The Network Society & Knowledge Economy Portugal in the Global Context Lisboa, March 4-5, 2005

1. The Network Society & Knowledge Economy • Portugal in the Global Context • Lisboa, March 4-5, 2005

2. Organizational reform and technological modernization in the public sector

3. Internet and Mobile Technology in health systems:Organizational & Sociocultural Issues in a Comparative Context • James E. Katz (Rutgers University) Sophia K. Acord and Ronald E. Rice

4. Objectives • Why e-health for Portugal • Compare to US • Potential for e-health technology development • Look at social science dimension & suggest opportunities for Portugal • Conclusions

5. Part A: Why E-health?

6. E-health important lever for • Health improvement for populace • Modernization spur for infrastructure • Growth engine for economy • Serves human rights

7. Portuguese people • E-health offers great potential for reducing mortality • Improving health of children • Accident prevention & cancer in young people • Young people’s (15-34) mortality rates among highest in EU • Cardio-vascular disease high in older people

8. Portugal: Low density of healthcare practitioners • >80% of healthcare professionals work in 3 largest cities • >60% in Lisboa • Shortage of dentists & nurses • 3 dentists per 100k in 1988 • 3.1 nurses per 100k in 1994 • versus US: About 190 MDs per 100k

9. Portugal • ~ 7% of GDP (1992) to healthcare • 2nd lowest in Europe

10. USA • 13% of Gross National Product (GNP) consumed in 2004 • Compares 5.6% in 1960 • For US auto-makers, cost of worker healthcare more than raw materials • 50 percent of Americans take at least one prescription drug • 17% take four or more

11. Survey of EU 2003 • Portugal, Spain significantly lower in Internet use • After Greece, were the lowest in the EU (for Spain, 13% and Portugal 14%)

12. Portuguese respondents • 1.6% use the Internet to seek health information daily • 2% said they did so weekly • 2% monthly • 8% still less often

13. Portugal, Spain have low rate of rural Internet health access • Especially among the elderly

14. Portuguese physician practices • Only 58% of Portuguese physicians use the Internet • Only 40% do for medical purposes • Well below the EU average • (European survey, 2003)

15. Portugal also leader • Smart cards • EU road map

16. Part B: E-health use in US

17. US • 80% of adult Internet users (half of population) searches on health and medical topics • 30% of email users have sent or received health-related email • December 2002

18. Consumers in US • Connect to online support groups • Visit websites • Special sites for volunteers & reports on trial of new therapies • 25% looked online for drug information • December 2002

19. Patient want ready email contact with physicians • 80% said they wanted this, according to Feb 2005 online survey • But not if had to pay additional (< 30%) • (Wall St. Jor, Mar 2, 2005) • Survey suggests importance of personalized & tailored info, but also cost constraints

20. Problems with major websites • Readability • (Ebenezer, 2003) • Rarely aimed at patients • (Tench et al., 1998) • E.g., NHS library & mdconsult.com • Both aim to provide accurate and secure information to health-seekers

21. Patients are unaware of high-quality data sources • Health seekers tend to use general search engines, such as Google • Instead of turning to specialized resources • (Boston Consulting Group, 2001, 2003) • (Sigouin & Jadad, 2002)

22. Centralized and commercial websites non-interactive • Lack customer interaction features • Instead provide only unidirectional information • (Cudmore & Bobrowski, 2003)

23. Example: Pharmaceuticals • Fewer than 1 in 3 pharmaceutical company websites offer way to respond online to consumer requests • Fewer than 1 in 2 health-supply websites respond to online requests or questions • (Pharmaceutical, 2003)

24. Public sites also one-way • Government health sites are even less interactive • (Rice, Peterson & Christine, 2002)

25. Personal websites • Personal health websites play big role in construction of medical knowledge online • Represents growth of interest in ‘local’ knowledge • In a search for rheumatoid arthritis, 34% of relevant sites were posted by an individual, more than those posted by non-profit organizations, and over 6 times more than those posted by educational institutions • (Suarez-Almazor et al., 2001)

26. Physician websites offer great potential • In the US, 1 in 3 physicians have web site • Obstetrics/gynaecology and internal medicine specialists highest rate • (AMA, 2002) • Most physician websites focus on practice enhancement tactics, rather than concrete patient service • Sanchez (2002)

27. Many commercial support services available • Offer physicians electronic support • Websites • Secure emails • Patients find sites are cumbersome, partly due to the concerns about liability and assumption of responsibility

28. Part C: Potential for e-health technology development • Been concentrating on www • USA highly web-oriented • Visual • Mobile • Multi-media services (MMS)

29. Physician webcams for practitioners • Promising in concept, difficult in implementation

30. Example of double-headed microscopes • Bamford et al. (2003) implemented a country-wide network of physician 35 webcams in UK histopathology departments • A year after installation, 71% had not even used the networking software • All using physicians found it effective for diagnosis and exchanging opinions

31. Why failed? • Excessive workloads preventing physician training • IT staff reluctance to render assistance • Above all, user attitudes • Bamford et al. (2003)

32. Mobile phone • Studies from Spain provide contrast in usage patterns • Marquez Contreras et al. (2004) conducted a controlled group study with hypertension patients; members of the intervention group were sent reminder text messages to their mobiles 2 days a week. Hypertension was significantly lower (52%) in the control group compared to the intervention group (65%)

33. Mobiles in LDCs: An extensible model?

34. AIDS fight in Kenya • Free text messaging services available • Users send text questions and receive free answers • Sends out daily tips • how to prevent infection • deal with disease’s consequences

35. Mali & AIDS • Local mobile company sends free text health slogans twice a month to each of the company’s 350,000 subscribers

36. Mali & malaria • Prints AIDS and malaria prevention slogans on at least one million of the pre-paid phone cards • Used mostly by low-income customers • Sample message: • "Protect your family against malaria - use an insecticide-treated mosquito net“ • (Plus News, 2004)

37. Examples show • Mobile health applications: health information can be inserted directly into the daily lives of targeted populations • Contrasts with more traditional systems that are physically and psychologically remote from the active health-seeking population

38. Advanced mobile videophone and multi-media messaging • Mobile medical application which uses commercial 3G wireless cellular data service • When the patient is in a remote location, transmits trauma patient’s video, images, and electrocardiogram signals to trauma specialist • Chu and Ganz (2004) • Weiner et al. (2003) used videoconferencing in nursing homes for unscheduled, night-time consultations • Mobile multimedia applications were especially effective in dealing with mental health patients

39. Part D: Challenges & opportunities for e-health • Look at social science dimension & suggest opportunities for Portugal

40. Most technical facilities in a few locations • E-health offers remote access to expensive resources

41. Other values • Social support highly valued • Users want individualized, specific outcome information from expert sources

42. Cultural and social aspects in deployment • Inherent bureaucratic logic of one-way information flow • Organizations must reap rewards of sunk costs and prior efforts • (Castells, 2004)

43. Difficult environment • Privacy • Equal accessibility • Commercial free speech & access to markets • Effectively informing, protecting, and enabling patients and healthcare workers • Legal & medical accountability & quality

44. And cost • Expensive! • But investment in top-down systems much higher than bottom-up • Quality control an enduring problem

45. Digital divide & mobiles • Digital divide caused by mobiles? • In fact, the very portability of mobile phones and PDAs, enhanced by further device-to-device wireless technologies, actually make them versatile • Provide health care to remote areas, elderly, and disabled • Lavez et al. (2004)

46. Huge amount accomplished • Large sunk costs provide vast info • Formally (top-down) • Resulting in the creation of many useful centralized services (some commercial, some governmental) • Informally (self-organizing upwards) • Resulting in numerous resources of varying interactivity and quality

47. Part E: Conclusion • E-health an enormous opportunity for Portugal • Mobile applications may fit particularly well • Developing country model?

48. Quandary • How to make systems that allow democratic co-creation, individualization & support, address quality • High degree of interactivity and tailoring wanted by users, but hard to achieve efficiently • EU roadmap for e-health • Quality, privacy & liability concerns may seal off local initiatives

49. Exciting, hopeful future • Work the problem from two directions • Top down • Enable (or at least not disable) local creation • And two levels • Quality, tailored information • Socially supportive & meaningful context

50. The possiblity • With social, organizational & technical research, savvy applications can be created that achieve vital objectives