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

Part A: Why E-health?Part A: Why E-health?

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)

Portugal also leaderPortugal also leader

Smart cardsSmart cards

EU road mapEU road map

Part B: E-health use in USPart B: E-health use in US

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%)

Mobiles in LDCs: Mobiles in LDCs: An extensible model? An extensible model?

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

ObrigadoObrigado Thank you Thank you