Medicine: The Age of e-Patients
More and more Israeli adolescents, both Jewish and Arab, are becoming e-patients—health consumers who use the Internet to learn about their health issues and, often, those of family and friends as well. Almost half of Jewish 7th- to 12th-graders (43 percent) and two thirds of Arab students (63 percent) in 158 Israeli schools go online to get information, primarily about fitness and exercise, diet, nutrition and eating disorders, cigarettes and drugs, contraception and pregnancy.
This is important information for epidemiologist Yehuda Neumark, Ph.D., M.P.H., who led the survey of over 7,000 teens nationwide that produced these results. He directs the Hadassah–
Hebrew University Braun School of Public Health and Community Medicine, whose focus throughout its 52 years has been improving the health of communities and their different populations, with particular emphasis on preventive care.
These youngsters have parents who are separated by a wide digital divide,” he says. “That is, the Jewish adults are far more likely to access the Internet and have the skills to do so than the Arabs. But, as our study shows, this divide has disappeared in a single generation. Virtually all Israeli adolescents have Internet access and skills. And like teens in the United States, Europe and African countries, a large proportion of them use those skills to seek health facts, in privacy and in their own time.”
While the “e” in e-patient properly indicates “electronic,” it has also come to signify patients who are empowered, engaged, equipped and enabled. “The development of the e-patient is among the most important technocultural revolutions of the past century,” says Neumark. “The Internet has become a powerful tool for improving health status, and something that Hadassah’s school of public health is both using and helping to advance.”
The initial survey of health surfing among high school students generated pivotal questions. First and most crucial: How accurate and complete is the Hebrew-language online information out there? Closely following it is how much faith do young Internet users place in the Web sites they consult? And do they check their veracity and, if so, how? Is their checking, for example, confined to comparing information from different Web sites—which is of limited value since many sites copy from one another.
These were the questions asked in Neumark’s follow-up project, which evaluated the quality of online information about oral contraceptives.
“We chose oral contraception to answer our questions because it is a topic with clear boundaries—unlike, say, drugs or alcohol, where boundaries are harder to set,” says Neumark.
The research team looked at 29 Hebrew-language Web sites that deal with “the pill”—from the national health funds, contraception-specific sites and health portals to promotional, commercial, women’s health and lifestyle sites. They found that the quality of online information varied widely, with just over half of it no more than partially accurate to totally incorrect. Despite this, each site earned an average 70-percent credibility or believability rating.
“These results make it very clear that guidelines for health Web site content must be established,” says Neumark. The public health school team has taken its findings to organizations, such as the Israel Anti-Drug Authority (currently revamping its Web site), while they move on to their next stage: gathering information about the attitudes of physicians and other health care providers in Israel to the e-adolescent.
“This is the other side of the coin,” he adds. “To complete the picture, we need to know how the health care establishment interacts with young e-patients. Do they advise them to look for background, facts or guidance on the Internet? Do they have the skills to discuss adequately issues that can arise from Internet searches?”
One of the examples that the survey looks at is how medical professionals respond to a 15-year-old girl who has upped, lowered or stopped her medications because of something she has read online. “If, as we expect to find, at least some health care professionals lack the necessary skills,” Neumark notes, “we can then think about the kind of training that will strengthen their e-health literacy, so they can help their patients seek out high-quality health information on the Internet.”
While medical technologies have until now been fully controlled by health care professionals, the Internet is equally in the hands of patients—a shared access that is redefining the roles of physician and patient. “With adolescents particularly receptive to online health information, the Internet can become a very powerful preventive tool for negative behaviors, such as addiction,” says Neumark, who has extensively studied drug and alcohol (and, more recently, inhalant) misuse and dependency among young Israelis. “The earlier primary prevention begins, the more effective it is. It is well known that the earlier youngsters have access to drugs, the earlier they will start using, and the earlier they use, the more likely they will become dependent. We have a precious opportunity to impact positively on the health behavior and attitudes of young Israelis by guiding the development of youth-oriented health-information Web sites.”
Modern communications technology extends, of course, beyond the Internet. Dr. Hagai Levine, a public health physician and epidemiologist from the faculty of the school of public health, is using mobile phone text-messaging to help smokers quit. “Studies in the United States and other countries have shown that real-time texting can be effective in helping people kick the habit,” he explains. “The texts can be supportive messages, serious or humorous, regular reminders or emergency responses to cravings.”
A cell phone can be an ideal delivery mechanism for tailored interventions because it is low cost, carried by most people and immediate. “Our pilot study,” says Levine, “testing a modified version of a smoking-cessation program developed in the United States, was found to be feasible and acceptable to smokers in Israel. This has led to the development of a national program in Israel, on track at the moment, with the support of the Israel Cancer Association and Health Ministry. Lessons we learned doing this can be applied to other countries developing, evaluating and implementing such programs.”
Nor is technological communication limited to the public health school’s programs in Israel. Thirty students—among them, three Palestinians—are currently enrolled in the school’s one-year International Master’s of Public Health Program, and they confront a very different world from when the course was first launched 42 years ago. The knowledge and skills they are taught have been expanded to embrace developing communications technologies.
Dr. David Okia from Uganda is one of the students. Like the 750 graduates from 90 nations who have preceded him, he will go home to play a key role in his country’s health care system. His idea is using mobile phone technology to enable isolated doctors in rural Uganda to consult in real time with leading medical practitioners for advice, instructions and uploading images and other data for interpretation.
“The idea was triggered when I operated on a woman for what I thought was obstructed labor,” he says. “Midsurgery, however, I found that her uterus was ruptured—a life-threatening condition that I didn’t know how to repair. We were 200 miles from the nearest ob/gyn, but I got him on the phone. He walked me through the surgery and the patient survived.”
Papua New Guinea is looking to the pubic health school for help in developing something similar in its western province, an area twice the size of Israel, with 100,000 scattered inhabitants. Visiting the school in mid-May, the provincial governor put in motion plans to collaborate with Hadassah on developing an e-medicine or telemedicine system.
Even the school’s traditional models of health care are getting an upgrade. Community-oriented primary care, or COPC, a public health care delivery system that was brought from South Africa by the school’s founders, was developed at Hadassah over several decades. It now operates in communities worldwide, successfully integrating clinical medicine with public health. Nepal is the most recent to request the model, and Hadassah is working with Kathmandu’s Dhulikhel Hospital to open a network of 20 health-outreach COPC centers throughout rural Nepal. Software is now being developed to collect data for ongoing community monitoring—on computers donated to each clinic by Israel’s Foreign Ministry.
While the Internet and communications technology are far from being exclusively medical tools, their potential benefits to health are boundless. The Hadassah–Hebrew University Braun School of Public Health and Community Medicine believes that by identifying and addressing the factors that underpin their use, and by helping health professionals and health consumers alike become discerning users, they can be shaped into one of the greatest health benefits of our time.