Dissertation - Chapter 1

Tomorrow's leaders in health promotion are being educated at American University today.

CHAPTER I

THE PROBLEM AND ITS CONTEXT

The Health Domain

Introduction to the Problem

The concurrent revolutions that are taking place in the healthcare and technology sectors have been forcing a wide-spread and radical transformation in the way Americans work, live, spend leisure time, and seek solutions to society's most compelling problems. Many Americans consider health and technology the juggernauts of the 20th century in terms of their impact on and importance for the future of society (Boostrom, 1997; Koop, 1996; Newton, 1996). For example, C. Everett Koop stated that the integration of cutting-edge technology will enable great advances in public health (Koop, 1995). Nicholas Negroponte, one of the pioneers of the Information Age, believes that in the new "Digital Age" the importance and potential of technology for the future and in people's everyday lives cannot be underestimated (Negroponte, 1996).

There is ample evidence in the literature to support the predictions that the next generation of advanced information technologies have the potential to make a profound impact in consumer's lives and all areas of healthcare (Science Panel on Interactive Communication and Health, 1999; Street, Gold, & Manning, 1997; Harris et al., 1995). The case for the predictions that is being made by authorities from many domains is based on the health, economic, and social needs, trends, and realities that characterize the American society in the Information Age. While a strong scientific and theoretical case for the importance, value, and future of the best-of-the-breed health-enhancing technologies can be made, there are a variety of reasons why there is a dearth of credible scientific evidence about programs and systems that have made the transition from theory to implementation and testing in the real world.

Unfortunately, relatively little progress has been made in implementing some of the most powerful and potentially useful applications of advanced information technologies for the improvement of health and the quality of life of Americans (Street et al., 1997). While consumer acceptance of technology and the demand for on-line health information and services among many segments of the general population has been high, the information technology (IT) revolution in the healthcare arena has not been universally embraced nor fully leveraged in the same way it is in other sectors of the economy (Intel, 2000; Miller, Brown & Elliot, 1996). Moreover, many of the most promising theories, best practices, and research findings from the health, behavioral, and informatic sciences have not been incorporated into the array of health-related products and services that have emerged during the early stages of this information revolution. Yet, there are many reasons why everyone who has a vested interest in health should begin to think of how IT could be integrated into every aspect of the healthcare process (Harris et al., 1995). Many of the issues, opportunities, and implications of health-promoting technologies will be presented during the course of this study.

Many experts have stated that the next generation of health-promoting technologies that will feature state-of-the art information systems should be developed and made accessible to all Americans (Department of Health and Human Services, 1997; Gustafson, 1997). The impact of these sophisticated intelligent systems, if they were deployed on a population-wide basis and across the full spectrum of care, would result in enormous improvements in the health status and quality of life for all Americans and institutions at many levels (Moynihan, 2000; Velicer & Prochaska, 1999; University of Wisconsin-Madison, 1998; Chapman, 1997; Alemi & Higley, 1995).

The purpose of this study is to explore how state-of-the-art IT systems can be developed for the enhancement of the health and well-being of Americans. The goal of this study is to produce a design and a conceptual framework for a model informatic system that can lead to improvements in the health status of individuals as well as a reduction of the economic burden on organizations and the society as a whole. Although this study covers a broad spectrum issues that cross multiple domains, the four primary audiences for this report are:

health practitioners and agents of care who need to seek innovative ways to improve their level of service, effectiveness, and performance; to be aware of the issues, trends, and perspective in the information technology sector; to be cognizant about how technology can facilitate the behavioral change process, and to assume an active leadership role for the adoption and integration of technology into the healthcare process,
developers and informaticists who need to fully understand the underlying theories, models, and concepts of behavioral change as well as the mindset, thought processes, and working environment of consumers and healthcare professionals so that they can design the best and most appropriate systems for each user group,
researchers who need to understand the issues of each of the domains so they can develop evaluation techniques and conduct investigations that are appropriate for this new domain, and
consumers and institutions who need to be informed and really understand what they are getting and how to choose what is best for them.

This study will make a significant contribution to the body of science in each of those areas because of the unique nature of the study design and the "big picture" or systems approach that was used by the researcher. An outcome of the Systems Development Life Cycle (SDLC) and systems modeling process will be a conceptual framework that those working in their own field of expertise can use and improve upon.

The remainder of this chapter will be divided into eight sections. The first section will feature a discussion of the problem. The context of the problem will be defined in the second section. Six key criteria for a model informatic system will be presented in section three. A brief overview of the key issues for information and health informatic systems will be covered in the fourth section. A discussion of the research objectives and other aspects that are related to this particular study will be included in the final four sections.

The Problem: Lifestyle Choices That Compromise the Health Status of Americans

When asked to list the most important things in their lives, most Americans rank health among their top priorities. It is generally agreed that the preservation of good health and the pursuit of a high quality of life are among the most essential human needs. However, in the complex and fast-paced world that typifies the American culture, competing priorities and demands such as work, family, and responding to the pressing issues of the day often divert people's attention from attending to their health needs until there is an overt problem or symptom. Moreover, the level of health literacy in America is alarmingly low (Williams et al, 1995). Consumers do not feel that they have the right tools that they need to control their health (Ratzan, Filerman, & LeSar, 2000; Eng et al., 1998; Center for the Advancement of Health, 1994).

There are many conflicting points of view about the complex issues related to the quality of life and health status of Americans. For example, a 1998 Gallup poll and recent Centers for Disease Control (CDC) data found that 85% - 86% of Americans are generally satisfied with the state of their health and well-being (Newport, 2000; National Center for Chronic Disease Prevention and Health Promotion, 2000). However, some researchers have described the environment most Americans live in as "toxic" (Nestle & Jacobson, 2000). In fact, a series of recent reports on the levels of physical inactivity, obesity, substance abuse, and stress have concluded that Americans are at great risk for premature morbidity and mortality because of their contemporary lifestyle choices and health habits (United States Department of Health and Human Services, 2000a; Allison et al., 1999; Pate et al., 1995; Hahn et al., 1990).

The relatively poor health status of the majority of Americans, despite the abundance of health, medical, and economic resources, is very perplexing. It is an enormous problem for individuals and the nation as a whole. Some of the answers to this paradox are found in the literature. For instance, in 1993, McGinnis and Foege published a landmark article on the relationship between health and lifestyle choices. After reviewing the death certificates of Americans from 1977 to 1993, they discovered a statistical relationship between all-cause mortality and lifestyle factors in 50% of the cases (McGinnis & Foege, 1993). They concluded that if individuals adopted more proactive and health-enhancing habits and lifestyles choices, the risk of premature morbidity and mortality would be reduced substantially and the overall quality of life of Americans would be improved.

There are many important questions associated with the complex relationship between lifestyle choices and health. For example, is it more a motivational, physical, social, environmental, or genetic problem? Second, should it be viewed as more an individual, community, population-wide, or public health problem? Third, on whom should the onus for change be placed? Fourth, how and by whom can the problem best be addressed?

In this study, the problem is viewed as the poor health habits and lifestyles choices of Americans individually and collectively. The solution to the problem is presented in the context of the questions that were posed in the previous paragraph as well as some of the sections below. The research problem for this study deals with how an information technology system can be designed in the most effective way so that it can help people and organizations improve the health and quality of life of all Americans by influencing their lifestyle choices and moving them in the direction of optimal health and well-being. These topics are developed more fully in the sections that follow.

The Health Problem: Its Context

The health problem in America can be examined from multiple perspectives. In this study, the problem is framed within a particular context that is described in the four subsections that follow. As was stated previously, the problem in this study emanates from the poor health habits and lifestyle choices of Americans. The consequences of the health problem are manifested in many ways including the health status and quality of life of individuals as well as in the population as a whole. The discussion of the context will begin with a definition of health.

A Definition of Health

A variety of definitions of health are found in the health, medical, and lay literature. Many of these definitions have often evolved or changed over time for various reasons. A more detailed discussion of the issues and reasons has been provided in the literature review and in excellent texts by Glanz, Downie, and the Healthy People 2000 document.

The profession of those who practice, perform, or provide health-related services is often a very influential factor in the context of how health practitioners choose to define health. In fact, until the middle of the 20th century, it was common for most health practitioners as well as the general population to view health as merely the absence of outward signs or symptoms of disease or illness (Bowling, 1991). Using that definition medical and health practitioners reserved most of their attention and treatments for patients or clients who presented as "sick." Moreover, patients generally didn't seek medical services until they were "sick."

In 1946 the World Health Organization (WHO) adopted a more positive and all-encompassing definition that considers health as a dynamic state of complete social, psychological, and physical well-being and not merely the absence of disease or infirmity (WHO, 1951). This new definition of health called for a radical transformation in how individuals viewed their own health as well as for all of the practitioners who tend to the health-related needs of those under their care. In the United States, this reconceptualization of health has been adopted slowly and unevenly within the health professions and throughout the general population.

Several theorists and professions embraced the new WHO conceptualization of health and offered expanded definitions from the original version. For example, in 1986, O'Donnell offered one of the earlier operational definitions. He encouraged professionals to practice health promotion as a "science and art of helping people change their lifestyle toward a state of optimal health" (O'Donnell, 1986a). In 1989, O'Donnell added the concept of balance among the dimensions of health as well as the principles and components of a health-enhancing environment to his definition.

O'Donnell's full conceptualization of health (Chapter II) is used as the working definition of health in this study. His multidimensional definition can be applied equally well to multiple stakeholders including individuals who seek to improve their health, practitioners who minister to the health needs of those under their care, providers who develop or dispense products and services for consumers, and organizations and governments who are responsible for the healthcare of their constituencies.

The Scope and Severity of the Problem

A general discussion of some of the main points related to the scope of the problem are addressed in this section. The incidence, cost, and some of the key points from several perspectives of the entities along the health supply chain are among the topics covered below. Extensive background information and more detailed coverage of these topics are provided in Chapter II and in excellent resources such as Healthy People 2000: National Health Promotion and the Morbidity and Mortality Reports and the Behavioral Risk Factor Surveillance System from the Centers for Disease Control Disease Prevention.

Three parameters have been established to frame the discussion and to define the scope of the health problem. First, in this study, the primary focus will be on those actions that can be taken to influence the state of one's health. Primarily, this is because lifestyle behaviors, which can be directly controlled and changed by individuals, account for over 50% of the incidence of premature morbidity and mortality in the United States (McGinnis et al., 1993). Although, genetic interventions, medical procedures, and medical technology are powerful and important, they are beyond the range of the types of lifestyle changes that can be used to enhance the health of individuals, communities, and organizations.

Second, the scope of healthcare spans multiple disciplines. The condition of ones health is vitally important to every individual. Moreover, the health of individuals has implications for every family grouping, community, and organization in the United States. Everyone, from "womb to tomb," is actually part of a vast, complex, and interrelated healthcare supply chain.

Third, with the working definition of health for this study, it is important to remember that health issues and treatment do not merely begin when a person feels sick or reports to a health practitioner with a concern. The attainment of or movement toward optimal health lasts throughout an entire lifetime. Therefore, although it is more difficult to measure "positive health," it is useful to view health on a continuum.

The Health Continuum Figure 1

The ultimate goal of health interventions is to move toward an optimal state in all of the dimensions of health and push treatment "upstream." Ideally, everyone strives to become a truly healthy individual, one who strives for optimal health and quality of life. Finally, it is important to note that it is the responsibility of practitioners and the entire healthcare system to support the attainment of that goal.

The Health Statistics

An abundance of staggering and alarming statistics are available to illustrate the magnitude, pervasiveness, and consequences of ill-health. For example, in 1998 the total healthcare expenditure for the United States was $1.1 trillion dollars and the yearly growth rate was 5.6%. Moreover, that amount is expected to double to $2.2 trillion by 2008. In America, for the year 1998 an average of $3,925 or 13.5% of our gross domestic product (GDP) was spent on each person on healthcare, the highest percentage in the world (Health Care Financing Agency, 2000 http://www.hcfa.gov/hipaa/hipaahm.htm). However, the new Medicare Trustees' Report of 2000 projected that in 75 years the percentage will rise to 30% of the GDP (United States Department of Health and Human Services Office of the Assistant Secretary for Planning and Evaluation http://aspe.os.dhhs.gov/health/medpanel). Further, in 1998 there were over 100 million Americans with at least one chronic condition, and in 2000 the projected cost of chronic care will be $503 billion (Robert Wood Johnson Foundation, 1998). Yet, these cost statistics reflect only a portion of the hardship due to ill-health, since many ailments are handled outside the healthcare system, and the real estimates of lost productivity, happiness, and the burden of suffering associated with illness are in many ways incalculable.

Equally staggering estimates have been offered to describe the size of the potential market and the possible or projected savings that could accrue from information technology-related advancements in healthcare. For example, Gates stated that a 20-30% savings on each dollar could be achieved by integrating information technology into healthcare (Gates, 1999 p. 335). Moynihan suggests that $125 million per week could be saved if standards that are already available today were employed for electronic transactions (Moynihan, 2000 http://www.themcic.com/industry/ehealth.htm). The Forrester Research Group projects that the healthcare e-commerce market will reach $370 billion by 2004 (Forrester Research Group, 1998 http://www.forrester.com/Research/Datainsight/0,1039,3850,00.html).

A comprehensive record of the leading causes of death and the incidence of chronic illness in the United States is available through the National Center for Health Statistics' morbidity and mortality statistical databases (National Center for Chronic Disease Prevention and Health Promotion, 2000). For example, according to the death certificates in 1990, the five leading causes of death were heart disease (720,058), cancer (505,322), cerebrovascular disease (144,088), unintentional injuries (91,983), and chronic lung disease (86,679). However, McGinnis stated that the real causes of death that are directly attributable to lifestyle choices in 1990 were tobacco (400,000), diet/activity patterns (300,000), alcohol (100,000), microbial agents (90,000), and toxic agents (60,000) (McGinnis, Deering, & Patrick, 1995 p. 130). Moreover, McGinnis pointed out that although over 50% of the real causes of death are preventable, less than 5% of the annual budget for healthcare costs are devoted to programs that are designed to reduce the burden that is caused by health-compromising lifestyle choices. In a more recent report that was published in 2000, the Center for Advancement of Health estimates that 70% of the healthcare spending in the United States could be saved by modifying behavioral risk behaviors (Center for Advancement of Health, 2000c p. 4).

Recent epidemiological evidence from the CDC reveals a rise in the trends toward ill health for medical conditions that can be reduced by lifestyle changes. In 1996, for example, 960,000, or 40% of all of the deaths in America, were due to cardiovascular diseases. An estimated 58 million Americans, almost one-fourth of the nation's population, live with some form of cardiovascular disease. The estimated cost of cardiovascular disease in the United States in 1999 was $287 billion due to healthcare expenditures and lost productivity (Centers for Disease Control, 2000 http://www.cdc.gov/nccdphp/brfss/at-a-gl.htm).

Statistics about specific health conditions and lifestyle choices such as physical activity, diet, and nutritional habits provide additional documentation of the health-compromising trends and behaviors of Americans. For example, Pate found that an estimated 250,000 deaths per year in the United States are attributable to a lack of regular physical activity (Pate et al., 1995). In 1998 it was estimated that 67% of the population was inactive, and between 27% and 31% were totally sedentary (United States Department of Health and Human Services, 1998). In Washington, DC, 49% of the population was totally sedentary (Stephens & Caspersen, 1994). Moreover, of those individuals who begin a formal exercise program, approximately 50% drop out within the first three to six months (Dishman, 1988).

A CDC report examined the economic implications of physical inactivity. The CDC estimated that in 1989 the cost of physical inactivity in the United States was $5.7 billion and 35% of the "excess" coronary heart disease occurred among persons with sedentary lifestyles (Centers for Disease Control, 1993). More recently Colditz placed the direct economic burden of physical inactivity at $24 billion for 1995 (Colditz, 1999). Keeler estimated that the cost of a sedentary lifestyle was $1900 for each individual in the United States (Keeler, Manning, Newhouse, Sloss, & Wasserman, 1989). Further, Pronk estimated that the excess costs to healthcare organizations for physical inactivity, obesity, and tobacco use was $172 per year per participant (Pronk et al., 1999).

The second area, diet and nutrition, has implications for an array of health conditions. For example, Americans spend $33 billion on the diet industry annually, yet over 50% of the US population are classified as obese, overweight, or susceptible to the comorbidities that are associated with obesity (Bierut, 2000; Allison, et al., 1999). Allison and his colleagues studied the annual death rate due to obesity. They found a conservative estimate of 280,000 deaths per year (all subjects) and 325,000 (for non-smokers) due to obesity. Mokdad found that 6.8% of the healthcare costs are attributable to obesity-related morbidity in the United States (Mokdad et al., 1999). In fact, the CDC estimates that reducing the fat intake by 1% to 3% would reduce the overall incidence of coronary heart disease by 32,000 to 92,700 cases and produce a savings of $4.1 to $12.7 in medical and productivity costs over 10 years (United States Department of Health and Human Services, Centers for Disease Control and Prevention, 1999).

Another useful technique for understanding the context and scope of the health problem is to use an international view of the dynamics of health. For example, the average country spends $1,728 per person on healthcare, compared to $3,925 in the United States (Health Care Financing Agency, 2000). By comparing the relationship between the amount of money spent on healthcare and longevity in the United States with some of the industrialized European nations, researchers have been able to dispel the myth that healthcare spending is directly related to longevity (Table 1) (Reddy, 1996).

Table 1 Health Expenditure in Gross National Product (GNP) and Life Expectancy

Life Expectancy in 1991

Country %GNP Devoted to Health - 1991 Males Females

American 12.7% 72 79

Germany 8.0% 73 79

Great Britain 6.1% 73 79

Switzerland 7.5% 75 83

The economic luxury and high levels of discretionary income of industrialized nations allow them more flexibility in allocating their resources. However, health-related conditions and diseases that are directly attributable to the lifestyles of affluent societies often consume the majority of those resources.

The magnitude and impact of the health problem has implications for individuals as well as providers at multiple levels including organizations, communities and governments. The motivating forces for addressing the health problems range from bottom-line business and economic factors to humanistic reasons. The health strategies that individuals and agencies choose to address the health problems have important implications throughout the healthcare supply chain. Three of the most prominent health models that have been used throughout the healthcare system to address the needs of Americans are presented in the next section and are summarized in Figure 1.

Three Major Health Models

A variety of strategies and models have been used to address the health needs of Americans. It is important for each of the primary audiences for this study to understand the models and how they influence the context in which healthcare is dispensed. The traditional medical, public health, health education, health belief, health promotion, disease management, evidence-based medicine, population-based, and ecological health models were among the most widely accepted during the 20th century (Glanz et al., 1996). Traditionally, healthcare providers, agencies, and practitioners have based the programs and services they offer to individuals, groups or targeted populations on one or more of these models. How the health problem is viewed, the approach to treatment, and the measures of success often differ substantially from model to model.

Three of the most prominent models have been chosen for this study to illustrate the differences in approaches to addressing the health problem in America. A superficial summary of the three models and the healthcare context in which they are implemented will be provided in this section and the one that follows. The models will be compared and contrasted on the basis of six criteria that are germane to this study. A more in-depth discussion of the models is provided in Chapter II.

The Traditional Medical Model

The oldest and most prominent health model is the traditional medical model. It forms the foundation of the healthcare system in the United States. The medical model is a physician-centric model where the doctor is the focal point of care. Patients come to physicians to be treated for diseases and ailments, for rehabilitation, and occasionally for preventive services. Doctors may request a variety of additional services for their patients. Physicians have linkages with other healthcare practitioners and agencies across the healthcare system. However, the doctor is commonly the one who controls the access to all of the services in the spectrum of care.

The medical model is primarily a reactive model. The majority of care is dispensed in response to a visit to a medical facility by an individual. Individuals ordinarily initiate the visit and they are usually treated face-to-face and one at a time. Comprehensive and prospective treatment with patient education is rare. The course of treatment generally ends when the presenting condition is resolved or palliated. The medical model is often referred to as "sickcare" as opposed to "healthcare" (Health Enhancement Systems, 2000).

The Public Health Model

In the second model, public health programs and services are most often dispensed through population-wide strategies. Public health agencies and practitioners are generally funded by governments or non-profit entities that operate in communities or defined geographical areas. Public health programs and services may be either proactive or reactive. Most clients are served when an agency initiates contact through proactive targeted campaigns or programs. However, clients may initiate an interaction by accessing services through facilities such as clinics. Public healthcare workers frequently reach their clientele through outreach programs that are often delivered in community settings. Although health education is a key element in the public health arsenal, a great deal of the resources are devoted to containing or eradicating disease, inoculating those who might be a high priority or at high risk for a targeted health condition, or through surveillance systems. Clients often have multiple short-term points of contact with teams of providers. Campaigns are frequently delivered through mass-media channels and they often focus on raising awareness, influencing attitudes, or developing knowledge. One of the goals of public healthcare workers may be to help their clients develop self-sufficiency, life-skills, and support networks.

The Health Promotion Model

The third model shares some of the techniques and strategies with the first two models; however, the health promotion model has a very different orientation in many respects. A few of the most important principles of the model are highlighted below. First, the health promotion model is client-centered. The individual is ultimately and primarily responsible for his or her health. Health promotion programs, practitioners, and providers strive to empower the individual. Optimal wellness is at the core of the health promotion model. As was stated previously, the real goal of health promotion is to strive for optimal wellness, balance in all of the dimensions of health, and to create a health-enhancing environment. Health promotion efforts are designed to push all "treatments" upstream (Orleans et al., 1999). Treatment is really a continuous multidimensional process that extends throughout all stages of a lifetime. Therefore, it can be said that health promotion goes beyond prevention.

Health promotion programs and services may be sponsored by a variety of providers including health and medical practitioners, public health entities, individuals, groups from the private sector such as employers, or by businesses such as health clubs. The interventions may be offered in a range of public or private settings such as businesses, at work, school, or home. Educational, skill building, lifestyle, and support programs and services are delivered through a variety of mediums and channels including person-to-person, in groups, and through mass media. Health promotion messages may be "broadcast" in multiple formats or tailored to the unique preferences of each individual.

The motivation and incentives for individuals and groups to pursue or deliver health promotion services are varied. Individuals may be motivated by a variety of personal, health, or economic reasons for addressing their health needs as they see them. Organizations may have a personal or population-wide investment in the health of their constituencies.

Many health promotion practitioners are aware of and are willing to use multidisciplinary approaches and tools in their programs. Since behavioral scientists have known for over 40 years that just providing information to individuals is not the most effective way to help people in their quest for healthier lives, health promotion professionals may use more eclectic approaches (Strecher, 2000). Many health promotion practitioners have become advocates for and are incorporating the best practices of the behavioral sciences and they are basing their programs on powerful models such as the Transtheoretical model and the Proceed/Precede model, since these models are congruent with the health promotion theory (Smedley, & Syme, 2000; Glanz et al., 1996). Moreover, they are designed to maximize the potential for behavioral change at an individual or collective level.

In summary, the context, goal, and means of addressing the health needs of Americans differs substantially for each of the models. Practitioners and program designers must understand the implications of using and the differences between the models as well as the different advantages and disadvantages of the solutions they choose for addressing the health needs of their constituencies. However, Lasker makes a strong case for a health promotion approach in the following quote from his report, Making the Powerful Connection: The Health of the Public and the National Information Infrastructure.

Only about 10 percent of all early deaths in this country can be prevented [once disease occurs] by medical treatment. Population-based approaches have the potential to prevent 70 percent of premature deaths thorough measures that target underlying risk (Lasker, 1995 p. 1).

A brief discussion of six criteria that are important for the context of health promotion programming is presented below.

Key Criterion and Aspects of the Health Models

A brief discussion of the three health models, from a short list of key criteria that are relevant to the nature of this study, will be presented below. The six criteria that were culled from the literature and organized in Table 2 were selected because of their relevance to the three health models, the problem and its context, and their implications for designing effective technology-based solutions that can address the problem. The discussion that follows will provide greater clarity about the characteristics of the three models and how they are being conceptualized in this study.

The first criterion in the table illustrates how the models differ on several dimensions with respect to the goal and philosophy. First, the models differ on the basic concept of health. They range from disease or sick free in the medical and public health model to the continuum of health and optimal wellness for the health promotion model. The second, third, and fourth criteria relate to treatment. The medicine model is predominately curative and downstream. The public health model may be treatment or preventive and either down- or upstream. The health promotion model emphasizes total wellness and strives to push treatment upstream.

The third dimension of the philosophy of the models provides a key point of contrast. In medicine, treatment generally focuses on one manifestation of an illness at a time, while the health promotion model emphasizes a multidimensional approach. Because public health campaigns often view health through an environmental perspective, they may be considered multidimensional. In health promotion, the increased use of sharing and monitoring data and the emphasis on using best and evidence-based practices is a contributing factor to the greater dimensionality of the model.

The second criterion listed in the table summarizes the onus of responsibility in the model. The medical model is a physician-centric model, because most physicians see themselves as primarily responsible for the health of their patients who seek or "pull" their services. By contrast, in health promotion the responsibility for health rests on the individual. Health promotion practitioners may employ a mix of push and pull strategies. They often develop collaborative relationships with people by seeking out individuals or groups and strive to empower them and promote their adoption of healthy lifestyles and behaviors. In public health, the "push" approach and responsibility for providing services is common.

The approach to treatment is the third criterion from the table where there is a great deal of variability between the models. Health promotion is founded on a proactive philosophy while medicine is predominately reactive. Medical conditions are generally treated as episodes of illness in medicine and public health while lifetime health and wellness are stressed in the health promotion model.

Programming and materials used is the fourth area where the models vary greatly. In medicine most of the initial treatments are dispensed through one-on-one sessions in doctors' offices. Instructions are given verbally. Additional information may be provided in the form of some generic print materials. Public health and health promotion programs often use a mix of one-to-one counseling and group interventions.

Table 2. Key Criterion for Three Major Health Models

Criterion Medical Public Health Health Promotion

I. Goal and philosophy 1. A well/disease-free patient.2. Cure sickness/ palliate. 3. Unidimensional treatment.4. Downstream. 1. A well/disease-free individual/ community/ nation. 2. Prevent, eradicate, inoculate, and monitor. 3. Occasionally multidimensional health. 4. Often upstream. 1. Optimal wellness and quality of life for individual and health-enhancing environment. 2. Empowerment and proactivity. 3. Multidimensional health. 4. Evidence-based concepts. 5. Predominately upstream.

II. Responsibility for health 1. Primarily the physician then the individual 1. Primarily the agency then the individual. 1. Primarily the individual then the provider of the service.

III. Approaches to treatment and interventions 1. Treatment of disease or condition until symptom free 2. Reactive 3. By episode. 1. Programs and campaigns for specific conditions until goal is met. 2. Pro and reactive. 3. Short-term. 1. Proactive programming for multidimensional health with emphasis on lifelong behaviors.

IV. Programming and materials 1. Primarily person-to-person contact with oral recommendations and generic print materials. 1. Generally targeted group programs with oral education and generic print material. 1. Person-to-person and group programs.2. Interaction, multimedia and tailoring are encouraged.

V. Settings for treatment or intervention 1. Generally in physicians office, hospital, or clinic. 1. Usually in community or through agency office. 1. Various, such as work/school, home, and the public domain.

VI. Provider collaboration and linkages to support networks 1. Multiple providers are rarely linked. 2. Support networks occasionally involved. 1. Multiple agencies and providers may collaborate. 2. Support networks occasionally involved. 1. Linkages among providers and support networks are encouraged.

The use of generic print materials is common in all three models; however, greater efforts are being made to incorporate multimedia materials and even customize or tailor materials and programs to the unique characteristics of an individual or a specific-target population in health promotion programs. Because the goal of most public health programs is to reach large audiences, tailoring is rare.

The primary or traditional setting is the fifth area where the models differ greatly. Public health and health promotion programs are offered in a wide range of settings; however health promotion programming has expanded into several strategically important public and private service areas including the workplace, easy access venues, and even over the Internet. Medical practice is generally conducted in a very limited number of traditional settings such as physicians' offices, clinics, and hospitals.

The final criterion in the table where the models differ is the types of linkages and networking that are used. Medical treatment is often described as "islands of information." All aspects of the medical encounter are held closely by the physician. If additional specialized care is needed, the patient and part of his or her medical history may be passed on to a specialist. The support network of the patient may be involved to assist in the care of the individual. In public health, dynamic linkages with other health entities are much more common, and group support networks may be encouraged. Linkages with other healthcare entities and the involvement of support networks are encouraged in health promotion programs, however the linkages are often less formalized. This is particularly true of programs in worksite settings.

In summary, each of the differences and nuances between the models have very important implications for the types of programs and services that are available for individuals and populations who want to address the health problems as well as the context in which they are delivered. Certain attributes of these models have become defining boundaries for what is commonly done or even possible. Some of the attributes of the models have become distinguishing characteristics or barriers for individuals and organizations that are trying to find ways to integrate information technology into all avenues of the healthcare delivery system. Many of the issues that have implications for the use of information technology as a means of assisting, facilitating, or supporting health-related lifestyle change will be explored in greater detail in the sections that follow.

The Technology Domain

Introduction to Technology

Technology, the other juggernaut that is at the heart of this study, is a phenomenon that has impacted or revolutionized every aspect of life in the United States. Some of the most profound and unprecedented advancements in technology and IT in particular have occurred during the last half of the 20th century. In fact, during the last half of 20th century most of the developed nations made the transition from the Industrial Age to the Information Age (Quinn, 1997). Advancements in technology have made it possible as well as practical to collect, analyze, produce, and distribute information and knowledge, which is the fundamental element as well as the key to advancements in the Information Age.

The focus of the previous sections has been on the problem and its context. In this section, the discussion will be devoted to key aspects of IT as a solution that can be applied to the health problem in America. The first part of this section will cover the key definitions of technology. The second part will include a brief description of the types of modern information technologies that can be applied to the health problem as it has been defined for this study. An abbreviated discussion of the differences and some key points related to the generic and advanced information technologies when they are applied within a health promotion framework will be featured in the third section. In the fourth section the concept of health promotion informatics will be elaborated upon.

Technology Definitions

Today in the computer world, when most people refer to technology they actually mean information technology. However, scientists, engineers, and researchers such as Everett Rodgers point out that there is also a great deal of knowledge and understanding that is associated with the development, functionality, implications, and context of technologies (Rogers, 1995). Rodgers prefers a broader conceptualization of technology to include other aspects, which he refers to as the "software" of the technology. He states that the full power of computer and information technology can only be fully exploited or optimized when the hardware and the software are both present and working in tandem. Although this study is focused on information technologies, that broader conceptualization of technology will be maintained throughout this study.

A variety of definitions of IT can be found in the literature. For example, Held defines IT as "the technology of data processing and information management, telecommunication, and data management" (Held, 1995 p. 113). As the name implies, IT is very information or data-centric. Moreover, Held's definition incorporates the field of telecommunications and implies that there is a science related to the management of the data. Although not mentioned specifically, the definition certainly is meant to include the field of computer science which is generally regarded as the third cornerstone in the IT triad. This working definition encompasses and is sufficient to describe the bulk of the generic information technologies that will be referred to in this investigation.

Informatics is an essential term in this study. Several key elements that are essential for a full representation of the type and scope of modern advanced information technologies that were envisioned for the model system design, are missing from a strict interpretation of the definition IT.

The Pan American Health Organization defines informatics as "an umbrella term used to encompass the rapidly evolving discipline of using computing, networking, and communications -- methodology and technology -- to support health related fields" (Pan American Health Organization, 1998 p. 3). This definition has a broad scope that reflects the multidisciplinary nature of informatics. Many authors consider the best applications of informatics to be a balance of the technical applications of the information sciences and the artful design and implementation of those methodologies. In short, informatics can be described as the art and science of IT.

In this study the term informatic systems will be used to make the important distinction between generic task-limited IT systems and the advanced informatic systems that are designed to and embody the full spectrum of IT-related disciplines and exploit them to the fullest extent. By definition, advanced informatic systems exemplify the best-of-the-breed as well as next generation technologies and designs. In short, the informatic systems are based on state-of-the art research and theories from multiple disciplines including the information sciences as well as the field of human-factors research, and the behavioral and social sciences.

Modern Information Technology

Three major technical areas have merged to form the modern discipline of IT. In the earliest days, the computer and information sciences were the foundational elements of the IT domain. However, since the telecommunication sciences merged with the other two domains, the field of IT has taken on an entirely new dimension. The synergy that developed through the merger of these three fields has fueled a radical transformation of the electronic information industries. The sophistication of the existing technologies grew exponentially and spawned new and emerging technologies that have diffused rapidly throughout all sectors of the economy as well as the non work-related and discretionary computing market.

The modern IT environment features relatively stable operating systems that are comparatively easy to use and that can generally communicate with each other on a consistent basis. In the United States many areas of the economy are becoming increasingly data and information intensive, digital, and dependent on IT. The information technologies have achieved a critical mass, are relatively cheap, and developers and users have found a full array of useful, recreational, as well as malicious purposes for them (Ernst & Young LLP, 1996).

Traditional/Generic and Advanced Technologies

Classification schemes, such as the example offered below in Table 3, can be used to distinguish between the traditional/generic and advanced types of information technologies. However, developing stable taxonomies for traditional/generic and advanced technologies is problematic for several reasons. First, the class and characteristics of technologies vary greatly according to which perspective or set of criteria that are being used. Second, the rapid pace of change of technology means that what is considered advanced today may be redundant or mundane tomorrow. Third, because of many factors including the overlap of technologies between two or more disciplines, there are many gray areas within any classification scheme.

This table is being offered as an example of how the key attributes might vary from the traditional/generic to advanced technologies. These characteristics were chosen to illustrate some of the differences in features and capabilities of the type of system that is envisioned for the design portion of this study. In Table 4 and the section that follows these attributes will be explored in the context of the health promotion model and a health informatic system.

Table 3. Sample Classification Scheme for Technologies

Traditional/Generic IT Advanced Informatic Systems

System centric default interfaces User Centric learns user preferences

Changeable adaptable Dynamic, intelligent, self-changing

Compatible components Seamless and fully interoperable

Networkable and able to communicate with other systems Fully integrated in all dimensions across entire value chain

Push or pull It knows and uses the best tactic

Multiple devices and technology windows can plug and play Flawless variable interface exchanges with any digital device

Adjustable settings for improved performance The system modulates itself to optimize performance

Extensible Morphs to changing conditions

Reusable parts and code segments Object-oriented technologies

Primarily text based on screen and print Mixed and multimedia for input and output

Use of and access to databases Array of knowledgebases and data mining

SQL Fuzzy logic and neural networks

Health Promotion Informatics

There are a variety of informatic domains that have specific areas of concentration for some health-related fields. For example, medical informatics is a well-established field that deals with the medical and clinical aspects of health as well a variety of other processes in the medical and healthcare sector. Other areas of concentration include public health informatics, which combines two domains for the benefit of healthy communities (Friede, Blum, & McDonald, 1995). Consumer health informatics is designed to "support consumers in obtaining information, analyzing their unique healthcare needs, and helping them make decisions about their own health" (U. S. General Accounting Office, 1996 p. 1). Warner uses the term "interventional informatics" to describe the application of IT to improve the quality of life individuals (Warner, 2000 http://www.pulsar.org/febweb/papers/globalmed.htm).

In this study the term health promotion informatics is used to describe the development and application of informatic systems that are based on health promotion concepts for the improvement of the health and quality of life of individuals and groups of various sizes. The three main areas within the health promotion informatics domain are informatics, health promotion, and the behavioral sciences.

In Table 4 the attributes listed in Table 2 from the health promotion model have been extended into the domain of information technology. Some of the key differences between the traditional/generic information technologies and advanced informatic systems have been highlighted.

Table 4. Attributes of Health Promotion Model Applied to Traditional/Generic Information Technology and Advanced Informatic Systems

Attributes of Health Promotion Traditional/Generic Information Technology Advanced Informatic Systems

I. Goal 1. Empowering - The user learns and uses the system and adapts to the interface. 2. System-centric. 1. Optimizing The interface and intelligent dynamic system continually adapts to the user. 2. User-centric.

II. Responsibility 1. Individual. 2. The user generally initiates actions. 3. The user seeks programs and services. 1. Collaborative. 2. The individual is in control but the system and agents adapt to and anticipate needs.

III. Treatments 1. Most services are "pulled". 2. Interactions and preferences may be retained between sessions. 3. Feedback optional. 1. Services are often "pushed". 2. Interactions are cumulative and lifelong. 3. Feedback loop embedded.

IV. Programming and materials 1. Generic printware through individual sites and portals. 2. Some multimedia. 1. Interactivity and tailored programs and services for each interaction based on knowledgebase(s).

V. Settings and access 1. Universal access. 2. Technology windows rarely linked. 1. Ubiquitous access. 2. Seamless fully- integrated access channels and technology windows.

VI. Provider linkages and support networks 1. Providers and sites may be linked but rarely share data. 2. Minimal use of support networks. 1. Providers and sites are fully integrated and exploited. 2. Support networks encouraged and integrated.

The first attribute of the model in the list in the table is related to the goal of health promotion. Health promotion practitioners and programs aim to develop empowerment and optimization among the users. Any IT system can be empowering. However, a system that is based on user-centric concepts can be more easily optimized, matched, or tailored for the user if the historical user profile follows the user or the system can access their personal preferences usage patterns (Joachims, Freitag, & Mitchell, 1997). Moreover, they have a greater potential for promoting change and repeated use by individuals and groups (Warner, 2000; Shneiderman, 1998).

Responsibility is the second area of importance in the table. In the traditional/generic systems the user must guide and is expected to initiate all of the interactions. The user must know all of the capabilities of the system as well as where to access or how to find the resources that can benefit him or her to the greatest extent possible. Advanced systems can be designed so that the user maintains full control of the system; however, artificial intelligence techniques, knowledge bases, and user, collaborative, and predictive networking systems are available to help maximize the experience of users and the optimize quality of the output from the system for each user.

The types of treatment is the third area of importance. In the traditional/generic systems most services are "pulled." Some of the information about the session may be retained and feedback may be captured. The advanced technology systems feature mechanisms that provide either push or pull treatments depending on the situation. Information from previous experiences with the system and continual feedback loops can be embedded in the system. These concepts allow all interactions to become part of a lifetime record or history that the system leverages for the benefit of the user.

The fourth attribute is related to the type of services, programming, and materials presented by the system. The majority of the output from traditional/generic systems is in the form of text-based displays on the screen or print materials. The use of sound and video are increasing; however, they are relatively limited and unsophisticated. In advanced systems, full interactivity and multimedia are encouraged by matching the output to the profile and needs of the user. Content data, information, and resources for the users are available through knowledge bases that contain warehouses of materials in a variety of formats and are delivered through interactions that are facilitated by intelligent interface engines.

The settings and access to the systems is the fifth attribute. In traditional systems the potential for access is universal. However, the choices and interoperability of devices that may be linked into the system are generally limited and the devices rarely function to full capacity in real-time. The advanced systems feature an unlimited array of fully integrated interfaces and devices of all types that operate simultaneously and in real-time. The array of devices and technology windows are defined or determined by the preferences and needs of the users.

The final attribute is the type of provider linkages and support networks. Most traditional/generic systems can be networked and can exchange data and information. However, proactive support and collaborative networks are rare. Fully integrated collaborative networks and supply chains are hallmarks of advanced informatic systems.

In summary, the power, potential, and reach of health promotion programs and services can be increased substantially by developing and using advanced informatic systems to address some of the compelling lifestyle-related health problems in the United States. Although they are very sophisticated and complex, the combinations of the attributes and characteristics of these systems allow them to overcome many of the shortcomings and barriers that have limited the efficacy of the generic systems in use today.

Clearly, there is ample evidence to suggest that given the attributes and advantages of the advanced informatic systems as summarized in Table 4 it is possible to influence the health-related decisions and patterns of behavior of individuals and groups. Health promotion theories have been proven to be effective in changing and supporting health-enhancing behaviors for individuals and population groups of all sizes (Velicer, 1999; Bulger, 1997). Now that telecommunications and information systems are becoming seamless, intelligent, integrated, mature, and ubiquitous enough to reach everyone it is reasonable to assume that they can be developed into highly effective systems that will influence the lifestyle choices of Americans. Moreover, there is an excellent match between the principles and concepts of health promotion and the features of the advanced informatic systems. With the next generation of informatic systems it will be possible to do things that have never been tried before. It is theoretically possible and safe to say that technology can be used to support long-term healthy lifestyle choices in individuals, populations, and groups and to develop health-enhancing cultures in homes, communities, workplaces, and schools throughout the country. Although it is an enormous step and a new era, all that is left is to design, build, and test them.

Importance and Rationale for the Study

The poor health habits and lifestyle choices of individuals are compromising the health status and quality of life of Americans. The incidence of "excess" morbidity and mortality and the diminished quality of life that are directly attributable to these health-compromising contemporary lifestyles are consuming inordinate amounts of resources in the United States. This is clearly a compelling problem that can be changed. The conceptual framework for a model a system design would be an important step forward because it will give practitioners and developers a benchmark, something to aim for and improve upon.

Finding ways to effectively address the health problem, by developing new systems or reconfiguring and reengineering some of the current key healthcare systems that feature some of the most promising approaches, strategies, or techniques, such as information technologies, is clearly a daunting but necessary task. Designing models for best-of-the-breed systems is a fundamentally important research problem.

The health, economic, and social implications from this constellation of "preventable" problems have reeked havoc on individuals, families, organizations, and communities throughout America. Yet the track record of the traditional methods and approaches focused on resolving the problem has been disappointing (United States Department of Health and Human Services, 2000; Center for the Advancement of Health, 2000b). Clearly some essential ingredients, or combinations of them, are missing from the models and products that are in use today (Street et al., 1997). However, because of the advances in the behavioral sciences and the impressive array of new and innovative options and solutions that have become available from the new and emerging information technologies, there is hope that the critical health needs and problems of Americans can be impacted by health-promoting informatic systems. Although the Transtheoretical Model is an excellent theoretical starting point, unfortunately, at this time there is no simple, comprehensive, universally accepted, and comprehensive IT model that is ideally suited to serve as a framework for building the next generation of advanced informatic systems.

The logic behind basing health promoting systems on modern information technologies is sound. Information systems have been used to successfully address a wide range of problems including health. Key components from effective models can be structured and embedded in well designed systems that can be made available to users across the healthcare spectrum.

During the last decade of the 20th century the application of the information sciences has extended throughout many sectors of the economy. Researchers have begun to identify and understand some of the factors that determine what works best, what doesn't, and why. The importance and issues related to some of the key building blocks have been documented in the literature. Most important, systems designers, theorists, and authorities from a range of health-related fields are beginning to work with experts from the behavioral and informatic sciences.

These trans and multidisciplinary teams are beginning to understand and apply the state-of-the-art and scientific techniques to systems design. Innovative and exemplary systems, such as Guardian Angel, One-of-a-Kind, Health-O-Vision, and CHESS, that are based on scientifically sound health, behavioral change, and informatic principles, can serve as prototypes for the next generation of health-promoting informatic systems.

Now it is realistic to assume that the full power and potential of technology can be incorporated into systems and applied in a variety of ways to these multidimensional problems. Systems that draw from the full spectrum of information technologies can be conceptualized, designed, developed, and implemented in ways that are matched to the unique needs of each individual, demographic segment, or the population as a whole. Moreover, these tailored technology systems can be designed to be flexible, dynamic, and to increase in their intelligence and capabilities over time. The model systems will be based on evidence-based concepts that feature the best practices, theories, and models from multiple fields of study including the computing, information, behavioral, and social sciences.

Because of some of the key advancements that have taken place in the fields of health and information technology, there is now sufficient reason to think that the healthcare needs of all Americans can be provided for and that no one needs to be left out or on the wrong side of the technology or "digital divide." Because of the Internet, as well as the next generation of integrated multidimensional technologies that will evolve from it, we can assume that these resources will be available to anyone, any time, anywhere (Mossberg, 2000). Access issues can be resolved for those who are often in the most need, yet are often the farthest away from high quality health and IT services. In the near future all Americans will have the capacity to access an array of "technology windows" through which they can access information, interpersonal and decision support systems, and other powerful resources that will help them to resolve disease states and live a healthier and higher quality of life.

One of the major reasons why it is realistic to think in such an optimistic way is that through the Internet and the phenomenon associated with it, we have begun to learn to think in ways that will allow us to more fully exploit these globally networked intelligent systems. A vitally important lesson that has been learned from previous technology endeavors is that most projects that are this complex, multidimensional, and important are destined to failure if designers do not follow the concepts of systems thinking. This study is designed to work toward developing an all-inclusive conceptual framework, systems model, or design as one of the fundamental concepts of this approach.

There are several important reasons why this particular study should be carried out. First, this researcher has not been able to locate any design studies of this scope in this area. Since all indications are that health promotion informatics will be an enormously important area in the future, design studies of this type are extremely important for all stakeholders including developers, policy makers, practitioners, entrepreneurs, academicians, and consumers. This study will be an important resource for those who will work in this area from a theoretical as well as practical standpoint. This study provides a conceptual model or map from which projects can be built and evaluated.

Second, this study is timely. Many individuals and entities such as "dot.com's" have realized that when the technology has as much potential and is this good, such a system will be built. It is important that the individuals or groups who are well versed on the key issues from multiple dimensions be involved in the conceptualization of these systems. All too often the traditional systems have been developed by teams that are led by programmers who are too far removed from or do not understand the issues or working environment of health professionals and consumers, and therefore the systems are underutilized or underachieve.

Third, the design, framework, and other deliverables that are produced through this study will be important for individuals who will be planning, developing, or evaluating the systems of the future. This study emphasizes a design that takes into account projections for several years in the future. Therefore, it will serve as a framework for a fully integrated multidimensional system that has a goal of addressing the health needs of the United States in a highly efficient manner. This process did not attempt to fully reinvent the wheel. It instead is an intelligent assemblage and arrangement of the best parts available.

In summary, there is a good match between the problem and the potential of technology for addressing the problem. Key concepts and components for a model system were found across several disciplines. Pioneering individuals and groups including Szolovitz, Prochaska, Velicer, Bulger, and others have already provided some excellent groundbreaking work. However, developers currently do not have a comprehensive framework or blueprint that they can use to build these systems. Developers have had to muddle through the design process and the result, frequently, has been that systems will never reach their full potential. A model systems design and conceptual framework would be a significant contribution to the body of science.

Research Objectives

The themes for this study revolved around the development of a model health promotion informatic system that is designed to influence the health-related lifestyle choices of Americans. The conceptual framework and the model system design was the outcome or deliverable of this study. The goal of the system is to promote healthier lifestyle choices among the users. The research question was concerned with how to design a system that can achieve that goal in an optimal manner. Therefore, the goals of this study are stated not as hypothesis or questions but as research objectives that relate to the development and design of the model system (Gall, Borg, & Gall, 1996). The study was executed according to the methodology and process as outlined in Chapter III.

Research Objective #1: To develop a framework for the key concepts, issues, and characteristics of the health promotion, behavioral, and informatic models, theories, and constructs that will serve as the foundation for the system design (SDLC step # 1)
Research Objective #2: To develop a framework that represents the issues, characteristics, concepts, and interrelationships among the various aspects of the problem and the individuals and groupings of potential users of the system (SDLC step # 1)
Research Objective #3: To identify the key aspects of the potential solutions and categorize the theories, key concepts, issues, and attributes of the computing, telecommunications, and other related technologies and develop a short-list of the compatible and complementary technologies that will fit into a model system (SDLC steps # 1 - 3)
Research Objective #4: To execute the design modeling process in an organized, sequential, and complete manner as outlined in Chapter III (SDLC steps # 1 - 4)
Research Objective #5: To develop a documentation record of the design process that will include the artifacts and supplemental materials for the design prototype and evaluation of the model (SDLC step # 5)

Definition of Terms

The following terms and definitions are used in the different sections of this study. Other important definitions are provided in Chapter II.

Health promotion, "The science and art of helping people change their lifestyles toward an optimal state of health" (O'Donnell, 1986a p. 4).
Informatics, "that scientific discipline that studies the structure and general properties of scientific information and the laws of all processes of scientific communication " (general/technical) (Mikhailov et al., 1984 p. 365); "the field that concerns itself with the cognitive, information processing, and communications tasks of medical practice, education, and research" (medical informatics) (Greenes, 1990 p. 824); and "an umbrella term used to encompass the rapidly evolving discipline of using computing, networking, and communications -- methodology and technology -- to support health related fields" (health informatics) (Pan American Health Organization, 1998 p. 1).
Information Technology, "The technology of data processing and information management, telecommunication and data management" (Held, 1995 p. 113).

Assumptions

Several basic assumptions have been made for this study. First, even though it is presumptuous to assume that a single system design can be a "model," it was assumed that the basic concepts, components, and relationships among the parts of the system could be identified and modeled. However, this will be an enormous task given the scope and complexity of the problem and the number of domains involved.

The second major assumption of this study is that an informatic system can be effective in promoting health-enhancing lifestyle choices and behaviors among individuals and populations in the United States. This assumption is based on observations and outcomes from studies of approaches and systems that are using similar though much smaller and less sophisticated approaches and technologies.

The third set of assumptions relates to the boundaries of the study. In order to define a manageable scope for this study, it is necessary to establish boundaries and limits, and to prioritize the key concepts, issues, and outcomes for the model system. It is assumed that the decisions related to these factors have been inclusive enough to be able to arrive at an exemplary design.

The compatibility of the technologies, issues, and solutions that will be part of the model system comprises a fourth set of assumptions. Although the theoretical models and concepts such as interoperability and standardization de-emphasize parochial approaches, technical, managerial, and sociocultural problems are always found when trying to integrate the parts. It is assumed that these problems, once identified, can be resolved in real life.

There are many actors, stakeholders, and perspectives that must be represented in the model system. It is assumed that the final design will be flexible enough to accommodate the needs of all those who will be involved in the development process or who will use or be served by the system.

Finally, several of the technologies that will be part of the design are still on the "drawing board" or have not been implemented in healthcare settings. It is assumed that the final versions of these technologies will be compatible to those described in the model and that when all of the pieces are assembled, they will work together in the real world.

Limitations

There are several limitations for this study. First, since it is a design study, no attempt will be made to test whether it actually works in real life. Second, several of the assumptions that were listed in the previous section can only be tested during a pilot testing or implementation phase. Third, since technology is developing at such an astonishing rate, new and improved technologies may emerge before the design can be completed and published. Fourth, some of the downsides and negative aspects of technology may become a significant barrier in the development and use of the system (Postman, 1992). Fifth, by relying primarily on the technologies from the United States, some more appropriate solutions for a model system may have been omitted. Sixth, there is an element of bias associated with how this researcher conceptualized the problem and perceived the characteristics and worth of the different technologies that will be applied to it.

Organization of the Study

Chapter II features a review of the literature in health, as well as innovative technology-based solutions. The comprehensive examination of the relevant literature included a survey of the appropriate theories, the design process, the key elements or components of a model, and exemplary systems that have already been developed. A detailed discussion of the methodology of the study is provided in Chapter III. Chapter IV provides a comprehensive illustrative and narrative description of the model system. The conclusions and implications of the model system, policy recommendations, suggestions for practitioners, and future study are presented in Chapter V.

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