The Internet is changing the doctor-patient relationship as it provides patients with the potential to make better health decisions via easy access to vast amounts of health information. In the present study, we attempted to investigate the interest in and experience with using the Internet for a variety of health-related activities among a group of primary care patients in Rhode Island. The main findings were that great gaps exist between the health-related activities patients are currently doing on the Internet and the activities they would like to be doing.
For 4 of the 14 Internet health-related activities in the questionnaire, there was an opportunity gap (see definition in Data Analysis section of Methods) of greater than 30%. Three of the 4 health-related activities with the largest opportunity gap were related either directly or indirectly to health care quality, including using the Internet to: (1) "find out if your health care provider was giving you all of the tests or treatments that you are due to have?", (2) find out how the quality of care your doctor provides compares to other doctors?", and (3) "find out what questions you should ask your doctors when you see them?" Another area of opportunity focused on the ability of the Internet to perform administrative functions, including appointment scheduling and creating an online chart. Increasing transparency in quality of care has become a major policy issue, as highlighted in the recent Institute of Medicine report, Crossing the Quality Chasm [18
Based on our survey, the Internet is meeting the needs of primary care patients for information about diseases and medications, because for each of these activities the majority of patients were interested and the opportunity gap was small. With regards to e-mail, fewer patients in our survey with Internet access were interested in e-mailing their health care providers than noted by Sittig and colleagues (32% vs 65%, respectively) [11
]. This difference is most likely due to response bias in the study by Sitttig and colleagues, which reported data on a survey e-mailed to registered users of http://www.webmd.com/
, which had aresponse rate of only 15.9%.
Web sites designed to enable patients to learn about the quality of care they are receiving and the questions they should be asking during doctor visits currently do exist, but are relatively uncommon. Two sites in particular, http://www.doctorquality.com/
,allow patients to rate health care providers and facilities, but currently have limited functionality due to the lack of high-quality data upon which to base information. On the other hand, many Web sites have suggested questions that patients should ask their doctor (eg, http://www.niddk.nih.gov/health/diabetes/pubs/bldsgr/bldsgr.htm
).Patients may not know these sites or may not perceive them to be useful. Future studies will be necessary to understand how best to either (1) develop Internet resources to address these unmet needs or (2) make the Web sites that meet these needs more available or known to online health seekers.
Another area of potential development focused on the ability of the Internet to perform administrative functions, including appointment scheduling and creating an online chart. Although some patients may have used e-mail with their provider to perform administrative functions [9
], use of this technology is not widespread and is not well integrated into the triage and traditional workflow of clinical care. New programming standards, including Extensible Markup Language (XML), that increase the flexibility of the Internet for use as a data warehouse may accelerate the development of these applications [22
]. Electronic medication-refill requests integrated with physician decision support systems could potentially reduce errors and be cost-effective [23
]. Thus, this Internet-based administration of health care may be desirable to both health care consumers and payers.
If the history of the Internet has been a teacher, then the findings in our survey have great implications for health care providers, insurers, and hospitals. Content on the Internet has generally tracked consumer demand because the two most common ways that Web sites are funded is either by advertising revenue or by subscriptions. Our study suggests that patients want to start to use the Internet not only as a source of information about conditions and medications, but also as a way to inform their health care decisions. Half of our respondents were interested in using the Internet to find out about the quality of care their doctor provides and several Web sites are currently being developed specifically for this purpose (eg, http://www.doctorquality.com/www/
).Should history prove correct, that the Internet evolves to deliver what consumers desire, our data suggest that consumers may have the greatest potential as a driver of improving health care quality.
The study, however, has several noteworthy limitations:
- First, our survey did not measure every current health-related activity available on the Internet, because we based questions on the responses of our focus group participants and on the knowledge of the investigators. For example, support groups and health risk appraisal sites (eg, http://www.realage.com/, http://www.yourcancerrisk.harvard.edu/, http://chess.chsra.wisc.edu/Chess/)are common on the Internet [24-28], but our survey did not measure the use or interest in these online health-related activities.
- Second, our measurement of the opportunity gap for online health-related activities was intuitive but somewhat arbitrary. For example, we did not measure the degree to which patients' perceived needs were met by each online health-related activity. Diaz and colleagues reported, however, that health information on the Internet was generally perceived as quite useful, ranked second only to health information from a physician or nurse . Also, though the opportunity gap for lifestyle modification over the Internet was small, few sites that offer personally tailored information exist . From a public health perspective, delivery of interactive, tailored health information can be effective in changing patient health behaviors [30,31]. Future studies should examine this issue in more detail.
- Third, though our response rate was greater than 80%, our survey was only done in 4 primary care practices in Rhode Island, therefore it may not generalize to other populations or settings.
- Fourth, our survey relied on self-report of Internet health-related activities. Future studies should consider methods such as installing software on patients' computers to record their Internet activities .
Despite the study's limitations, the results of this study have important implications as the number of patients using the Internet for health-related activities continues to grow. People frequently use the Internet to gather health information; about 6 million Americans do so each day [1
]. This study confirms these findings but also identifies additional activities where patients show interest in furthering their use of the Internet. As the spectrum of available health-related Internet activities expands, patients may soon use the Internet to research the quality of physicians, schedule their own appointments, and investigate the quality of care they receive. The traditional doctor-patient relationship will continue to evolve as health care on the Internet advances.
Future studies are needed to address this rapidly-evolving technology. Given that the field is quite new, valid and reliable measurements need to be developed. The majority of the data on Internet use is collected using self-reported surveys, as in the present study, yet little is known regarding the validity or reliability of such survey data on Internet use [1
]. Without these improved methodologic approaches, the science of the field will move slowly, as studies of doctor-patient communication have been hampered by over-reliance on survey data, rather than more-valid and more-reliable methods, such as videotape and audiotape methods [32
]. Eysenbach and colleagues made an important step in this direction by videotaping sessions in which individuals were asked to find specific health-related information on the Internet [3
]. Another approach is to incorporate technologies that track and record the sites visited and activities performed on health-related Web sites [3
]. Given the proliferation of health-related activities on the Internet, these methodologic advances are greatly needed to advance research in the field.