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Health Promotion Informatics: A Literature Review

John Studach

Dr. Frederic Jacobs

School of Education

American University

Methods of Inquiry 21.610

March 24, 1997

Note: This is a work in progress that will be an expanded version of the literature review. It is presently being edited. No completion date has been set. Last updated, March 31, 1997.

Summary

Chronological Narrative

Preface

The essence of this literature review is about crafting an investigation and synthesizing the enormous amount of tangential information into a clear picture of a field of study that does not yet exist in a formal sense. Consequently, the majority of what is currently available is so new it has not yet been evaluated empirically, or subjected to the scrutiny of the peer-review and formal publication process. However, there is an overabundance of evidence that indicates this emerging area of study will play a phenomenally important role in our lives in the 21st century. Five years ago almost no one would have envisioned the radical changes in the healthcare industry and that the Internet was virtually unknown. This helps to put into perspective the astonishing rate of change that is occurring.

New paradigms for information technologies and health are being formed by visionaries and pioneers who are projecting well into the next century. Every author from the well over 100 sources that were reviewed for this paper is thoroughly convinced that humankind is on the threshold of a radically different way of living. The changes that have been identified and predicted by experts such as Naisbitt in his Megatrends series, Negroponte in Being Digital, and Champy and Hammer in their Reengineering books point to a confluence of powerful technological, economic, governmental, societal, cultural, and demographic forces. The consensus of opinion among the authors is that radical and fundamental changes will occur in every segments of society. However the authors do not agree on terminology, the number or types of interrelationships among the core forces, trends, and revolutions, or the magnitude of impact that we will experience.

The primary focus of this paper will evolve from the two concurrent revolutions that have been mentioned in every book, article, or personal interview cited in the reference list. Some of the elements are evolving, but the vast majority are part of a revolution. The first is the information/ technological revolution which Dr. Eugene Boostrom described in a January, 1997 meeting of the Global Health Network at the World Bank as the, "biggest juggernaut that ever rolled" (Boostrom, 1997). Terms and subsets included under this broad umbrella are refer to three revolutions; information, telecommunications, and information technology. Nicholas Negroponte , one of the founding fathers of the information technology movement saw the revolution at both the macro and micro level. In the 1970's he predicted that information would be at the core of our daily living. At the same time he said that technology is merely the ability to "hurl electrons through space" (Negroponte, 1995). All of these technologies are described as enabling technologies; those which enable systems, programs, and applications to function interoperatably.

The second revolution is taking place in the health arena. Every government entity and healthcare provider is acutely aware of the extraordinary changes interplay between the complex forces in this field. In its' first term, the Clinton Administration made a high profile attempt to reform healthcare. In an address to the Partnerships for Networked Consumer Health Information Conference, C. Everett Koop summarized his views on the health care revolution stating, "After a lot of high expectations for the possibilities of health care reform in the Administration, the great juggernaut has come to naught." However, "Don't think that health reform is a dead issue. The private sector is reforming, maybe revolutionizing, health care every day" (Koop, 1995). It is appropriate to note that his videotaped presentation was broadcast to the conference over the internet.

This review is based on a descriptive methodology. The research questions that will be addressed are, "What is health promotion informatics and what is the current state of affairs? How has or could the advances in information and communication technology impact and/or be integrated into the field of health promotion? The unique nature of this investigation necessitates both synthesis and extrapolation from very diverse disciplines. Finally, it is worth noting that virtually every reference for this paper was searched or acquired electronically.

The Health Revolution

Patrick and Koss begin with a fundamental assumption in both of their white papers that were submitted to the Department of Health and Human Services; "Health is one of the qualities of life that Americans value highly for themselves and their families" (Patrick and Koss 1995, 1996). Health is an all-encompassing term which includes; health education, health promotion, public and population health, disease prevention as well as traditional and alternative medicine, and patient care. In the last four years, one segment of health, healthcare reform has dominated much of the attention of the media as well as many parts of the public and private sector. Much of the fascination with healthcare is due to the enormous economic investment that governments and business are making in an effort to provide comprehensive medical programs and services to their constituencies. Miller that states, "In 1993 we spent more than $844 billion for health care; close to $938 billion was spent in 1994 (Miller, 1996). The United States was expected to spend more than $1 trillion on health care in 1995, or a full 14 percent of the U.S. gross domestic product (GDP). This percentage is expected to grow to 16 percent of the GDP by the year 2000 and to reach 18 percent by 2005. This increase is being fueled by both a rising standard of living, which allows more to be expended for health care, and a faster rate of price increases for health care than for other segments of the economy (Council on Competitiveness, 1995). Fitzmaurice noted that costs and the demand for services are escalating at exorbitant rates in some sectors and the national healthcare expenditures have risen by 10.5% per year for the last eight years,- more than double the consumer price index (Fitzmaurice, 1995, p. 43). Many legislators, economists, and business leaders are predicting economic catastrophe unless radical changes are made in the health care system.

Many new models and approaches are being tried in hopes of simultaneously reducing the demand for services and increasing the quality of services and quality of life. Some of these approaches hope to demonstrate lifestyle and behavioral changes can be achieved for the targeted objectives as outlined in the US Public Health Service comprehensive health strategies publication Healthy People 2000 . This document was developed in 1979 under the leadership of J. Michael McGinnis the Surgeon General during the Carter Administration. A global statement "Health for All by the Year 2000" was adopted in 1978 at the World Health Organization (WHO) Alma Ata conference.

One of the most promising health models is health promotion. The term 'health promotion' has come to refer to a movement which has gathered momentum in the 1980's. The WHO now uses the following definition of health: "Health is a state of complete physical, mental, and social well-being, and not merely the absence of disease or infirmity." (Downie et. al. 1990, p.2). Downie's model has three overlapping spheres; health education, prevention, and health protection that are the basis of efforts to enhance positive health and prevent ill-health. He goes beyond the WHO definition by recognizing that the, "overall goal may be summed up as the balanced enhancement of physical, mental, and social facets of positive health, coupled with the presentation of physical, mental, and social ill-health" (Downie, p. 25). All of the health promotion models are based on the premise that individuals and nations becoming advocates and active participants in determining their health status. In 1979, E. Smith defined health education as a, "communication activity aimed at enhancing positive health and preventing or diminishing ill-health in individuals and groups, through influencing the beliefs, attitudes, and behavior of those with power and of the community at large" (Downie p. 28). Consumer health information includes, "any material that enables individuals to understand their health and make health-related decisions for themselves or their families" (Patrick and Koss, 1995). Consumer health education encompasses information and the process of computing information in ways that promote and enhance individual health, self-care, shared decision making, patient education, and rehabilitation.

Patrick and Koss (1996) maintain that by the early 1990's consumer health education efforts were grounded in traditional health promotion; providing behavioral support to improve lifestyles and health. Much of the recent programming in the healthcare sector has been adapted to reflect the health promotion models. Although almost all of the early work in health technology began in the traditional fields of medicine and nursing, however, recent efforts have been made to incorporate more of the emerging technologies in health promotion fields.

Koop PAHO in 93 - there were 4,000 health related sites

in summer '96 there were 25,000 """

The Information/Technology Revolution

Every form of written or broadcast media is filled with references to the transition from an industrial to an information based economy. Dunlop and Kling, in Computerization and Controversy describe computer systems as, "one of the most distinctive and complex technologies of the late 20th century " (1991, p. xiii). It has altered, "our social life as powerfully as automobiles altered social life by the 1950'"(1991, p. xv). This movement will touch us all at work, leisure time, and in how we conduct and see business. In the 1960's John Scully, the former chairman of Apple Computers wrote an essay titled, A Lesson in History. In it he drew parallels between the catalytic effect of networked computers on the information revolution and the impact of print technology as a catalyst for the Renaissance (Dunlop and Kling, 1991, p. 24). The National Telecommunications and Information Administration stated, "by the 21st Century, telecommunications and information-related industries will account for approximately 20% of the US Economy" (US Department of Commerce, 1996). In Dunlop and Klings' compacted history of the evolution of personal computers they identify some crucial developments and impacts of the information and technology revolution. In 1945 Vannevar Bush, science advisor to President Roosevelt described a vision of a fast, flexible, remotely accessible desk-sized computer, called memex, which would allow a researcher to search electronically through fast archives of articles, books and notes (1991, p. 17). In the 1960's teams working in Doug Englebart's Stanford Research Institute were investigating ways that computers could be "augmenting the human intelligence" (1991, p. 19). It was Englebart who also conceptualized "hypertext" and is credited with developing a working "mouse".

Three other authors made significant contributions to shaping the information and technology revolution. Alvin Toffler's 1980's bestseller, The Third Wave stimulated enthusiasm for computerization among the general population. Dunlop and Kling also mentioned Ian Reineke's book Electronic Illusions: A Skeptics View of Our High Tech Future which along with Cliff Stoll's Silicon Snakeoil call for a rethinking of the projections, impact and place of computers, and the information revolution.

Ultimately the goal of the information and technology revolution is ubiquitous computing. It is dependent of four major factors; computer hardware and software, telecommunication infrastructure, interoperability and networking protocol, and widespread acceptance of technology by the general population. Great advances in computer power, the array and sophistication of software applications, and ease of use has led to unparalleled proliferation of computer technology. Moore's Law which states that "every 18 months the processing speed of computers doubles" (Biggerstaff, 1996) illustrates the speed of development in this field. In the 1970's IBM's breakthrough in personal computer market made computers commonplace in the business world and set the stage for expansion into the home market. Many sources include astounding statistics about the growth of computers such as the Electronic Industries Association which found that computers and peripherals rose by 14 percent in 1996 and telecommunications grew by 16 percent. (United States Census Bureau) The Council on Competitiveness reported that in 1995, 37 percent of U. S. households had computers, and the number was expected to reach 40 percent by the beginning of 1996 with sixteen percent of the home computers having modems (Council on Competitiveness, 1996). Furthermore, the Internet is the fastest growing communications medium in history with an average monthly increase of 15 percent in the amount of content information traffic. The Internet continues to double in size, as it has done yearly since 1988. The "network of networks" is made up of nearly five million "host computers" on over 28,000 networks and is estimated to reach between 15 million and 30 million people, encompassing at least 30,000 databases. There are one million new users logging on each month. (Council on Competitiveness, 1996)

The Internet is the most universally well known form of networked computing. ARPANET, the, grew out of work in the 1960's at the University of California in collaboration with the Department of Defense (Ernst and Young 1996, p. 10). In 1990, the original ARPANET was dismantled in leaving the National Science Foundation NSFNWT as the primary infrastructure (Ernst and Young, p. 10). The Transfer Communication Protocol/Internet Protocol (TCP/IP) allows a computer on any platform to communicate either through the plane old telephone system (POTS), or other means such as high-speed data links, satellites, and infrared waves. This flexibility and common architecture allows for seamless integration and communication.

Everett Rogers in Diffusion of Innovations offered diffusion theory as a framework for understanding how technology is adopted in stages. His bell-shaped distribution found in the general population 2.5% were innovators who would try and use anything, and another 13.5% were early adopters. There is also a corresponding 16% who are slow to adopt any change or are technophobic. He stated that in organizations 25% of employees must use a technology to reach a critical mass of acceptance. At the organizational level there is a positive cost-benefit ratio in terms of the investment. These trends are mirrored the stages of adoption in the society as a whole.

It would be difficult to identify a specific date as the beginning of the information revolution. The process of changing over from an industrial-based to an information-based economy has been a gradual process. Many leaders in information and data-intensive industries such as finance, business, government, and education feel that the transition has been made. They regard information as the capital and currency of their organization and the world. Individuals and organizations who have it have power, and can use information to guide, influence, and control their destiny. Boostrom states, "In developing countries the primary cause of death is information deficiency" (Boostrom, 1997).

Information and communication technology and Informatics

As computer networks evolved and became the industry standard in the business world the line between the computer technology and telecommunications fields has become less distinct. When the two fields merged a new range of opportunities and issues surfaced. The computing world began to develop and apply the principles of computer and information science in the workplace. Computer managers and researchers found that although computer technology were relatively stable and consistent, the organizational factors and human side of the interface were far less predictable. In the business world a great deal of work particularly in enterprise-wide systems and applications is being done to improve our understanding of how to make information systems more effective and efficient. Champy and Hammer (1993) found 70% failure rates in organizations that deployed technological based reengineering processes. They contend that these exceedingly high failure rates are often due to a lack of firm leadership and commitment from top level management and an understanding of organizational culture, the change process, and human factors principles in information technology. Two areas of computer science; human factors and human-computer interface use the principles and theories of psychology and sociology and apply them to organizational culture, change theory, and communication models. These advances have been essential for a comprehension of and advancements in the information revolution.

Informatics is a relatively new area of study within the computer and communications field. It encompasses all of the principles of computing, telecomputing, and human factors domains as it applies to the management, distribution, and flow of information. Nanna Nagy offered a broad definition of informatics that, "includes both the supply side and the demand side of microelectronics-based information technology" (Nagy, 1991). In 1985, Informatics Worklife developed a vision of an office environment where, "Informatics blends information-processing and telecommunications technology, and as such, forms the basis for office automation and the 'office of the future" (Informatics Worklife, 1985) . That vision has since been extended to enterprise-wide, national, and global information systems.

Only in the last decade have the concepts and principles of informatics begun to be appear in health-related fields. Medical and nursing informatics are relatively widely known however, applications of health and consumer health informatics are comparatively rare. For example, a February, 1997 keyword search of CATS on Aladin found 370 citations for informatics, 92 for medical informatics, and 3 health informatics references. Similar results were found on GENL with 96 informatics references, 23 citations for medical informatics, 4 for health informatics, and none were frond for consumer health informatics. Almost all of those citations refer directly to issues related to the "healthcare juggernaut".

Several definitions of health-related informatics were found. Each includes three components; computers, technology, communications, or information science, human factors principles, and some outcome related to health. Robert Greenes defined medical informatics as, "the field that concerns itself with the cognitive, information processing, and communications tasks of medical practice, education, and research" (Greeenes, 1990). The Pan-American Health Organization defines health informatics, "as being an umbrella term used to mean and to encompass the rapidly evolving discipline of using computing and communications, methodology and technology, to support these tasks" (Pan American Health Organization, 1996, p. 1). A 1996 Government Accounting Report defines consumer health informatics as, "the use of modern computers and telecommunications to support consumers in obtaining information, analyzing their unique health care needs, and helping them make decisions about their own health" (United States General Accounting Office, 1996, p.1).

Most of the development in informatics has been driven by the medical community and healthcare-related issues. Among the most well known and well developed systems and applications are; the patient data record, electronic data information transfer, telemedicine, teleradiology, and telehealth, decision support systems for physicians and nurses, nursing management systems, and management and record processing systems.

Experts in the field have also identified a variety of issues that relate to the area of information and communication technology that impacts health-related informatics. Among the most important issues are the impact of past, present, and future legislation and public policy and the development and management issues related to the new technologies, advantages, and barriers.

Some of the most substantial influences on the development of information and communications technologies have occurred during the terms of three democratic presidents. It was President John Kennedy who set the tone for a national health movement by calling on Americans to engage in a more active way of life. During the tenure of President Carter three significant developments took place. Carter signed legislation and, "committed himself to working toward a universal national health insurance program" at a time when " even political liberals are looking desperately for a means to cap or reduce expenditures for medical care." By signing P.L. 101-239 in 1989, he established The Agency for Health Care Policy and Research (Lindberg, 1979, p. vii). Second, during his administration, "Congress passed the National Consumer Health Information and Health Promotion Act and in 1978 Congress passed a law that created a network of organizations called the Health Systems Agencies (Crawford, p. 22). Third, during his administration the Healthy People 2000: Goals for the Nation were established.

Some of the significant legislative acts during the Carter Administration served as the foundation for recent legislative initiatives from the Clinton Administration. The three highest profile health-related initiatives were the, Reinvention of Government program, the National Information Infrastructure (NII), and Healthcare Reform Act. These three initiatives by The Clinton Administration have served as center pieces for reengineering healthcare, streamlining and providing more efficient government, and moving toward ubiquitous computing and telecommunications. The NII has many counterparts including the Global Information Infrastructure and the National Health Information Infrastructure (Koop, 1996). All three are essential components for seamless and effective health-related systems in the 21st century.

Among the other relevant legislative efforts are the Clinton Administration's proposed Health Security Act of 1993 gives, "appreciable attention to information systems and related matters. It calls for the establishment of a National Health Board to oversee the creation of an electronic data network with regional centers that collect, compile, and transmit information. The board will, among other things, provide technical assistance on; 1. the promotion of community-based systems and 2. the promotion of patient care information systems that collect data at the point of care or as a by-product of the delivery of care" (Donaldson, 1994, p. 40)

At each step of the process legal, humanitarian, and business issues arise. For example, when information or services are delivered across state lines, question such as, "What is a medical device? " must be addressed. Currently, the FDA Cosmetic Act defines a medical device as, "an instrument, apparatus, implement, machine, contrivance ... or other similar or relate article, including any component part or accessory, which is intended for the diagnosis of disease or other conditions, or in the cure, mitigation, treatment or prevention of disease... Current discussions are trying to define what and how the product was advertised and how that impacts on companies and licensing of medical practitioners are impacted when they provide services such as telemedicine over state lines" (Crawford, p. 38).

Another significant issue for governments and businesses is universal access. Michaelson observed that the guidelines from the National Telecommunications Information Administration tries to, "balance between using and trying new experimental technology that can meet the needs of the masses versus those who are available but may not optimally meet the needs of all" (US Department of Commerce, 1996).

Interoperability, or universal standards is a major concern for the business community and governments. The lack of standardized hardware, software, data, and communications protocol has severely hampered sharing of information and progress in this field. Each system, computer, company, database, or network that can not "talk" to each other is isolated. For example, Crawford describes Managed Care Organizations today as having four separate information subsystems, or islands of information, "these islands are not digitally interconnected or integrate, and thus have very little direct and immediate impact on one another" (Crawford, 1996 p. 10). The "best of breed" systems selection approach of the late 1980s and 1990s resulted in many organizations creating "islands of automation" that rely often on highly proprietary standards and protocols for transmitting health care data. The trend of moving away from proprietary systems and software has opened up a great many new opportunities.

The economic impact of standardization would be enormous. According to Crawford estimates from a 1992 Workgroup for Electronic Data Interchange report concluded, "if standards were established for major transaction sets, and if the level of electronic data interchange penetration reached 90 percent within three years, total administrative savings of all transactions could exceed $3 billion" (Crawford p. 18). Public and private sector health-related providers are hoping to achieve open systems, "that exercises the entrepreneurial part of our economy and challenges both proprietary systems and broadly mandated economies..... A truly open system is in the public domain and thoroughly available as a foundation on which everyone can build" (Ernst and Young, 1996, 1 p. 47).

In an open systems environment governments, business, and individuals share a common concern for security, privacy, and confidentiality of information, data, and records that are stored and transmitted electronically. Crawford concluded that, "the success of interlocking these various systems together will be dependent upon the degree to which the privacy and confidentiality of the data are secured" (Crawford, 1996 p. iii). According to an Ernst and Young/ Information Week Survey of business organizations, "72% of the respondents were not sure or unsure about security over the internet (Ernst and Young, 1996 p. 16).

Another major concern for providers and individuals who access information is computer literacy. The concern extends to constructing information and services that are appropriate for the preferred learning channels and styles, media type, individual stage of change, and other factors that are unique for each individual. An article in Lancet also notes that, "since most doctors are not computer literate informatics professionals will control medical data" (Lancet, 1990). The Lancet editorial argues that the main reason that the predicted the computerized data explosion has not yet happened is that few medical people can be bothered to learn how to use computers.

The private sector has made substantial investments in information systems particularly at the corporate level. The financial industry, the top spenders, dedicated an average of 7.5 percent of their revenue compared to the top health care companies who invested only about 1.8 percent of their revenues in health-related information systems initiatives (Biggest 1995). The current economic and political climate has mandated some of the adjustments and the industry is changing rapidly. For example, a survey by Miller in 1994 found that, "the health care industry spent $8.5 billion on computerized information systems, up 13% from the previous year. Some expect a 50% percent increase in 1995" (Crawford, 1996 p. 10). In 1994???? Microsoft and Oracle each invested more than $100 million in software development in health-related areas. (Crawford, 1996 p. 34) Parr (1996) estimated that health care-related companies account for over 12% of the desktop computers.

The corporate level changes have made information technology managers in health-related industries acutely aware of the changes and conflicting interests in their industry. A 1996 study of healthcare information technology managers found a field in disarray and with a great many challenges; "49% believe they need to control costs due to the continued pressures of managed care; 57% said that managed care will have a positive impact either through lowering costs or improving outcomes; 70% were concerned about unauthorized access to their systems; 40% of their organizations have upgraded their information technology infrastructures and 18% have begun systems integration this year; 31% say that their organizations lack overall strategic information systems plans, which was up from 19% last year; 73% do not presently belong to a community health information network; 36% have web presence for their organizations and 37% are planning them; 50% believe that in the next three years access to on-line health care information and services from the home will be the most significant health-care computer development affecting the average consumer; and 41% said that there will be negative consequences including; business forces will negatively impact clinical practices (26%), and mistrust of physicians as gatekeepers (15%).

Pressures for profits and the bottom line of business and governments are now changing the delivery of health care at a pace hardly imaginable a few years ago. Businesses in particular, must pay attention to the bottom line and decisions must be based on the economic viability of each project. This often causes a dilemma for decision makers and puts them at odds with providing for the common good. There is danger that the goals of demand management could be subjugated to the demands of the bottom line. Crawford contends that, "the real bottom line must continue to be the health of the individuals and wellness for the nation as a whole" (Crawford, 1996, p. 32).

One of the advantages of the emerging health are infrastructure is that integrated information systems can be, enhanced, integrated, streamlined, refocused, and utilized for decision making, educational purposes, increasing market share, providing a continuum of care, reducing costs and improving health status of members within integrated managed care organizations " (Crawford, 1996 p. 7). Managed care organizations are looking for ways to produce low volumes of use by moving the emphasis form treating the sick to prevention and wellness. Traditional measures of profit, such as visits, patient days, hospital census and volumes of high-end services have now become indicators of cost.

Relevance and Quality of Research

Ernst 1. The consensus in the industry is that , as of 1995, the Internet has reached a critical mass in both content, and number of users. Today, 35 million people across the globe use electronic mail and WWW services through the internet. This figure is expected to reach 200 million over the next five years.

Informatics Worklife 1985 v4n2 pl. 8-9" Informatics blends information-processing and telecommunications technology, and as such, forms the basis for office automation and the 'office of the future".

Although there is a paucity of empirical research in this field, there is a phenomenal amount of development and change occurring. From the previous sections the reader can deduce that many of the very powerful and often conflicting forces are converging on and are being played out in the health-related industries. It is safe to predict that there will be continual explosive growth in health-related industries. The most promising solutions in this arena will emerge from the confluence of health promotion and information and communications technologies however, traditionally the health sector has been more inclined toward evolution rather than revolution. The health industry is more often a late comer rather than an early adopter. It remains to be seen what the direction and the pace the industry can tolerate as well as what the impact of health promotion informatics will be. A great many signs and essential ingredients are already in the cauldron.

In the field of technology things are changing at hyperspeed, especially in the last five years. The relentless pace of technology has left practitioners and managers feeling that it is all that they can do to try to cope with phenomenal pace of change. There seems to be is little time or resources available for research. Moreover, what can be tested today is often obsolete by the time a well-designed study could be designed and completed. The paradigms and models are often based on vision and projection rather than fact and data. However several fundamental principles are emerging that are worthy of testing and validating.

Many research questions can in some way be traced back to a common mission or vision. Three core themes have emerged during the course of this literature review.

First, the outright adoption of or evolution toward health promotion is the most promising and viable approach for meeting the demands for health needs both in humanistic and economic terms. There is a plethora of longitudinal population trend, epidemiological, and cost-benefit studies support the efficacy of these programs. (-- put in AWHP foldouts --- United States Department of Health and Human Services, 1996, September) Several exemplary programs have evaluated their programs using empirically tested approaches in their programs. Some of these are based on integration of technology. For example the research of Strecher Kreuter on targeted health messages has tremendous implications. They gave Personal Digital Assistants (PDA's) to patients who were waiting for appointments with their medical providers. On the PDA's were micor- applications that collected information about their personal preferences and stages of change. The data from the PDA's was transferred through infrared technology to a central data base. Personalized, customized, and targeted interventions and support programs were immediately produced based on the information obtained on the short questionnaire. The interventions were based on expert and decision support systems that

were based on the latest and most effective practices in the field. Their research has been duplicated with a variety of health behaviors including smoking with pregnant mothers, nutrition and food choice, and activity patterns. The changes have been equally impressive across a variety of cultures. The CHESS systems have been installed in the homes of patients to help in monitoring and supporting outpatients. Significant increases in compliance with treatment regimens have been found with diabetes, and HIV/AIDS patients. The Micromass company is using the targeted interventions approach with world wide web based applications. When they are registering at the site, individuals fill in a short personal profile and then computer generated materials that are tailored for each individual. The materials are available for a variety of health-risk related behaviors. The power and flexibility of the program also allows for different versions to be produced that are at different reading levels. Some are very informational while others are written in a comic book form.

Interventions and support systems that are personalized and tailored to each client can be extremely effective. There is a movement toward greater use of "push" technologies, that generate information and support to clients proactively. They don't just wait for a teachable moment, they create one that is based on the unique characteristics of the client. Such programs that can be delivered through a variety of information channels or "windows" such as TV's, public kiosks, personalized on-line newsletters or papers will become a mainstream delivery system in the near future.

With the infrastructure in place it will now be possible to pool the data for individuals and populations. A personal medical record, and/or community or population specific data can collected and archived in massive data warehouses. Individuals will accumulate a cumulative record which can be extremely useful in generating the best treatment or lifestyle behavior options. Health providers with the assistance of intelligent agent systems can probe the past record of clients to help them develop effective intervention programs. Public health agencies can access the data and generate community health profiles for a variety of demographic segments. These precise need and use profiles can enable them to more effectively deploy resources and intervene early in the cycle of many forms of health epidemic and support users through availability of complete and accurate data, practitioner reminders and alerts, clinical decision support systems, links to bodies of medical knowledge and other aids.

Powerful economic, sociological, and technological forces driven the atmosphere of radical change and reorganization across business community. These trends are extending to governments, agencies, and institutions. When systems and programs are designed and based on multidisciplinary approaches featuring high levels of collaboration and open communication systems provided that they are able to solve the logistical, communication, and cultural barriers, they are highly effective.

It is becoming increasingly apparent that highly complex problems are best solved by teams of astute players that represent all of the relevant areas. The composition of the hybrid teams frequently includes a broad spectrum of expertise in: project management; computer, communications, and multimedia technology; social sciences such as communications, cognitive, behavioral, and social psychology; business, organization and marketing techniques, and production people who understand the principles of influencing and changing behavior. Large and small-scale products using these teams have been very successful. Among the most common are CD-ROM's such as Macro International, Web-based applications and services such as Micromass, and Mayo Clinic. There will be mega-sites and on-line magazines. For example, Healtheon, the health division of Netscape signed with Blue Shield of California in 1996 to provide health information to its clients. There are currently 306 magazines on the University of Michigan telecomputing site (xxxxxxx). Workplace Vitality reports that the number of health care-related worksites doubles every 60 days (Workplace Vitality, 1997). A survey of users on their web site by FIND/SVP found that: "80% of all adult U.S. Internet users are potential Healthier Med Retrievers; 37.6% of all U.S. Internet users had retrieved health or medical information from the Interned and/or commercial on-line service within the last 12 months; There are currently 74 distance health-medical-related topics; the breakdown of content among 148 Usenet newsgroups and 115 e-mail lists - the top two primary subject areas were - diseases, illnesses, an procedures, and mental health.

Third, applications that use the enabling power of the computing and technology are superior. One of the most advanced attempts at integrating very sophisticated technology with health is in applying expert systems, artificial intelligence, or neural networks. In short, these systems rely on the ability of computer programs to capture the best knowledge available, put it into a form of a dynamic database, and then approximate the "thinking" and decision making process of a human. The newest systems have advanced in their versatility, ease of use, and most importantly accuracy. Neural networks are an advanced concept that allows the system to "learn" over time. The premise is that it learns to make better choices over time, dynamically update its intelligence base, and can remember preferences of users. Futurists are working on systems that become a personal health advocate for a person. from For example Guardian Angel

The new environment we will be working in will be a seamless, integrated, ubiquitous one. Koop sees the NII as holding "great promise for improving the quality of life for all individuals. It will transform the way people learn, work and live. It will also create new opportunities for individuals to communicate, collaborate and receive information of all kinds. Information technology will be the strong, flexible adhesive that pulls together the information needed for decisions regarding the value of health care investments.

Several practitioners who are already working with the technology have begun to understand what is currently possible and what is not. Karen Michaelson, Director of the Inland Northwest Community Network (TINCAN) in Cheney Washington says, "You can't tell people what technology can do for them because they can't imagine what it can do, you have to show them the possibilities (US Department of Commerce 1996. p41).

There will be great shifts in the attitudes, leisure-time pursuits, and use patterns. Some will be generation specific. The average American Internet user is on-line six and one-half hours a week. People find the time by watching less television and making fewer long-distance telephone calls. The difference is most pronounced in the generation-x users. Half of Internet users first signed on in 1995. (Find-SVP New York).

Health promotion and technology is one of the natural places where trends have converged. Society is stressing more prominently the concept of individual responsibility for health. The consumer movement has spread into the health care field, with many consumers requesting to be active participants in decision making. Economists and other proponents of health care reform have identified informed consumer choice as one element of a better-functioning marketplace (Enthoven, 1993) (Sangl, p1. 1996).

Social learning theory and other change models help us to be aware of the importance of the perception and attitudes of clients. Two quotes summarize the disparity of attitudes between these two. One recent posting on a listserve on the "Great debate on technology". Remember the old saying, " Any teacher who can be replaced by technology, should be" (Hedir-L posting, March 12, 1997) Some would say that becoming redundant or the lack of contact with a human is one of their greatest fears. At the other end of the continuum is the attitude that the final product is the most important thing, an informed consumer should be a valued end in itself" (Sofaer, 1992).

working definition of health promotion informatics

? harris? 25 a historic shift from passive, closed and producer-driven media to interactive (or smart), seamlessly connected and user-driven media (Harris, 1995) NONE IN BIB YET

Paul Valery - the trouble with the present is that the future isn't what it used to be. IBM internet.ibm.com/alphasworks.

conclusions/statements

David Weber Health Care Forum January/February '95 v38n1 p. 16-17 Through a glass, virtually viewed from the perspective of the year 2019, the dimensions of cyberhealth were only beginning to suggest themselves at the end of the 20th century. Consumer health informatics was only in its infancy

motto This is an example of an opportunity to Think globally act locally

"those who are closest to important new technical innovations have a responsibility to provide reasoned interpretations of those innovations and their significance (Simon, 1997 p. viii). that leaves the few of us who see this vision and who are looking for possibilities and opportunities.

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