CyberHealthcare

James G. Anderson, Ph.D.

Purdue University

eHEALTH Commerce

• $370 billion business by 2004

• $15 billion will be spent on prescription drugs

• $1.9 billion will be spent on over-the-counter drugs

• $3.3 billion will be spent on natural health cures

The Virtualization of Health Care Delivery

• Few organizations have adopted enterprise-wide information systems.

• Separate systems exist in pharmacy, radiology, clinical laboratories, inpatient services, outpatient services, emergency department, etc.

• The Internet can be used to collect aggregate, store, analyze and access data from all of these functional areas.

The Cyber Medical Marketplace

• Mediconsult charges $195 to provide personalized information on alternative treatments

• Virtual House Calls can monitor patients with chronic diseases at home by the Internet

• Patients can enroll in clinical trials on the Web

The Cyber Medical Marketplace

• Body Parts are for sale on the Web (e.g., semen, ovarian eggs, kidneys)

• “CyberCouches” Mental health services are provided over the Internet

• “CyberPharmacies” Prescription and unapproved drugs can be procured from Web sites

Consumer Use of the Web

• 1 out of 3 Americans obtain health information from the Web annually

• Consumers obtain disease-specific information

• Consumers join online support groups

• Consumers are helped to manage chronic illness

Consumer Use of the Web

• Paradox: The availability of a wealth of information and services, but no guarantee of their quality and accuracy

Avoiding Drug Interactions

• Mrs. S. was prescribed two antibiotic drugs. She used the internet to look up the drug’s profile in the Consumer Reports Drug Database. She discovered that one drug could interact with the blood thinner that she was already taking. She informed her physician who changed her prescription.

Support via the Web

• Mrs. H, a widowed 60-year-old was diagnosed with cancer. After a radical mastectomy and on chemotherapy, she found herself frightened and confused. She joined CHESS Network, a computer-based support system designed to provide people facing major illnesses with information and social support.

Recruiting Donors

• Daniel, a 32-year-old has chronic myelogenous leukemia that kills 60-70% within 5 years. No one in his family has the proper genetic match to donate bone marrow. The family established a Web site and was successful in recruiting two potential matching donors.

Management of Chronic Illness

• John G., a 73-year-old man, has congestive heart failure. After discharge from the hospital, he lives at home where his condition is monitored by a Web service. Each morning he enters his vital signs into his chart by computer. A nurse reviews his chart and talks to him once a week.

Potential Problems

• Licensing and regulation

• Inaccurate and out-of-date information

• Unverified and fraudulent health claims

• Conflicts of interest

• Threats to privacy and confidentiality

• Doctor-patient conflicts

Caveat Emptor (Buyer Beware)

• Plastic surgery is highly advertised on the Internet. One woman went to a surgeon who advertised that he performed plastic surgery on eyelids. The surgeon who claimed to be board certified was actually an oral surgeon.After the surgery, the woman required corrective skin grafts.

Foreign Sales of Drugs on the Internet

• Many Internet pharmacies are set up in foreign countries to avoid U.S. laws. Vitality Health Products in Bankok, Thailand, promotes prescription free drugs by e-mail at low prices. Popular drugs include: Minoxidil and Propecia for hair loss, Viagra, Retin-A for aging skin, and others. The site advises customers what to do if customs seizes the order.

Inaccurate Information: Childhood Diarrhea

• Investigators using widely used search engines found 15,000 sites with information on treatment of childhood diarrhea. A random sample found only 60 sites made information available from traditional medical sources. Only 20% contained treatment recommendations that conformed to American Academy of Pediatric guidelines.

Inaccurate Information: Childhood Cancer

• An analysis was performed of 371 Web sites that contained information on Ewing’s Sarcoma, a bone cancer that afflicts children. About 1/3 of the sites contained information that did not come from peer reviewed sources. Six percent contained errors. Survival rates reported varied from 5% to 85%. Some gave information on alternative medicine.

Unverified Health Claims: Snake Oil

• The FTC has identified hundreds of Web sites promoting unverified cures for 30 ailments including AIDS, MS, liver disease, arthritis, and cancer. Proposed cures included: Fatty acids, shark cartilage, magnets. Two months after being warned by the FTC, 75% of the sites were still operating.

Unverified Health Claims: The Return of Laetrile

• Christian Brothers Contracting Corp. sells Laetrile over the Web sites CancerAnswer and ApricotsFromGod. Tablets of vitamin B-17 are available for $95 per 100. A 21-day supply of injectable Laetrile sells for $750.

Beware of Dangerous Medical Advice Online

• J. Rupert Wells, claims to have found a cure for cancer, Radol. The substance contains quinine and gives off a glow that is not radioactive as advertised.

Conflicts of Interest: Web Site Sponsorship

• Drug companies are investing heavily to create a dominant presence on the web. For example, HealthTalk’s hepatitis C site is funded by Amgen which produced Infergen, a brand of interferon. The Web site features testimonials by patients who use Amgen products.

Conflicts of Interest: drkoop.com

• The drkoop.com Web site provides information on medical conditions and advice on topics such as purchasing health products and services. In return for listing products and services, Dr. Koop was originally entitled to receive 2% of the revenues derived from sales of products, a fact that was not revealed on the Web site.

Public Concern Over Privacy and Confidentiality

A Gallup Survey found:

• 84% of the public said they were concerned that personal health information is being made available to others without their consent.

• Only 7% were willing to store o4r transmit health information over the Internet

• Only 35% trusted a managed care company with their health information

Breach of Security

• A certified sex therapist operated a Web site to treat people for sexual problems. Treatment is conducted over the Internet. In March 1999 the sexual and medical histories of 15 women and 75 men who had consulted the doctor were inadvertently posted on a public Web site.

Privacy and Confidentiality:Patients Told They Had AIDS

• The 13 year old daughter of a hospital clerk in a Florida hospital used her mothers ID and password to print out a list of names and addresses of patient who were seen in the emergency department. She then called patients and falsely told them they were infected with the HIV virus.

Privacy and Confidentiality: Tracking Consumers

• Pharmatrak is surreptitiously tracking Internet users on behalf of pharmaceutical companies. When consumers visit its clients’ Web sites, Pharmatrack invisibly places an identification code on the consumer’s computer. This permits the company to record consumers’ activity when they access Web sites.

Privacy and Confidentiality: Cancer Support Sites

• A number of Web sites provide information and support for cancer patients. Some sites claim to provide more sophisticated services than nonprofit sites such as Oncolink and Medline. These sites ask patients to provide personal data in exchange for medical information. Personal data is then sold to advertisers and business partners.

Privacy and Confidentiality: Data Mining

• A woman in Texas received a letter containing personal details about her and threatening her with rape. A convicted rapist who was serving time in a Texas prison had written the letter. He was entering data for a data mining company that had obtained the information from a product questionnaire that the woman had filled out and sent back to the company.

Doctor-Patient Conflict over Therapy

• A woman with ovarian cancer was being treated at a major medical center. The woman and her husband concluded after searching the Web that intensive therapy with a combination drugs would be a more appropriate therapy than the one she was currently receiving. Her doctors felt the current treatment was more appropriate.

Physician SkepticismAn AMA survey of physicians found:

• Only 11% of physicians felt that the Internet was useful in providing patient information

• Only 9% of physicians were willing to personally answer e-mail from patients.

Legal Battles

• Newsday filed a suit under the Freedom of Information Act to obtain information about physicians in New York State who performed CABG.

• The AMA is fighting to prevent the posting of Common Procedural Terminology (CPT) codes on Websites the public can access.

• Consumers to date are denied access to the National Practitioner Databank

Cultural Change

• The Internet has the potential to change the organizational structure and delivery of health services.

• Potential benefits include: more cost-effective health care, reduction of medical errors, better management of chronic disease, greater patient responsibility for the patient’s own health care.

Cultural Change

• While the Internet holds considerable promise, it raises a host of social and ethical issues that will have to be resolved in order to realize its full potential.

Tips on the Reliability of Web-Based Health Sources

• Who sponsors the Web site?

• Is the site current?

• Is the information factual or does it represent opinions?

• Is the Web site intended for medical professionals or the general public?

Recommended Websites• AMA Health Insight• Centers for Disease Control and Prevention (CDC)• Healthfinder• HealthWeb• HIV InSite• Mayo Clinic Health Oasis• MEDLINEplus• National women’s Health Information Center• NOAH: New York Online Access to Health• Oncolink: University of Pennsylvania

Discussion - Regulation

Currently in the U.S. physicians are licensed to practice in a specific state. Also, prescription drugs are approved by the FDA. Since the provision of health services and drugs over the Internet transcends state and national boundaries, should an international organization be created to license physicians and approve drugs? Would this be feasible?

Discussion - Consumer Information

Hundreds or even thousands of Web sites exist that provide information on specific health related topics. How can the consumer be protected from inaccurate, misleading and fraudulent information? Should the FTC regulate health-related Web sites and prosecute sponsors of sites that make fraudulent claims for health products?

Discussion - Conflicts of Interest

For-profit companies such as pharmaceutical companies sponsor many health-related Web sites. How can the public be protected from conflicts of interest? Would a notice on the site regarding sponsorship be sufficient?

Discussion - Privacy and Confidentiality

Surveys indicate that the public is deeply concerned about violations of the confidentiality of their medical information. One proposal would require written consent from each patient before their medical records could be accessed for any purpose other than the provision of care. Do you agree with this proposal. How would it affect medical research, public health, and health care management?

Discussion - Doctor-Patient Conflicts

At present, the public does not have access to information about the quality of care provided by individual doctors and hospitals such as mortality rates after surgery and information concerning malpractice awards and criminal convictions of physicians. Should this information be made public? If so, how can health care providers’ rights be protected?