A look at the "dark side" of ehealth

by Hans on 2006/08/10

A look at the “dark side” of ehealth

In his book Amusing Ourselves to Death: Public Discourse in the Age of Show Business,
Neil Postman writes about the unconscious effects of television in society. He later generalizes that technologies inherently favour certain types of interaction, thinking, conceptualization, and communication. For example, the written word (i.e., text) emphasizes rational, logical thought and expression, whereas multimedia (like television of the computer) utilizes and favours emotional responses visual stimulation. These technologies (unconsciously) change how we interact with and conceptualize the world around us. A good example is when movies switched from silent to spoken word pictures, or from black and white to colour. For more on this topic, you can read the works of Marshall McLuhan.

So what does all of this have to do with ehealth? As we move from the current versions of our health care system to one that is increasingly electronic, what types of changes can we expect to see? Much has been written about all the potential positive effects of using ehealth, most notably making health care safer, more dynamic, and more cost-effective. I do not doubt that some of these possibilities will be realized some time in the future. But, what of the potential negative effects of ehealth? Are we overlooking the “dark side” of ehealth? (Note: I’m going to focus on some of the systematic changes that we might see as Gunther Eysenbach has done some interesting work on the quality of health information and possible negative outcomes)

In the past, health care (or more aptly, medicine) has already seen a dramatic shift in the mid 1900’s. Physicians were originally considered extended family members, making house calls and acting as healer, confidante, psychologist, and more. With the advances in microbiology and emergence of science based medical programs like Johns Hopkins, community based practitioners were replaced by scientist-physicians who relied upon new scientific discoveries and now, the “best available evidence”. Health care has seen a shift from individual to community based care. In Canada, this shift has also been further institutionalized and cemented by the passing of legislative acts. I’m not suggesting that these changes are bad. I’m just recounting what has happened to try and see what might happen as we embark on the new ehealth world.

So, what’s in store for health care? Here are some of thoughts on the potential dark side of “ehealth”:

  • Everything is electronic: Having your personal health information in an electronic format is very useful and beneficial. But, have you ever thought of the possible negative consequences? I’m not trying to sound alarmist, but let’s examine the possible scenarios. When everything is electronic, this information becomes available to anyone who can legally (or illegally) access it. The Veteran’s Affairs services had a laptop computer containing health information of 26.5 million patients stolen. Luckily the computer was recovered with no apparent information compromised. Does your local family practice have sufficient electronic security and privacy protection in place? Also, when everything is electronic, information (either correct or incorrect) can be spread across the “system” at an alarming rate. We learn from identity theft of credit fraud that having out-dated or incorrect information can be very problematic. Will health care be any different? I honestly don’t know.
  • Have you paid your electricity bill? As we move towards everything ehealth, are we setting ourselves up for a calamity? Electricity is something that we all need. If the power black-out of 2002 didn’t remind us, we should take note of what technology firms are doing because of the rising cost of electricity. Google and Yahoo are building server farms in rural areas to get access to electricity and purchasing lower powered equipment. What are our health care organizations and providers doing to ensure there will be electricity during times of crisis? I know that hospitals have gas generators to provide electricity, but petroleum is also becoming very expensive too. If our electrical systems were to go down, how will we get to the data when physical storage (i.e., paper) is no longer maintained? It’s just a thought.
  • Me, myself, and I: One of the assumptions with ehealth is that individuals will become “consumers” of health care, thus becoming more responsible over the management of their own health. I’m not opposed to this change as individuals should take care of themselves. But, aren’t we making a big assumption that people want this responsibility? This change means individuals will need to become more responsible over their own health information (e.g., who has access to it, where it is stored, etc.) and coordinating their care. If individuals are to maintain their own personal health records, what technical skills and resources do they need to be able to do this? In the past two weeks, I’ve had two computers die on me – recovering my information was a pain in the ass, but I was able to recover my data. If this happened to my parents when I wasn’t around, they’d be lost. Will individuals (or practitioners) be up to the task?
  • The disappearance of the family physician?: Okay, this one’s probably what I’m most interested in. As individuals become more involved and active in their own care, will we see the loss of general practitioners and family physicians? One of the advantages of ehealth is purportedly being able to access services irrespective of geography. In other areas of society, we have seen technology cut out the “middle-men”, allowing the individual to interact directly with the producers of the goods. Does this mean that we will see individual patients contacting specialists directly? Recently, my uncle had a need to see a specialist. Unfortunately, the specialist was only able to see him 6-8 months in the future. So, I asked around to see if some of my physician friends could help my uncle. They were. Unfortunately, my uncle’s family physician decided not to forward a referral and so my uncle couldn’t see the specialist a colleague suggested (even though he could be seen in a week or two). Will patients decide to skip seeing a family physician and go straight to the specialist?
  • Health care’s “last mile”: Because health care must be delivered by a person (at least until we develop electronic delivery systems), we still have to deal with what I will call “health care’s last mile”. In the telecommunications industry, the “last mile” is what they call the effort required to get the new technology to the consumer’s home (e.g., high-speed internet). Someone has to go and physically connect and configure connections (depending on the technology). In health care, people are needed to deliver care. Combined with the disappearance of the family physician, will we see our health care evolve into groups of specialists (who diagnose and consult) and nurses (who follow-up on the instructions at the local level)? We see this type of phenomenon occurring in business circles – the “bar-bell” effect. The “middle layers” of organizations are thinned out so that you are left with highly skilled executives overseeing a vast army of workers with very few middle-level managers. Maybe that’s why I don’t see overseas outsourcing as a viable option in healthcare. But, with more electronic resources being developed, what will the role of the family physician be? Nurses, of various qualifications, will likely be around to provide home care services, work in hospitals, and generally deliver care that individual patients cannot.

I’m not suggesting that we revert back to the “good ol’ days” of paper. But, I think we need to examine some of the potential changes that may occur. It’s this idea of informed consent (i.e., being aware of and understanding the potential risks and benefits). Do we really know what will happen as we move towards a completely ehealth system? Have we even thought about this issue? Or are we so enthralled by the new technologies, moving pictures, and sounds that we forget about what the consequences might be? After looking at some of these potential negative aspects/scenarios, I’m still a supporter of ehealth. I just think we need to start thinking more about what we want the technology to do for us, and to accept potential side-effects after some thought, rather than reacting to changes in a haphazard fashion.

One last thought to end this post. Noted futurist, Alvin Toffler, predicted that advanced technological societies will need to deal with something called massification and demassification – I’ll call it the paradox of the individualized groups. Are we going to see a fragmentation of the health care system because of our increased ability to access information and services irrespective of geography?

Author’s Notes:

  1. I wrote this post using the new plug-in for Microsoft Word. Not sure that I like it, but I’ll give it a few more tries. On the plus, I can write a post without being connected to the Internet with all of the features of Word (I’m not sure if that’s a benefit, but it seems like an advantage over typing in a browser window on Blogger).
  2. Sorry for not writing posts over this past summer, but I’ve been going through a series of minor health issues that have kept me from doing pretty much anything. As I get over one thing, another issue seems to pop up. Added to all of this fun was the fact that both my laptop and desktop died on me within a span of two weeks. Data recovery and trying to set-up a computer is not fun.
  3. I have a few other posts planned, so be on the look-out. I’m hoping to write about open source in health care, a summary of my disruptive innovations in health care, and a few others.

{ 2 comments }

Richard August 19, 2006 at 6:48 am

Hans: ran across your blog today and read back through several of your posts. We see eye to eye on many things, except for the decline of generalism.

Working at the University of Pennsylvania as a generalist I run across this meme routinely, yet I and my partners continue to thrive, and for good reason.

Good primary care doctors humanize the medical experience, understand and balance complex and often competing demands, know the limits of their competence, and coordinate care when patients receive services at other levels of care.

High quality primary care incorporates all of these elements. Don’t relegate it to the waste bin unless you’ve tasted it. Like ripe summer tomatoes, once you’ve had the real thing you’ll have a hard time going back.

Like you I agree that eHealth technologies will make health care (and specifically primary care) more patient centered.

Keep up the good writing!

Hans August 21, 2006 at 3:34 pm

Hi Richard,

Thank you for the great comment – I always enjoy hearing about positive developments and experiences in the health care system. Regarding the question of the generalist in healthcare, I wasn’t predicting their demise. I was just wondering if generalists will face similar pressures as seen in other industries. Technology seems to have forced many industries to adopt a “bar-bell” shape, and I was just wondering if health care is sufficiently different to be able to resist this change from happening.

As for primary care, I will be the first to agree with you that good primary care can have an inordinate effect on a person’s health when in contact with the health care system. My immediate family and I have been fortunate to find an excellent primary/family physician who has taken care of our needs. But, I have learned that my experience has been more the exception rather than the norm.

Glad to you enjoy the reading – hope you come back.

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