Abstract
This is an interesting book which unveils various political, social and ethical matters associated with the use of technology for communications between health professionals and consumers. The work is based on a study by the authors to evaluate the claims of health technology supporters and the book is a novel way of reporting their results. West and Miller examined a variety of empirical data sources as well as using a national telephone survey to explore access to, attitudes towards and experiences of health-care technology. Although the book has been written from an US perspective, many of the questions raised about the use of health-care technology pertain to other industrialised nations as well.
The authors cover diverse topics such as online content, the relationship between technology and attitudes to health care, information acquisition and digital medicine. Problems surrounding online content and sponsorship are dealt with in a straightforward manner which highlights the differences between government, commercial and charity (not for profit) health websites. The authors found that commercial websites have more advertisements, more conflicts of interest and inadequate disclosure statements. Reassuringly, publicly-funded websites such as those run by the government offer better accessibility, clear sponsorship statements and appear to have fewer conflicts of interest. The section on equal access is particularly interesting as US legislation has deemed equal access to apply to electronic media as well as to physical structures such as government buildings. Accessibility and usability of health technology as performance indicators suggest that literacy, physical and emotional impairment, financial and social barriers have to be addressed to ensure inclusion for all members of society.
West and Miller provide substantial information to support their premise that health-care technology still has a long way to go before it can be considered part of routine health-care practice. Chapter 3 outlines survey data from the authors' e-health survey of 48 states (1478 responses) in which they found results broadly similar to other studies. E-health surveys indicate that 30–35% of the population access health-care websites. Some 5% of patients use email to communicate with their health-care provider and about 7% renew prescription medications via electronic communication. When we consider that home computers and Internet facilities have been available for some years, then these results are surprising. The other interesting finding of West and Miller's survey was that patients often independently accessed health information on the web as a way to confirm or to seek other information from that which had been given by their health-care provider. In addition, the more that health information was accessed online the fewer were the usual health-care contacts. The authors go on to say that this is completely the opposite of what happens when a health-care provider offers an email service for patients or when patient prescriptions are available electronically. Extrapolating from these results raises a wide variety of questions regarding non-attendance rates, adequacy of information by health professionals, availability of hardcopy health resources, accessibility to information and finally patient health outcomes for people who utilise health information when they have symptoms without assessment by a health professional.
Advocates of health technology often suggest that having ready access to information could improve a person's overall health. To test this concept the authors examined the benefits of information technology on a number of consumer perceptions about health care. Chapter four provides a detailed account of this. The authors conclude that the e-health revolution ‘remains more hope than reality’ and that the digital divide is related to gender, age, education and income which are the same variables associated with poor health outcomes in large epidemiological studies.
The following chapters expand on these disparities, first through the link with language as a barrier, especially for those without English or with English as a second language. Second, the authors describe the characteristics of website users, where the differences between public and private website users make for interesting reading. It appears from West and Miller's research that the better educated user is more critical of access to both public and private websites. Downloads occur more frequently from private sites, which the authors suggest may be linked to a strategy (marketing) related to a unique group of individuals based on certain characteristics.
The final chapters contain an international comparison which highlights the importance of government support for technological advances if technology as part of health care is to be realised. However, I still wonder whether health-care technology in countries where government investment is optimum and where significant support exists will be able to demonstrate a positive change in health outcomes. Also, I wonder whether technology will be able to influence the health of disadvantaged people, especially those who have limited incomes, a low level of education and who are from non-English speaking backgrounds.
The focus of the final chapter is on improving what the authors call ‘digital medicine’ but in reality is the application and interface of health-care technologies with health professionals, their practice and consumers. The central themes are those that should be considered when implementing any new technological strategy or intervention. These comprise improving education, literacy, low-cost equipment, investment in infrastructure, training, and legal, ethical and privacy matters.
West and Miller are to be congratulated on writing a book that is easy to read. The authors raise questions worthy of consideration, especially with the large investment that governments are currently making in technology. Of critical importance are the conflicts of interest and disclosure statements, as well as the need for evidence that health care will improve with the investment in technology. Rapid developments in technology often make equipment obsolete within a short period of time, although the authors do not address this problem. Overall their book will be useful for commissioners of health-care services, health professionals and researchers.