Joseph V. Henderson

INTRODUCTION TO EVALUATION OF INTERACTIVE HEALTH COMMUNICATION APPLICATIONS

Virtually all aspects of society have been altered in some way by advances in computer and communication technologies. In 1997, the information technology industry was the single largest industry in the United States in terms of sales and accounted for 33% of the growth in GDP in 1996.1,2 An estimated 41.5 million U.S. adults were active users of the Internet in 1997,3 and more than 43% of Internet users have used it to research health information.4 At the same time that these new technologies have emerged, consumers seem to be demanding increasing access to a wide range of information, including health information, and social support as a vehicle for recovering from illness. Consumer demand for health information and the availability of new media technologies have spurred substantial interest in interactive health communication (IHC), the interaction of an individual—consumer, patient, caregiver, or professional—with or through an electronic device or communication technology to access or transmit health information or receive guidance and support on a health-related issue.5 Using this definition, IHC encompasses technology-mediated health communication and does not include direct communication such as face-to-face clinician-patient counseling. The panel chose the term IHC because it focuses on the content rather than on the technology that facilitates IHC. The panel uses the term IHC applications to refer to the operational software programs or modules that interface with the end user. This includes health information and support Web sites and clinical decision-support and risk assessment software (which may or may not be online), but does not include applications that focus exclusively on administrative, financial, or clinical data, such as electronic medical records, dedicated clinical telemedicine applications, or expert clinical decision-support systems for providers. Some of these latter applications, however, are integrated with health communication functions. The panel uses the term IHC technologies to refer to the hardware and infrastructure technologies that run or disseminate IHC applications, such as networks, computers, telecommunications equipment and the like. IHC applications are increasingly accessible to the public through the Internet and non-networked technologies, such as stand-alone computers and kiosks.6,7 Their major functions are to: (1) relay information, From the Office of Disease Prevention and Health Promotion, US Department of Health and Human Services (Eng), Washington, DC; University of Wisconsin-Madison (Gustafson), Madison, WI; Dartmouth Medical School (Henderson), Dartmouth, NH; Oregon Health Sciences University (Jimison), Portland, OR; and San Diego State University and the University of California, San Diego (Patrick), San Diego, CA. Address correspondence to: Thomas R. Eng, VMD, MPH, Office of Disease Prevention and Health Promotion, HHS, 200 Independence Avenue, SW, Room 738G, Washington, DC 20201. Address reprint requests to: Mary Jo Deering, PhD, Office of Disease Prevention and Health Promotion, U.S. Department of Health and Human Services, 200 Independence Avenue, SW, Washington, DC 20201. Other panel members and staff: Linda Adler, MPH, MA, National Member Technology Group, Kaiser Permanente, Oakland, CA; Farrokh Alemi, PhD, Cleveland State University, Cleveland, OH; David Ansley, Consumer Reports, Yonkers, NY; Patricia Flatley Brennan, RN, PhD, FAAN, School of Nursing and College of Engineering, University of Wisconsin-Madison, Madison, WI; Molly Joel Coye, MD, MPH, The Lewin Group, San Francisco, CA; Mary Jo Deering, PhD, Office of Disease Prevention and Health Promotion, U.S. Department of Health and Human Services, Washington, DC; Albert Mulley Jr, MD, MPP, Massachusetts General Hospital, Boston, MA; John Noell, PhD, Oregon Center for Applied Science, Inc. and Oregon Research Institute, Eugene, OR; Thomas C. Reeves, PhD, University of Georgia, Athens, GA; Thomas N. Robinson, MD, MPH, Stanford University School of Medicine, Palo Alto, CA; and Victor Strecher, PhD, MPH, University of Michigan Comprehensive Cancer Center, Ann Arbor, MI. For example, less than one year after free Medline searches became available on the Web, the number of searches increased 10-fold, and 30% of users were members of the general public (Testimony of Dr. Donald A.B. Lindberg, Director, National Library of Medicine to the House Appropriations Sub-Committee on Labor, HHS and Education, March 18, 1998. Accessed on April 6, 1998. Available from: URL: http://www.nlm.nih.gov/pubs/staffpubs/od/budget99.html For example, a search for the keyword “health” on the World Wide Web using common search engines yielded more than 16 thousand indexed Web sites (www.yahoo.com) and 20 million matching Web pages (altavista.digital.com) on October 28, 1998.

Comprehensive, Technology-Based Clinical Education: The “Virtual Practicum”

This article discusses the application of technology to promote more comprehensive clinical education in the biopsychosocial aspects of primary care. Comprehensive refers to the inclusion, in addition to scientific and technical knowledge, of knowledge that is less easily characterized, quantified, and taught: empathy, intuition, the demonstration of artistry. Clinical education will be increasingly facilitated by the proliferation of computers capable of displaying combinations of text, graphics, video, and sound; broadband networks capable of delivering these multiple media to the home or office; and new methods for using these technologies for education and training. However, current models for technology-based learning are limiting, lagging behind the rapid technological evolution driving our entry into the Information Age. Some recent educational models (Schons reflection-in-action and reflective practicums [1], Boisots E-space [2], Kolbs learning cycle [3]) provide for a more comprehensive and complete view of health professional education. This article describes these models in depth and proposes a new model for technology-based clinical training, the “Virtual Practicum,” based on them. The Virtual Practicum is illustrated with a new interactive CD-ROM program, dealing with primary care of patients with HIV/AIDS. The concepts presented here are generally useful in thinking about clinical education, regardless of the means used.

Absence of a tachycardic response to shock in penetrating intraperitoneal injury

The belief that tachycardia is an early and reliable indicator of shock has recently been challenged. We examined 144 battlefield casualties with penetrating intraperitoneal injury to determine whether patients in shock presented with pulse rates that were significantly more rapid than those in patients not in shock. No differences in mean pulse rates were found when using objective operational definitions of shock. In contrast, the only pulse rate difference was noted when shock was defined on the basis of the surgeons subjective clinical impression and this was attributed to selection bias. The absence of a tachycardic response in battlefield casualties with penetrating abdominal wounds cannot be taken as an indication that serious injury and significant intraperitoneal bleeding have not occurred. Caution should be exercised when using this parameter as a guide for therapeutic interventions, and further study is indicated to determine whether a similar pattern is seen in civilian practice.

Interactive videodisc to teach combat trauma life support

Training military physicians in trauma management is a dilemma in peacetime, since there are few opportunities to gain clinical experience within the military care system. This program provides experience in clinical decision making through case simulation. Five cases, of increasing difficulty, are presented in a single videodisc side. The program is implemented on a system based on the IBM PC, and is written in the C programming language. The program emphasizes clinical realism by providing many clinical options at each decision point, and by audiovisually depicting combat clinical care in very realistic ways. The user interface is flexible and, though complex, is easy to use; it is supported by a narrated, on-line tutorial.

The importance of operational definitions in design of a combat casualty information system

Attention to the quality of information in design of a medical information system is fundamental to the success of that system. This point is made using WWI and WWII combat casualty statistics. While the analyses presented are legitimate, serious problems of interpretation arise from the operational definitions used in gathering and analyzing these data. The impact of this is illustrated in a hypothetical battle, a model emphasizing the introduction of biases resulting from an apparent inattention to operational definitions on the part of combat care managers in WWII. The paper concludes with some broad recommendations.