How the Internet Is Transforming the Physician-Patient Relationship 12/4/01
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How the Internet Is Transforming the Physician-Patient Relationship
[Medscape TechMed 1(3), 2001. © 2001 Medscape, Inc.]
James G. Anderson, PhD, Professor of Medical Sociology, Purdue
University, West Lafayette, Indiana
Introduction
The Internet is rapidly changing the doctor-patient relationship. By
providing access to medical information, online medical advice,
computer-based home-monitoring systems, and online support groups, the
Internet is making it possible for patients to assume much more
responsibility for their own health care. In doing so, however, patients
may challenge the traditional role of the physician in providing care.
At the same time, the Internet is prompting patients to ask new
questions about access to cost and quality of care information. These
issues are thoroughly covered in a soon-to-be published text by James
Anderson and Kenneth Goodman[1] and are outlined below.
Healthcare via the Internet
An estimated 52 million Americans have used the Internet to find
information about diseases, medical treatment, and the availability of
clinical trials, according to a survey by the Pew Internet and American
Life Project.[2] About 55% of the Internet users surveyed had accessed
health information, but only 9% of those who used the Internet for
health-related reasons had exchanged e-mail with their physician.
Information technology provides patients with access to health-related
information, allowing them to exert much more control over their own
health care than ever before.[3]
Patients can access medical advice directly via the Internet. One system
developed in the United Kingdom called NHS Direct provides advice on
health and medical problems both on the Web and over the telephone.[4]
In the United States, Internet-based medical services are used by an
increasing number of patients. America's doctor
(http://www.americasdoctor.com/) has contracts with more than 142
physicians who provide basic health-related advice. WebMD
(http://www.webmd.com/) provides online group discussions with medical
experts on various topics. CyberDocs (http://www.cyberdocs.com/), which
was started in 1996, offers consultation or "virtual house calls" with
board-certified physicians for $50 to $100 a session. By 1999 this
online service reported an average of 3000 online visits per day, or
about 100,000 per month.[5]
The traditional emphasis of medical informatics has been to provide
information and decision support tools to professional healthcare
providers. Currently there is an increasing emphasis on consumer
informatics. This new branch of health informatics attempts to provide
consumers -- in their role as patients -- with direct online access to
health information to help them better manage their health decisions.[6]
For example, medical HouseCall is a decision-support system for
consumers derived from Iliad, originally designed to assist physicians
in decision-making.[7] The system consists of 4 programs: symptom
analysis, medical encyclopedia, drug interaction, and medical record.
These modules were made available to consumers on a Web site. Consumers
use HouseCall to keep their own medical record to determine questions to
ask their doctor, look up medical terms in the encyclopedia, and check
on drugs, and drug interactions.
Other systems under development incorporate patient preferences for
different outcomes into the decision-making process regarding screening
and testing.[8] One such program was designed to assist men with
enlarged prostates to decide among the options of watchful waiting,
medications, and surgery. The program is available online to assist men
in considering these options and choosing a treatment based on their
individual preferences.[9] Another application uses automated computer
interviews with patients combined with multimedia presentation at the
bedside to elicit preferences regarding the treatment of deep-vein
thrombosis.[10]
Physician-Patient Conflicts
While these applications of health informatics are not designed to
replace the physician in decision making and provision of care, some
physicians question their effectiveness.[11] In 1 recent study,
Forrester Research interviewed 40 healthcare executives and 20
physicians.[12] Physicians, compared with administrators, consistently
rated the Internet as less useful in providing patient education,
purchasing products and services, obtaining medical records, and
processing insurance claims. One physician stated, "The jury's still out
on the Net's cost-effectiveness in hospitals. Doctors are people whose
time is worth a fairly substantial amount of money. Taking time from the
highly remunerative practice of medicine to spend on computers,
especially for surgeons, would have to have a fairly high ROI."
Collectively, only 9% of the respondents felt that physicians would
personally answer e-mail messages from patients. Major reasons given by
physicians for not using the Internet more actively in managing patient
care have to do with time and compensation. Specifically, physicians
indicated that they did not feel that they would be adequately
compensated for their time and effort. Also, they didn't perceive that
using the Internet would save them time or increase their productivity.
One physician who was interviewed stated: "If I have to answer 30
e-mails a day, I'll get no work done." Another commented: "Basically
e-mail is not a big winner for us... It's time-consuming, and we don't
get paid to do it."
In the face of this skepticism, however, some healthcare providers are
moving ahead with plans to incorporate the use of the Internet into the
provision of care. Kaiser Permanente is spending over $2 billion to move
all of its operations onto the Internet.[13] Kaiser is creating a
computerized patient record for its 9 million members. Also, all 361 of
its clinics and hospitals and over 100,000 physicians, nurses, and
dentists will be able to communicate with one another and with patients.
Members of the health plan can use the system to search online for
health information, obtain advice from nurses and pharmacists, request
an appointment, or join an online discussion group.
Disputes Over Access to Online Data
Consumer reports and profiles about the performance of healthcare
professionals and organizations are increasingly being made available to
the public on Web sites. Consumer advocates argue that disclosure of
performance data will help consumers to choose high-quality providers.
Opponents argue that performance ratings unfairly penalize healthcare
providers and organizations that treat high-risk patients. They argue
that surgeons may be discouraged from operating on high-risk patients.
They also argue that the public pays little attention to such ratings in
choosing a healthcare provider.
A review of the evidence of the effects of public disclosure of
performance data is mixed.[14] The only study that found an effect of
public disclosure on consumer decision making was the New York State
coronary artery bypass graft (CABG) mortality report. The study, updated
in January 2001, indicated that hospitals and physicians with better
outcomes experienced higher rates of growth in market share after the
disclosure of the performance data.
Consumer access to data on the costs of medical procedures is also in
dispute. Consumer Web sites have posted the Common Procedural
Terminology (CPT) codes and descriptions of medical procedures along
with estimated prices based on the amounts the US government reimburses
physicians for these procedures. The American Medical Association (AMA)
has responded by seeking court orders shutting down the Web sites based
on the association's claim to a proprietary right to the CPT codes. The
AMA has lobbied the US Congress in support of a bill that would prevent
public access to this information.[15]
Consumers are denied access to the National Practitioner Data Bank. This
database was created by the US Congress in 1986 and contains information
about malpractice awards, civil and criminal actions against physicians,
and licensing board decisions. Insurance companies, managed care
organizations, and state licensing boards use the data bank. Consumer
advocate groups and committee chairs of the commerce committee of the US
House of Representatives argue that patients have a right to these data.
The AMA and other professional medical groups argue that the data bank
contains mostly information about malpractice awards and payments that,
in many instances, has little to do with a practitioner's performance.
In response to calls for public disclosure, the Federation of State
Medical Boards plans to issue a report on the release of performance
information. The report will include a model for states to release
performance information on healthcare providers.[16] This action may
help to assuage the growing consumer demand for additional performance
and cost data that can be used in decisions regarding the choice of
healthcare providers.
The Challenge of the Internet
Physicians are coming to realize that the Internet and other information
technologies will change the way they practice medicine. These new
technologies permit physicians to more rapidly access medical
information and patient records and to collect data directly from
patients. Applications such as palm-based prescription writers have the
potential to reduce prescription errors. At the same time, adoption of
these technologies is slow. New applications must be easy to adopt and
use, must meet physician needs, and must be cost-effective, not just for
the healthcare organization but also for the physician.
The next generation of the Internet will allow practitioners and
consumers to access global medical knowledge bases. Linkages among
sources and databases along with intelligent software will help Internet
users find pertinent medical information.[17] Patients will increasingly
come to the physician with information from the Internet about illness
and treatment. The quality of this information, at present, is extremely
variable in terms of its reliability and completeness. Some information
may be false and can actually be harmful.[18] However, physicians can
assist patients in finding and interpreting reliable and up-to-date
information. In doing so, they will make the physician-patient
relationship more productive. Convincing physicians to take the lead in
building new relationships with their patients by using newly available
Internet technologies is just the latest challenge facing the medical
community.[19]
Sidebar - Suggested Reading
* Anderson J. CyberHealthcare: reshaping the physician-patient
relationship. MD Computing. 2001;18:21-22.
References
1. Anderson JG, Goodman KG. Ethics and Information Technology: A
Case-Based Approach to a Health Care System in Transition. New York:
Springer-Verlag; In press. Publication information available at:
http://www.springer-ny.com/detail.tpl?cart=100592677141505&ISBN=03879530
86 Accessed November 16, 2001.
2. Web users search for medical advice most often. Wall Street
Journal. November 27, 2000:B14.
3. Smith R. The future of healthcare systems. BMJ.
1997;314:1495-1496.
4. Pencheon D. NHS direct: evaluate, integrate or bust. BMJ.
1998;317:1026-1027.
5. Anderson JG. The business of cyberhealthcare. MD Computing.
1999;16: 23-25.
6. Eysenbach G. Consumer health informatics. BMJ.
2000;320:1713-1716.
7. Bouhaddon O, Lambert JG, Miller S. Consumer health informatics:
knowledge engineering and evaluation studies of Medical HouseCall. Proc
AMIA Symp. 1998;612-616.
8. Brennan PF, Strombom I. Improving health care by understanding
patient preferences: the role of computer technology. J Am Med Inform
Assoc. 1998;5:257-262.
9. Barry MJ, Fowler FJ, Mulley AG, Henderson JV, Wennberg JE.
Patient reactions to a program designed to facilitate patient
participation in treatment decisions for benign prostatic hyperplasia.
Med Care. 1995;33:772-773.
10. Lenert LA, Soetikno RM. Automated computer interviews to elicit
utilities: Potential application in the treatment of deep venous
thrombosis. J Am Med Inform Assoc. 1997;4:449-456.
11. United States General Accounting Office. Consumer health
informatics: Emerging issues. Washington DC: US Government Printing
Office; 1996. Publication No.T-AIMD-96-134.
12. Barrett MJ. Why doctors hate the net. The Forrester Report.
March 2000.
13. Kaiser Permanente online connects Web-based information to care
delivery. Internet Healthcare Strategies. 1999;1:6-8.
14. Marshall MN, Shekelle, PG, Leatherman, S, Brook RH. The public
release of performance data: What do we expect to gain? A review of the
evidence. JAMA. 2000;283:1866-1874.
15. Carrns A. AMA Fights for control over doctor-price data web
sites are providing. Wall Street Journal. August 25, 2000: A1.
16. Keep data bank access limited. American Medical News. April 3,
2000.
17. Eysenbach G, Sa ER, Diepgen TL. Shopping around the Internet
today and tomorrow: Towards the millennium of cybermedicine. BMJ.
1999;319:1294.
18. Stolberg SJ. Trade agency finds Web slippery with snake oil. New
York Times. June 25, 1999: A16.
19. Shepperd S, Chatrnock D, Gann B. Helping patients access high
quality health information. BMJ. 1999;319:764-766.
Dr. Anderson is a Professor of Medical Sociology at Purdue University.
He has co-authored 3 books on the social impact of medical informatics
applications. He is the past Chair of the Ethical, Legal, and Social
Issues Working Group and the Chair-Elect of the Quality Improvement
Working Group of the American Medical Informatics Association (AMIA).
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