Spring 2006 Edition

May 31, 2006

Across the globe disparities in health and healthcare have been documented for hundreds of years. The causes of these disparities are complex and related to social, medical, environmental, economic, healthcare system and behavioral determinants. Currently governments and healthcare systems are struggling to effectively reduce these differences. To complicate matters further, the number of individuals with chronic diseases is rapidly growing. Increasingly much of the care needed for effective management of these chronic diseases is performed outside of the hospital setting by non-physicians. However the US healthcare system is still primarily oriented toward acute, hospital based, emergency care and therefore currently largely unable to consistently provide high quality care to every person.

Unlike any other time in history, health professionals recognize that a significant portion of their activities involve the management of information. As such, information technology has become central to medical care, health communication and research (1). To date, drug databases may be searched in seconds for potential drug interactions, electrocardiograms are analyzed via computers and patients vital signs are constantly monitored in the intensive care units and operating rooms by computers (1). Advanced decision support and telemedical tools, electronic health records, electronic patient records, computerized physician order entry systems, remote sensing, early detection and advanced warning systems are being developed that promise to significantly impact medical care in ways that are currently only imaginable(1). While this unprecedented evolution in the information sciences is indeed exciting it is the changing nature of health and medical practice itself that is the most revolutionary. This shift from acute, inpatient treatment to chronic, community based, guided self care and health risk management will demand unique advances from the information technologies.

Effective chronic care, unlike acute treatment oriented care, is a much more collaborative process between patients and providers. It involves a much larger reliance on provider directed self-care and community based health risk management, disease management, care coordination, and care facilitation. Obviously then, the number of potential factors existing in the environment that may be important in the ultimate genesis of disease or disparities is potentially huge. Given this reality, e-Health and computer information technologies may offer the only hope of harnessing this vast array of information and using it to understand disease as it exists in populations, and to design the most effective interventions to address the health challenges people face every day, in their communities.

Achieving health improvements in whole populations will also necessitate interventions that may be distinctly different than strategies employed in individual clinics or doctor’s offices. This is in part true because many people in a given population may never see the healthcare provider. Thus future healthcare systems that remain dominated by an inpatient based, single patient-provider model, can be reasonably expected to achieve only marginal results at the population level, despite providing high quality care to those individuals able to access this traditional system.

In addition to its impact on medical care, e-Health promises to have tremendous impact in the area of health behavior change. Knowledge derived from the behavioral sciences will likely provide unique insights that ultimately prove critical to achieving sustained behavior change and to the uptake of computer based technologies. For example, while the provision of high quality health information is requisite for informed decision making by both providers and patients, evidence from the behavioral sciences strongly suggests that information alone is insufficient to motivate significant behavior change in many patients, particularly over the long term (2-5).

The theory of Reasoned Action is a theory of health behaviorism that attempts to explain how individuals make decisions regarding a given behavior. This particular theory appears to best explain health behaviorism among African-Americans and Latinos. It posits that the most important determinant of behavior is behavioral intent. The two fundamental drivers of behavioral intent are attitude toward performing a given behavior and subjective norms associated with the behavior. Finally attitude is determined by an individual’s beliefs regarding a behavior while subjective norms are determined by an individual’s perception of whether important referent individuals approve or disapprove of performing the behavior (2). Among African-American populations, the opinions of those in their personal social networks are often considered of equal or greater importance than the opinions or recommendations of the outside “expert”. This is in part due to the fact that a significant level of mistrust exists between many African-Americans and the healthcare system. This mistrust also impacts the level of African-American compliance with and adherence to medical regimens (6-11). As such, mistrust, misperceptions and myths impede medication compliance among African-American patients, their interactions with the healthcare system and possibly their willingness to embrace computer based e-Health solutions like kiosks and online health services that have been developed by “the experts”.

e-Health and information technology interventions then, that are not built on the realities of population and environmental dynamics or health behaviorism, may only be able to achieve limited improvements in population health or disparities, despite significant up front investments and entrepreneurial interest. In the end, it is challenging to conceive of how population health will be improved and disparities reduced or eliminated without taking advantage of emerging opportunities in e-Health. To be successful though, a population perspective will need to be employed in medical care and increased expertise in the Behavioral Sciences will need to be integrated into information technologies and e-Health, to enable us to retain our title as the nation with “the best healthcare system in the world”.

M. Chris Gibbons, MD, MPH
Johns Hopkins Medical Institutions

The views expressed in this article are those of the author and do not imply endorsement by The Robert Wood Johnson Foundation or the Health e-Technologies Initiative.

Reference List

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