Millions of people use the Internet as a source for health information yet little is understood about the use of the Internet for other health-related activities.
We conducted the present study to understand, among primary care patients, the interest in and experience with using the Internet for a variety of health-related activities.
Cross-sectional survey in the setting of 4 community-based primary care practices in Rhode Island. A single self-administered questionnaire included the following: 14 items measuring interest in using the Internet for a variety of health-related purposes, demographics, self-reported health status, and self-reported health care quality.
The survey was completed by 300 patients, 109 without access to the Internet and 191 with access to the Internet. Experiences with and attitudes about each of the health-related activities on the Internet varied widely across each activity. Regardless of access, patients were most interested in using the Internet for finding information about diseases and medications. However, patients with Internet access were more interested, compared to those without access, in each of the health-related activities on the Internet. Among patients with access to the Internet, the largest gap between interest and experience (the
Much opportunity remains for developing health-related Internet Web sites to address the unmet needs of primary care patients.
The Internet continues to evolve as an increasingly-important source of health information for millions. Based on a national survey in March 2002, an estimated 73 million Americans have used the Internet for health information, with approximately 6 million Americans going online for health advice each day [
Furthermore, the pace of eHealth development has meant that more and more traditionally offline health-related activities can now be done online. For example, in addition to researching their medical conditions and seeking second opinions, patients can now access information about the quality of care in hospitals (
This revolution in health care information has great potential to affect the way that patients interact with their physicians. Though many studies have examined the information available on the Internet, both in terms of patient's experiences and the quality of the information, little work has been done to evaluate the use of the Internet for other health-related activities, such as finding information about the quality of care that a hospital provides (
Although access to many Internet-based health care activities is still limited, the potential for patient-centered applications is broad. We conducted the present study to understand, among primary care patients, the interest in and experience with using the Internet for a variety of health-related activities including electronic communication with health care providers, use of electronic records, ordering medications, and assessing the quality of care. We have defined the difference between what people are doing and what people are interested in doing on the Internet as the
We recruited a convenience sample of 4 community-based primary care practices from Providence County, Rhode Island. Physicians in each practice were affiliated with the Brown University teaching-hospital network. One of the practices was a state-supported, suburban public-health clinic serving low-income individuals, while the other 3 were suburban, primary care practices. The practices had an average of 3 full-time physicians on staff. The demographic profile for Providence County includes: 14.6% over the age of 65, 13.4% Hispanic or Latino, 6.5% Black or African American, and 15.5% of people living below the federal poverty level [
A research assistant approached 355 consecutive adult outpatients from June 1, 2001 to August 15, 2001, to complete a self-administered questionnaire. Subjects were paid $20 to complete the survey. The Institutional Review Board of The Miriam Hospital approved the protocol.
In order to identify online health-related activities, 20 subjects were recruited for 2 focus groups by e-mailing notices to employees of The Miriam Hospital and Rhode Island Hospital and placing posters in public areas in both hospitals. Focus group participants were asked to identify health-related activities that they currently performed on the Internet. Health-related activities that were noted more than once or that the investigators felt were emerging Internet capabilities were added to the Internet Interest and Experience Survey below.
Questionnaire items were created to measure the interest of subjects in using the Internet for each of 14 potential activities, such as to "find information about a specific disease or medical condition" and to "find out what questions you should ask your doctors when you see them?" All 14 items were asked of each subject, regardless of whether or not they currently had access to the Internet. The 14 items are in the
Brief screening questions for age, gender, educational attainment, health insurance status, perceived health, and race and ethnicity were adapted from the year-2000 Behavioral Risk Factor Surveillance System (BRFSS) [
Many of the Internet Interest and Experience Survey (IIES) items had a bimodal distribution, so IIES items were categorized into
All data analyses were carried out using SPSS for Windows, version 10.0.5. Chi-square tests and analysis of variance were used to examine differences in categorical data among variables with 2 categories (eg, age and gender), and more than 2 categories (education level only), respectively. Due to the presence of some missing data, some analyses include fewer than 300 individuals. No variable included in our analysis was missing for more than 2% of the sample.
The survey was completed by 300 patients, for a response rate of 84.5%. Approximately two-thirds (63.7%) reported having Internet access at home, work, school, family or friend's home, or at a library. The mean patient age was 45.2 years (range: 18-75 years), 83.0% (n = 249) were female, 21.3% (n = 64) had completed at least 4 years of college, and 9.7% (n = 29) had no health insurance.
Background characteristics by Internet access
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Age |
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69.5, df = 1 |
Gender |
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.2, df = 1 |
Education |
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24.0, df = 2 |
Race |
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.7, df = 1 |
Health insurance status |
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1.0, df = 1 |
Self-reported health rating |
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7.8, df = 1 |
Perceived quality of care |
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3.5, df = 1 |
Subjects with access to the Internet most frequently reported using it to: (1) find information about a disease (67.0%), (2) find information about a medication (53.4%), and (3) to help modify their lifestyle (such as quitting smoking) (46.6%). The greatest opportunity gap existed for using the Internet to: (1) find out if their health care provider is giving them the tests and treatments they need (39.8%), (2) schedule an appointment with their doctor (36.6%), and (3) find out how the quality of care their doctor providers compares to other doctors (35.9%). For example, in
Self-reported interest and experience of primary care patients with the use of the Internet for specific health-related activities among patients with Internet access (n = 191) - percentages reflect individuals who were more interested in using the Internet for each health-related activity
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Find out if your health care provider was giving you all of the tests or treatments that you were due to have? | 57.1 (191) | 17.3 (191) | 39.8 (76) |
Schedule an appointment with your doctor? | 44.0 (191) | 7.4 (191) | 36.6 (70) |
Find out how the quality of care your doctor provides compares to other doctors? | 50.0 (191) | 14.1 (190) | 35.9 (68) |
Find out what questions you should ask your doctors when you see them? | 57.6 (191) | 24.6 (191) | 33.0 (63) |
Find out what tests or treatments you are due to have when you see your doctor? | 53.9 (191) | 25.1 (191) | 28.8 (55) |
Create your own personal, online, medical chart of your past illnesses, tests and treatments? | 28.4 (191) | 5.8 (190) | 22.6 (43) |
Find information about the quality of care a hospital provides? | 49.7 (191) | 28.8 (191) | 20.9 (40) |
Find information about the quality of care a doctor provides? | 47.6 (191) | 33.0 (191) | 14.6 (28) |
Find a doctor to see for your personal care? | 35.3 (191) | 21.5 (191) | 13.8 (26) |
Buy medications from a pharmacy? | 30.4 (191) | 17.3 (191) | 13.1 (25) |
Send an email (electronic mail message) to a doctor, nurse, or other health professional? | 32.3 (190) | 19.4 (189) | 12.9 (24) |
Look for information about a medication? | 65.8 (191) | 53.4 (190) | 12.4 (23) |
Find information about a specific disease or medical condition? | 74.9 (191) | 67.0 (191) | 7.9 (15) |
Help you modify your lifestyle? (examples include quitting smoking, becoming physically active, losing weight, changing your diet) | 52.6 (191) | 46.6 (190) | 6.0 (11) |
* Listed in order of descending opportunity gap.
§ Opportunity gap = percentage of patients having
The Internet is changing the doctor-patient relationship as it provides patients with the potential to make better health decisions via easy access to vast amounts of health information. In the present study, we attempted to investigate the interest in and experience with using the Internet for a variety of health-related activities among a group of primary care patients in Rhode Island. The main findings were that great gaps exist between the health-related activities patients are currently doing on the Internet and the activities they would like to be doing.
For 4 of the 14 Internet health-related activities in the questionnaire, there was an opportunity gap (see definition in Data Analysis section of Methods) of greater than 30%. Three of the 4 health-related activities with the largest opportunity gap were related either directly or indirectly to health care quality, including using the Internet to: (1) "find out if your health care provider was giving you all of the tests or treatments that you are due to have?", (2) find out how the quality of care your doctor provides compares to other doctors?", and (3) "find out what questions you should ask your doctors when you see them?" Another area of opportunity focused on the ability of the Internet to perform administrative functions, including appointment scheduling and creating an online chart. Increasing transparency in quality of care has become a major policy issue, as highlighted in the recent Institute of Medicine report, Crossing the Quality Chasm [
Based on our survey, the Internet is meeting the needs of primary care patients for information about diseases and medications, because for each of these activities the majority of patients were interested and the opportunity gap was small. With regards to e-mail, fewer patients in our survey with Internet access were interested in e-mailing their health care providers than noted by Sittig and colleagues (32% vs 65%, respectively) [
Web sites designed to enable patients to learn about the quality of care they are receiving and the questions they should be asking during doctor visits currently do exist, but are relatively uncommon. Two sites in particular,
Another area of potential development focused on the ability of the Internet to perform administrative functions, including appointment scheduling and creating an online chart. Although some patients may have used e-mail with their provider to perform administrative functions [
If the history of the Internet has been a teacher, then the findings in our survey have great implications for health care providers, insurers, and hospitals. Content on the Internet has generally tracked consumer demand because the two most common ways that Web sites are funded is either by advertising revenue or by subscriptions. Our study suggests that patients want to start to use the Internet not only as a source of information about conditions and medications, but also as a way to inform their health care decisions. Half of our respondents were interested in using the Internet to find out about the quality of care their doctor provides and several Web sites are currently being developed specifically for this purpose (eg,
The study, however, has several noteworthy limitations:
First, our survey did not measure every current health-related activity available on the Internet, because we based questions on the responses of our focus group participants and on the knowledge of the investigators. For example, support groups and health risk appraisal sites (eg,
Second, our measurement of the opportunity gap for online health-related activities was intuitive but somewhat arbitrary. For example, we did not measure the degree to which patients' perceived needs were met by each online health-related activity. Diaz and colleagues reported, however, that health information on the Internet was generally perceived as quite useful, ranked second only to health information from a physician or nurse [
Third, though our response rate was greater than 80%, our survey was only done in 4 primary care practices in Rhode Island, therefore it may not generalize to other populations or settings.
Fourth, our survey relied on self-report of Internet health-related activities. Future studies should consider methods such as installing software on patients' computers to record their Internet activities [
Despite the study's limitations, the results of this study have important implications as the number of patients using the Internet for health-related activities continues to grow. People frequently use the Internet to gather health information; about 6 million Americans do so each day [
Future studies are needed to address this rapidly-evolving technology. Given that the field is quite new, valid and reliable measurements need to be developed. The majority of the data on Internet use is collected using self-reported surveys, as in the present study, yet little is known regarding the validity or reliability of such survey data on Internet use [
The first author (CNS) is a part-owner of an SBIR (Small Business Innovative Research)-supported company (Green Lights, Inc.), which is developing a Web-based tailored-messaging system to help patients prepare for doctor visits.
Internet Interest and Experience Survey
(Each numbered question was asked in two ways.)
Please answer the following questions based on a scale of 1 to 5 where 1 is "not at all interested" and 5 is "extremely interested".
How interested are you to use the Internet to...
Have you ever personally used the Internet to...
Send an e-mail (electronic mail message) to a doctor, nurse, orother health professional?
Find information about the quality of care a doctorprovides?
Find information about the quality of care a hospitalprovides?
Find out what tests or treatments you are due to have when yousee your doctor?
Schedule an appointment with your doctor?
Help you modify your lifestyle? (examples include quittingsmoking, becoming physically active, losing weight, changing yourdiet)
Find a doctor to see for your personal care?
Find information about a specific disease or medicalcondition?
Find out if your health care provider was giving you all of thetests or treatments that you were due to have?
Find out how the quality of care your doctor provides comparesto other doctors?
Find out what questions you should ask your doctors when you seethem?
Buy medications from a pharmacy?
Look for information about a medication?
Create your own personal, online, medical chart of your pastillnesses, tests and treatments?