Ser.cies.iscte.pt

Use of the Internet and E-mail
for Health Care Information
Results From a National Survey
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 useand 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-
care.1-6 While questions remain about its ary 2002 among a sample drawn from a research panel of more than 60000 US house- holds developed and maintained by Knowledge Networks. Responses were analyzed formation,3,8-13 and potential difficulties 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.
information about health and health care, 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.
health purposes and the effects it has on 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 realized and provide a context for fruit- health care and the development of policies that might influence this role should notpresume that use of the Internet for health information is universal or that the Inter- net strongly influences health care utilization.
ture role of the Internet in health care.
paring existing estimates can be difficult 80%18-20 of adults with Internet access use because details on aspects such as selec- it for health care purposes. Many of those gest much lower rates of use.14,29,30 Com- who use the Internet for health pur-poses are reported to use it frequently.
Author Affiliations: Department of Health Research and
Bundorf ); and VA Health Services Research and Devel- Policy, Stanford University School of Medicine (Drs Baker, opment Health Economics Resource Center, VA Palo Alto Wagner, and Bundorf ), and Center for Health Policy and Health Care System, Palo Alto, Calif (Dr Wagner).
Center for Primary Care and Outcomes Research, Stan- Corresponding Author and Reprints: Laurence Baker,
ford University (Drs Baker, Wagner, and Bundorf and PhD, Stanford University School of Medicine, HRP Red- Ms Singer), Stanford, Calif; National Bureau of Eco- wood Building, Room 253, Stanford, CA 94305- and others of the role of the Internet in nomic Research, Cambridge, Mass (Drs Baker and 5405 (e-mail: laurence.baker@stanford.edu).
2400 JAMA, May 14, 2003—Vol 289, No. 18 (Reprinted)
2003 American Medical Association. All rights reserved.
USE OF THE INTERNET AND E-MAIL FOR HEALTH which appear online or as private releases rather than in peer-reviewed journals.
of ways, all of which substantiate its va- lidity. We conducted specific tests of the extent of Internet use for health, coupled validity of the survey sample used for this for the condition-specific questions.
indicators from other major national sur- nated, makes it difficult to focus discus- appendix to this article that is available to 12878 individuals consisting of a ran- as a foundation for future steps. This ar- viduals aged 50 or older and veterans. Re- stratification weights, which correct the e-mail use for health care. Previous lit- veteran status, to account for the overs- ports based on surveys of limited sets of patients cite widespread access to e-mail College Station, Tex). PϽ.05 was con- reported rates of Internet use for health ward it,34,35 but few studies identify the prevalence of e-mail use in practice.36 Fi- have Internet access because all have the Prevalence of Internet and E-mail
Use for Health Information
their use of the health care system.
viduals who did not obtain Internet access vice. TABLE 1 describes the demo-
graphic characteristics of the sample.
aged 21 years or older about their use of (TABLE 2). Approximately 40% of In-
or advice about health or health care dur- was use of e-mail or the Internet to com- households, inviting them to join the re- of questions about use of the Internet and health in the past year. Use of e-mail or search panel. To facilitate surveying the panel and to create an incentive for par- the perceived effects of Internet or e-mail in which an individual agrees to partici- tions, respondents who self-reported hav- lems (defined as a “heart attack,” coro- Internet. The ability of this research panel nary heart disease, angina, heart failure, 2003 American Medical Association. All rights reserved.
(Reprinted) JAMA, May 14, 2003—Vol 289, No. 18 2401
USE OF THE INTERNET AND E-MAIL FOR HEALTH (PϽ.001). We observed strong relation- Internet for health. Fifty percent of re- spondents said that they had used the In- and higher rates of Internet use for health ternet or e-mail in at least 1 of the 4 mea- the Internet for health information with- out use of e-mail. Rates of e-mail use were Table 1. Sample Characteristics of Internet
Weighted %
ternet use also reported using e-mail for ined use of e-mail or the Internet to con- tact others with similar health concerns, Demographics and
less likely to use e-mail or the Internet Internet Use for Health
to contact others with similar health con- ABLE 3 reports results from logistic re-
health status were more likely to do so.
Effects of Internet Use
on Health Care
health. Individuals aged 75 years or older *Because of item nonresponse, unweighted n = 4280 for income distribution, 4760 for health status distribution,and 4756 for chronic condition distribution.
they had ever used the Internet or e-mail †The 5 chronic conditions inquired about are heart prob- lems, cancer, diabetes, hypertension, and depression.
for health purposes a series of ques-tions about the effects of Internet ore-mail use on their knowledge about Table 2. Prevalence and Frequency of Internet and E-mail Use for Health Information*
health care issues and their use of health Frequency of Use, Weighted %
In the Past Year, About
More Than
Less Than
How Often Did You
Last Year
Once/wk Once/mo 2-3 mo Every 2-3 mo
tions about the effects of the Internet or information or adviceabout health or health e-mail specific to their condition. Those or strongly disagreed that the Internet or e-mail had various effects. TABLE 4 re-
strongly agreed or agreed that use of the conditions or concernslike yours? (n = 4722) *Data are shown as weighted percentages of responses in each category. Sample sizes differ across questions be- standing of health care issues, but fewer 2402 JAMA, May 14, 2003—Vol 289, No. 18 (Reprinted)
2003 American Medical Association. All rights reserved.
USE OF THE INTERNET AND E-MAIL FOR HEALTH Use of the Internet
for Prescription Drugs
tivities such as improving their ability to own or influencing their choice of health health care that are often reported.
care professional. We obtained similar re- (TABLE 6). Five percent or less said that
respondents indicated that use of the In- with Internet access use the Internet for health care purposes.15,16,18-20 However, our results are consistent with other, per- toms, conditions, or treatments, while the scription drugs, or search for the cheap- est place to buy a prescription drug.
health is relatively infrequent. Seventy- use of the health care system ranged from the health care system (TABLE 5). Re-
Extent and Frequency
of Internet Use for Health
Internet or e-mail use in the last year on tion or advice about health or health care use of the Internet or e-mail had no effect population uses the Internet at all,29 sug- gesting that about 20% of the entire adult Table 3. Use of Internet for Health Information by Demographic Characteristics*
Search for Health
Information
on the Internet
E-mail Physician
E-mail Family/Friends
E-mail Others
Odds Ratio
Odds Ratio
Odds Ratio
Odds Ratio
(95% Confidence
P
(95% Confidence
P
(95% Confidence
P
(95% Confidence
P
Characteristics
Interval)
Interval)
Interval)
Interval)
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.
2003 American Medical Association. All rights reserved.
(Reprinted) JAMA, May 14, 2003—Vol 289, No. 18 2403
USE OF THE INTERNET AND E-MAIL FOR HEALTH health care,19,20 is based on samples de- out the existence of selection bias in our veloped by using online recruitment.
pect that selection bias is likely to have larly enthusiastic about the Internet and significantly influenced our results.
ferences in reported use rates is differ- ing to participate in surveys about it.
port the highest rates of Internet use for tive importance. Other possible expla-nations include differences in the Table 4. Perceived Effects of Internet or E-mail Use on Health Care Understanding and
Strongly Agree,
Effect of Using the Internet or E-mail
Respondents
Weighted %
Among Respondents With None of 5 Chronic Conditions
Improved my understanding of symptoms, conditions, Improved my ability to manage my health care needs without visiting a doctor or other health care the past year, and some other surveys are Led me to seek care from different doctors or other health care providers than I otherwise would have Among Respondents With Ն1 of 5 Chronic Conditions
Improved my understanding of possible treatments for ever or never?”18 Differences in the speci- Improved my understanding of other symptoms, role in the variations in the findings, al- conditions, or treatments in which I was interested Affected treatments I am using for [condition] Improved my ability to manage my [condition] by myself Improved my ability to manage other health care needs without visiting a doctor or other health care stantially different than the past year.
Led me to seek care from different doctors or health It is tempting to interpret a finding that care providers for [condition] than I otherwise wouldhave the Internet for health care information— *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 ports—as disappointing news for the In- with similar health care concerns; or used the Internet for any purpose related to prescription drugs. The full questionpreamble was, “Thinking overall about all of the times in the last year that you used the Internet or e-mail for things ternet. It is not clear to us that this is the related to health or health care, to what extent would you agree or disagree with the following statements? Using theInternet or e-mail . . .” Response choices on a 4-point Likert scale were strongly agree, agree, disagree, strongly case. Although the Internet existed a de- 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.
used it then for health care purposes.
That the number of people using the In- Table 5. Perceived Effect of Internet Use on Physician Visits and Telephone Calls*
Weighted %
Did Using the Internet or
E-mail Affect Either of the Following?
Increased
Decreased
No. of times visited a physician or other health care provider No. of times telephoned a physician or other health care use for other activities. Results from the *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 theInternet to communicate with a provider, friend, family member, or other person with similar health care concerns; or survey of the US population, suggest that 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 yearthat you used the Internet or e-mail for things related to health or health care, did using the Internet or e-mail affect 2404 JAMA, May 14, 2003—Vol 289, No. 18 (Reprinted)
2003 American Medical Association. All rights reserved.
USE OF THE INTERNET AND E-MAIL FOR HEALTH 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 Get a prescription from a physician that respondent has never seen in person ing stocks online. In this context, a uti- lization rate of 40% seems relatively high.
Search for the cheapest place to buy prescription drugs lization rate of about 40% is that the In- *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.
number of sources of health informa-tion available to interested individuals, use.16,29 Our results, though, show little of which the Internet is one. Optimal re- being of patients. Previous work has fre- likely to be achieved if individuals seek the Internet.3,8-13 Erroneous or poorly tar- geted information may lead to poor treat- even for everyone with Internet access.
extraneous, irrelevant, or invalid infor- care professionals and detract from their ability to provide care efficiently.
tion would be the best course of action.
ily or friends about health issues, which subset of the population that uses it.
net use for health care. In particular, we ternet and e-mail to benefit patients, al- tion are less likely to use the Internet for health care. These findings parallel more Effects of Using the Internet
on Health Knowledge
and Health Care Use
we observe are objectively high or low.
provide benefits to populations that need frequency of use than often reported.
health care. Information gleaned from the interest when they use the Internet. Sec- Internet may improve patients’ ability to ond, although it is tempting to infer that tion that frequent Internet use for health interact efficiently and productively with health care professionals. In some cases, E-mail Use for Health Care
ability to identify the objective quality E-mail use in general is widespread, with out additional help. Of course, it is also 2003 American Medical Association. All rights reserved.
(Reprinted) JAMA, May 14, 2003—Vol 289, No. 18 2405
USE OF THE INTERNET AND E-MAIL FOR HEALTH chases. Nonetheless, the Internet clearly 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.
tuting for other information sources.
21. May 1, 2002. Available at: http://www.harrisinteractive.com. Accessed April 9, 2003.
19. Taylor H. Cyberchondriacs Update. Harris Poll No.
ports,15 our results suggest that the In- 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.
Author Contributions: Study concept and design:
Available at: http://www.harrisinteractive.com. Ac- Acquisition of data: Baker, Wagner, Singer, Bundorf.
21. Reid B. Rx for the future: get an Ix, “info therapy”
Analysis and interpretation of data: Baker, Wagner, seeks role in health care. Washington Post. June 25, Drafting of the manuscript: Baker, 22. Landro L. The informed patient: if doctors pre-
Critical revision of the manuscript for important in- scribe information, will patients pay or surf the Web? tellectual content: Wagner, Singer, Bundorf.
Wall Street Journal. April 25, 2002:D4.
Statistical expertise: Baker, Bundorf.
23. Elias M. Getting help over the Net. USA Today.
Obtained funding: Baker, Wagner, Singer, Bundorf.
Administrative, technical, or material support: Baker, 24. Bly L. A network of support patients find emo-
the Internet does function as a means for tional, practical advice—and each other. USA Today. Funding/Support: This research was supported by
25. Martin JP. A world of support; the Web is chang-
grants from the National Institute on Aging, the Vet- ing medicine for doctors and patients. But is it lead- erans Administration, and Stanford University.
ing to better health care? Washington Post. August Acknowledgment: We thank Jennie Dalton Bowen of
Stanford University and J. Michael Dennis of Knowl- 26. Watson R. The new patient power. Newsweek.
fects on actual health care utilization are edge Networks for their assistance with the study.
27. Carey B. Many Web sites can skirt privacy law,
confidentiality. Los Angeles Times. November 26,
REFERENCES
1. Kassirer JP. The next transformation in the deliv-
28. Schorow S. Web sites may net useful wellness in-
ery of health care. N Engl J Med. 1995;332:52-54.
formation. Boston Herald. January 23, 2002:Arts & 2. Silberg WM, Lundberg GD, Musacchio RA. As-
sessing, controlling, and assuring the quality of medi-
cal information on the Internet. JAMA. 1997;277: 29. A Nation Online: How Americans Are Expand-
Prescription Drugs
ing Their Use of the Internet. Washington, DC: Dept 3. Purcell GP, Wilson P, Delamothe T. The quality of
of Commerce, National Telecommunications and In- health information on the Internet. BMJ. 2002;324: formation Administration and Economics and Statis- tics Administration; February 2002.
30. Fogel J, Albert SM, Schnabel F, Ditkoff BA, Neu-
4. Blumenthal D. Doctors in a wired world. Milbank Q.
2002;80:525-546.
gut AI. Use of the Internet by women with breast can- 5. Gingrich N, Magaziner I. Two old hands and the new
cer. J Med Internet Res. 2002;4:E9.
31. Borowitz SM, Wyatt JC. The origin, content, and
new thing. Health Aff (Millwood). 2000;19:33-40.
6. National Research Council. Networking Health: Pre-
workload of e-mail consultations. JAMA. 1998;280: nience for patients and saving money.
scriptions for the Internet. Washington, DC: Na- 1321-1324.
32. Eysenbach G, Diepgen TL. Responses to unsolic-
tional Academy Press; 2000.
7. Kleinke JD. Vaporware.com: the failed promise of
ited patient e-mail requests for medical advice on the the health care Internet. Health Aff (Millwood). 2000; World Wide Web. JAMA. 1998;280:1333-1335.
33. Spielberg AR. On call and online: sociohistorical, le-
8. Impicciatore P, Pandolfini C, Casella N, Bonati M. Re-
gal, and ethical implications of e-mail for the patient- liability of health information for the public on the World physician relationship. JAMA. 1998;280:1353-1359.
Wide Web. BMJ. 1997;314:1875-1879.
34. Couchman GR, Forjuoh SN, Rascoe TG. E-mail
9. Culver JD, Gerr F, Frumkin H. Medical informa-
communications in family practice: what do patients tion on the Internet: a study of an electronic bulletin expect? J Fam Pract. 2001;50:414-418.
board. J Gen Intern Med. 1997;12:466-470.
35. Mandl KD, Feit S, Pena BM, Kohane IS. Growth and
determinants of access in patient e-mail and Internet use.
10. Pealer LN, Dorman SM. Evaluating health-
related Web sites. J Sch Health. 1997;67:232-235.
Arch Pediatr Adolesc Med. 2000;154:508-511.
11. Wyatt JC. Measuring quality and impact of the
36. Sittig DF, King S, Hazlehurst BL. A survey of pa-
World Wide Web. BMJ. 1997;314:1879-1881.
tient-provider e-mail communication: what do pa- 12. Griffiths KM, Christiansen H. Quality of Web-
tients think? Int J Med Inf. 2001;61:71-80.
based information on treatment of depression: cross 37. Wagner TH, Baker LC, Bundorf MK, Singer SJ. Use
sectional survey. BMJ. 2000;321:1511-1515.
of the Internet Among the Chronically Ill. Stanford, 13. Meric F, Bernstam EV, Mirza NQ, et al. Breast can-
purchasing prescription drugs online.
cer on the World Wide Web: cross sectional survey 38. Spiegel D, Bloom JR, Kraemer HC, Gottheil E. Effect
of quality of information and popularity of Websites.
of psychosocial treatment on survival of patients with CONCLUSION
metastatic breast cancer. Lancet. 1989;2:888-891.
14. Pennbridge J, Moya R, Rodrigues L. Question-
39. Classen C, Butler LD, Koopman C, et al. Supportive-
naire survey of California consumers’ use and rating expressive group therapy and distress in patients with of sources of health care information including the In- metastatic breast cancer: a randomized clinical inter- use of the Internet for health care among ternet. West J Med. 1999;171:302-305.
vention trial. Arch Gen Psychiatry. 2001;58:494-501.
adult Internet users, moderate effects of 15. Fox S, Rainie L, Horrigan J, et al. The Online Health
40. Lorig KR, Laurent DD, Deyo RA, Marnell ME, Mi-
Care Revolution: How the Web Helps Americans Take nor MA, Ritter PL. Can a back pain e-mail discussion Better Care of Themselves. Washington, DC: Pew In- group improve health status and lower health care ternet and American Life Project; November 26, 2000.
costs? Arch Intern Med. 2002;162:792-796.
office visits, telephone calls to health care 16. Horrigan JB, Rainie L. Getting Serious Online.
41. Potts HW, Wyatt JC. Survey of doctors’ experi-
Washington, DC: Pew Internet and American Life ence of patients using the Internet. J Med Internet Res. 2406 JAMA, May 14, 2003—Vol 289, No. 18 (Reprinted)
2003 American Medical Association. All rights reserved.
Use of the Internet and E-mail
for Health Care Information
Results From a National Survey
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 useand 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-
care.1-6 While questions remain about its ary 2002 among a sample drawn from a research panel of more than 60000 US house- holds developed and maintained by Knowledge Networks. Responses were analyzed formation,3,8-13 and potential difficulties 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.
information about health and health care, 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.
health purposes and the effects it has on 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 realized and provide a context for fruit- health care and the development of policies that might influence this role should notpresume that use of the Internet for health information is universal or that the Inter- net strongly influences health care utilization.
ture role of the Internet in health care.
paring existing estimates can be difficult 80%18-20 of adults with Internet access use because details on aspects such as selec- it for health care purposes. Many of those gest much lower rates of use.14,29,30 Com- who use the Internet for health pur-poses are reported to use it frequently.
Author Affiliations: Department of Health Research and
Bundorf ); and VA Health Services Research and Devel- Policy, Stanford University School of Medicine (Drs Baker, opment Health Economics Resource Center, VA Palo Alto Wagner, and Bundorf ), and Center for Health Policy and Health Care System, Palo Alto, Calif (Dr Wagner).
Center for Primary Care and Outcomes Research, Stan- Corresponding Author and Reprints: Laurence Baker,
ford University (Drs Baker, Wagner, and Bundorf and PhD, Stanford University School of Medicine, HRP Red- Ms Singer), Stanford, Calif; National Bureau of Eco- wood Building, Room 253, Stanford, CA 94305- and others of the role of the Internet in nomic Research, Cambridge, Mass (Drs Baker and 5405 (e-mail: laurence.baker@stanford.edu).
2400 JAMA, May 14, 2003—Vol 289, No. 18 (Reprinted)
2003 American Medical Association. All rights reserved.
USE OF THE INTERNET AND E-MAIL FOR HEALTH which appear online or as private releases rather than in peer-reviewed journals.
of ways, all of which substantiate its va- lidity. We conducted specific tests of the extent of Internet use for health, coupled validity of the survey sample used for this for the condition-specific questions.
indicators from other major national sur- nated, makes it difficult to focus discus- appendix to this article that is available to 12878 individuals consisting of a ran- as a foundation for future steps. This ar- viduals aged 50 or older and veterans. Re- stratification weights, which correct the e-mail use for health care. Previous lit- veteran status, to account for the overs- ports based on surveys of limited sets of patients cite widespread access to e-mail College Station, Tex). PϽ.05 was con- reported rates of Internet use for health ward it,34,35 but few studies identify the prevalence of e-mail use in practice.36 Fi- have Internet access because all have the Prevalence of Internet and E-mail
Use for Health Information
their use of the health care system.
viduals who did not obtain Internet access vice. TABLE 1 describes the demo-
graphic characteristics of the sample.
aged 21 years or older about their use of (TABLE 2). Approximately 40% of In-
or advice about health or health care dur- was use of e-mail or the Internet to com- households, inviting them to join the re- of questions about use of the Internet and health in the past year. Use of e-mail or search panel. To facilitate surveying the panel and to create an incentive for par- the perceived effects of Internet or e-mail in which an individual agrees to partici- tions, respondents who self-reported hav- lems (defined as a “heart attack,” coro- Internet. The ability of this research panel nary heart disease, angina, heart failure, 2003 American Medical Association. All rights reserved.
(Reprinted) JAMA, May 14, 2003—Vol 289, No. 18 2401
USE OF THE INTERNET AND E-MAIL FOR HEALTH (PϽ.001). We observed strong relation- Internet for health. Fifty percent of re- spondents said that they had used the In- and higher rates of Internet use for health ternet or e-mail in at least 1 of the 4 mea- the Internet for health information with- out use of e-mail. Rates of e-mail use were Table 1. Sample Characteristics of Internet
Weighted %
ternet use also reported using e-mail for ined use of e-mail or the Internet to con- tact others with similar health concerns, Demographics and
less likely to use e-mail or the Internet Internet Use for Health
to contact others with similar health con- ABLE 3 reports results from logistic re-
health status were more likely to do so.
Effects of Internet Use
on Health Care
health. Individuals aged 75 years or older *Because of item nonresponse, unweighted n = 4280 for income distribution, 4760 for health status distribution,and 4756 for chronic condition distribution.
they had ever used the Internet or e-mail †The 5 chronic conditions inquired about are heart prob- lems, cancer, diabetes, hypertension, and depression.
for health purposes a series of ques-tions about the effects of Internet ore-mail use on their knowledge about Table 2. Prevalence and Frequency of Internet and E-mail Use for Health Information*
health care issues and their use of health Frequency of Use, Weighted %
In the Past Year, About
More Than
Less Than
How Often Did You
Last Year
Once/wk Once/mo 2-3 mo Every 2-3 mo
tions about the effects of the Internet or information or adviceabout health or health e-mail specific to their condition. Those or strongly disagreed that the Internet or e-mail had various effects. TABLE 4 re-
strongly agreed or agreed that use of the conditions or concernslike yours? (n = 4722) *Data are shown as weighted percentages of responses in each category. Sample sizes differ across questions be- standing of health care issues, but fewer 2402 JAMA, May 14, 2003—Vol 289, No. 18 (Reprinted)
2003 American Medical Association. All rights reserved.
USE OF THE INTERNET AND E-MAIL FOR HEALTH Use of the Internet
for Prescription Drugs
tivities such as improving their ability to own or influencing their choice of health health care that are often reported.
care professional. We obtained similar re- (TABLE 6). Five percent or less said that
respondents indicated that use of the In- with Internet access use the Internet for health care purposes.15,16,18-20 However, our results are consistent with other, per- toms, conditions, or treatments, while the scription drugs, or search for the cheap- est place to buy a prescription drug.
health is relatively infrequent. Seventy- use of the health care system ranged from the health care system (TABLE 5). Re-
Extent and Frequency
of Internet Use for Health
Internet or e-mail use in the last year on tion or advice about health or health care use of the Internet or e-mail had no effect population uses the Internet at all,29 sug- gesting that about 20% of the entire adult Table 3. Use of Internet for Health Information by Demographic Characteristics*
Search for Health
Information
on the Internet
E-mail Physician
E-mail Family/Friends
E-mail Others
Odds Ratio
Odds Ratio
Odds Ratio
Odds Ratio
(95% Confidence
P
(95% Confidence
P
(95% Confidence
P
(95% Confidence
P
Characteristics
Interval)
Interval)
Interval)
Interval)
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.
2003 American Medical Association. All rights reserved.
(Reprinted) JAMA, May 14, 2003—Vol 289, No. 18 2403
USE OF THE INTERNET AND E-MAIL FOR HEALTH health care,19,20 is based on samples de- out the existence of selection bias in our veloped by using online recruitment.
pect that selection bias is likely to have larly enthusiastic about the Internet and significantly influenced our results.
ferences in reported use rates is differ- ing to participate in surveys about it.
port the highest rates of Internet use for tive importance. Other possible expla-nations include differences in the Table 4. Perceived Effects of Internet or E-mail Use on Health Care Understanding and
Strongly Agree,
Effect of Using the Internet or E-mail
Respondents
Weighted %
Among Respondents With None of 5 Chronic Conditions
Improved my understanding of symptoms, conditions, Improved my ability to manage my health care needs without visiting a doctor or other health care the past year, and some other surveys are Led me to seek care from different doctors or other health care providers than I otherwise would have Among Respondents With Ն1 of 5 Chronic Conditions
Improved my understanding of possible treatments for ever or never?”18 Differences in the speci- Improved my understanding of other symptoms, role in the variations in the findings, al- conditions, or treatments in which I was interested Affected treatments I am using for [condition] Improved my ability to manage my [condition] by myself Improved my ability to manage other health care needs without visiting a doctor or other health care stantially different than the past year.
Led me to seek care from different doctors or health It is tempting to interpret a finding that care providers for [condition] than I otherwise wouldhave the Internet for health care information— *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 ports—as disappointing news for the In- with similar health care concerns; or used the Internet for any purpose related to prescription drugs. The full questionpreamble was, “Thinking overall about all of the times in the last year that you used the Internet or e-mail for things ternet. It is not clear to us that this is the related to health or health care, to what extent would you agree or disagree with the following statements? Using theInternet or e-mail . . .” Response choices on a 4-point Likert scale were strongly agree, agree, disagree, strongly case. Although the Internet existed a de- 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.
used it then for health care purposes.
That the number of people using the In- Table 5. Perceived Effect of Internet Use on Physician Visits and Telephone Calls*
Weighted %
Did Using the Internet or
E-mail Affect Either of the Following?
Increased
Decreased
No. of times visited a physician or other health care provider No. of times telephoned a physician or other health care use for other activities. Results from the *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 theInternet to communicate with a provider, friend, family member, or other person with similar health care concerns; or survey of the US population, suggest that 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 yearthat you used the Internet or e-mail for things related to health or health care, did using the Internet or e-mail affect 2404 JAMA, May 14, 2003—Vol 289, No. 18 (Reprinted)
2003 American Medical Association. All rights reserved.
USE OF THE INTERNET AND E-MAIL FOR HEALTH 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 Get a prescription from a physician that respondent has never seen in person ing stocks online. In this context, a uti- lization rate of 40% seems relatively high.
Search for the cheapest place to buy prescription drugs lization rate of about 40% is that the In- *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.
number of sources of health informa-tion available to interested individuals, use.16,29 Our results, though, show little of which the Internet is one. Optimal re- being of patients. Previous work has fre- likely to be achieved if individuals seek the Internet.3,8-13 Erroneous or poorly tar- geted information may lead to poor treat- even for everyone with Internet access.
extraneous, irrelevant, or invalid infor- care professionals and detract from their ability to provide care efficiently.
tion would be the best course of action.
ily or friends about health issues, which subset of the population that uses it.
net use for health care. In particular, we ternet and e-mail to benefit patients, al- tion are less likely to use the Internet for health care. These findings parallel more Effects of Using the Internet
on Health Knowledge
and Health Care Use
we observe are objectively high or low.
provide benefits to populations that need frequency of use than often reported.
health care. Information gleaned from the interest when they use the Internet. Sec- Internet may improve patients’ ability to ond, although it is tempting to infer that tion that frequent Internet use for health interact efficiently and productively with health care professionals. In some cases, E-mail Use for Health Care
ability to identify the objective quality E-mail use in general is widespread, with out additional help. Of course, it is also 2003 American Medical Association. All rights reserved.
(Reprinted) JAMA, May 14, 2003—Vol 289, No. 18 2405
USE OF THE INTERNET AND E-MAIL FOR HEALTH chases. Nonetheless, the Internet clearly 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.
tuting for other information sources.
21. May 1, 2002. Available at: http://www.harrisinteractive.com. Accessed April 9, 2003.
19. Taylor H. Cyberchondriacs Update. Harris Poll No.
ports,15 our results suggest that the In- 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.
Author Contributions: Study concept and design:
Available at: http://www.harrisinteractive.com. Ac- Acquisition of data: Baker, Wagner, Singer, Bundorf.
21. Reid B. Rx for the future: get an Ix, “info therapy”
Analysis and interpretation of data: Baker, Wagner, seeks role in health care. Washington Post. June 25, Drafting of the manuscript: Baker, 22. Landro L. The informed patient: if doctors pre-
Critical revision of the manuscript for important in- scribe information, will patients pay or surf the Web? tellectual content: Wagner, Singer, Bundorf.
Wall Street Journal. April 25, 2002:D4.
Statistical expertise: Baker, Bundorf.
23. Elias M. Getting help over the Net. USA Today.
Obtained funding: Baker, Wagner, Singer, Bundorf.
Administrative, technical, or material support: Baker, 24. Bly L. A network of support patients find emo-
the Internet does function as a means for tional, practical advice—and each other. USA Today. Funding/Support: This research was supported by
25. Martin JP. A world of support; the Web is chang-
grants from the National Institute on Aging, the Vet- ing medicine for doctors and patients. But is it lead- erans Administration, and Stanford University.
ing to better health care? Washington Post. August Acknowledgment: We thank Jennie Dalton Bowen of
Stanford University and J. Michael Dennis of Knowl- 26. Watson R. The new patient power. Newsweek.
fects on actual health care utilization are edge Networks for their assistance with the study.
27. Carey B. Many Web sites can skirt privacy law,
confidentiality. Los Angeles Times. November 26,
REFERENCES
1. Kassirer JP. The next transformation in the deliv-
28. Schorow S. Web sites may net useful wellness in-
ery of health care. N Engl J Med. 1995;332:52-54.
formation. Boston Herald. January 23, 2002:Arts & 2. Silberg WM, Lundberg GD, Musacchio RA. As-
sessing, controlling, and assuring the quality of medi-
cal information on the Internet. JAMA. 1997;277: 29. A Nation Online: How Americans Are Expand-
Prescription Drugs
ing Their Use of the Internet. Washington, DC: Dept 3. Purcell GP, Wilson P, Delamothe T. The quality of
of Commerce, National Telecommunications and In- health information on the Internet. BMJ. 2002;324: formation Administration and Economics and Statis- tics Administration; February 2002.
30. Fogel J, Albert SM, Schnabel F, Ditkoff BA, Neu-
4. Blumenthal D. Doctors in a wired world. Milbank Q.
2002;80:525-546.
gut AI. Use of the Internet by women with breast can- 5. Gingrich N, Magaziner I. Two old hands and the new
cer. J Med Internet Res. 2002;4:E9.
31. Borowitz SM, Wyatt JC. The origin, content, and
new thing. Health Aff (Millwood). 2000;19:33-40.
6. National Research Council. Networking Health: Pre-
workload of e-mail consultations. JAMA. 1998;280: nience for patients and saving money.
scriptions for the Internet. Washington, DC: Na- 1321-1324.
32. Eysenbach G, Diepgen TL. Responses to unsolic-
tional Academy Press; 2000.
7. Kleinke JD. Vaporware.com: the failed promise of
ited patient e-mail requests for medical advice on the the health care Internet. Health Aff (Millwood). 2000; World Wide Web. JAMA. 1998;280:1333-1335.
33. Spielberg AR. On call and online: sociohistorical, le-
8. Impicciatore P, Pandolfini C, Casella N, Bonati M. Re-
gal, and ethical implications of e-mail for the patient- liability of health information for the public on the World physician relationship. JAMA. 1998;280:1353-1359.
Wide Web. BMJ. 1997;314:1875-1879.
34. Couchman GR, Forjuoh SN, Rascoe TG. E-mail
9. Culver JD, Gerr F, Frumkin H. Medical informa-
communications in family practice: what do patients tion on the Internet: a study of an electronic bulletin expect? J Fam Pract. 2001;50:414-418.
board. J Gen Intern Med. 1997;12:466-470.
35. Mandl KD, Feit S, Pena BM, Kohane IS. Growth and
determinants of access in patient e-mail and Internet use.
10. Pealer LN, Dorman SM. Evaluating health-
related Web sites. J Sch Health. 1997;67:232-235.
Arch Pediatr Adolesc Med. 2000;154:508-511.
11. Wyatt JC. Measuring quality and impact of the
36. Sittig DF, King S, Hazlehurst BL. A survey of pa-
World Wide Web. BMJ. 1997;314:1879-1881.
tient-provider e-mail communication: what do pa- 12. Griffiths KM, Christiansen H. Quality of Web-
tients think? Int J Med Inf. 2001;61:71-80.
based information on treatment of depression: cross 37. Wagner TH, Baker LC, Bundorf MK, Singer SJ. Use
sectional survey. BMJ. 2000;321:1511-1515.
of the Internet Among the Chronically Ill. Stanford, 13. Meric F, Bernstam EV, Mirza NQ, et al. Breast can-
purchasing prescription drugs online.
cer on the World Wide Web: cross sectional survey 38. Spiegel D, Bloom JR, Kraemer HC, Gottheil E. Effect
of quality of information and popularity of Websites.
of psychosocial treatment on survival of patients with CONCLUSION
metastatic breast cancer. Lancet. 1989;2:888-891.
14. Pennbridge J, Moya R, Rodrigues L. Question-
39. Classen C, Butler LD, Koopman C, et al. Supportive-
naire survey of California consumers’ use and rating expressive group therapy and distress in patients with of sources of health care information including the In- metastatic breast cancer: a randomized clinical inter- use of the Internet for health care among ternet. West J Med. 1999;171:302-305.
vention trial. Arch Gen Psychiatry. 2001;58:494-501.
adult Internet users, moderate effects of 15. Fox S, Rainie L, Horrigan J, et al. The Online Health
40. Lorig KR, Laurent DD, Deyo RA, Marnell ME, Mi-
Care Revolution: How the Web Helps Americans Take nor MA, Ritter PL. Can a back pain e-mail discussion Better Care of Themselves. Washington, DC: Pew In- group improve health status and lower health care ternet and American Life Project; November 26, 2000.
costs? Arch Intern Med. 2002;162:792-796.
office visits, telephone calls to health care 16. Horrigan JB, Rainie L. Getting Serious Online.
41. Potts HW, Wyatt JC. Survey of doctors’ experi-
Washington, DC: Pew Internet and American Life ence of patients using the Internet. J Med Internet Res. 2406 JAMA, May 14, 2003—Vol 289, No. 18 (Reprinted)
2003 American Medical Association. All rights reserved.
Primary care redesign ideas are relatively easy to formulate; tracting tank to produce a coffee extract that is then trans- implementing these ideas in a clinically thoughtful manner is Air samples from storage tanks were collected throughout Thomas Bodenheimer, MD
the roasting process for the determination of CO levels. In this Department of Family and Community Medicine
case, the maximum levels of CO in the storage tank were found University of California at San Francisco
to be 10 000 to 100 000 ppm. An ambient CO concentration of5000 to 10 000 ppm can lead to a COHb saturation of as highas 75% (a lethal level) within a few minutes.3 RESEARCH LETTER
Comment. Industrial coffee extraction may place workers
at risk of CO poisoning. Workplace standards, improved in- Carbon Monoxide Poisoning
dustrial systems, and better worker education may help to re- From Industrial Coffee Extraction
Fusae Nishimura, DVM, PhD
To the Editor: The process of commercial coffee roasting
Shuntaro Abe, MD
releases large amounts of carbon monoxide (CO),1 which Tatsushige Fukunaga, MD, PhD
sometimes reach life-threatening levels.2 We report a case of a Department of Forensic Medicine and Sciences
death due to CO poisoning sustained during commercial cof- Mie University School of Medicine
Mie, Japan
Report of a Case. A 23-year-old employee of a roasting plant
1. Clarke RJ. Roasting and grinding. In: Clarke RJ, Macrae R, eds. Coffee Tech-
collapsed and lost consciousness soon after entering a storage nology. Vol 2. New York, NY: Elsevier Applied Science Publishers; 1987:73-89.
2. Newton J. Carbon monoxide exposure from coffee roasting. Appl Occup En-
tank (approximately 2 m in diameter and 2.7 m in height) to retrieve a tool that he had dropped into the tank. When re- 3. Logemann E, Werp J. Forensische toxikologie. In: Foster B, ed. Praxis der Re-
moved from the tank 40 minutes later, he was found to be in a chtsmedizin. New York, NY: Georg Thieme Verlag Stuttgart; 1986:674-781.
state of cardiopulmonary arrest and was transported to the hos-pital. Resuscitation attempts, including cardiac compression CORRECTIONS
and administration of 100% oxygen, were unsuccessful.
Five coworkers also were transported to nearby hospitals.
Incomplete Acknowledgment: In the Original Contribution entitled “Use of the
Three of these had collapsed and lost consciousness when they Internet and E-mail for Health Care Information: Results From a National Survey” went inside or approached the tank, while 2 others reported published in the May 14, 2003, issue of THE JOURNAL (2003;289:2400-2406), theFunding/Support section on page 2406 should have read “This research was sup- presyncopal symptoms. All 5 recovered soon or within a few ported by grants from the Center on the Demography and Economics of Health hours, although 1 was hospitalized and given oxygen.
and Aging of Stanford University (National Institute on Aging grant AG17253),the Veterans Administration, and Stanford University.” The medicolegal autopsy of the deceased worker was per- formed in our department 17 hours after the death. A cherry- Incorrect Wording and Data: In the JAMA-EXPRESS Original Contribution en-
titled “Clinical Features and Short-term Outcomes of 144 Patients With SARS in
red discoloration was seen on the back. Slight bruises were found the Greater Toronto Area” published in the June 4, 2003, issue of THE JOURNAL on the left temporal area and the left forearm. Multiple pete- (2003;289:2801-2809), 2 errors occurred on page 2804. The second full sen-tence in the first column should have read “. or because they did not meet the chial hemorrhages were observed in the pericardium and on case definition requiring admission.” Also, in the second full paragraph under “Treat- lung surfaces. Both lungs showed severe edema and conges- ment and Associated Toxicities,” the second sentence should have read “Sixty- tion. The concentration of CO hemoglobin (COHb) was 26% two patients (49%) experienced a decrease in hemoglobin level of at least 2 g/dLafter ribavirin was initiated.” in the heart blood. No other toxic gases or drugs were de-tected. The cause of death was determined to be acute CO poi- Author Name Missing From Byline: In the Original Contribution entitled “Re-
sponse to Smallpox Vaccine in Persons Immunized in the Distant Past” published
in the June 25, 2003, issue of THE JOURNAL (2003;289:3295-3299), “Kathleen R.
According to the result of the subsequent forensic inspec- Lottenbach, MA” should appear in the byline after “Lihan Yan, MS” and before“Robert B. Belshe, MD.” In the author affiliations on page 3295, “and Ms Lot- tion, the company involved in this incident uses an extract- tenbach” should be added after “Newman.” On page 3299, under “Acquisition ing process on coffee beans that have already been roasted of data, Analysis and interpretation of data, Drafting of the manuscript, and Ad- and ground. This process, which is widely used in the ministrative, technical, or material support” “Lottenbach,” should be added be-fore “Belshe” and under “Study supervision” “, Lottenbach” should appear after industry, involves adding water to ground beans in an ex- 334 JAMA, July 16, 2003—Vol 290, No. 3 (Reprinted)
2003 American Medical Association. All rights reserved.

Source: http://ser.cies.iscte.pt/index_ficheiros/Baker.pdf