applications will likely have major implications for health professionals who provide individual- and population-based health services. For clinicians, the major areas of impact are likely to include patient care, the clinician-patient relationship, and the organization of medical systems (HCI, 1994; Kassirer, 1995; OTA, 1995; Blumenthal, 1997).

The premise of clinical decision-support IHC applications is that patient care is participatory and largely patient-directed. In this model, the health professional functions as a facilitator or partner in care rather than as an authority. Although this may come naturally to some health professionals, others will need to develop new strategies of communication rooted in an understanding of their patients’ needs and preferred clinical outcomes, and an acceptance of the increasing role and responsibility of patients in decisionmaking. In addition, the use of some IHC applications, such as those that facilitate remote health monitoring and self-care, will require clinicians to take a more proactive approach in identifying health problems and care delivery. It should be noted, however, that regardless of information access, some proportion of people would prefer to relate to their provider as an authority figure rather than on an equal level. One of the challenges for clinicians will be to determine the appropriate balance between their role as an "authority" versus their role as a "partner" for any given patient.

The ability to translate, integrate, or link clinical protocols to IHC applications may impact on patient expectations and provide a powerful way to monitor quality-of-care from the patient’s perspective. It is possible that the quality of patient care may be improved by telemedicine-oriented IHC applications that assist real-time specialty consultations, increase access to information databases and continuing education opportunities, and facilitate clinical decisionmaking (Blumenthal, 1997). In addition, these technologies are beginning to have a profound impact on the training of health professionals in patient care both in terms of enabling innovative methods for teaching and developing patient communication skills (Henderson, 1995; MacKenzie and Greenes, 1997).

IHC applications that promote peer and emotional support and provide health information through nontraditional channels may be perceived by some to diminish a patient’s trust and confidence in, or dependence on, his or her clinician. Information and advice from other information sources, such as online publications reporting new research, or anecdotal sources, such as online chat groups, can be used to challenge—or "second guess"—clinicians (Keoun, 1996a). These factors, the sheer volume of biomedical information produced every day, and the increasing ease of access to health information, create an environment in which the public’s perception about authorities for health information is changing. Physicians and other traditional health professionals may come to be perceived as one of many sources of authoritative medical knowledge, and clinicians may become one of several types of professionals that individuals rely on to help solve a health problem. In some cases, patients may have greater access to information about their conditions than their health care providers.

The above challenges, however, can sometimes lead to greater rather than diminished confidence in health care providers (Gustafson, Robinson et al., 1999). Some IHC applications, such as shared decisionmaking tools and provider-patient electronic communication applications, can enhance the clinician-patient relationship by providing clinicians with valuable insights into patient needs and improving their patient communication skills (Borowitz and Wyatt, 1998). It is also possible that patient compliance with treatments may improve through increased access to information and support. In addition, a recent survey of Californians with Internet access showed that they considered information from their physicians and other health care providers to be the most useful and trustworthy of all information sources, including the Internet (NHF, 1998).

The trend to reduce health care costs will increase the demand for IHC applications that promote self-care, enable demand management of services, and supplement face-to-face interactions with electronically mediated ones. Many health plans already communicate with members through e-mail and Web sites. Deployed as tools to assist with administrative matters, such as changing an address or checking on insurance status, IHC will increasingly be used for health care-related functions, such as remote management of patients (Alemi, 1998). As this evolves, confidentiality and privacy concerns regarding the transmission of personal health information beyond the traditional medical record will be major issues.

In a fragmented health care system, IHC applications have potential to help integrate service delivery by enhancing provider communication and centralizing information resources. It is also possible that, as health care delivery increasingly relies on information technology to maximize efficiencies, smaller health plans that cannot invest as heavily on technology as the better capitalized plans will become less price competitive. On the other hand, implementing cost-effective IHC applications may allow smaller health organizations to be more competitive because they do not have large physical plants to maintain and support.

As health care delivery systems look to further reduce costs, some components of care delivery may be reassigned from relatively expensive professionals, such as physicians, to less costly providers, such as nurses and other health professionals. This may already be happening as new types of professionals such as "care managers" or "health resources specialists" who have substantial skill at finding and coordinating resources, are beginning to emerge to assist patients. The delivery of health information and education, once under the purview of physicians, may be delegated to expert "communication/information specialists," redefined health educators, or interactive systems. Even if this only occurred within a small segment of the population, the "disintermediation" of the traditional "mediators" of health care would represent a major shift in roles and responsibilities for many clinicians (Blumenthal, 1997).

The application of information technology to public health systems is likely to result in profound changes because most of the core functions of public health, such as monitoring health status, diagnosing community health problems, and evaluating personal and population-based health services, are heavily reliant on the collection, analysis, and dissemination of data and information (PHFSC, 1994). IHC applications targeted for public health professionals could facilitate communication between the health care and the public health sectors and among public health professionals themselves. This may result in improved coordination and integration between the health care and public health systems (The Medicine/Public Health Initiative, 1998), but it also raises significant concerns about data quality.

IHC applications also can improve the reach and use of public health services by increasing awareness of services and expanding community outreach. This may be a particular benefit in rural areas where distance has been a significant barrier to service delivery. If current trends in public demand for health information continue, it is likely that the general public and others will want enhanced access to health data—in terms of both disease risk and health status—on a local and national level. Currently, however, many local health departments do not have the staff, resources, or technical capacity to collect, analyze, and disseminate community health data and information (CDC, 1997; PHF, 1998). Smaller health departments, in particular, may find themselves challenged by balancing the demand for more community-tailored information with finding resources to provide and maintain it. By implementing IHC applications collaboratively, however, local health departments may improve operating efficiencies.

With improvements in the technical capacity of health departments, IHC may become a central strategy for community health education, community outreach for services, and social marketing for positive health behaviors. In fact, some health departments are already developing applications that serve these functions (ASTHO, 1998). For example, providing access to interactive tools that assess and communicate individual disease risk, and provide support for behavior change, can be important initiatives to improve community health. In addition, IHC may have a particular impact on one of the central functions of public health departments—disease surveillance and monitoring of community health indicators. In the future, "disease surveillance" may be blended into a larger system of "health surveillance," and a substantial proportion of health information and data may be generated by routine collection of data from many community settings rather than driven by reports from clinical encounters. This may lead to both more accurate community health monitoring and improved detection of disease outbreaks (O’Carroll, 1997).

Technology Trends and IHC

The technologies underlying IHC are undergoing rapid change and evolution (NAS, 1996). Developers and other stakeholders should be cognizant of how emerging technology trends may influence future applications. Pertinent trends include:

1. The ubiquitous presence of computers and the Internet in society
2. Wide availability and increasing use of computers and the Internet for personal use in the home
3. Dramatic increases in the affordability and portability of network-capable computers and other communication devices increasing justification, given their perceived benefit, for their purchase by the public
4. The emergence of the Internet and the World Wide Web as a means for public access to health information and support (Slack, 1997)
5. The convergence of IHC technologies into a common carrier (the Internet and World Wide Web) and decisions by both public and private sector organizations to support a common carrier for health information (Tifflin and Rajasingham, 1995; Agnew and Kellerman, 1996)
6. The imminent availability of a next-generation, broadband ² Internet (e.g., Internet2 and the Next Generation Internet) capable of delivering high Quality of Service (QoS) and interactive multimedia programming, including full motion video and increasingly engaging and easy-to-use interfaces (Henderson, 1995; Henderson, 1998; Shortliffe, 1998)
7. The emergence of novel methods of information access and analysis, including knowledge repositories (Haynes et al., 1997), intelligent and mobile "agents," "data mining," and "expert systems" as discussed later (Apte, 1977; Kotz et al., 1997; Maes, 1997)

The first four of these trends project an environment in which most users will have access to network-based services, and most will be capable of using them. The last three will have great impact on the kinds of distance learning applications that can be provided. This makes possible learning experiences that are more involving, effective, and efficient than before, as well as information retrieval that is extremely easy or transparent to the user. Next-generation IHC applications may be capable of delivering extraordinary learning experiences to individuals and organizations, independent of time and location.

Developers, purchasers, and policymakers can help set the direction of the application of these technologies, and derive advantage from them. This requires an understanding of the underlying technologies and how they can be applied, research on the current and future state of the infrastructure, and the actual application of technologies and tools to improve infrastructure for personal and public health.

Agents are information-processing programs that can act autonomously and adapt to a user’s needs. They are aimed at reducing "information overload" and facilitating the information-retrieval process. For example, agents can simplify interfaces by eliminating steps or choices that a user must make after several encounters with a system. Agents can facilitate use of complex databases by translating arcane database queries into user-friendly dialogs. They also can automate tedious searches for new information by performing searches in the background until new information is located and identified as potentially useful. In addition, mobile agents are programs that can migrate from machine to machine. This allows complex queries to be done at the location of a large database without downloading that database to the user’s workstation over slow channels. The particular advances that allow agents to perform such tasks are in the areas of machine learning, information retrieval, high-level scripting languages, graphical interfaces, and generic World Wide Web technology.

The rate of growth of information content on the Web, in the technical literature, and implicitly in electronic records may overwhelm people who wish to use health-related information. Through use of information retrieval and Web technology, it may be possible to build agents that can constantly monitor several databases and other repositories of information for new material pertinent to a provider’s needs and areas of expertise. When that information is identified, the agent formats it into a natural presentation and notifies the user of its availability.

By design, agents move much of the tedium and complexity of information gathering and correlation into the background so that a novice can easily begin using more powerful capabilities. Developers have already demonstrated such agents with Web "clipping" services that utilize user-friendly interfaces and e-mail systems. Furthermore, it is possible to program agents that gradually adapt to a user’s experience by creating shortcuts and anticipating actions based on prior usage. This property of agents arises from the design of the agent system by understanding the needs of users and building systems that amplify the users’ abilities without forcing new processes onto them.

The emergence of expert systems has important implications for IHC development. Potentially, for example, they could help users self-diagnose their conditions and even select from a variety of available treatment options. One powerful feature of expert systems is that they can improve themselves over time if they can collect data on the accuracy of their earlier conclusions and recommendations. Such systems have great potential for improving participation in health care and empowering consumers. They also have the potential to reduce costs-of-care by allowing, over the long term, consumers to manage their own care rather than relying on clinicians.

To date, however, expert systems have not lived up to their promise. They frequently have not been as accurate as expected in the conclusions they reach. Hence, such systems need to be very carefully evaluated in a wide variety of applications before they should be made available for such important decisions as diagnosis and treatment selection. Moreover, because they often are systems whose underlying structure changes over time, their evaluation would need to be ongoing. Even so, expert systems will likely be a fundamental component of IHC applications that enhance self-care and reduce health care costs.

It is likely that some automated tools will be built into applications to assist in the assessment of quality and maintenance of information. Because tailoring of information in automated systems may involve complex algorithms and databases can be automatically updated by agents, the ability of people to adequately evaluate these IHC applications may be compromised, and research and development on this issue are needed. This and other evaluation issues are discussed more fully in Chapter IV.

¹ Shared decisionmaking is the process in which health care professionals and patients (or other interested parties) jointly assess and decide on treatment options.
² "Broadband" refers to network bandwidth that is wide enough to carry advanced services such as high quality motion video. Quality of Service (QoS) is used here to describe the technical quality of media services, such as full motion video, of sufficient quality to support educational goals. Measures of QoS include video window size, frame rate, and the latencies between selecting a video stream and its actually starting, and synchronization between video and audio.

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Comments: SciPICH@nhic.org   Updated: 05/09/01