Research Critique

current as of November 4, 2009. Online article and related content

http://jama.ama-assn.org/cgi/content/full/289/18/2400

. 2003;289(18):2400-2406 (doi:10.1001/jama.289.18.2400) JAMA

Laurence Baker; Todd H. Wagner; Sara Singer; et al.

Information: Results From a National Survey Use of the Internet and E-mail for Health Care

Correction

Contact me if this article is corrected. http://jama.ama-assn.org/cgi/content/full/jama;290/3/334

Correction is appended to this PDF and also available at

Citations Contact me when this article is cited. This article has been cited 241 times.

Topic collections

Contact me when new articles are published in these topic areas. Communication; Patient Education/ Health Literacy Medical Practice, Other; Patient-Physician Relationship/ Care; Patient-Physician Informatics/ Internet in Medicine; Internet; Medical Informatics; Medical Practice;

Related Letters

. 2003;290(17):2257.JAMACarlos A. Rizo et al. . 2003;290(17):2256.JAMATerry Kind et al.

. 2003;290(17):2256.JAMAJoshua Fogel. . 2003;290(17):2256.JAMATracey Bessell et al.

. 2003;290(17):2255.JAMAKaren Donelan. . 2003;290(17):2255.JAMARoger C. Holstein et al.

Use of the Internet for Health Information and Communication

http://pubs.ama-assn.org/misc/permissions.dtl [email protected] Permissions

http://jama.com/subscribe Subscribe

[email protected] Reprints/E-prints

http://jamaarchives.com/alerts Email Alerts

at Penn State Milton S Hershey Med Ctr on November 4, 2009 www.jama.comDownloaded from

ORIGINAL CONTRIBUTION

Use of the Internet and E-mail for Health Care Information Results From a National Survey Laurence Baker, PhD Todd H. Wagner, PhD Sara Singer, MBA M. Kate Bundorf, PhD, MBA, MPH

T HE INTERNET HAS BEEN RECOG- nized for many years as an im- portant, if concerning, mecha- nism for transforming medical

care.1-6 While questions remain about its limitations,7 concerns regarding misin- formation,3,8-13 and potential difficulties with the confidentiality of personal in- formation,14,15 the Internet appears to have promise as a means to disseminate information about health and health care, enhance communication, and facilitate a wide range of interactions between pa- tients and the health care delivery sys- tem. These kinds of changes could pro- duce important improvements in health care and, ultimately, the health of the population. Understanding the extent to which the Internet is being used for health purposes and the effects it has on health care use would help identify the extent to which these benefits are being realized and provide a context for fruit- ful discussions of the current and fu- ture role of the Internet in health care.

Commonly cited estimates suggest that more than half15-17 and as much as 80%18-20 of adults with Internet access use it for health care purposes. Many of those who use the Internet for health pur- poses are reported to use it frequently. These estimates have been widely dis- seminated and now frequently form the context for discussions among the media and others of the role of the Internet in

health care.21-28 However, other, per- haps less well-publicized reports sug- gest much lower rates of use.14,29,30 Com-

paring existing estimates can be difficult because details on aspects such as selec- tion or nonresponse bias are frequently

Author Affiliations: Department of Health Research and Policy, Stanford University School of Medicine (Drs Baker, Wagner, and Bundorf ), and Center for Health Policy and Center for Primary Care and Outcomes Research, Stan- ford University (Drs Baker, Wagner, and Bundorf and Ms Singer), Stanford, Calif; National Bureau of Eco- nomic Research, Cambridge, Mass (Drs Baker and

Bundorf ); and VA Health Services Research and Devel- opment Health Economics Resource Center, VA Palo Alto Health Care System, Palo Alto, Calif (Dr Wagner). Corresponding Author and Reprints: Laurence Baker, PhD, Stanford University School of Medicine, HRP Red- wood Building, Room 253, Stanford, CA 94305- 5405 (e-mail: [email protected]).

Context The Internet has attracted considerable attention as a means to improve health and health care delivery, but it is not clear how prevalent Internet use for health care really is or what impact it has on health care utilization. Available estimates of use and impact vary widely. Without accurate estimates of use and effects, it is difficult to focus policy discussions or design appropriate policy activities.

Objectives To measure the extent of Internet use for health care among a repre- sentative sample of the US population, to examine the prevalence of e-mail use for health care, and to examine the effects that Internet and e-mail use has on users’ knowl- edge about health care matters and their use of the health care system.

Design, Setting, and Participants Survey conducted in December 2001 and Janu- ary 2002 among a sample drawn from a research panel of more than 60 000 US house- holds developed and maintained by Knowledge Networks. Responses were analyzed from 4764 individuals aged 21 years or older who were self-reported Internet users.

Main Outcome Measures Self-reported rates in the past year of Internet and e-mail use to obtain information related to health, contact health care professionals, and ob- tain prescriptions; perceived effects of Internet and e-mail use on health care use.

Results Approximately 40% of respondents with Internet access reported using the Internet to look for advice or information about health or health care in 2001. Six per- cent reported using e-mail to contact a physician or other health care professional. About one third of those using the Internet for health reported that using the Internet affected a decision about health or their health care, but very few reported impacts on measurable health care utilization; 94% said that Internet use had no effect on the number of physician visits they had and 93% said it had no effect on the number of telephone contacts. Five percent or less reported use of the Internet to obtain pre- scriptions or purchase pharmaceutical products.

Conclusions Although many people use the Internet for health information, use is not as common as is sometimes reported. Effects on actual health care utilization are also less substantial than some have claimed. Discussions of the role of the Internet in health care and the development of policies that might influence this role should not presume that use of the Internet for health information is universal or that the Inter- net strongly influences health care utilization. JAMA. 2003;289:2400-2406 www.jama.com

2400 JAMA, May 14, 2003—Vol 289, No. 18 (Reprinted) ©2003 American Medical Association. All rights reserved.

at Penn State Milton S Hershey Med Ctr on November 4, 2009 www.jama.comDownloaded from

not presented in the reports, many of which appear online or as private releases rather than in peer-reviewed journals.

The wide variation in estimates of the extent of Internet use for health, coupled with the fact that the highest estimates have been the most widely dissemi- nated, makes it difficult to focus discus- sions about the role of the Internet in health care and develop appropriate re- sponses. Clearer information is needed as a foundation for future steps. This ar- ticle reports results from a survey that measures the extent of Internet use for health care among a large, well- defined, representative sample of the US population.

We also examined the prevalence of e-mail use for health care. Previous lit- erature expresses both optimism and concern about the use of e-mail for pa- tient-physician communication.31-33 Re- ports based on surveys of limited sets of patients cite widespread access to e-mail and generally favorable attitudes to- ward it,34,35 but few studies identify the prevalence of e-mail use in practice.36 Fi- nally, we examined the effects that In- ternet and e-mail use has on users’ knowledge about health care topics and their use of the health care system.

METHODS During December 2001 and January 2002, we surveyed a nationally repre- sentative sample of the US population aged 21 years or older about their use of the Internet and e-mail for health. We drew our sample from a research panel of more than 60 000 households devel- oped and maintained by Knowledge Net- works (Menlo Park, Calif ), a survey re- search firm. To construct the panel, Knowledge Networks used random- digit dialing to contact potential panel households, inviting them to join the re- search panel. To facilitate surveying the panel and to create an incentive for par- ticipation, they provide all households in which an individual agrees to partici- pate in the panel with free Internet ac- cess via WebTV (Microsoft Inc, Red- mond, Wash). Surveys of individuals from the panel are conducted using the Internet. The ability of this research panel

to support nationally representative analyses has been studied in a number of ways, all of which substantiate its va- lidity. We conducted specific tests of the validity of the survey sample used for this study, which showed that it tracks key indicators from other major national sur- veys. (These analyses are reported in an appendix to this article that is available from the authors.) Our survey was sent to 12 878 individuals consisting of a ran- dom sample of adults aged 21 years or older and random oversamples of indi- viduals aged 50 or older and veterans. Re- sponses were obtained from 8935 (69.4%) of those surveyed. We use post- stratification weights, which correct the distribution of respondents to match the known distribution of the US popula- tion on age, sex, race, education, re- gion, metropolitan residence, and veteran status, to account for the overs- amples and for nonresponse.

Previous studies have typically reported rates of Internet use for health care among respondents with Internet access. All of the members of our sample have Internet access because all have the WebTV provided by Knowledge Net- works. Because our sample contains indi- viduals who did not obtain Internet access on their own, as a whole it is probably not directly comparable with samples with Internet access analyzed in other studies. To provide comparable infor- mation, we analyzed the subgroup of our sample who reported that they had used the Internet before they were given WebTV. We expect this group of “Inter- net users” to be comparable with those identified in other studies as Internet users. Of the 8935 survey respondents, 4764 reported using the Internet before getting WebTV.

The survey contained an extensive set of questions about use of the Internet and e-mail for health care information and the perceived effects of Internet or e-mail use on health care use. In some sec- tions, respondents who self-reported hav- ing any of 5 chronic conditions were asked questions specific to their condi- tion. The 5 conditions were heart prob- lems (defined as a “heart attack,” coro- nary heart disease, angina, heart failure,

or other heart problems), cancer, diabe- tes, hypertension, and depression. Respondents who indicated having more than 1 condition were randomly assigned 1 of the conditions that they indicated for the condition-specific questions. Comparisons of Internet and e-mail use among patients with different condi- tions are presented elsewhere.37

We analyzed responses using stan- dard tabulations. We used logistic re- gression analyses to investigate the re- lationships between Internet and e-mail use for health care and age, sex, an- nual household income, education, self- reported health status, and residence in a Metropolitan Statistical Area. These models exclude cases with missing data f o r h o u s e h o l d i n c o m e a n d s e l f - reported health status. Standard er- rors in the regressions are adjusted for the complex survey design. Analyses were performed using Stata (Stata Corp, College Station, Tex). P�.05 was con- sidered statistically significant.

RESULTS Prevalence of Internet and E-mail Use for Health Information

Our analysis sample included 4764 in- dividuals who responded to the survey and who reported that they had used the Internet before receiving the WebTV ser- vice. TABLE 1 describes the demo- graphic characteristics of the sample.

The survey asked 4 main questions about use of the Internet and e-mail for health care purposes in the last year (TABLE 2). Approximately 40% of In- ternet users in our sample reported that they used the Internet for information or advice about health or health care dur- ing the past year. Next most common was use of e-mail or the Internet to com- municate with family or friends about health in the past year. Use of e-mail or the Internet to communicate with a health care professional or with other people who have similar health condi- tions or concerns was less common.

Among those who use the Internet for health care, use was relatively in- frequent. Thirty-one percent of respon- dents (who comprised 78% of those who reported ever using the Internet for

USE OF THE INTERNET AND E-MAIL FOR HEALTH

©2003 American Medical Association. All rights reserved. (Reprinted) JAMA, May 14, 2003—Vol 289, No. 18 2401

at Penn State Milton S Hershey Med Ctr on November 4, 2009 www.jama.comDownloaded from

health) said they used the Internet for health every 2 to 3 months or less. Only 9% of respondents (22% of those who said they used the Internet for health) said they used the Internet once a month or more. Similar frequencies were observed for use of e-mail.

We examined the relationship be- tween the use of e-mail and use of the Internet for health. Fifty percent of re- spondents said that they had used the In- ternet or e-mail in at least 1 of the 4 mea- sured ways. Of these, 42% reported using the Internet for health information with- out use of e-mail. Rates of e-mail use were notably higher among those who re- ported Internet use for health. Forty- seven percent of those who reported In- ternet use also reported using e-mail for 1 or more of the 3 measured purposes as opposed to 16% of those who did not report using the Internet. Specific ex- amination of the association between health Internet use and e-mail commu- nication with physicians showed that 10% of those who reported Internet use also reported e-mail communication with a physician as opposed to 3% of those who did not report Internet use.

Demographics and Internet Use for Health TABLE 3 reports results from logistic re- gression analyses that examined the re- lationships between respondent demo- graphics and Internet and e-mail use for health. Individuals aged 75 years or older were much less likely to report use of the Internet for health than younger in- dividuals. The odds of use for men were

about half of the odds for women (P�.001). We observed strong relation- ships between higher education levels and higher rates of Internet use for health but no strong relationship with in- come. Respondents who self-reported worse health status were more likely to report using the Internet for health and health care.

There were no significant demograph- ic relationships for the rate of making e-mail contact with a physician or other health care professional, for which the rate of any use was low in general. Re- lationships between demographics and rates of e-mail contact with family or friends were similar to those found for Internet use for health. When we exam- ined use of e-mail or the Internet to con- tact others with similar health concerns, we found no trend toward less use with age and a weak relationship with edu- cation. Higher-income households were less likely to use e-mail or the Internet to contact others with similar health con- cerns, and individuals reporting worse health status were more likely to do so.

Effects of Internet Use on Health Care We asked respondents who reported that they had ever used the Internet or e-mail for health purposes a series of ques- tions about the effects of Internet or e-mail use on their knowledge about health care issues and their use of health care. Those who indicated having heart problems, cancer, diabetes, hyperten- sion, or depression were asked ques- tions about the effects of the Internet or e-mail specific to their condition. Those who did not indicate having 1 of these conditions were asked more general questions. These questions were phrased so that respondents could indicate that they strongly agreed, agreed, disagreed, or strongly disagreed that the Internet or e-mail had various effects. TABLE 4 re- ports the percentages of respondents who strongly agreed or agreed that use of the Internet or e-mail had the indicated effect. Among those without any of the 5 chronic conditions, 67% said that use of the Internet improved their under- standing of health care issues, but fewer

Table 1. Sample Characteristics of Internet Users (N = 4764)*

Weighted %

Age, y 21-34 32.7 35-49 38.1 50-64 21.3 65-74 5.8 �75 2.1 Mean (SD) 42.5 (13.7)

Male sex 47.2 Household income, $

�25 000 21.2 25 000-49 999 34.5 50 000-74 999 23.5 �75 000 20.7

Education, y �12 41.4 13-16 49.1 �16 9.6

Health status Excellent/very good 54.8 Good 34.3 Fair/poor 11.0

Residency Urban 79.9 Nonurban 20.1

Chronic conditions† �1 43.7 0 56.3

*Because of item nonresponse, unweighted n = 4280 for income distribution, 4760 for health status distribution, and 4756 for chronic condition distribution.

†The 5 chronic conditions inquired about are heart prob- lems, cancer, diabetes, hypertension, and depression.

Table 2. Prevalence and Frequency of Internet and E-mail Use for Health Information*

In the Past Year, About How Often Did You

Frequency of Use, Weighted %

Ever in Last Year

More Than Once/wk

About Once/wk Once/mo

Every 2-3 mo

Less Than Every 2-3 mo

Look on the Internet for information or advice about health or health care? (n = 4760)

39.7 1.6 2.2 4.8 6.1 25.0

Use e-mail or the Internet to communicate with a doctor or other health care provider? (n = 4737)

6.0 0.8 0.4 0.6 0.9 3.3

Use e-mail or the Internet to communicate with a family member or friend about health or health care? (n = 4734)

25.5 1.5 2.0 3.3 3.9 14.8

Use e-mail or the Internet to communicate with other people who have health conditions or concerns like yours? (n = 4722)

11.2 0.8 1.1 1.6 1.5 6.3

*Data are shown as weighted percentages of responses in each category. Sample sizes differ across questions be- cause of item nonresponse.

USE OF THE INTERNET AND E-MAIL FOR HEALTH

2402 JAMA, May 14, 2003—Vol 289, No. 18 (Reprinted) ©2003 American Medical Association. All rights reserved.

at Penn State Milton S Hershey Med Ctr on November 4, 2009 www.jama.comDownloaded from

respondents said that the Internet af- fected more substantive decisions or ac- tivities such as improving their ability to manage their health care needs on their own or influencing their choice of health care professional. We obtained similar re- sults among those with 1 or more of the chronic conditions. About half of these respondents indicated that use of the In- ternet improved their understanding of their chronic condition, treatments for their chronic condition, or other symp- toms, conditions, or treatments, while the percentage indicating effects on deci- sions about health or health care or on use of the health care system ranged from 7% to 32%.

Two questions specifically asked about effects of Internet use on contacts with the health care system (TABLE 5). Re- spondents were asked about the effect of Internet or e-mail use in the last year on the number of times they had visited or telephoned a physician or other health care professional. In both cases, more than 90% of respondents indicated that use of the Internet or e-mail had no effect on the number of contacts.

Use of the Internet for Prescription Drugs We asked respondents who self- reported that they had taken a prescrip- tion medication in the past year sev- eral questions about their use of the I n t e r n e t f o r p r e s c r i p t i o n d r u g s (TABLE 6). Five percent or less said that they used the Internet to obtain pre- scriptions either from their physician or from an online physician whom they had not seen in person, purchase pre- scription drugs, or search for the cheap- est place to buy a prescription drug. Thirty-three percent indicated that they had used the Internet or e-mail to learn more about a prescription drug.

COMMENT Extent and Frequency of Internet Use for Health

We estimate that approximately 40% of the adult US population with Internet access used the Internet for informa- tion or advice about health or health care in 2001. About half of the adult US population uses the Internet at all,29 sug- gesting that about 20% of the entire adult

population in the United States used the Internet for health care purposes in 2001. These numbers are substantially lower than the rates of Internet use for health care that are often reported. Highly publicized reports have sug- gested that a majority and, in some re- ports, even as many as 80% of US adults with Internet access use the Internet for health care purposes.15,16,18-20 However, our results are consistent with other, per- haps less widely publicized reports of 35% to 37% in recent years.14,29

We also found that Internet use for health is relatively infrequent. Seventy- eight percent of those who ever used the Internet for health care in 2001 re- ported using it every 2 to 3 months or less. Only 22% of those who ever used the Internet reported using it once a month or more. Again, our estimates are much lower than those reported in other studies. One recent report indi- cated that 59% of adults who search for health information online do so about once a week to once a month.15 In an- other report, the mean number of times per month users said they looked for

Table 3. Use of Internet for Health Information by Demographic Characteristics*

Characteristics

Search for Health Information

on the Internet E-mail Physician E-mail Family/Friends E-mail Others

Odds Ratio (95% Confidence

Interval) P

Value

Odds Ratio (95% Confidence

Interval) P

Value

Odds Ratio (95% Confidence

Interval) P

Value

Odds Ratio (95% Confidence

Interval) P

Value

No. of observations 4274 4259 4256 4247

Age, y 35-49 1.1 (0.8-1.4) .60 0.8 (0.5-1.4) .52 0.9 (0.6-1.2) .33 1.0 (0.6-1.5) .87

50-64 1.1 (0.8-1.4) .65 0.7 (0.5-1.2) .19 0.9 (0.7-1.2) .57 0.9 (0.6-1.4) .78

65-74 1.2 (0.8-1.6) .41 0.5 (0.3-1.0) .07 0.8 (0.6-1.2) .38 0.8 (0.5-1.4) .47

�75 0.6 (0.4-1.0) .048 0.7 (0.3-1.6) .44 0.9 (0.5-1.6) .74 1.3 (0.6-2.7) .44

Male sex 0.5 (0.4-0.6) �.001 1.1 (0.7-1.7) .55 0.6 (0.5-0.8) �.001 0.7 (0.5-1.0) .08

Household income, $ 25 000-49 999 1.0 (0.7-1.4) .96 0.7 (0.4-1.2) .17 0.8 (0.6-1.1) .15 0.7 (0.5-1.2) .18

50 000-74 999 0.9 (0.7-1.2) .56 0.5 (0.3-1.0) .06 0.8 (0.5-1.1) .12 0.4 (0.2-0.6) �.001

�75 000 1.1 (0.8-1.5) .53 0.7 (0.4-1.3) .27 0.9 (0.6-1.3) .55 0.5 (0.3-0.8) .004

Education, y 13-16 2.0 (1.6-2.5) �.001 1.2 (0.8-2.0) .39 1.4 (1.1-1.8) .005 0.9 (0.6-1.3) .50

�17 2.8 (2.0-3.9) �.001 1.4 (0.8-2.5) .21 2.5 (1.7-3.5) �.001 1.1 (0.7-1.7) .70

Resident of MSA 1.2 (0.9-1.6) .15 1.0 (0.5-1.7) .86 0.9 (0.6-1.2) .38 0.9 (0.6-1.4) .62

Health status Good 1.1 (0.9-1.4) .39 1.4 (0.9-2.2) .18 1.5 (1.1-1.8) .003 1.3 (0.9-1.9) .12

Fair/poor 1.8 (1.3-2.5) �.001 1.4 (0.8-2.6) .29 2.3 (1.6-3.2) �.001 2.1 (1.3-3.4) .004 Abbreviation: MSA, Metropolitan Statistical Area. *Models contain an intercept. Referent categories are as follows: age 21 to 34 years; female sex; household income under $25 000; 12 or fewer years of education; nonresidence

in an MSA; and excellent/very good health status.

USE OF THE INTERNET AND E-MAIL FOR HEALTH

©2003 American Medical Association. All rights reserved. (Reprinted) JAMA, May 14, 2003—Vol 289, No. 18 2403

at Penn State Milton S Hershey Med Ctr on November 4, 2009 www.jama.comDownloaded from

health information online was 3, and the median was 1.2.18 Our results can- not be directly compared with these re- sults, but our results imply a median number of uses per month much lower than 1.2.

One plausible explanation for the dif- ferences in reported use rates is differ- ences in the samples. Some previous work, including the surveys that re- port the highest rates of Internet use for

health care,19,20 is based on samples de- veloped by using online recruitment. Other previous work used telephone surveys. One possibility is that the samples used in these studies overrep- resent individuals who are particu- larly enthusiastic about the Internet and who might be both more likely to use it for health information and more will- ing to participate in surveys about it. Although we cannot unequivocally rule

out the existence of selection bias in our own sample, our analyses of the sample are consistent with the view that it is representative of the population of the United States and, thus, we do not ex- pect that selection bias is likely to have significantly influenced our results.

Although sample differences are a plausible explanation, we cannot pro- vide specific evidence about their rela- tive importance. Other possible expla- nations include differences in the wording of questions and the presenta- tion of the survey. We believe that our question about Internet use for health provides a wide scope for an affirma- tive answer and is thus likely to cap- ture a broad range of use and unlikely to lead us to underestimate use, but our question did ask about Internet use in the past year, and some other surveys are less precise about the time frame to which questions pertain. For example, a recent Harris Poll asked, “How often do you look for information online about health topics—often, sometimes, hardly ever or never?”18 Differences in the speci- fication of the time frame could play a role in the variations in the findings, al- though the comparable questions on other prominent surveys generally ap- pear to refer to current use patterns, which may not imply a time frame sub- stantially different than the past year.

It is tempting to interpret a finding that 40% of adults with Internet access use the Internet for health care information— much lower than common previous re- ports—as disappointing news for the In- ternet. It is not clear to us that this is the case. Although the Internet existed a de- cade ago, very few people would have used it then for health care purposes. That the number of people using the In- ternet for health has grown to include 40% of online adults could easily be viewed as a success. A useful point of comparison is reported rates of Internet use for other activities. Results from the US Census Bureau’s Current Popula- tion Survey, a highly regarded regular survey of the US population, suggest that about 62% of online adults use the In- ternet to check news, weather, or sports information; 42% play games online; and

Table 4. Perceived Effects of Internet or E-mail Use on Health Care Understanding and Decisions*

Effect of Using the Internet or E-mail No. of

Respondents

Agree or Strongly Agree,

Weighted %

Among Respondents With None of 5 Chronic Conditions

Improved my understanding of symptoms, conditions, or treatments in which I was interested

1119 67

Improved my ability to manage my health care needs without visiting a doctor or other health care provider

1112 30

Led me to seek care from different doctors or other health care providers than I otherwise would have

1104 12

Affected the way I eat or exercise 1115 27

Among Respondents With �1 of 5 Chronic Conditions

Improved my understanding of [condition] 1382 48

Improved my understanding of possible treatments for [condition]

1378 46

Improved my understanding of other symptoms, conditions, or treatments in which I was interested

1396 58

Affected treatments I am using for [condition] 1364 16

Improved my ability to manage my [condition] by myself 1359 27

Improved my ability to manage other health care needs without visiting a doctor or other health care provider

1375 30

Led me to seek care from different doctors or health care providers for [condition] than I otherwise would have

1360 7

Affected the way I eat or exercise 1370 32

*Questions were asked of those who said that they had used the Internet to look for information or advice about health or health care; used e-mail or the Internet to communicate with a provider, friend, family member, or other person with similar health care concerns; or used the Internet for any purpose related to prescription drugs. The full question preamble was, “Thinking overall about all of the times in the last year that you used the Internet or e-mail for things related to health or health care, to what extent would you agree or disagree with the following statements? Using the Internet or e-mail . . .” Response choices on a 4-point Likert scale were strongly agree, agree, disagree, strongly disagree. Condition was specified as heart problems, diabetes, cancer, hypertension, or depression based on the chronic condition(s) the respondent indicated. Sample sizes are unweighted; percentages are weighted.

Table 5. Perceived Effect of Internet Use on Physician Visits and Telephone Calls*

Did Using the Internet or E-mail Affect Either of the Following?

Weighted %

Increased No

Effect Decreased

No. of times visited a physician or other health care provider 3 94 3 No. of times telephoned a physician or other health care

provider 2 93 5

*Data are shown as weighted percentages of responses in each category. Questions were asked of those who said that they had ever used the Internet to look for information or advice about health or health care; used e-mail or the Internet to communicate with a provider, friend, family member, or other person with similar health care concerns; or used the Internet for any purpose related to prescription drugs. Unweighted sample sizes are 2548 and 2553, re- spectively, for the 2 questions. The full question preamble was, “Thinking overall about all of the times in the last year that you used the Internet or e-mail for things related to health or health care, did using the Internet or e-mail affect either of the following?”

USE OF THE INTERNET AND E-MAIL FOR HEALTH

2404 JAMA, May 14, 2003—Vol 289, No. 18 (Reprinted) ©2003 American Medical Association. All rights reserved.

at Penn State Milton S Hershey Med Ctr on November 4, 2009 www.jama.comDownloaded from

39% shop online.29 At the lower end, 18% report using the Internet for banking or paying bills, 17% report accessing chat rooms or listservs, and 9% report trad- ing stocks online. In this context, a uti- lization rate of 40% seems relatively high.

One intuitive interpretation of a uti- lization rate of about 40% is that the In- ternet holds the most promise for a sub- set of the population. There are a number of sources of health informa- tion available to interested individuals, of which the Internet is one. Optimal re- sults for health care delivery are most likely to be achieved if individuals seek information from the source that is most effective for them, and that source may not be the Internet for everyone, not even for everyone with Internet access. It may not be reasonable to expect that everyone with Internet access will use the Internet for health care or that en- couraging everyone with Internet ac- cess to use it for health care informa- tion would be the best course of action. This, though, would not mean that the Internet is not highly valuable for the subset of the population that uses it.

Some particular challenges are high- lighted by our analysis of the relation- ships between demographics and Inter- net use for health care. In particular, we find that individuals with less educa- tion are less likely to use the Internet for health care. These findings parallel more general findings about the prevalence of Internet use for any reason29 and raise important questions about the ability of the Internet as currently structured to provide benefits to populations that need health information and potentially have a difficult time getting it.

Overall, these findings suggest that discussions about using the Internet for health care should be calibrated to ac- count for a lower prevalence and lower frequency of use than often reported. Actions taken based on the presump- tion that frequent Internet use for health is the rule rather than the exception could be misdirected.

E-mail Use for Health Care E-mail use in general is widespread, with nearly all online adults reporting its

use.16,29 Our results, though, show little use of e-mail in patient-physician com- munications. We estimate that 6% of US adults with Internet access used e-mail to communicate with a health care pro- fessional in 2001, consistent with other reports suggesting limited use in prac- tice.16,36

Other forms of communication fa- cilitated by e-mail should not be over- looked in discussions of the role of on- line activities in health. About one quarter of Internet users said that they used e-mail to communicate with fam- ily or friends about health issues, which could facilitate better access to or in- formation about health care. Al- though the number was smaller, some also said that they used e-mail or the Internet to communicate with other pa- tients. Studies show that information sharing can help patients in at least some situations.38-40

Effects of Using the Internet on Health Knowledge and Health Care Use The Internet and e-mail could influ- ence health care through a variety of channels. One key way is by enhancing the provision of information. This may provide intangible benefits like making patients more comfortable or confident about their care. It may also produce more tangible effects on their use of health care. Information gleaned from the Internet may improve patients’ ability to interact efficiently and productively with health care professionals. In some cases, it may make them better able to care for themselves and reduce the need to con- sume expensive health care resources with problems that can be managed with- out additional help. Of course, it is also

possible for the Internet to provide in- formation that would reduce the well- being of patients. Previous work has fre- quently pointed out wide variations in the quality of information available on the Internet.3,8-13 Erroneous or poorly tar- geted information may lead to poor treat- ment choices. An overabundance of extraneous, irrelevant, or invalid infor- mation may place new burdens on health care professionals and detract from their ability to provide care efficiently.

Consistent with some other work,15,41

our results suggest that Internet users can find information they consider use- ful on the Internet. The majority of re- spondents indicated that using the In- ternet or e-mail improved at least some aspect of their knowledge about health care issues. This appears to be an en- couraging sign of the ability of the In- ternet and e-mail to benefit patients, al- though some further information would be valuable. First, since there are not clear benchmarks for the number of us- ers who should be able to benefit from use, it is not clear whether the results we observe are objectively high or low. On one hand, perhaps it is reasonable to expect that the Internet should be able to provide at least some valuable information to almost everyone who seeks information online. On the other hand, perhaps many users already have a good understanding of their issue of interest when they use the Internet. Sec- ond, although it is tempting to infer that the well-being of users who find infor- mation they consider useful online will have been improved, this is not neces- sarily true. Our study did not have the ability to identify the objective quality of the information found by users, nor did this study determine whether In-

Table 6. Internet Use for Prescription Drugs*

Ever Use of E-mail or the Internet in Past Year to Yes, Weighted %

Get a prescription from participant’s own physician 2

Get a prescription from a physician that respondent has never seen in person �1

Purchase prescription drugs 5

Learn more about a drug 33

Search for the cheapest place to buy prescription drugs 4

*Questions were asked of those who said that they had taken any prescription medication in the past year. Unweighted sample sizes are 3668, 3667, 3668, 3670, and 3649, respectively. The full question preamble was, “In the past year, did you ever use e-mail or the Internet to . . . ?” Response options were “yes” or “no.” Percentages are weighted.

USE OF THE INTERNET AND E-MAIL FOR HEALTH

©2003 American Medical Association. All rights reserved. (Reprinted) JAMA, May 14, 2003—Vol 289, No. 18 2405

at Penn State Milton S Hershey Med Ctr on November 4, 2009 www.jama.comDownloaded from

ternet use provided information to us- ers that they would not otherwise have obtained as opposed to simply substi- tuting for other information sources.

In contrast with some other re- ports,15 our results suggest that the In- ternet is much less frequently an influ- ence on health care utilization, such as by affecting treatments used or mak- ing respondents more able to manage conditions on their own. More than 90% of respondents said that using the Internet had no effect on either physi- cian visits or telephone contacts.

As a whole, these results suggest that the Internet does function as a means for informing consumers about health and health care, although there may still be room for improvement. Effects on ac- tual decisions are less common, and ef- fects on actual health care utilization are very limited. Discussions of the role of the Internet should not presume that it is now regularly having strong impacts on actual health care utilization.

Prescription Drugs The role of the Internet in prescrip- tion drug markets is increasingly dis- cussed. The Internet may be a useful way to facilitate the purchase of pre- scription drugs, improving conve- nience for patients and saving money. It may also undermine traditional phar- macy practices designed to maintain safety, with patients seeking prescrip- tions from online physicians with lim- ited information on their clinical char- acteristics. Our results show that the practical reality of either of these po- sitions is currently very small. Al- though some respondents report that the Internet is a source of information about prescription drugs, almost no one indicated obtaining prescriptions or purchasing prescription drugs online.

CONCLUSION We found evidence of moderate rates of use of the Internet for health care among adult Internet users, moderate effects of the Internet on the knowledge of users, and very small effects on actual use of office visits, telephone calls to health care professionals, and pharmaceutical pur-

chases. Nonetheless, the Internet clearly is an important tool with the potential to improve information dissemination and perhaps to improve health care de- livery and outcomes. Continuing ef- forts to maximize the potential of this tool could have great value.

Author Contributions: Study concept and design: Baker, Wagner, Singer, Bundorf. Acquisition of data: Baker, Wagner, Singer, Bundorf. Analysis and interpretation of data: Baker, Wagner, Singer, Bundorf. Drafting of the manuscript: Baker, Critical revision of the manuscript for important in- tellectual content: Wagner, Singer, Bundorf. Statistical expertise: Baker, Bundorf. Obtained funding: Baker, Wagner, Singer, Bundorf. Administrative, technical, or material support: Baker, Wagner, Singer, Bundorf. Study supervision: Baker. Funding/Support: This research was supported by grants from the National Institute on Aging, the Vet- erans Administration, and Stanford University. Acknowledgment: We thank Jennie Dalton Bowen of Stanford University and J. Michael Dennis of Knowl- edge Networks for their assistance with the study.

REFERENCES 1. Kassirer JP. The next transformation in the deliv- ery of health care. N Engl J Med. 1995;332:52-54. 2. Silberg WM, Lundberg GD, Musacchio RA. As- sessing, controlling, and assuring the quality of medi- cal information on the Internet. JAMA. 1997;277: 1244-1245. 3. Purcell GP, Wilson P, Delamothe T. The quality of health information on the Internet. BMJ. 2002;324: 557-558. 4. Blumenthal D. Doctors in a wired world. Milbank Q. 2002;80:525-546. 5. Gingrich N, Magaziner I. Two old hands and the new new thing. Health Aff (Millwood). 2000;19:33-40. 6. National Research Council. Networking Health: Pre- scriptions for the Internet. Washington, DC: Na- tional Academy Press; 2000. 7. Kleinke JD. Vaporware.com: the failed promise of the health care Internet. Health Aff (Millwood). 2000; 19:57-71. 8. Impicciatore P, Pandolfini C, Casella N, Bonati M. Re- liability of health information for the public on the World Wide Web. BMJ. 1997;314:1875-1879. 9. Culver JD, Gerr F, Frumkin H. Medical informa- tion on the Internet: a study of an electronic bulletin board. J Gen Intern Med. 1997;12:466-470. 10. Pealer LN, Dorman SM. Evaluating health- related Web sites. J Sch Health. 1997;67:232-235. 11. Wyatt JC. Measuring quality and impact of the World Wide Web. BMJ. 1997;314:1879-1881. 12. Griffiths KM, Christiansen H. Quality of Web- based information on treatment of depression: cross sectional survey. BMJ. 2000;321:1511-1515. 13. Meric F, Bernstam EV, Mirza NQ, et al. Breast can- cer on the World Wide Web: cross sectional survey of quality of information and popularity of Websites. BMJ. 2002;324:577-581. 14. Pennbridge J, Moya R, Rodrigues L. Question- naire survey of California consumers’ use and rating of sources of health care information including the In- ternet. West J Med. 1999;171:302-305. 15. Fox S, Rainie L, Horrigan J, et al. The Online Health Care Revolution: How the Web Helps Americans Take Better Care of Themselves. Washington, DC: Pew In- ternet and American Life Project; November 26, 2000. 16. Horrigan JB, Rainie L. Getting Serious Online. Washington, DC: Pew Internet and American Life Project; March 3, 2002.

17. Brodie M, Flournoy RE, Altman D, et al. Health information, the Internet, and the digital divide. Health Aff (Millwood). 2000;19:255-265. 18. Taylor H. Cyberchondriacs Update. Harris Poll No. 21. May 1, 2002. Available at: http://www .harrisinteractive.com. Accessed April 9, 2003. 19. Taylor H. Cyberchondriacs Update. Harris Poll No. 19. April 18, 2001. Available at: http://www .harrisinteractive.com. Accessed April 9, 2003. 20. Taylor H. Explosive Growth of “Cyberchondri- acs” Continues. Harris Poll No. 44. August 11, 2000. Available at: http://www.harrisinteractive.com. Ac- cessed April 9, 2003. 21. Reid B. Rx for the future: get an Ix, “info therapy” seeks role in health care. Washington Post. June 25, 2002:F1. 22. Landro L. The informed patient: if doctors pre- scribe information, will patients pay or surf the Web? Wall Street Journal. April 25, 2002:D4. 23. Elias M. Getting help over the Net. USA Today. May 22, 2001:D7. 24. Bly L. A network of support patients find emo- tional, practical advice—and each other. USA Today. July 14, 1999:D1. 25. Martin JP. A world of support; the Web is chang- ing medicine for doctors and patients. But is it lead- ing to better health care? Washington Post. August 31, 1999:Z10. 26. Watson R. The new patient power. Newsweek. 2001:54. 27. Carey B. Many Web sites can skirt privacy law, confidentiality. Los Angeles Times. November 26, 2001:S3. 28. Schorow S. Web sites may net useful wellness in- formation. Boston Herald. January 23, 2002:Arts & Life section:45. 29. A Nation Online: How Americans Are Expand- ing Their Use of the Internet. Washington, DC: Dept of Commerce, National Telecommunications and In- formation Administration and Economics and Statis- tics Administration; February 2002. 30. Fogel J, Albert SM, Schnabel F, Ditkoff BA, Neu- gut AI. Use of the Internet by women with breast can- cer. J Med Internet Res. 2002;4:E9. 31. Borowitz SM, Wyatt JC. The origin, content, and workload of e-mail consultations. JAMA. 1998;280: 1321-1324. 32. Eysenbach G, Diepgen TL. Responses to unsolic- ited patient e-mail requests for medical advice on the World Wide Web. JAMA. 1998;280:1333-1335. 33. Spielberg AR. On call and online: sociohistorical, le- gal, and ethical implications of e-mail for the patient- physician relationship. JAMA. 1998;280:1353-1359. 34. Couchman GR, Forjuoh SN, Rascoe TG. E-mail communications in family practice: what do patients expect? J Fam Pract. 2001;50:414-418. 35. Mandl KD, Feit S, Pena BM, Kohane IS. Growth and determinants of access in patient e-mail and Internet use. Arch Pediatr Adolesc Med. 2000;154:508-511. 36. Sittig DF, King S, Hazlehurst BL. A survey of pa- tient-provider e-mail communication: what do pa- tients think? Int J Med Inf. 2001;61:71-80. 37. Wagner TH, Baker LC, Bundorf MK, Singer SJ. Use of the Internet Among the Chronically Ill. Stanford, Calif: Stanford University; 2003. 38. Spiegel D, Bloom JR, Kraemer HC, Gottheil E. Effect of psychosocial treatment on survival of patients with metastatic breast cancer. Lancet. 1989;2:888-891. 39. Classen C, Butler LD, Koopman C, et al. Supportive- expressive group therapy and distress in patients with metastatic breast cancer: a randomized clinical inter- vention trial. Arch Gen Psychiatry. 2001;58:494-501. 40. Lorig KR, Laurent DD, Deyo RA, Marnell ME, Mi- nor MA, Ritter PL. Can a back pain e-mail discussion group improve health status and lower health care costs? Arch Intern Med. 2002;162:792-796. 41. Potts HW, Wyatt JC. Survey of doctors’ experi- ence of patients using the Internet. J Med Internet Res. 2002;4:E5.

USE OF THE INTERNET AND E-MAIL FOR HEALTH

2406 JAMA, May 14, 2003—Vol 289, No. 18 (Reprinted) ©2003 American Medical Association. All rights reserved.

at Penn State Milton S Hershey Med Ctr on November 4, 2009 www.jama.comDownloaded from