Communications of the ACM
Communications of the ACM
Asynchronous Health Care Communication
Telemedicine and e-health both depend on communication technologies. Telemedicine is an established field that uses telecommunications to facilitate consultations between health care providers and remote patients and between specialists and primary care providers [6]. Telemedicine is championed by health care professionals seeking more efficient and equitable allocation of medical resources. However, the field serves relatively few patients today, its growth hindered by the high cost of specialized equipment, difficulty coordinating interstate professional licensing, lack of third-party reimbursement, and liability issues [8].
E-health is a relatively new field that uses the Internet to deliver access to health care information and services and has been led primarily by entrepreneurs from outside the health professions [6]. While e-health promises to deliver content, commerce, connectivity, and clinical care, most e-health Web sites limit themselves to content and commerce [5]. General health content has attracted millions of visitors to e-health Web sites, helping them be more knowledgeable health care consumers while raising their expectations regarding health care services [3]. Commercial profit has proved elusive, however, and the field has contracted in recent years [5].
Telemedicine and e-health may both be on the verge of dramatic new growth arising from an unplanned sourceonline communication. Doctors, nurses, therapists, and other health care providers are under increasing pressure to use email and Web-based applications for interpersonal communication with their patients. While these providers are clearly experienced in using information technology (IT) for transaction processing, records management, scheduling, and intra-office communication, the idea of using IT to communicate with patients has been slow to develop. Increasing patient demand and a changing health care market now make it likely that Internet-based communication between providers and patients could soon be an everyday part of health care throughout the Internet-connected world.
The term asynchronous health care communication (AHCC) describes interpersonal, computer-mediated communication (CMC) between providers and their patients for telemedicine and e-health functions. Basic AHCC can be implemented using general-purpose CMC software, including email and Web-based chat and discussion forums. However, communications related to health care involve sensitive and specialized topics, legal confidentiality, and a formalized relationship between provider and patient, all of which place special requirements on communication and make it likely that specialized AHCC applications will emerge in preference to off-the-shelf software. Because the health professions are so large and diverse, integrated AHCC systems could represent a lucrative new market for technology products. Thus, it is important even at this early stage to begin to view AHCC as its own topic area with potentials, priorities, and idiosyncrasies setting it apart from existing forms of CMC.
Proponents of both telemedicine and e-health claim these fields encompass interpersonal communication, though neither field has promoted AHCC. Although telemedicine can be conducted via media "as simple as telephones and fax machines or as complex as PCs and full-motion interactive multimedia" [4], it relies primarily on interactive video [6]. Telemedicine today is moving to video delivered via the Internet, an environment where even basic AHCC provides value by augmenting video consultations with asynchronous messaging, including follow-up questions and reminders.
E-health promises connectivity and clinical care as core capabilities [6]. Certain community-service e-health Web sites provide both features [10], but few for-profit e-health Web sites promote freely accessible communication between users and clinical personnel, and many fall short of providing useful connectivity among users. AHCC encompasses technologies and procedures that deliver aspects of connectivity and clinical care currently missing in many e-health offerings.
AHCC adds value to telemedicine and e-health and could drive growth in both fields. Telemedicine's growth has been slow, and focusing on interactive video technology has restrained the field from integrating AHCC. Meanwhile, E-health's growth has been explosive and uncoordinated, and a scramble for market share has resulted in the oversupply of general health care content but relatively little connectivity or clinical care. Thus, neither field offers much empirical knowledge about the role AHCC might play in future growth.
The idea that AHCC will drive the growth of telemedicine and e-health worldwide has precedent in the root causes of the Internet's growth in the 1990s. At that time, attention centered on the role of graphical Web browsers and Web content in driving Internet expansion. However, much of the growth actually stemmed from the public's desire to communicate using text-based email. Circumstances now set the stage for similar communication-led growth in telemedicine and e-health.
Perspectives on AHCC
Communication between providers and their patients has numerous benefits. It increases patients' satisfaction with those providers and compliance with therapeutic regimens [8], and it reduces patient stress and the risk of malpractice claims against providers [7]. AHCC offers a new avenue to increase communication that simultaneously introduces new risks and pitfalls. Not surprisingly, providers, patients, and the health care market offer conflicting perspectives concerning AHCC.
Provider. Relatively few mainstream providers emphasize AHC in their operations, but several indicators suggest this could change quickly. In a 2001 study of three large hospitals in the U.K.'s West Midlands [2], researchers reported 65% of responding physicians use email, with significantly more usage by younger physicians. Of email users in the study, 93% use it to communicate with friends but only 7% to transmit clinical data and 3% to communicate with patients. Despite infrequent use of email in their current work, 90% of the responding physicians felt they would be using email for work-related purposes within five years.
Communication increases patients' satisfaction with their providers and compliance with therapeutic regimens, and it reduces patient stress and the risk of malpractice claims against providers.
AHCC has made inroads in certain health care niches where patients are assured of being Internet-connected. A 2000 study of 88 collegiate centers in the U.S. [9] found almost 67% used some form of electronic communication with their student patients. Among responding centers, 64% used email to provide administrative advice, 27% to give medical advice, and 15% to forward laboratory results. Approximately 60% were planning or considering more AHCC in their operations for providing medical advice, administering surveys, and handling insurance claims.
Although providers expect to use more AHCC in the future, concerns have been raised in the health care research literature:
- Not sufficiently confidential. Over 60% of hospital physicians in the West Midlands study felt email is not secure enough to use in transferring patient data [2].
- More liability for providers. Providers are concerned that AHCC exposes them to new medico-legal liabilities (such as for failing to meet licensing requirements and for medical negligence [1]). Legislators and regulators lag in developing legal structures to support related risk management [7].
- No standard policies and procedures. Even among U.S. collegiate health centers using AHCC, 88% reported no formal policy covering electronic communication with patients [9].
- Increased demand on time. Providers are concerned about message volume and the time demand of communicating electronically [9].
- No immediacy. CMC media do not provide the immediacy of feedback available in face-to-face and telephone conversations [9] or the immediacy of message delivery necessary to support urgent communication [7].
- Dehumanized health care. It may be inappropriate to use AHCC for certain communications (such as to report abnormal test results or to deliver bad medical news) [7].
Despite these concerns, providers recognize the need to improve communication with their patients. Competitive pressure and managed care practices have reduced physician office visits to 15 minutes or less on average, and virtually all communication with patients takes place during these brief events [3]. Providers may wish to "wait until more empirical studies demonstrate the viability of email" [6], but pressure is mounting to make AHCC available quickly.
Patient. A 2000 survey of 1,000 online health care consumers in the U.S. [3] found strong demand by patients for new Internet and other technology-supported services to improve the health care-communication process (see the figure here). Key findings include the following:
Inadequacy of office visit arrangements. Patients are especially frustrated by forgetting to ask questions during office visits, having to make later appointments to have simple questions answered, and difficulty getting through to providers by phone.
Patients educated about health care options. Over 75% say they have searched the Internet for health care information; 39% search at least once a month.
Patients want physicians online. Almost 67% say they would use email to communicate with their physicians, and 84% want to receive email alerts based on their medical histories, including reminders for annual checkups and flu shots.
Patients want a combination of technology and personal service. While providers worry about being supplanted by Internet-based advice, patients make it clear they want online access to augment rather than replace in-person and telephone communication with their providers.
These results indicate AHCC has strong appeal to online health consumers, though it is difficult to predict from an opinion survey the level of actual use that would occur if AHCC systems were widely available or how important AHCC might prove in contrast with other online features providers might offer.
Providers may have doubts about implementing AHCC, but pressure by patients and changes in the health care market toward patient cost-sharing appear destined to force the issue.
A 1999 study of the Internet-based ComputerLink community health information network (CHIN) developed at Case Western Reserve University in Cleveland sheds light on these issues [10]. ComputerLink provides an online medical encyclopedia, a sophisticated, interactive decision-support utility, email communication with a nurse-moderator, and an electronic bulletin board primarily for caregivers to Alzheimer's patients. Monitoring over an 18-month period revealed the following scope of system use: 61% communicate via electronic bulletin board; 24% email to the nurse-moderator; 9% encyclopedia; and 6% decision support. The authors observed that users "put little emphasis on ComputerLink's decision-support functionality, focusing more on email and bulletin-board services" [10]. These results reinforce opinion-survey findings and suggest AHCC will be used frequently when it becomes available.
Market Perspective
During the past decade, managed care has proliferated throughout the U.S. health care market as "an effort by employers, the insurance industry, and some elements of the medical profession to establish priorities and decide who gets what from the health care system" [12]. Today, this market is in turmoil due to two key failures of managed care: First, the practice of offering comprehensive benefits while restricting care via constrained formulas and utilization reviews has resulted in a political backlash against managed care [12]. And second, anticipated improvement in efficiency and economy through better coordination and management practices have not materialized [5]. As a result, insurers have begun to retreat from managed care toward fee-for-service arrangements in which the insured have a stake in keeping costs down [12].
The consequence of this change is to increase incentives for insured patients to be more involved in their own health care. "Each of the four key Internet health sectors, including content, commerce, connectivity, and care, accelerates the move away from managed care and toward a health care system based on individual choice ... Patients increasingly arrive in their physicians' offices armed with printouts, citations, etiological theories, referral requests, and suggested interventions. Most important, the Internet stokes the culture of individual choice, the sentiment that each person is responsible for managing his or her own health ..." [12].
Insured patients in the emerging health care market are obliged to share more of the costs of treatment and have greater incentive to find providers that accommodate their personal needs. These patients apply market pressure that couldn't arise under managed care. Although providers lag in offering online services, including AHCC [2], a new culture of health care consumerism could motivate rapid changes [12].
Providers may have doubts about implementing AHCC, but pressure by patients and changes in the health care market toward patient cost-sharing appear destined to force the issue. Effective AHCC will give telemedicine greater reach and support the connectivity and clinical care goals of e-health. Both fields promise to improve quality of life for large cross sections of society, making AHCC development an important social issue. Some obstacles to AHCC can be overcome only through social, political, and organizational changes. It will take time for medico-legal case history specific to AHCC to develop and for generally accepted policies and procedures governing AHCC to emerge. But many obstacles are technical in nature, so we must begin to plan their solutions in designing and developing future AHCC systems.
Systems of the Future
Email, online chat, and discussion forums are being adopted as basic AHCC systems [6]. These general-purpose CMC applications were not designed or intended to support many AHCC functions desired by patients (such as accessing results of lab tests, paying for medical services, making appointments, and viewing progress charts) [3] and by providers (such as conducting telemedicine consultations, routing appointment questions to front-desk personnel, and routing prescription-refill requests to the practice nurse) [7]. Even so, basic AHCC systems are proving successful in certain settings and include features worth keeping or expanding in future designs:
Standardization and client ubiquity. Application standards, including SMTP and HTTP, ensure portability of email and Web-based messages across computing platforms. Client software that is inexpensive and widely available has made it possible to access and send messages from virtually any Internet-connected computer. Providing client-side access that is both standardized and ubiquitous is essential to the success of AHCC. This requirement cautions against basing future solutions on proprietary client software.
Simple operation. Basic AHCC systems require little start-up training or ongoing guidance for successful use. Even after being away from their computers, people still retain sufficient skill to resume communicating using email and Web-based media. Future systems should continue to emphasize simplicity of operation.
Self-documentation. Basic AHCC systems typically automate message storage, so documentation is readily retrieved for review or audit; this function is essential in AHCC applications [7].
Message security. A variety of encryption and authentication methodologies have emerged for email, including secure multipurpose Internet mail extensions (S/MIME), and Internet applications, including secure sockets layer (SSL), secure HTTP (S-HTTP), and secure electronic transactions (SET). These methodologies handle billions of dollars of Internet transactions worldwide annually; they can support confidential AHCC in conformance with federal regulations governing the protection of health-related information [11]. AHCC can overcome doubts concerning message confidentiality by emulating Internet-based financial systems that implement central security management, mandatory application of security protocols, and simple user interfaces for client log-in authentication.
Development Directions
AHCC needs to incorporate several new functions that are not supported well by general-purpose CMC software; the following clearly need attention:
Enhanced communication channels. AHCC's text-based roots should not deter designers from incorporating other communication channels appropriate to the situation, including Internet-delivered interactive video for telemedicine consultations.
More immediacy. Email can be used to notify recipients that new messages have arrived and confirm to senders that messages have been opened, but both features depend on software implementation and application settings. One way to improve immediacy is to integrate other communication media with AHCC (such as automated telephone services delivered through VoiceXML). A combination of online and telephone services can notify patients of new messages, authenticate message recipients, confirm message receipt, and deliver message content to patients using the medium that best fits each patient's circumstances.
Automatically assisted patient communication. System automation can and should assist patients by filling in standard information for them, listing current prescriptions, and providing a history of their office visits. Instead of relying exclusively on open-ended messaging, patients should be prompted to choose the type of contact they wish to make and then be guided to supply the specific information needed to complete it. Most patients are not interested in being pen pals with their providers and would welcome assistance and guidance in achieving results.
Streamlined graphics delivery and online annotation. AHCC designers should make it easy to incorporate graphics (such as radiology images) specific to the clinical setting. Equally important is providing easy-to-use tools for patients, as well as providers, to annotate graphics and message text. The ability to quickly add emphasis by underlining or drawing lines around key points and clarifying content with notes in the margins is as essential in AHCC as in conventional written communication.
E-health links. E-health has been relatively successful as a source of general health information, but patients express concern about the quality, accuracy, and personal relevance of that information [6]. Providers should be able to use AHCC to link their patients to appropriate e-health content.
Management tools. AHCC should automate triage and routing of messages, reply scheduling, auditing, and numerous other system management activities to support system management by AHCC professionals, improve service to patients, and reduce the load on providers.
Integrated with other health care IT. Combining AHCC with the business IT of providers, insurers, and employer benefits offices would give patients one-stop access and control of their own health care records, scheduling, and finances.
Conclusion
As consumer-oriented and technology-savvy patients converge on the changing health care market, AHCC emerges as a strong growth driver for both telemedicine and e-health. Though AHCC implementation will occur primarily in the health professions, technology designers and developers should also be aware of the trend. It seems clear that future AHCC needs will not be met by existing communication technologies, and innovation in this area could spur a substantial new market for technology products and important benefits for society as a whole.
References
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