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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 31, 1997

Summary

A look though The Washington Post classified ads on any Sunday clearly shows where a great deal of resources, opportunities, and the future will be in the 21st century. Employment opportunities in health and computer technology and telecommunications are the two largest sections. That level of interest reflects what is happening in society.

These two areas have generated an enormous amount of debate and interest in the press, legislature, and in public forums, however comparatively little attention has been devoted to looking at the convergence of these two megatrends in foreseeable future. In the last two decades development of concepts, systems, and applications of health-related technologies has lagged far behind most of the other segments of the corporate community. Moreover, there has been a paucity of empirical research and scholarly publications in this area.

This literature review will survey professional publications and scholarly research in the area of health and information and communication technologies, however the ultimate goal will be to look in depth at two specific fields, health promotion and informatics. One of the main thrusts of this review will be on defining a unique field while at the same time looking at the development and application of these systems and methods from the perspective of a health promotion practitioner.

Two factors have exerted an enormous influence on the scope of this investigation. First, the investment in economic and human terms in these two areas is immense. The implications of all decisions will effect many people. Second, there are phenomenal opportunities and exciting future directions for health promotion informatics. The ultimate success of these developments will in part be dependent on a national vision and commitment to a balance between economic pressures and the health needs and universal access for mankind.

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 process. However, there is an abundance 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 envisioned the proposed radical changes for the healthcare industry and that the Internet was virtually unknown.

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 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. 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. The first is the information/ technological revolution which Dr. Eugene Boostrom described 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 accessed electronically.

The Health Revolution

Patrick and Koss begin their white papers with one fundamental assumption, "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. In 1993 we spent more than $844 billion for health care; close to $938 billion was spent in 1994. In 1995, the expected cost will be more than $1 trillion. For 1995, 2000 , and 2005 the projected percent of the U.S. gross domestic product devoted to health care will be 14, 16, and 18 percent respectively. A large part of this increase is being fueled by a rising standard of living and aspirations for the very best treatment. The result is an exponentially larger demand for expenditures for health care and a rate of price increase for health care that is greater than other segments of the economy (Miller, 1996; Council on Competitiveness, 1995). Fitzmaurice also 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). 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. Two comprehensive programs that advocate a preventative approach have been developed to target strategic health objectives. "Healthy People 2000" was developed in 1979 during the Carter Administration and a global statement "Health for All by the Year 2000" was adopted in 1978 at the World Health Organization (WHO) Alma Ata conference (US Department of Health and Human Services, 1990).

The health promotion concept which gained momentum in the 1980's has become one of the most highly regarded approaches for meeting the health needs of humankind. The WHO now defines health as, "a state of complete physical, mental, and social well-being, and not merely the absence of disease or infirmity." Downie 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" His health promotion 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 (Downie, 1990). 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. Recently, consumer health education programs have begun to experiment with ways to merge the information delivery process with technology in ways that promote and enhance individual health, self-care, shared decision making, patient education, and rehabilitation.

Although almost all of the early work in health technology began in the traditional fields of medicine and nursing, recent efforts have been made to incorporate more of the emerging technologies in health promotion programs. These programs will be described in more detail below.

The Information/Technology Revolution

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. The National Telecommunications and Information Administration predicts that by the 21st Century, telecommunications and information-related industries will account for approximately 20% of the US Economy (US Department of Commerce, 1996). Information can be conceptualized as both a science and a technology where computers are viewed as a tool for the science and a vehicle for the technology.

Many leaders in information and data-intensive industries such as finance, business, government, and education believe that the transition has been made. They regard information as the primary capital and currency of their organization and the world. Individuals and organizations who have information, have power, and can control their destiny. Boostrom's statement, "In developing countries the primary cause of death is information deficiency" illustrates the importance of information in the future (Boostrom, 1997).

Today, every form of written or broadcast media is filled with references to computer technology and 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 " which has altered, "our social life as powerfully as automobiles altered social life by the 1950's "(Dunlop and Kling, 1991). In John Scully's 1960's essay, "A Lesson in History", (1991) 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 provide a compacted history of the evolution of personal computers with highlights the impact of some of the crucial developments 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). 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). 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. Other authors such as Ian Reineke's book Electronic Illusions: A Skeptics View of Our High Tech Future and 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 and "windows" everywhere that the general population can use to access information. The evolution of ubiquitous computing is dependent of four major components; computer hardware and software, telecommunication infrastructure, interoperability and networking protocol, and widespread acceptance of technology by the general population.

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. In the 1980's there has been significant progress in the home market. 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). The Electronic Industries Association found that computers and peripherals rose by 14 percent in 1996 and telecommunications grew by 16 percent (United States Census Bureau, 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 and it 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 and one million new users logging on each month (Council on Competitiveness, 1996).

The Internet, the most universally well known form of networked computing grew out of the University of California and the Department of Defense's collaborative work in the 1960's. Today, Transfer Communication Protocol/Internet Protocol (TCP/IP) allows a computer on any platform to communicate with each other through the regular telephone system or by other means such as high-speed data links, satellites, and infrared waves. This flexible 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 that 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 for organizations to realize a positive cost-benefit ratio in terms of the investment, 25% of employees must use a technology to reach a critical mass of acceptance. These trends are mirrored the stages of adoption in the society as a whole.

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. Champy and Hammer (1993) found 70% failure rates in organizations that deployed technological based reengineering processes was 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 three health informatics references. Similar results were found on GENL with 96 informatics references, 23 citations for medical informatics, four 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 operational 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). 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).

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 identified many important issues that relate to health-related informatics such as legislation and public policy, corporate and economic pressures, and issues related to the principles of social sciences including education, psychology, sociology, and communication. A more in-depth analysis of these issues is available on the internet (Studach, 1997).

It is interesting to note that significant advances in legislation and public policy have occurred during 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"(Lindberg, 1979). 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, 1996). 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. 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 which calls for the establishment of a National Health Board to oversee the creation of an electronic data network that promotes community-based systems and patient care information systems that collect data at the point of care (Donaldson, 1994)

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, 1996).

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). The "best of breed" systems selection approach of the late 1980's and 1990's 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). In 1994 Microsoft and Oracle each invested more than $100 million in software development in health-related areas (Crawford, 1996) and 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).

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). 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

Many factors are contributing to the paucity of empirical research in the various fields that relate to health promotion informatics. Very powerful and often conflicting forces are being played out in health-related industries often at "hyperspeed". Unfortunately, the health sector has traditionally been more comfortable moving at a evolutionary rather than revolutionary pace. The health industry is more often a late comer instead of an early adopter. 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 and there is little time or resources available for evaluation or research. Moreover, what can be tested today is often obsolete by the time a well-designed study can be conceptualized, completed, and published. Consequently, new 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.

First, 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 to support the efficacy of these programs. (Pelletier, 1996; US Department of Health and Human Services, 1996)

A few of these studies include attempts by health promotion practitioners to integrate technology into their programs (Crawford, 1996; Council on Competitiveness, 1996; Donaldson, 1994; Ernst & Young 1996; Pan-American Health Organization, 1996; US Department of Health and Human Services 1995, 1996; and US General Accounting Office, 1996). For example, research by Strecher and Kreuter on targeted health messages has tremendous implications (Rosenstock, 1988). Dynamic expert systems were developed by capturing heuristics from leaders in multidisciplinary health-related fields. Strecher and Kreuter gave Personal Digital Assistants (PDA's) to patients who were waiting for appointments with their medical providers. Micro- applications that collected information about personal preferences and stages of change were installed on PDA's. Data that was entered in the PDA's was transferred through infrared technology to a central data base. Personalized, customized, and targeted interventions and support programs that ran for weeks or months were immediately generated based on the information obtained from the short questionnaire. The interventions were derived from expert and decision support systems that featured 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 (Kreuter, 1996). Similar and equally impressive results have been found across a variety of cultures.

The Micromass company is using the targeted interventions approach with world wide web based applications. New users who visit the Micromass site are asked to are register and fill out a short personal profile. Computer generated health materials are tailored for each individual for a variety of health-risk related behaviors. The power and flexibility of the program even allows for different versions to be produced that are appropriate for several reading levels. Some forms are more technical or informational while others are written in a comic book format.

Dr. Gustafson from the University of Wisconsin, Madison has developed the CHESS programs. They a variety of home-based monitoring and supporting systems for outpatients. Personal computers have been installed in the homes of patients to help them access information. Moreover, significant increases in compliance with treatment regimens have been found with diabetes, and HIV/AIDS patients. Researchers at the University of Wisconsin are pilot testing systems that can eventually be delivered over to the internet to a much wider audience (Motley, 1997).

Interventions and support systems that are personalized and tailored to each client can be extremely effective. Recently, entrepreneurs have been exploring the use of "push" technologies, that can generate information and support to clients proactively. These programs don't wait for teachable moments, they create one that is based on the unique characteristics or use patterns of the client. Such programs that can be delivered through a variety of information channels or "windows" including; TV's, public kiosks, personalized on-line newsletters or papers. Some experts are predicting that these formats will become mainstream delivery systems in the near future.

Now that the national information infrastructure governmental and corporate health providers are beginning to pool aggregate data for individuals and populations. The Koop Foundation is leading the development of much of the next generation of technology for the personal medical record, and/or community or population specific data that will collected and archived in massive dynamic data warehouses (Houston, 1996). Data from individuals will accumulate on cumulative record which can be extremely useful in generating the best treatment options or lifestyle and behavior interventions. 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 data and generate community health profiles for a variety of demographic segments. Data about the individual needs and use profiles can enable these agencies to more effectively deploy resources or intervene much more quickly during public health epidemics.

There is a growing trend toward using multidisciplinary teams to develop health promotion systems. Several companies and institutions are deploying hybrid teams with broad spectrum of expertise including: 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 this team approach have been very successful. CD-ROM's by companies such as such Macro International, Web-based applications and services such as Micromass, and Mayo Clinic have generated much interest in the last year.

There will be a proliferation of mega-sites and on-line magazines. For example, Healtheon, the health division of Netscape signed with Blue Shield of California in 1996 to provide a full array of health information to its clients. There are currently 306 health-related magazines on the University of Michigan telecomputing site. 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 (Vitality, 1997). The market offers enormous potential.

Applications that use the enabling power of the computing and technology are superior to manual systems for highly complex projects. One of the most intriguing attempts at integrating very sophisticated technology with health is 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 the neural network learns to make better choices over time, dynamically updates its intelligence base, and remembers preferences of users. Futurists are working on systems that become a personal health advocates for each person. For example, the Guardian Angel; a personal Lifelong Active Medical Assistant is being developed by a consortium of institutions including MIT, Tufts NEMC, Childrens Hospital, US VA, IBM, Gensym, and Kaiser Permanente. The concept of this initiative is that the Guardian Angel would look out for the health and well-being of each person. By knowing the personal preferences, goals, aspirations, and needs of each individual the system can prod and promote the individual to an optimal quality of life.

Much of the ultimate success of these sophisticated systems will be dependent on the attitudes and perceptions of the users and developers. One of the first hurdles is creating a vision. 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 (1996, US Department of Commerce).

There will be great shifts in the attitudes, leisure-time pursuits, and use patterns of people. Some will be generation specific. The FIND/SVP study found that the average American Internet user is on-line six and one-half hours a week. People find the extra time by watching less television and making fewer long-distance telephone calls. The difference is most pronounced in the generation-x users. (Vitality) .

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". The user said "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).

Concluding Statements

Three quotes summarize much of the diverse and convoluted information that was collected in this wonderful learning experience.

Paul Valery offered, "the trouble with the present is that the future isn't what it used to be." David Weber observed, "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. Finally, Herbert Simon said, "those who are closest to important new technical innovations have a responsibility to provide reasoned interpretations of those innovations and their significance (Simon, 1997). By the virtue of our vision it is incumbent on the few of us who are fortunate to possess this foresight to move forward toward the wealth of possibilities and opportunities that the 21st century offers.

References

Biggerstaff, T. (1996, January). Moore's Law : Change or die. IEEE Software. 13:(1), 4 - 6.

Blackburn, B. (1997, March 12 - 13). The International Electronic Mail Directory for Health Educators <ncahperd@SHELBY.NET> <HEDIR-L@SIU.EDU>, HEDIR-L Digest.

Boostrom, E. (1997, January 3). Global Health Network Meeting. World Bank, Washington, D.C.

Champy, J. & Hammer, M. (1993). Reengineering the corporation : a manifesto for business revolution. New York, NY : Harper Business.

Council on Competitiveness. (1996). Highway to Health: Transforming U.S. Health Care in the Information Age. Washington, D. C.

Crawford, C. (1996, May). Managed care and the NII: a public/private perspective, Final Draft, Department of Health and Human Services, Washington, D. C.

Donaldson, M. S. , and Lohr K. N.. (1994). Health Data in the Information Age; Use, Disclosure, and Privacy. Washington, DC: National Academy Press.

Downie, R., Fyfe, C., & Tannahill, A. (1994). Health Promotion: Models and Values. New York: Oxford University Press.

Dunlop, C. & Kling, R. (1991) Computerization and Controversy. San Diego, CA: Academic Press Inc.

Ernst & Young LLP .(1996, March). The Role of The Internet

in Health Care: Framework.

Ernst & Young LLP (1997, February) The Role of The Internet in Health Care Current State.

Gold, R. (1996, December 3) Personal Interview. Calverton, MD.

Greeenes, R. (1990, February 23). Medical Informatics: An Emerging Academic Discipline and Institutional Priority, JAMA , 263: (8) 1114 - 1120.

Healthcare Information and Management Systems Society, (1996) HIMSS/HP Leadership Survey. http://www.himss.orghpsrvy.html and Business & Health Data Watch (1995, July) p. 17.

Koop, C. (1995). Introductory remarks to Partners for networked health information for the public Conference: http://odphp.osophs.dhhs.gov/koop.htm

Kreuter, M. (1996). Communication Strategies for Health Promotion Programs, American Journal of Health Promotion. Michigan; Keego Harbor.

Houston, K. (1996, December). Personal Interview at the Koop Foundation, Gaithersburg, Maryland.

Lancet (1990, April 7). 335: 824 - 825.

Lindberg, D. (1979). The Growth of Medical Information Systems in the United States. Boston, MA.: Lexington Books.

Miller, J. (1996, February). Is "Value" the New Frontier? Integrated Health Report, 1 - 11.

Motley, C. (1997, February 13). Personal Interview at the Government Accounting Office, Washington, DC.

Naisbitt , J. & Aburdene, P. (1990). Megatrends 2000 : ten new directions for the 1990's. New York: Morrow.

Nagy, N. (1991, December). Informatics and the Developing World Finance and Development. 28: (4), 45 - 47.

Negroponte, N. (1995). Being digital, (1st ed.). New York: Knopf.

Pan-American Health Organization. (1996) Telecommunications in Health and Health Care. Washington, D. C.: Pan-American Health Organization.

Parr, J. (July 20, 1996) There is nothing like an aim, Hospitals & Health Networks.

Patrick, K., & Koss, S. (1996, February), Consumer Health Information White Paper. Department of Health and Human Services, Washington, D. C.

Pelletier, K. (1996). A review and analysis of the Health and Cost-effective outcome studies of comprehensive health promotion and disease prevention programs at the worksite: 1993-1995 update, American Journal of Health Promotion 10(5): 380 - 8.

Rogers, E. (1962). Diffusion of innovations. New York: Free Press of Glencoe.

Rosenstock, I. Strecher, V., Becker, M. (1988, Summer). Social Learning Theory and the Health Belief Model, Health Education Quarterly. 15 (2); 175 - 183.

Sangl, J. & Wolf L. , (1996, Fall) Health Care Financing Review, 18 (1), 1 - 8.

Simon, H. (1977). The new science of management decision. Englewood Cliffs, N.J. : Prentice-Hall.

Studach, J. (1997, March 31). Literature Review: Health Promotion Informatics.

United States General Accounting Office. (1996). Consumer Health Informatics: Emerging Issues. United States General Accounting Office, Washington, D. C..

Michaelson, K. (1997, February 14). Remarks from a workshop on Lessons Learned from the Telecommunications and Information Infrastructure Assistance Program. United States Department of Commerce.

United States Census Bureau. (1996). Statistical Abstract of the United States, 1996: The National Data Book. Washington, D. C.

United States Department of Health and Human Services, Public Health Service. (1990). Healthy People 2000: National Health Promotion and Disease Prevention Objectives, United States Government Printing Office, Washington D. C.

United States Department of Health and Human Services, Public Health Service. (1995, December). Partners for Networked Health Information for the Public: Summary Conference Report. United States Government Printing Office, Washington D. C.

United States Department of Health and Human Services. (1996, September). Physical Activity Research Digest: Economic Benefits of Physical Activity. 2: (7), President's Council on Physical Fitness and Sports: Washington, D.C.

Valery, P. (1997) IBM internet.ibm.com/alphasworks.

Vitality Magazine (1997, March) FIND/SVP Study, 10.

Weber, D. (1995, January/February). Health Care Forum. 38: (1), 16 - 17.

Workplace Vitality (1997, February) Digest, 11: (2), 4.

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