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John Studach Ph. D. Candidate

National Center for Health Fitness

International Institute for Health Promotion

American University

Maraciabo, Venezuela

6 of August of 1998

This paper has been adapted from an oral presentation to the current written form. Much of Section II follows the PowerPoint outline format with some expanded thoughts and brief descriptions.

Health Informatics: A Peek into the Future

Purpose: The purpose of this paper is to provide an overview of the field of health informatics and to familiarize the readers with some of the uses and implications of the latest developments in health technologies for our professional and personal lives.

Goals:

• familiarize the reader with the basic concepts, terms, and definitions of health informatics
• describe several technologies and applications that can be applied to health, physical education, and medicine
• identify trends that have influenced the development and diffusion of health and technology
• discuss current developments in the United States, South America, and Venezuela
• discuss the implications of these developments and the ramifications for the future of health and medicine
• identify sources and resources for individuals who want to explore health informatics in greater detail.

I Introduction

I am extremely excited and honored to have been selected to submit a paper on this topic for several reasons. I am thoroughly convinced that the developments and advances in health informatics that have occurred over the last decade will have a profound impact on the future of healthcare and education. Moreover, in the next millennium health technologies will become fully integrated into every aspect of our personal and professional lives. Finally, no other tool at our disposal has the potential to make such a profound impact on healthcare costs, program delivery, and quality of life.

The purpose of this paper is to challenge the reader to think, question, and dream about the future of our professions and how the developments of these emerging technologies can be incorporated into our lives and work. Only if we seek, explore, and think outside of the traditional paradigms can we realize the true potential of these potent and powerful tools.

I do not believe that technology is a panacea or a solution for all of our problems. Technology is only a tool. The secret of using any tool is to be able to select the right tool for each job. But first, we must know what tools are available and have access to them. Then we must know which of the tools at our disposal is best for each situation as well as how to use them properly and efficiently. Getting to a minimal level of proficiency often requires access to additional resources, experience, training, support, mentoring, a willingness to take risks, and in many cases a new perspective or vision.

These innovative technologies are called "enabling" because they permit us to perform tasks more easily or do things that were not even possible a few years ago. An in-depth understanding of these enabling capabilities usually requires the integration of multiple technologies. Often we must seek new approaches to delivery of our programs. In this new vision computers will be working in tandem with rather, than replacing people.

In the future, it will not be enough to "build it and they will come", as was dramatized in the movie Field of Dreams. But the first step in this process is to have a dream. Then is it up to visionaries and professionals working in teams to seek practical ways to incorporate that dream into every aspect of our work and our lives.

In the sections that follow, I challenge you to take a peek into the future. Accept that we have entered a new information age and that we must be committed to seeking new types of solutions to many of our pressing problems in health, education, and medicine. I encourage you to read and explore the thoughts of some of the great thinkers and practitioners who have been inspirational to me such as Nicholas Negroponte, C. Everett Koop, Alvin Toffler, Vannevar Bush, John Naisbitt, Francis de Dombal, Victor Strecher, James Prochaska, Everett Rogers, and Robert Karch.

A. Background

I became enthralled with the potential for computer technology because of three experiences. First, I began to use computers as a way to make my work easier. I realized that computers offered me an efficient solution for repetitive tasks. Knowing that the computer made less mistakes than I did was an important factor. I could take work that I had already completed, edit or reformat it, and then submit it as a different product for a new situation. I didn't have to start all over each time.

My first extended experience with the Internet in 1993 was a profound influence that propelled me to explore ways to infuse technology more deeply into my work and studies. At a weekend seminar, I began to realize that if I had access to a networked computer, I had access to unlimited resources. I could go to the best libraries in the world. I could send an electronic message to the greatest experts on the planet. I could instantly download programs, files, data, and information that would make my job much easier. In exchange, I could offer information to others who might think that what I thought is important and worthwhile.

The third experience was more subtle. While working on a project at a local elementary school with a professor, I was struck by the fact that the new generation of children will think of computers and the Internet differently. They will regard the emerging technology of today in the same way people have come to view cars, telephones, airplanes, radio, cellular phones, electricity, satellites, and TV. My professors' five-year old son Tony, thought that anyone should be able to see and talk to his father in real-time, 3000 miles away once they learned to turn on a computer, click on an icon, and look into a camera that cost only $99. The next wave of advancements in technology will be regarded as a natural part of their lives. Children are being raised in a vastly different world and have much different expectations about what is possible.

It is important for us to begin to rethink the way we provide service to others. We should seek ways to incorporate these powerful tools into our lives and our work. We need to reach out to people in other disciplines and learn what kinds of tools are available and how to use them. We must ask experts from other fields to help us through the frustrating learning times and most importantly to help inform them of the unique needs and challenges that exist in our professions. By working together and guiding others who are anxious to develop solutions for professionals in education, health, and medicine we can make sure that the final products will meet the requirements of our jobs and be of real value to those we serve.

II The concepts

A. Definitions and Terms

The following are lay definitions and terms of the words and concepts that I will be using in this paper. In some instances I have provided the context in which they will be used.

• Computer - many forms electronic devices such as workstations, laptops, personal digital assistants (PDA)s, Palmtops, NetPCs, intelligent chips, etc.
• Informatics - the application of the art and science of information science.
• Network - computers that are linked with other computers through telecommunications connections. The networks can be open as on the Internet or segregated into groupings such as a local area network (LAN), wide area network (WAN), and closed communities like intranets and extranets.
• Technology - I generally define technology as the devices or appliances related to computers, chips, hardware, software, and peripherals. However, it is often used in a broader context to include devices, as well as processes, that are associated with technology or the transferal of information or knowledge. There is a great deal of practical, technical, and tacit knowledge associated with technology.
• Telecommunications - provides connections between computing devices. The broad array of connections includes phone lines, fiber-optic cable, wireless, microwave, satellite etc.
• Internet - the Internet is the "network of networks"; the interconnection of computers through telecommunication linkages. The Internet encompasses many features such as the World Wide Web, e-mail, and a wide variety of less familiar applications such as file transfer protocol, electronic data transfer, and video conferencing, to name a few.
• World Wide Web (WWW) - the "Web" uses an application called a "browser" that permits the presentation of text, graphics, and multimedia files in standardized format across a variety of computing platforms.
• Electronic Mail - (e-mail) - messages that can be transmitted electronically. Although most messages are primarily text, many different types of files can be attached to the original message and transferred from the sender to the receiver. Each e-mail message can be addressed to one person or many individuals at one time.
• GII/NII/HII - the telecommunications infrastructure that allows connections among computers throughout the world. Subsets of the overall infrastructure are the global (GII), national (NII), and health (HII) information infrastructure.
• Health promotion - is defined by Michael O'Donnell as, "the art and science of helping people or groups to make lifestyle changes that lead to optimal wellness or higher quality of life." (O'Donnell, 1995).
• Telehealth/telematics - programs, applications, services that are delivered on or through the infrastructure. The programs are usually health or medically oriented. They include systems programs and applications that facilitate the distribution of information, education, telemedicine, remote monitoring, data collection and surveillance, and various forms of consultation and video conferencing.
• Health Promoting Technologies - refer to all systems, programs, and applications that provide information, education, motivation, and support behavior change or healthy environments.

III. The Need

Three startling statistics summarize the need as well as the opportunity for the future of health promoting technologies.

• 70% of chronic disease and early death are preventable through lifestyle changes (McGinnis, 1995). Implication: technology can have a positive impact on these behaviors and enormous savings in human and economic terms can be made.
• 20% success rates for health interventions in changing behavior are considered to be effective (Karch, 1996). Implication: traditional programs have been undereffective; new innovative approaches are warranted.
• 80% of all injuries, illnesses, and afflictions are managed through self-care (Kemper, 1993). Implication: informed individuals can be the best advocates for their health that will lead to significant reductions in utilization of resources for non-serious health and medical conditions.

IV. Forces or Drivers

A. General

Several factors have had a profound influence on the massive shift in resource allocation and the way business is being conducted. These interrelated factors are exerting pressure for change in the technology, medical, and health care sectors.

• Demographics - Among the significant changes that affect the composition of the world population are aging, multiculturalism, population shifts, and population diversity.
• Information age - Most experts have concluded that we are in the information age where information is power.
• Cost savings - Governments are being forced to reduce healthcare costs and deal with increased demand for services and expensive new technological options.
• Consumerism - In many countries, there has been a dramatic shift toward self-advocacy and consumer activism.
• Complexity - In the information age the ability to manage, filter, and control the flow of information will be critically important skills.

B. Technology

The pace of technology development has been astounding. There is no way to predict exactly what the future will be like, but we should assume that it will be radically different.

• Moore's Law - every 18 months the computing power (chips) doubles.
• Telecommunications - enormous advances have been made in areas including bandwidth, Internet II, satellites, wireless, microwave, and videophones that allow for moving massive amounts of data and cheaper communication anywhere.
• Diffusion of technology - the spread of technology has been rampant. It is being embedded in all aspects our lives and manufactured products.
• Performance - the business principles are driving much of the change process --> more, faster, cheaper, better; but with less resources.

C. Medicine/Health

Technology has made significant contributions to our capacity to provide better and more effective care and treatment for mankind. There is a never-ending desire and need for the best services that the health professions can provide.

• Medicine - the complexity of care and management issues are driving change (explosion of knowledge, competing demands, complexity of technology, and management of care and records).
• Health - users and providers are searching for ways to expand the exchange of information and new approaches for educating populations (awareness, communication, behavior change, and compliance).

D. Sport/Physical Education

Sport and physical education share some common needs. Technology offers many new opportunities for improvement in both fields.

• Sport - new ways of improving education, practice, and performance (knowledge and use of sophisticated training methods).
• Physical Education - innovative ways to approach teaching, training, practice, physical activity, and socialization (information, training, education, motivation, and movement).

V. Models and Theories

A. General

The bulk of my work is based on three interrelated domains health, technology, and behavioral sciences. The health promoting technologies are related to five areas that correlate to the three domains.

• Health --> health promotion (e.g. how can we help people to achieve optimal wellness and enhance their quality of life?).
• Technology --> programs and applications (e.g. what are the best and most appropriate systems, programs, and applications for health promotion?).
• Informatics --> the application of the science of information science (e.g. how can we use the principles of information science to design and deploy the most effective products?).
• Sociology --> diffusion of innovations and social marketing (e.g. what steps and approaches can be used to increase the diffusion of technology and enhance its impact?).
• Psychosocial --> customization/ personalization (tailoring) (e.g. how can the power of the technology be employed and what methods can be used to match the interventions with each user?).

Three models have been used in the health professions to provide services to their clients. The approaches to treatment or service are different for each of the models.

• Medical model - the emphasis is on treating diseases and illnesses when symptoms are manifested.
• Public/preventative health - in most countries programs are reactive and preemptive.
• Health promotion - the emphasis is on enhancement and optimization (Wellness and Quality of Life).

C. Theories and Models - Health Promotion

Four popular models have been developed for health education and health promotion programs. The models are used to explain how to achieve changes in health behavior in target populations.

• Health Belief Model - value expectancy theory - Jans and Becker
• Theory of Reasoned Action - beliefs and behavior - Bandura
• Theory of Planned Belief - behavioral control - Fishbein
• Transtheoretical Model - Stages of Change, self-efficacy, balance perceptions, goal setting etc. Prochaska and DiClemente
• Health technology - at present, there is no model that is appropriate for all of the dimensions of health promoting technologies (Cassell, 1998).

D. Health Informatics Principles

There are four major concepts on which health promotion technology is based. Each has features which can be integrated into systems and applications to achieve maximum success.

• Information age - open access, shared data, and ubiquitous computing windows
• Enabling - user-centric and exploit the full power of technology.
• Consumerism and empowerment - self-advocacy facilitated through technology and networking.
• Mass customization - tailoring --> dynamic (manual or intelligent) to the specific characteristics of each user.

VI. Measurement and Metrics

There are several ways to measure the success or effectiveness of interventions. It is important to evaluate each program. Several commonly mentioned criterion are listed below.

• Satisfaction - did they like it?
• Outcomes - did it make a difference?
• Interest - did it create awareness or open up new channels?
• Behavior change - did the behavior (or stages) change?
• Self-efficacy - was there a change in perceived control or competency?
• Use patterns - what, when, how much, and why measures of the parts of the system or program.
• Support - did the program increase the level of support? (connectedness) - (eg. chat room, listserve etc.).

VII What's Happening

A. In the USA

The United States is considered a leader in many areas of technology. The points below are among the most significant developments and trends. Many of these phenomenon overlap.

• Computers - enormous developments in all areas including ease or use, numbers, speed, multimedia capabilities etc.
• Telecommunications - great increases in capacity and options - phone, cable, wireless, microwave, satellite etc.
• Wired Communities - many new options and paradigms such as university campuses, businesses, Intranet, Extranet, Internet, virtual communities etc.
• Communications - the type and popularity of electronic communications such as e-mail, Listserves, Newsgroups, Bulletin boards.
• Approaches - significant developments in approaches are used to reach users such as push vs. pull.
• Datamining and market segmentation - full exploitation of data and application of data to customer markets ( eg. Firefly).

B. In South America

Significant developments are occurring throughout South American and the Caribbean. A few of them are mentioned below.

• WHO - has made a strong statement about the value and priority of information.
• PAHO - has major initiatives such as Informatics 2000 initiatives.
• Health Ministries - are implementing its plans through collaboration and summits.
• Professional organizations - are developing on-line services (eg. AMA, BMJ, CIUCFPESP, federations etc.).
• Libraries - are migrating toward full on-line access - (eg. BIREME, NIH/NLM etc.).
• Non-profit sector - many are developing on-line services - (eg. Red Cross, IHC, LaLeche Lingua, United Nations etc.).
• Universities - many are developing exemplary programs in training, education, and research.

C. In Venezuela

Some of the projects in Venezuela are mentioned below.

• PanAmerican Federation of Medical Schools - Dr. Pablo Pulido.
• Virtual University - training and telemedicine.
• Informatics 2000 task force - through PAHO.
• International Development Bank - Health Task Force - Dr. Jose Felix Oletta
• InterAmerican Consortium of universities and Training Centers of Health Education and Health Promotion Personnel.

VIII. Technology - Approaches

Several types, approaches and concepts are featured or built into these systems.

• Static vs. dynamic - those that remain the same vs. those that change "on the fly".
• One-way vs. interactive - linear vs. hyperlinked and user driven.
• Self-contained vs. distributed - single workstation vs. networked computers.
• Push vs. pull - information is provided without a request vs. user must actively seek information.
• Dumb vs. intelligent - a static self-contained system vs. one that learns and changes.
• Individual vs. expert - each person working alone vs. collaboration and use of heuristics.
• Synchronous vs. asynchronous - one way communication vs. simultaneous transmission.
• Real-time vs. store and forward - at the same moment vs. retrieved at a later time.

Health Technology Applications

Several of the most important applications and uses for technology in health, medicine, and education are listed below.

• Information - information can lead to better health.
• Decision support - technology can help make better decisions.
• Behavior management - intervention programs can help to guide individuals to better health.
• Compliance, tracking, monitoring - can help reinforce and sustain interventions.
• Surveillance - technology can help practitioners know where the problems are and the incidence.
• Support - can help to assist users and create a healthy environment.
• Training - can be used to help dissemination of best practices.

IX. Health Technology Applications

Some of the more advanced applications for technology can be incorporated into a variety of fields.

• Education - teacher training.
• Simulations - practice/pre-training.
• Expert systems/Artificial intelligence - assistance with advanced decision making.
• Web-based applications - ubiquitous access to and dissemination of information and data.
• Video conferencing - remote counseling, and face-to-face dialogues.
• Integrated multimedia/multimodal - use of many simultaneous channels in interventions.

X. Downside/Disadvantages

Many legitimate concerns that are associated with technology have been cited. When safeguards are not in place or systems are not designed or maintained properly, serious problems can occur.

• Privacy and confidentiality - breaches of personal or group ethics or standards.
• Language - sophisticated systems to handle multiple languages are not commonplace.
• Cultural appropriateness - it is difficult to design systems that are localized.
• "Profiteering" (unethical) - exploitation of users for profit.
• Netfilth - pornography, bigotry, and other indecent activities.
• Harm/damage to users - bad, misleading, or inappropriate information.
• Lack of touch - the lack of personal interaction.

XII. Barriers/Problems/Issues

Several obstacles and negative aspects that are associated with the implementation or spread of technology have been identified.

• Unrealistic expectations - considering technology as a panacea.
• Bad decisions and information - selecting the wrong system or taking bad advice.
• Technophobia - fear or aversion to technology.
• Isolationism - desire to avoid contact with others.
• Cost and access - the gap between the have's and have-not's.
• Security - preventing unauthorized access to data and systems.
• Awareness, understanding, tacit knowledge - lack of comprehension of what is available or possible.
• Support, training, help - lack of access to quality technical support.
• Competing priorities - advancement of technology often is a second tier option.
• Time - too much to do in too little time.

XIII. The Future

I believe that some of the following developments will apply in the future.

• Data/information intensive - data will be collected routinely and will be mined for strategically important information.
• Ubiquitous - anytime, anywhere, anyone - people will be able to access and communicate through a variety of appliances and technology windows that require little or no skills.
• Intelligent - systems will learn and adapt over time and use.
• Global and networked - everyone and everything will be interconnected.
• Seamless (and non-intrusive) - many sophisticated operations will take place often without the user knowing what is going on.
• Personalized - interfaces and programs will be customized to individuals.
• Support - systems will be used extensively for a variety of individual and group support functions.
• Guardian angel - systems will evolve into non-intrusive, intelligent, personalized health valets (Szoloivtz, 1994).

XIV. The End

A final thought: Although a great deal of study and advancement has taken place, some individuals are very concerned that a unhealthy gap will be created between those who have the resources and access to advanced technologies and those who do not. We must make sure that we do not create a world of have's and have-not's. We must make sure that our planning includes ways to make all people equal Thank you for the opportunity to present my thoughts. I think it is fitting to

end with a quote from Alvin Toffler. "The neglected fact that big breakthroughs often come not from a single isolated technology but from imaginative juxtapositions or combinations of several of them" (Toffler, 1980). I welcome your thoughts and comments. You can e-mail them to me at jstudac@american.edu

Bien salud y adios! Juan

Acknowledgments: Sincere appreciation is extended to the following people for their support and assistance in the development of this presentation: Dr. Robert Karch Executive Director National Center for Health Fitness at American University; Mr. Wolf Kristen, Director International Institute for Health Promotion at American University; Dr. Carlos Vera Guardia, President International Federation of Physical Education; Dr. Michael McDonald, President Global Health Initiatives; Dr. Roberto Rodriguez, PanAmerican Health Organization, and Mrs. Jeanne Studach and Norma Prindel my wonderful wife and mother respectively.

References

Cassell, M. M., Jackson, C., Cheuvront, B. et al. (1998). Health Communication on the Internet: An Effective Channel for Health Behavior Change? Journal of Health Communications, 3, 71-79.

Karch, R. C. (1996, June 4) Keynote Speech at the Inaugural Meeting of the International Institute for Health Promotion.

Kemper, D. W., Loring, K., Mettler, M. et al. (1993). The Effectiveness of Medical Self-Care Interventions: A Focus on Self-Initiated Responses to Symptoms. Patient Education and Counseling, 21, 29-39.

McGinnis, M. J., Deering, M. J., Patrick, K. et al. (1995). Public Health Information and the New Media: A view from the Public Health Service. In Harris, L., Henderson, J., Gorry, T., Silverman, B et al. Health and the New Media: technologies transforming personal and public health pp. 127-141. Mahwah, New Jersey: Lawrence Erlbaum Associates.

O'Donnell, M. P. (1995). Design of workplace health promotion programs. Rochester Hills, Mich: American Journal of Health Promotion.

Szoloivtz, P., Doyle, J., Long, W. J., Kohane, I., Pauker, S. G. et al. (1994, May). Guardian Angel: Patient-Centered Health Information Systems.

Toffler, A. (1980). The Third Wave. New York, New York: Morrow and Company.

Note: This page was designed by John Studach. Last updated on October 2, 1998.

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