Abstract
The greatest challenge to the full integration of information technology (IT) into the delivery of healthcare is the failure of acceptance by patients and practitioners. Failure to adopt telemedicine and e-health has dominated much of our scientific consideration of telemedicine in the last 20 years. Study after study documents the reluctance of physicians in particular to change the traditional approaches to care because they do not know how to use the technology, are too busy to learn, or plainly do not see the advantage or motivation to change. Such attitudes have been seen as a barrier that is frustrating to overcome. The technology for those of us involved in telemedicine seems so simple and the usefulness self-evident. Yet we continue to search for reasons and solutions to break the barriers to full application. Is this not the case for all technology? Actually, no!
Let us consider the use of the Internet. The World Wide Web was activated in August of 1991, and we saw a geometric momentum as the now 7 billion people of the world with huge disparities of resource, infrastructure, education, and need attained a global usage of over 2 billion in 2011. Growth for use expanded by 480% between 2000 and 2011. The penetration of users is at 38%. Perhaps the cell phone took a little longer. Martin Cooper made the technical leap in 1973, and the devices with their attendant need for infrastructure, user education, and marketing still allowed commercial use in 1977. Now there are 5.6 billion cell phones for the 7 billion people on earth, and their use is ubiquitous in every corner of the planet, remote or advanced. Internet and cell phone telephony are examples of technology precisely resonating to a crying need for information and connectivity. With the tools at hand, people embraced the technology with almost startling alacrity. The demand for the technology has blasted formidable barriers of infrastructure and economics to become part of our lives in such a way that the not so distant time before these technologies is hard to recall. There were no Likert scale analyses to find out what was needed to induce the information users of the world to adopt the new technology. There were no orientation sessions in schools and industry to plead with information managers to at least try these new things. There were no randomized controlled trials to prove or disprove parity with traditional libraries or rotary phone booths. After initial inspired and crucial government funding in the United States and Europe, the technology has never lacked for capital. The people saw something of value and bought it.
In the case of the Internet, the business community saw the value of collateral message delivery in advertising, search services, and such and never looked for government subsidy or grant programs. In fact, now who could imagine trying to pry the cell phone from the hands of a teenager or telling a grandmother that there was no more Internet to share photos of offspring and pets? Telemedicine is still looking for ways to pay for its rather meager costs. True, there are encouraging changes in the United States with regard to payers, but telemedicine is not seen in many places as a profit center of health systems. Grudging inclusion as a loss leader is a faint recognition for what should be the glue holding healthcare together.
Some technology follows more typical routes of consumer marketing. Apple's iPad® and extensive applications may represent an example of technology marketing into areas of not necessarily obvious crying need but highly successful commercial attraction. When the iPad was announced with considerable drama on January 27, 2010 the market was prepared for its commercial availability in April 2010. Three million devices were sold in 80 days in the United States, and by the end of the year there were 14.8 million sales. The product captured 75% of the tablet market in a flash, and the next generation, the iPad2, introduced in March of 2011, led to 15 million sales in short order. Apple did not hold extensive education sessions for Luddites. There were no randomized control trials to show that the iPad was equivalent to other devices or more cost-effective. It was simply marketed as a superior product, and the manufacturer serviced that product rather well. The advantages were grasped by new users, and sales flourished. There is a huge difference between product purchases with even millions of buyers and the rapid incorporation of cell phones in the daily lives of almost half the world population. The iPad is a product that flourishes with a few million buyers. One might call the tablet a commodity that would appear on a gift list. The cell phone is seen as a utility, a necessity, and billions of owners prove that. Telemedicine is more basic than that utility characterization. Health IT (HIT) is the glue to hold the care together, to keep the little but crucial pieces from falling away or losing the timeliness to be helpful. IT needs to be an embedded technology, dynamic, ever new in creativity, but irreplaceable.
In healthcare the software, hardware, and middleware for information management are hardly shocking technology breakthroughs. We have electronic records, e-prescribing, personal health records, electronic libraries, and the ability to monitor by mobile means the health status of even the most fragile patients at great distance. We have the ability to readily weave the entire global medical community into a virtual medical staff of profound expertise and make that expertise available at anytime, anywhere. We have the power to limit error and place every medical decision into an evidence-based format with ease. We can teach, conference, inform, analyze, comfort, treat, and coordinate healthcare issues with the almost effortless flow of electrons and photons in an electronic continuum of seamless information. However, the acceptance of electronic health records, e-prescribing, and e-health has been painfully slow and is still argued against by vocal and respected elements of healthcare and the public that fear the cost, resist change, challenge the value, and cling to paper. Is this the same public that is out there tweeting, sending images, talking endlessly into headsets as they walk along, endangering the public roadways with their texting from the car, and awaiting with breathless anticipation the next announcement of a new communication device? Yes it is. What is wrong with telemedicine? Why can we not pass through the barriers with the confidence that the user will see its value and greet the technology with enthusiasm?
In this issue of Telemedicine and e-Health there are two important and illustrative articles concerning barriers to telemedicine in healthcare. Chen and Hsiao from Taiwan report a scholarly approach to technology adoption, finding that the technology and software suffer from problems of perceived usefulness and ease of use. The approach is to look at a model for technology adoption and the human factors that limit acceptance and application. No one ever thought to look at the human factors that might slow the utilization of the Internet, but at least with this fine study we get some ideas about a process in IT adoption in medicine where things are not going well. The problems for the users are that they do not see that it is a useful change to their practices and the technology is not easy to use. That is not an insignificant problem. The Internet does not suffer from that lack of obvious usefulness or ease of use. Actually, it is hard to use the Internet in so many ways, and yet the public and even the medical profession has learned whatever was necessary because of the perceived value. Surely the community of telemedicine could take the well-gathered lessons of perceived barriers and make the case to the using medical population that this is a good idea. It is perhaps time to move on from Likert scales and the flawed notion that there are cultural differences in the world that make telemedicine so underutilized. Perhaps there is a cultural flaw in medicine that makes such a revolutionary technology abhorrent. That is not a very good answer. It is always bad analysis to blame the patient for lack of a cure. Perhaps we should take our lessons from the marketplace, the history of the Internet, and design a better product that will not just hit hard at a population of early adopters like the iPad but sink deep into the psyche and daily lives of healthcare workers. It is just possible we need a better product.
Telemedicine cannot really succeed with just a niche market of true believers. It really must be a part of the fabric of care. In this issue there is also a study by Dr. Mun's group on HIT in the patient-centered Medical Home. They describe what could be a large part of the answer for accelerated use of IT in medicine. They describe how to organize the medical home, around a framework of IT. The medical home has been advanced for some 20 years as a concept in which all patient care intersects at the Medical Home where specialty recommendations, longitudinal management, information, and potentially conflicting therapies can be sorted out into a coherent and effective care plan. The care calls for bringing IT into the place where patients are at the center of concern, the Medical Home. In the concept of the Medical Home, the primary care locus is the intersection of all information needed for patient care—past, present, and future. There is one place where all decisions for healthcare can be consolidated and longitudinal management can be consistent and easily evaluated for effectiveness. Now it is not clear that the Medical Home is going to become such an idyllic and standard place for care. However, it is a great place to start. It is incumbent upon IT designers to design a system of information with proper semantics to be understood by all users. There must be a consistency of language that allows all users to apply the data with the same ease as cell phone users. The slow pace of telemedicine and e-health adoption is probably not due to resource limitation or the unpleasant suspicion that healthcare workers are troglodytes. Heathcare is a partnership between an enlightened public and a well-prepared and interactive care community. We hope in the coming years to see more and more research into the barriers until we perhaps realize that there never were any such obstructions. Perhaps instead of barriers the problem is that we have inadvertently prompted the user community to build up barricades, built by the healthcare community to resist what has been perceived as a useless, time-consuming, and ineffective intrusion into what many believe are time-honored practices in the best interest of patients. Let us strive for a better product and pay attention to the users, patients, and health workers alike. Full inclusion of HIT should not be any harder than Internet or cell phones if we have the technology right. Let us try to shift from the barrier mentality and attack a problem we may have created ourselves. Let us see if we can gently dismantle the barricades erected in the path of telemedicine and e-health. Let us try to really help lead with e-health toward a brighter future for healthcare that is rich in information, accessible to all, and affordable.