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Since the early 1990's the Internet has enjoyed unprecedented use as a library of health-related information and resources. The freedoms it provides have seen access to it positioned high on professional, political, and cultural agendas. As with much of healthcare, however, who has access is in part determined by the so-called "digital divide" between various groups, such as those in differing socio-economic classes. A new divide has notionally been created between UK National Health Service professionals and their patients, as the former now have almost universal Internet access via the health service's wide-area network, NHSnet...

Viewpoint

Bruce McKenzie MB ChB, DMI RCSEd, MRCGP
Volume Editor of Medicine and the Internet (OUP 2002) and General Practitioner, Chesterfield, United Kingdom

Patient use of the Internet

Two principal benefits of the Internet for health-care consumers are health information (databases, Web sites, etc.) and support facilities offering self-help advice or pointing to additional resources (forums, mailing lists, etc). Numerous annotated Internet site guides are available to assist patients in locating these resources. Improving access to this online health-care information has the potential to enable patients to participate more actively in the decision-making process with their doctors [1]. A "free market in information" [2], however, provides equal access to both evidence-based and unsubstantiated health information, resulting in concerns over information quality (reviewed elsewhere [3]). It also raises other issues. For example, Coiera [2] asks whether ready access to knowledge of what is considered "best practice" will see resource-strapped health services struggle to cope with heightened societal expectations of optimal care for all—particularly given unavoidable inequities across national, financial, and cultural boundaries.

In 2001 there were almost 4,000 Internet users per 10,000 people in the UK and almost 5,000 Internet users per 10,000 people in the US [4]. More than half of Americans with Internet access use it for medical or health interests [5], but reliable comparative UK statistics are not available. Anecdotal evidence does suggest at least some British patients are using the Internet in this way, as indicated by the emergence of so-called "Internet printout syndrome", where patients attend their GP surgery (family practitioner office) clutching information downloaded from the Internet that they wish to discuss [6]. There is some US evidence to suggest that patients with poorer self-rated health status are the most likely to talk to their physician about information discovered online, even after adjustment for age, education and income [7]. Patients may choose to seek online information or advice for a variety of reasons [6]:

• A second opinion;
• More time to interrogate the resource;
• A wide variety of resources available (allopathic and complimentary);
• Dissatisfaction with their health care provider;
• To share experiences and mutual support;
• Convenient to the user (24/7 access);
• Privacy, especially when seeking help with embarrassing issues.

Medical use of the Internet

In addition to providing consumer health information, the Internet has and is being used for medical communications, the delivery of clinical care, medical education (undergraduate and postgraduate), medical research, publishing, and commerce [8]. The UK's nationalised health service (the NHS) offers unique opportunities to utilize and homogenize technology in healthcare. Information for health [9] is a 7-year plan (1998-2005) aiming to modernise IT infrastructure in the NHS and deliver a nationwide network (NHSnet) that permits Internet access for NHS staff. Uniform provision has thus been made to ensure health professionals have access to online resources such as the National electronic Library for Health (NeLH), MEDLINE, and various other accredited information resources. Currently 99% of NHS primary care physicians have Internet access at work, as do 92% of hospital-based consultants [10].

Internet access and the digital divide

To use the Internet, you must have access to one of the networks forming a part of it. For most people this means first having access to a personal computer (e.g. at home, work, or school), although recent technology convergence has allowed other electronic devices, such as mobile phones and televisions, to deliver Internet access. However it is accessed, technology is always involved—but the technology must first be afforded.

In the UK high-income and social grade AB homes are around three times as likely to have Internet access as DE-grade and low-income homes [11]. Eysenbach asserts that:

The vicious circle of low education and low health literacy and low income, poor health, and the inaccessibility of information technology, can only be broken if the field is not left to market forces alone but if public health policy actively brings information technology to those who are underserved [12].

Such inequities are aspects of the "digital divide" [13]. Although accredited information provision is being addressed by NHS policy initiatives such as public portals to the NeLH [14] and NHS Direct Online [15], these initiatives do not address the primary lack of Internet access within needy populations. Indeed, Information for health is fairly one-sided when it comes to supporting Internet access—yet patients do deserve similar access to Internet-based healthcare information as enjoyed by NHS professionals. Although UK Government policy aims to achieve universal access to Internet services for all those who want it by 2005 [16], there is no NHS-driven policy to provide Internet access to patients.

Revising the doctor–patient relationship

Narrowing the digital divide by facilitating patient access to the Internet may not be without consequences for the doctor–patient relationship. Limited evidence suggests that 64% of patients finding health information on the Internet discuss their findings with their doctor [17]. Kassirer was among the first to hypothesise an increased role for physicians in the interpretation of information gathered online by empowered patients [18]. Such a scenario would see physicians subordinate in health care, while others are sceptical about the ability or desire of consumers to take control, and view access to information as an opportunity for more equal dialogue between all parties [19]. Current NHS policy appears to take a more middle of the road approach:

Too many patients feel talked at rather than listened to. This has to change—patients must have more choice in their own treatment and more influence over the way the NHS works. [20]

This would seem to advocate that the current balance-of-power in the doctor–patient relationship must change. The Internet is perhaps one means to facilitate this change.

Previous research on information provision

Both traditional and computer-generated patient information leaflets have advantages and disadvantages, and contribute to improved patient outcomes [21]. Printing unfiltered information direct from the Internet is the new kid on the block and although the content of this information has been subject to detailed consideration [3], access to it has not. However, one study [22] showed an association between the intended use of a Web site for health information and having a home computer/ Internet access at home—suggesting access is a limiting factor.

No research evidence looking at in-house provision of Internet access for NHS patients is thus far published in the primary medical literature. Anecdotal reports of Internet access in GP waiting rooms have appeared in the media (for example, in Manchester [23]), but there are no indications that access provision in such cases has been the result of a needs assessment process or that it has been subject to post-implementation evaluation. A small US study of "moderated" Internet access (supervised by a medical student) in a family practice setting concluded that 94% of patients found Internet information helpful, 77% of patients would change a health behaviour as a result, 90% of patients were more satisfied with their visit than usual, and that 92% of patients would use the Internet at the clinic again [24].

Some companies offer information kiosks designed to restrict access to pre-selected information that can be accessed via a touch screen. Such systems can have additional benefits, such as usage statistics (number of uses, subjects studied, fact sheets printed, etc). These kiosks are in use in several NHS general practices, although offering patients unrestricted access appears to be an innovative notion, perhaps due to perceived risks such as inappropriate use and abuse.

Conclusion

Research is needed to assess the feasibility and advisability of a UK public health policy offering patients the same level of access to Internet-based healthcare information as pledged to NHS professionals in Information for health. Such research will need to consider patient views on the utility of Internet access relative to more conventional information provision and include a detailed risk assessment, together with projections concerning the resource implications of widespread access and its likely effects on the work patterns of healthcare providers.

The views expressed in this article do not necessarily represent the opinion of the author's employer.

References and notes

1. McKenzie BC. Medicine and the Internet: introducing online resources and terminology. 2nd edn. Oxford: Oxford University Press; 1997.
2. Coiera, E. The Internet's challenge to health care provision. British Medical Journal 1996;312:3-4.
3. McKenzie BC. Information quality issues. In: McKenzie BC (ed). Medicine and the Internet. 3rd edn. Oxford: Oxford University Press; 2002.
4. United Nations Conference on Trade and Development. E-commerce and development report, 2002. New York: United Nations; 2002. URL: http://www.unctad.org/
5. Cyber Dialogue. Cyber Dialogue releases Cybercitizen Health 2000 [press release] 2000 Aug 22. URL: http://www.cyberdialogue.com/
6. Brown H. Information for patients. In: McKenzie BC (ed). Medicine and the Internet. 3rd edn. Oxford: Oxford University Press; 2002.
7. Houston TK, Allison JJ. Users of Internet health information: differences by health status. Journal of Medical Internet Research 2002;4(2):e7. URL: http://www.jmir.org/2002/2/e7/
8. McKenzie BC. Access to the Internet. In: McKenzie BC (ed). Medicine and the Internet. 3rd edn. Oxford: Oxford University Press; 2002.
9. NHS Executive. Information for health. London: Department of Health; 1998. URL: http://www.doh.gov.uk/ipu/strategy/index.htm
10. NHS Information Authority. Connections [newsletter] 2002 Oct. URL: http://www.nhsia.nhs.uk/
11. Oftel. Consumers' use of the Internet: Oftel residential survey Q5 May 2001 [report]. 2001 May. URL: http://www.oftel.gov.uk/publications/research/2001/q5intr0701.htm
12. Eysenbach G. Consumer health informatics. British Medical Journal 2000;320:1713-16. URL: http://www.bmj.com/cgi/content/full/320/7251/1713
13. See http://www.digitaldividenetwork.org/
14. See http://www.nelh.nhs.uk/
15. See http://www.nhsdirect.nhs.uk/
16. Department of Trade and Industry, Department for Culture, Media and Sport. A new future for communications [white paper]. 2000 Dec. URL: http://www.communicationswhitepaper.gov.uk/
17. Health on the Net Foundation. Evolution of Internet use for health purposes? Feb/Mar 2001. 2002 Mar 4. URL: http://www.hon.ch/Survey/FebMar2001/survey.html
18. Kassirer JP. The next transformation in the delivery of health care [editorial]. New England Journal of Medicine 1995;332:52-3.
19. Lancet. Leap of faith over the data tap [editorial]. The Lancet 1995;345:1449-51.
20. Milburn A. The NHS Plan: a plan for investment; a plan for reform 2000 Jul. URL: http://www.nhs.uk/nationalplan/nhsplan.pdf
21. Kenny T, Wilson RG, Purves IN, Clark J Sr, Newton LD, Newton DP, Moseley DV. A PIL for every ill? Patient information leaflets (PILs): a review of past, present and future use. Family Practice 1998 Oct;15(5):471-9. URL: http://fampract.oupjournals.org/cgi/reprint/15/5/471
22. Smith-Barbaro PA, Licciardone JC, Clarke HF, Coleridge ST. Factors associated with intended use of a Web site among family practice patients. Journal of Medical Internet Research 2001 Apr-Jun;3(2):E17. URL: http://www.jmir.org/2001/2/e17/
23. Anonymous. Internet access for waiting patients. Manchester News 2001 Aug 21. URL: http://www.bbc.co.uk/manchester/news/082001/21/gp.shtml
24. Helwig AL, Lovelle A, Guse CE, Gottlieb MS. An office-based Internet patient education system: a pilot study. Journal of Family Practice 1999 Feb;48(2):123-7.

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