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The Network Society & Knowledge The Network Society & Knowledge EconomyEconomy
Portugal in the Global ContextPortugal in the Global Context
– Lisboa, March 4-5, 2005Lisboa, March 4-5, 2005
Organizational reform and Organizational reform and technological modernization in technological modernization in the public sectorthe public sector
Internet and Mobile Technology in health Internet and Mobile Technology in health systems:systems:
Organizational & Sociocultural Issues in a Organizational & Sociocultural Issues in a Comparative ContextComparative Context
James E. Katz (Rutgers University) James E. Katz (Rutgers University) Sophia K. Acord and Ronald E. RiceSophia K. Acord and Ronald E. Rice
ObjectivesObjectives
Why e-health for PortugalWhy e-health for Portugal
Compare to US Compare to US
Potential for e-health technology Potential for e-health technology developmentdevelopment
Look at social science dimension & Look at social science dimension & suggest opportunities for Portugalsuggest opportunities for Portugal
ConclusionsConclusions
E-health important lever for E-health important lever for
Health improvement for populaceHealth improvement for populace
Modernization spur for infrastructureModernization spur for infrastructure
Growth engine for economyGrowth engine for economy
Serves human rightsServes human rights
Portuguese peoplePortuguese people
E-health offers great potential for reducing E-health offers great potential for reducing mortalitymortality
Improving health of childrenImproving health of children– Accident prevention & cancer in young peopleAccident prevention & cancer in young people
Young people’s (15-34) mortality rates Young people’s (15-34) mortality rates among highest in EU among highest in EU
Cardio-vascular disease high in older Cardio-vascular disease high in older peoplepeople
Portugal: Low density of Portugal: Low density of healthcare practitionershealthcare practitioners
>80% of healthcare professionals work in >80% of healthcare professionals work in 3 largest cities3 largest cities– >60% in Lisboa>60% in Lisboa
Shortage of dentists & nursesShortage of dentists & nurses– 3 dentists per 100k in 19883 dentists per 100k in 1988
– 3.1 nurses per 100k in 19943.1 nurses per 100k in 1994
– versus US: About 190 MDs per 100kversus US: About 190 MDs per 100k
PortugalPortugal
~ 7% of GDP (1992) to healthcare ~ 7% of GDP (1992) to healthcare
22ndnd lowest in Europe lowest in Europe
USAUSA
13% of Gross National Product (GNP) 13% of Gross National Product (GNP) consumed in 2004consumed in 2004– Compares 5.6% in 1960 Compares 5.6% in 1960 – For US auto-makers, cost of worker For US auto-makers, cost of worker
healthcare more than raw materialshealthcare more than raw materials
50 percent of Americans take at least one 50 percent of Americans take at least one prescription drug prescription drug – 17% take four or more17% take four or more
Survey of EU 2003Survey of EU 2003
Portugal, Spain significantly lower in Portugal, Spain significantly lower in Internet useInternet use
After Greece, were the lowest in the EU After Greece, were the lowest in the EU (for Spain, 13% and Portugal 14%) (for Spain, 13% and Portugal 14%)
Portuguese respondents Portuguese respondents
1.6% use the Internet to seek health 1.6% use the Internet to seek health information dailyinformation daily
2% said they did so weekly 2% said they did so weekly
2% monthly 2% monthly
8% still less often 8% still less often
Portugal, Spain have low rate of Portugal, Spain have low rate of rural Internet health accessrural Internet health access
Especially among the elderlyEspecially among the elderly
Portuguese physician practicesPortuguese physician practices
Only 58% of Portuguese physicians use Only 58% of Portuguese physicians use the Internetthe Internet
Only 40% do for medical purposes Only 40% do for medical purposes – Well below the EU averageWell below the EU average
(European survey, 2003)(European survey, 2003)
USUS
80% of adult Internet users (half of 80% of adult Internet users (half of population) searches on health and population) searches on health and medical topicsmedical topics
30% of email users have sent or received 30% of email users have sent or received health-related emailhealth-related email
December 2002December 2002
Consumers in USConsumers in US
Connect to online support groupsConnect to online support groups
Visit websitesVisit websites– Special sites for volunteers & reports on trial Special sites for volunteers & reports on trial
of new therapiesof new therapies
25% looked online for drug information25% looked online for drug informationDecember 2002December 2002
Patient want ready email Patient want ready email contact with physicians contact with physicians
80% said they wanted this, according to 80% said they wanted this, according to Feb 2005 online surveyFeb 2005 online survey– But not if had to pay additional (< 30%)But not if had to pay additional (< 30%)
(Wall St. Jor, Mar 2, 2005)(Wall St. Jor, Mar 2, 2005)
Survey suggests importance of Survey suggests importance of personalized & tailored info, but also cost personalized & tailored info, but also cost constraintsconstraints
Problems with major websites Problems with major websites
ReadabilityReadability(Ebenezer, 2003) (Ebenezer, 2003)
Rarely aimed at patients Rarely aimed at patients (Tench et al., 1998) (Tench et al., 1998)
E.g., NHS library & mdconsult.comE.g., NHS library & mdconsult.com– Both aim to provide accurate and secure Both aim to provide accurate and secure
information to health-seekersinformation to health-seekers
Patients are unaware of high-Patients are unaware of high-quality data sourcesquality data sources
Health seekers tend to use general search Health seekers tend to use general search engines, such as Googleengines, such as Google– Instead of turning to specialized resources Instead of turning to specialized resources
(Boston Consulting Group, 2001, 2003) (Boston Consulting Group, 2001, 2003)
(Sigouin & Jadad, 2002) (Sigouin & Jadad, 2002)
Centralized and commercial Centralized and commercial websites non-interactivewebsites non-interactive
Lack customer interaction featuresLack customer interaction features
Instead provide only unidirectional Instead provide only unidirectional information information
(Cudmore & Bobrowski, 2003) (Cudmore & Bobrowski, 2003)
Example: PharmaceuticalsExample: Pharmaceuticals
Fewer than 1 in 3 Fewer than 1 in 3 pharmaceuticalpharmaceutical company websites offer way to respond company websites offer way to respond online to consumer requests online to consumer requests
Fewer than 1 in 2 Fewer than 1 in 2 health-supply websites health-supply websites respond to online requests or questions respond to online requests or questions
(Pharmaceutical, 2003)(Pharmaceutical, 2003)
Public sites also one-wayPublic sites also one-way
Government health sites are even less Government health sites are even less interactive interactive
(Rice, Peterson & Christine, 2002)(Rice, Peterson & Christine, 2002)
Personal websitesPersonal websites
Personal health websites play big role in Personal health websites play big role in construction of medical knowledge online construction of medical knowledge online
Represents growth of interest in ‘local’ Represents growth of interest in ‘local’ knowledgeknowledge
In a search for rheumatoid arthritis, 34% of In a search for rheumatoid arthritis, 34% of relevant sites were posted by an individual, more relevant sites were posted by an individual, more than those posted by non-profit organizations, and than those posted by non-profit organizations, and over 6 times more than those posted by over 6 times more than those posted by educational institutions educational institutions
(Suarez-Almazor et al., 2001) (Suarez-Almazor et al., 2001)
Physician websites offer great Physician websites offer great potentialpotential
In the US, 1 in 3 physicians have web site In the US, 1 in 3 physicians have web site
Obstetrics/gynaecology and internal Obstetrics/gynaecology and internal medicine specialists highest rate medicine specialists highest rate
(AMA, 2002) (AMA, 2002)
Most physician websites focus on practice Most physician websites focus on practice enhancement tactics, rather than concrete enhancement tactics, rather than concrete patient servicepatient service
Sanchez (2002)Sanchez (2002)
Many commercial support services Many commercial support services availableavailable
Offer physicians electronic supportOffer physicians electronic supportWebsites Websites
Secure emailsSecure emails
Patients find sites are cumbersome, partly Patients find sites are cumbersome, partly due to the concerns about liability and due to the concerns about liability and assumption of responsibilityassumption of responsibility
Part C: Potential for e-health Part C: Potential for e-health technology developmenttechnology development
Been concentrating on wwwBeen concentrating on wwwUSA highly web-orientedUSA highly web-oriented
VisualVisual
MobileMobile
Multi-media services (MMS)Multi-media services (MMS)
Physician webcams for Physician webcams for practitionerspractitioners
Promising in concept, difficult in Promising in concept, difficult in implementation implementation
Example of Example of double-headed double-headed microscopesmicroscopes
Bamford et al. (2003) implemented a Bamford et al. (2003) implemented a country-wide network of physician 35 country-wide network of physician 35 webcams in UK histopathology webcams in UK histopathology departmentsdepartments
A year after installation, 71% had not even A year after installation, 71% had not even used the networking software used the networking software
All using physicians found it effective for All using physicians found it effective for diagnosis and exchanging opinionsdiagnosis and exchanging opinions
Why failed?Why failed?
Excessive workloads preventing physician Excessive workloads preventing physician trainingtraining
IT staff reluctance to render assistanceIT staff reluctance to render assistance
Above all, user attitudesAbove all, user attitudesBamford et al. (2003)Bamford et al. (2003)
Mobile phoneMobile phone
Studies from Spain provide contrast in Studies from Spain provide contrast in usage patternsusage patterns
Marquez Contreras et al. (2004) conducted a Marquez Contreras et al. (2004) conducted a controlled group study with hypertension patients; controlled group study with hypertension patients; members of the intervention group were sent members of the intervention group were sent reminder text messages to their mobiles 2 days a reminder text messages to their mobiles 2 days a week. Hypertension was significantly lower (52%) week. Hypertension was significantly lower (52%) in the control group compared to the intervention in the control group compared to the intervention group (65%) group (65%)
AIDS fight in KenyaAIDS fight in Kenya
Free text messaging services availableFree text messaging services available– Users send text questions and receive free Users send text questions and receive free
answers answers
Sends out daily tipsSends out daily tips– how to prevent infectionhow to prevent infection
– deal with disease’s consequences deal with disease’s consequences
Mali & AIDSMali & AIDS
Local mobile company sends free text Local mobile company sends free text health slogans twice a month to each of health slogans twice a month to each of the company’s 350,000 subscribersthe company’s 350,000 subscribers
Mali & malariaMali & malaria
Prints AIDS and malaria prevention Prints AIDS and malaria prevention slogans on at least one million of the pre-slogans on at least one million of the pre-paid phone cardspaid phone cards– Used mostly by low-income customersUsed mostly by low-income customers
Sample message:Sample message:– "Protect your family against malaria - use an "Protect your family against malaria - use an
insecticide-treated mosquito net“insecticide-treated mosquito net“(Plus News, 2004)(Plus News, 2004)
Examples showExamples show
Mobile health applications: health Mobile health applications: health information can be inserted directly into information can be inserted directly into the daily lives of targeted populationsthe daily lives of targeted populations
Contrasts with more traditional systems Contrasts with more traditional systems that are physically and psychologically that are physically and psychologically remote from the active health-seeking remote from the active health-seeking populationpopulation
Advanced mobile videophone Advanced mobile videophone and multi-media messagingand multi-media messagingMobile medical application which uses Mobile medical application which uses commercial 3G wireless cellular data service commercial 3G wireless cellular data service
– When the patient is in a remote location, transmits trauma When the patient is in a remote location, transmits trauma patient’s video, images, and electrocardiogram signals to patient’s video, images, and electrocardiogram signals to trauma specialisttrauma specialist
Chu and Ganz (2004)Chu and Ganz (2004)
Weiner et al. (2003) used videoconferencing in Weiner et al. (2003) used videoconferencing in nursing homes for unscheduled, night-time nursing homes for unscheduled, night-time consultationsconsultations
– Mobile multimedia applications were especially effective in Mobile multimedia applications were especially effective in dealing with mental health patientsdealing with mental health patients
Part D: Challenges & Part D: Challenges & opportunities for e-healthopportunities for e-health
Look at social science dimension & Look at social science dimension & suggest opportunities for Portugalsuggest opportunities for Portugal
Most technical facilities in a few Most technical facilities in a few locationslocations
E-health offers remote access to E-health offers remote access to expensive resourcesexpensive resources
Other valuesOther values
Social support highly valuedSocial support highly valued
Users want individualized, specific Users want individualized, specific outcome information from expert sourcesoutcome information from expert sources
Cultural and social aspects in Cultural and social aspects in deployment deployment
Inherent bureaucratic logic of one-way Inherent bureaucratic logic of one-way information flowinformation flow
Organizations must reap rewards of sunk Organizations must reap rewards of sunk costs and prior effortscosts and prior efforts
(Castells, 2004)(Castells, 2004)
Difficult environmentDifficult environment
Privacy Privacy
Equal accessibilityEqual accessibility
Commercial free speech & access to Commercial free speech & access to marketsmarkets
Effectively informing, protecting, and Effectively informing, protecting, and enabling patients and healthcare workersenabling patients and healthcare workers
Legal & medical accountability & qualityLegal & medical accountability & quality
And costAnd cost
Expensive!Expensive!
But investment in top-down systems much But investment in top-down systems much higher than bottom-uphigher than bottom-up
Quality control an enduring problemQuality control an enduring problem
Digital divide & mobilesDigital divide & mobiles
Digital divide caused by mobiles?Digital divide caused by mobiles?– In fact, the very portability of mobile phones In fact, the very portability of mobile phones
and PDAs, enhanced by further device-to-and PDAs, enhanced by further device-to-device wireless technologies, actually make device wireless technologies, actually make them versatile them versatile
– Provide health care to remote areas, elderly, Provide health care to remote areas, elderly, and disabledand disabled
Lavez et al. (2004)Lavez et al. (2004)
Huge amount accomplishedHuge amount accomplished
Large sunk costs provide vast infoLarge sunk costs provide vast info
Formally (top-down)Formally (top-down)– Resulting in the creation of many useful Resulting in the creation of many useful
centralized services (some commercial, some centralized services (some commercial, some governmental)governmental)
Informally (self-organizing upwards) Informally (self-organizing upwards) – Resulting in numerous resources of varying Resulting in numerous resources of varying
interactivity and qualityinteractivity and quality
Part E: ConclusionPart E: Conclusion
E-health an enormous opportunity for E-health an enormous opportunity for PortugalPortugal
Mobile applications may fit particularly wellMobile applications may fit particularly well
Developing country model?Developing country model?
QuandaryQuandary
How to make systems that allow How to make systems that allow democratic co-creation, individualization & democratic co-creation, individualization & support, address qualitysupport, address quality– High degree of interactivity and tailoring High degree of interactivity and tailoring
wanted by users, but hard to achieve wanted by users, but hard to achieve efficientlyefficiently
EU roadmap for e-health EU roadmap for e-health – Quality, privacy & liability concerns may seal Quality, privacy & liability concerns may seal
off local initiativesoff local initiatives
Exciting, hopeful futureExciting, hopeful future
Work the problem from two directions Work the problem from two directions – Top downTop down– Enable Enable (or at least not disable) (or at least not disable) local creationlocal creation
And two levelsAnd two levels– Quality, tailored informationQuality, tailored information– Socially supportive & meaningful contextSocially supportive & meaningful context
The possiblityThe possiblity
With social, organizational & technical With social, organizational & technical research, savvy applications can be research, savvy applications can be created that achieve vital objectivescreated that achieve vital objectives