How the Internet Is Transforming the Physician-Patient Relationship-->medline

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How the Internet Is Transforming the Physician-Patient Relationship



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 has contracts with more than 142 physicians who provide basic health-related advice. WebMD provides online group discussions with medical experts on various topics. CyberDocs , 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

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. cart=100592677141505&ISBN=0387953086 Accessed November 16, 2001.

Wall Street Journal. November 27, 2000:B14.

Smith R. The future of healthcare systems. BMJ. 1997;314:1495-1496.

Pencheon D. NHS direct: evaluate, integrate or bust. BMJ. 1998;317:1026-1027.

Anderson JG. The business of cyberhealthcare. MD Computing. 1999;16: 23-25.

Eysenbach G. Consumer health informatics. BMJ. 2000;320:1713-1716.

Bouhaddon O, Lambert JG, Miller S. Consumer health informatics: knowledge engineering and evaluation studies of Medical HouseCall. Proc AMIA Symp. 1998;612-616.

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.

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.

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.

United States General Accounting Office. Consumer health informatics: Emerging issues. Washington DC: US Government Printing Office; 1996. Publication No.T-AIMD-96-134.

Barrett MJ. Why doctors hate the net. The Forrester Report. March 2000.

Kaiser Permanente online connects Web-based information to care delivery. Internet Healthcare Strategies. 1999;1:6-8.

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.

Carrns A. AMA Fights for control over doctor-price data web sites are providing. Wall Street Journal. August 25, 2000: A1.

Keep data bank access limited. American Medical News. April 3, 2000.

Eysenbach G, Sa ER, Diepgen TL. Shopping around the Internet today and tomorrow: Towards the millennium of cybermedicine. BMJ. 1999;319:1294.

Stolberg SJ. Trade agency finds Web slippery with snake oil. New York Times. June 25, 1999: A16.

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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