Promoting individual health using information technology: Trends in the US health system

Introduction

Information technology (IT) is an integral part of the healthcare systems in Western countries. In the USA, the Affordable Care Act passed in 2009 and rapid advances in technology for daily living have pushed the medical field to embrace IT (United States Department of Health and Human Services [USDHHS] Health Resources and Services Administration, 2012). It is used in various forms such as health informatics, diagnostic technology and communication technology at all levels of health care. The purposeful use of technology is relatively new to the field of health promotion. However, it has been in use in primary, secondary and tertiary care services for a long time. Technology-driven diagnostic tools, digital screening, computerised monitoring and treatment are just some examples of healthcare applications of technology.

Among all healthcare applications of technology, the use of IT has evolved as a revolutionary and rapidly emerging trend in health care. Self-management patient portals, electronic medical records, interactive preventive health records, personal health records, online peer support groups and social media are some of the latest trends in health IT (Berkovsky et al., 2015; Mitchell and Begoray, 2010). This paper focuses on the introduction and use of IT in health care and health education. Note that the terms ‘patients’ and ‘health consumers’ are used interchangeably in this paper.

IT in health care

One of the goals of the US healthcare system is to improve the quality of health care, which can only be achieved if medical and other health personnel (e.g. doctors, nurses, therapists and health educators), administrators and patients collaborate at different levels to assimilate complex information. Health IT has enabled this assimilation of information from various sources and hence emerged as a growing phenomenon in the field of health care. It has a wide range of applications in educational, administrative, clinical and research areas of health.

Role of the Government

As the largest purchaser and a significantly large provider of health care, the US Federal Government is expected to use its leverage to facilitate the expansion and adoption of IT in health promotion and patient-centred health care (Patel and Ruskefsky, 2014; USDHHS, 2011). Although both the public and the private sectors have contributed to enhancing the implementation of healthcare IT, the involvement of government has triggered widespread adaptation of this technology accompanied by its meaningful use in the health industry.

A classic example of the government’s role in the field of IT in health education is the Federal investment of US$5 million in electronic and mobile smoking intervention initiatives such as Text4Health (USDHHS, 2011). These interactive interventions use the innovative applications of information and communication technology that are commonly used by individuals of all age groups.

Another example of federal role in health care is the Health Information Technology for Economic and Clinical Health (HITECH) Act that was a part of the US Recovery and Reinvestment Act passed in 2009 (Jha et al., 2009). Incentives of approximately US$30 billion were sanctioned in the form of Medicare and Medicaid insurance payments to health organisations that incorporate electronic medical records as a part of their work system (Jha et al., 2009). Not only are they expected to use electronic medical records but also to make a substantial and system-wide transition to this new system. Additionally, the USDHHS Health Resources and Services Administration (2012) states that ‘the Affordable Care Act (2010) will support the adoption and meaningful use of certified electronic health record technology and technology-enabled quality-improvement strategies’ (para 3).

Role of the private sector

Literature presents convincing arguments in favour of private sector participation in improving healthcare access and equity by providing otherwise inaccessible electronic health applications for individual and professional use (Yoong et al., 2010). Additionally, this can allow the government to redirect its focus on incentivising the use of electronic health records in rural and underserved populations (Yoong et al., 2010). Private healthcare software corporations are focused on older adults for programmes such as interactive personal health records, whereas younger populations suffering from chronic conditions are directed towards smartphone health applications and devices (Chomutare et al., 2011; Krist et al., 2014).

Over the last decade, there has been a rapid surge in private eHealth, mHealth and electronic medical record companies trying to meet the expectations of health administrators, healthcare providers and patients. However, the role of private sector in health IT has always remained a debatable issue due to the multiple stakeholders involved and its positive as well as negative impacts on health care. Although the private sector is credited for innovations in electronic healthcare applications that have led to increased access and efficiency in health services, it is also accused of the digital gap in electronic health literacy and the rising costs of health care (Edsall and Adler, 2012; Van Deursen and Van Dijk, 2011; Yoong et al., 2010).

Electronic medical records

Electronic medical records, sometimes referred to as electronic health records, are software programmes used by healthcare providers to store and access patient information on electronic devices in hospitals, clinics or other points of health service delivery. According to DesRoches et al. (2013), the initial trends for the utilisation of electronic medical record systems have shown that the HITECH Act has had a considerable influence on the data recording and storage procedures in certain types of hospitals and other health organisations. These are mainly large teaching hospitals and health organisations situated in big cities.

Statistics show that before the HITECH Act incentive programme was implemented, there was a marginal increase in electronic medical record adoption rates from 9% in 2008 to 15% in 2010 in hospitals, but the number of large urban hospitals with a similar level of electronic medical record systems nearly doubled between 2010 and 2011, primarily because 2010 was the first year that federal incentives were available to the health organisations that adopted electronic medical record (DesRoches et al., 2013). This shows that although overall acceptance of this system is rising due to the incentive programme, more efforts are needed to make this system available to rural areas and small-sized health organisations.

Furthermore, it is important to note that the integration of IT within health care was a big change for health organisations. Just like any other change, it was a shift from status quo and needed financial investments, motivation and preparation work. Hence, it was also likely to face initial resistance from users. However, after realising its utility value, this resistance seems to be fading as more and more health organisations are accepting IT as a vital component of their system (Buntin et al., 2011; DesRoches et al., 2013). This is evident in a meta-analysis of recent studies on utilisation of health IT, in which approximately 92% of the 154 studies showed that the use of IT in health care produced favourable outcomes related to effectiveness, patient and provider satisfaction, accessibility and disease prevention (Buntin et al., 2011).

Personal health records

Electronic personal health records systems have been in use for several years, having recently gained popularity in preventive care (Otte-Trojel et al., 2015). These are web-based tools that store personal health information on electronic devices that is easily accessible to the patient, providing patients with opportunities to access and manage their own health information and thus helping them become well-informed health consumers. Personal health records can have major implications for the self-management of chronic diseases (Mitchell and Begoray, 2010). They combine information from various data sources and software to provide patients with tools to become active participants in their own health care. If integrated with electronic medical records, personal health records systems have the potential to become excellent health resources for patients, providing them with more up-to-date and accurate health information than either of the systems working individually.

Interactive preventive health records are a type of personal health record that has garnered a lot of attention in the recent years. A key feature of this interactive system lies in their ability to allow patients to actively participate in their routine preventive care by interacting with clinicians electronically and often from the comfort of their homes (Krist et al., 2014). This is particularly useful for patients with physical or mobility limitations. Older patients suffering from chronic diseases form the largest percentage of interactive preventive health records’ users, and more importantly, its use doubled the proportion of patients who completed all recommended preventive services (Krist et al., 2014).

Wellness portals are another category of personal health records, often used by insurance companies, employee health departments as well as primary care providers to track the wellness record of patients/employees. Such portals offer screening and resources to identify and support changes in health behaviours such as smoking, diet and physical activity (Berkovsky et al., 2015). Major health IT corporations in the USA have build patient portals and cloud services with an intent to meet the health promotion needs of patients and hospitals in managing huge amounts of healthcare data (Kuo, 2011; Mitchell and Begoray, 2010). This development is another push towards patient-centred health care, whereby patients can be empowered by sharing the ownership of their individual health information and participation in their disease management process.

IT in health education

IT plays an important role in the field of health education. The key areas targeted by IT in health education are the self-management of chronic conditions, prevention, treatment adherence, health-related communication, data collection, remote monitoring and continuing education for staff (Fiordelli et al., 2013). In technologically advanced countries, web-based health promotion approaches are inexpensive to produce and are able to reach a large number of intended populations in a short time span (Cullen et al., 2013).

Apart from electronic gadgets such as activity-tracking wristbands, personal biometric measuring devices and smartphones with wellness applications, specific forms of IT in health education include ‘eHealth’ (where ‘e’ stands for electronic) and, more recently, mHealth, where ‘m’ stands for mobile (Boogerd et al., 2015; Fiordelli et al., 2013). Both of these applications in health care have drastically improved the accessibility and availability of health information. They support a patient-centred model of health care founded on the principles of health promotion. eHealth and mHealth applications have gained tremendous popularity in the USA due to their consumer-oriented approach, convenience, privacy and utility value they offer to health consumers. Also, they are emerging as successful trends with health educators due to the scope and flexibility that it offers to organise, integrate and provide information.

Health coaching

Health coaching assisted by the Internet and telecommunication technology is used in various health and wellness programmes. Internet-based health coaching has shown to improve communication between patients and providers and has also been found to be supplement primary care services for chronic conditions (Leveille et al., 2009). This is an innovative approach with the potential to reach a broad range of target audiences including those residing in underserved areas. It is also cost-effective approach compared to face-to-face health education visits and offers greater scope, convenience and flexibility to both health coaches and patients. However, more conclusive research is needed to assess the contribution of Internet-based health coaching to improving patient outcomes.

Social media

Social media provide a recent addition to the area of health education IT. They are used by many health organisations to publicise their services and to provide health information updates to current and prospective health consumers. Social networking sites have gained tremendous popularity as tools for health communication and community health monitoring because of their capacity to reach large audiences within a short period of time. Nevertheless, user privacy and security of health data remain a matter of concern among health consumers using social media (Li, 2015). Another novel approach to online health education is the use of personal websites and health blogs created by health enthusiasts, health professionals and students. However, readers need to exercise caution in choosing and applying the information found in such blogs for decision-making purposes.

Past, present and future

From the perspective of educators, medical personnel, and patients or health consumers, IT promises to advance the efficiency, accessibility and convenience of data storage features in health care. The adoption of IT in health care has been slow compared to some other fields (e.g. finance and education). However, in recent years, there has been a lot of motivation to expand the role of IT in the health sector because of its ability to allow for a patient-centred approach in health care. The role of Federal Government as the largest purchaser and a considerably large provider of health care has allowed it to heavily influence the decision-making processes related to the use of IT (Jha et al., 2009; Patel and Ruskefsky, 2014).

Since the inception of health IT in the early 2000s, patients have been provided the opportunity to take charge of their health education by enabling easy access to health information ‘including information on their own health, such as diagnoses, lab results, personal risk factors, and prescribed drugs’ (Eysenbach, 2000: 1714). From the perspective of health providers, the Internet allowed them to offer long distance care (e.g. telemedicine) and share electronic links to external information sources including health databases and websites such as eMedicine or those of the US Centers for Disease Control and Prevention for the purpose of patient health education. Thus, IT encourages customisable, patient-centred care and also has the potential to provide patients with the opportunity to receive continuous and uninhibited access to health care while giving them a certain degree of control over their health decisions (Krist et al., 2014). Additionally, it allows tracking of communication between patients and providers. For clinical health personnel, this offers greater accountability and ease of sharing information as required.

Buntin et al. (2011) have found that use of IT increases patient and provider satisfaction as well as the overall quality of health care because it enhances the quality of healthcare services by improving access of health personnel to patient data and by empowering patients to competently manage their own health conditions and correspond with the health personnel. A disadvantage, however, to the electronic sharing of patient information is the issue of online security. Internet hacking and the misuse of personal health data are a major concern if data are not stored or shared properly with appropriate data safety measures.

Although high initial investments, sometimes triggered by the misallocation of financial resources, is a major drawback for incorporating IT in a traditional healthcare setting, the long-term cost-effectiveness that it offers offsets this drawback (Buntin et al., 2011). Initial attempts to implement healthcare IT were often met with resistance from providers, possibly due to lack of time and motivation to give up long-standing conventional modes of practice and adopt new forms of practice that needed additional training and preparation work. Although physicians found the role of IT in health care as valuable, they expressed dissatisfaction with electronic health records due to lack of technical support, high start-up costs and lack of motivation to go through the lengthy training programmes (required for using electronic medical records) that result in short-term loss of productivity (Edsall and Adler, 2012).

From the patient’s standpoint, a major disadvantage of IT in health education is the issue of credibility. Although there are excellent and user-friendly information sources available on the Internet, some sources may be less credible than others. Blogs, personal websites and social networks can make it difficult for patients to screen and choose the most accurate, relevant and reliable information (Minichiello et al., 2013). Patient-centred online health education allows self-directed individuals to choose their pace of learning, relevant content and learning outcomes. The use of online resources can be maximised by optimising website design, interface, reliability of sources and user-friendly and age-appropriate tools (Van der Vaart et al., 2013). However, additional factors to be considered are the computer and health literacy levels of the target audience. To date, many eHealth resources and applications remain underutilised, and more research is warranted to develop proper awareness and education strategies that may improve electronic health literacy and user-friendly application designs (Van der Vaart et al., 2013).

The remote applications of eHealth such as telemedicine can be especially valuable in areas afflicted by shortage of health providers and also for older adults and individuals with mobility limitations. Furthermore, online educational resources such as health information websites have been developed by reputable health organisations (e.g. the World Health Organization and the US Centers for Disease Control and Prevention). These resources bring evidence-based and reliable health information to those interested in health education.

Future trends point towards a heavily digitalised US healthcare system, which will include technology-driven health promotion efforts. The market for patient wellness portals and other personal health record systems is growing steadily in a variety of health settings because of their convenience and potential to increase the use of preventive and other primary care services (Krist et al., 2014). Further research is needed, however, to understand patient use of these portals and their potential to improve health outcomes (Krist et al., 2014; Leveille et al., 2009).

Despite the rapidly growing trend of offering patients online access to their personal health information and health education, health disparities are evident between the ‘haves’, that is, the technologically advanced groups with electronic literacy skills, and ‘have-nots’, which include social and technologically disadvantaged communities (Mitchell and Begoray, 2010). Literature suggests a digital divide between potential used based on differences in literacy skills, digital access, socioeconomic status and demographics (Neter and Brainin, 2012). eHealth literacy programmes may have some potential to reduce this divide and facilitate health consumers to navigate through the complex world of online health resources to maximum advantage (Van Deursen and Van Dijk, 2011). Effective leadership and technologically prepared personnel are needed to successfully implement such IT programmes in health care in countries that can afford them (Buntin et al., 2011; Ohuabunwa et al., 2015).