Health Information

on the Internet:

Economics, Regulation,

Policy & Ethics

Yale M. Braunstein, Ph.D.

Yale M. Braunstein

Professor, School of Information Management and Systems and Health Services and Policy Analysis Group, University of California, Berkeley

Lecture Outline

Economics & Pricing Regulation Ethics Sample Policy Areas

Information about health and medicine is increasingly available on the Internet. This lecture focuses on:

Economics of Information Provision

Why economics matters?

• The funding of the information source can influence the content

• Prices, if any, influence who will have access to the information

• Access to health information is related to the the provision of medical care and the overall level of health

Pricing Information (1)

How to price information?

• by byte

• by advertising

• by subscription

• hybrid schemes (such as storing and using advertising credits)

All (and more) will be used

Pricing Information (2)

Product-line development

Economies of scale

Economies of scope

Regulation

Regulation of the content of health and medical information can be viewed as ancillary to the regulation of service delivery.

Another model is to apply regulatory models from other areas—consumer product safety, privacy, etc.

Ethical and Legal Concerns May Be Different

Not everything that is legal is ethical

Not everything that is ethical is legal

Ethics• is based in cultures and sub-cultures• is different from good taste• may or may not be related to intent• is related to context

Sample Policy Areas

Privacy & Security

Intellectual Property

Control of Information

Licensure & Liability

Policy: Privacy Multiple aspects to privacy

• annoyance• actuarial information• willingness to pay• damages to character

Consumers value privacy -- therefore it has an economic dimension

Consumers could trade privacy for prices• define a property right in privacy

Confidentiality, Privacy and Security (1)

Current “standards of care” may be changing as they depend on customary practices, ethics codes, and law

Practitioners need to understand practical, technical, and legal limits of the technology

Patients may need to be informed of limits to privacy and privilege

Confidentiality, Privacy and Security (2)

Doctor-patient privilege applies to communications in the course of diagnosis or treatment

Does it apply when requesting or providing advice over the Internet?

There is a duty to maintain confidentiality• Is this possible over the Internet?• When using a cellular telephone?

Confidentiality, Privacy and Security (3)

U.S. federal law specifically permits operators of online services to monitor e-mail transmissions of subscribers

Employers can monitor e-mail of employees

Some states have taken a “cat’s out of the bag” approach--confidentiality has already been compromised so there is no longer anything to protect

Confidentiality, Privacy and Security (4) Do either patients or professionals understand they

have little reasonable expectation of privacy?• In fact e-mail and other online activity make it

difficult (or impossible) to:–know when disclosure has occurred–to obtain patient’s consent

• Not only can communications be intercepted, mis-delivered messages are quite common.

Privacy and security are NOT the same• The classic case is the sale of personal data by

GeoCities; the information sold was very secure but privacy was not respected.

Confidentiality, Privacy and Security (5)

Any electronic communication may lead to TGI (transaction generated information or access markers) that can make tracking easy

Do consumers want third parties* to know they obtained information on specific problems or treatments• vendors• insurers• employers, neighbors, etc.

Confidentiality, Privacy and Security (6)

Storage of records and notes in electronic format requires care• Especially if on a network• Especially if on a laptop

Use of passwords, encryption, and other methods such as removable media

Remember the Basic Question: What is the standard of care that is expected?

Policy: Intellectual Property (1)

Some intellectual property issues may fade with new approaches to licensing & pricing

Consumers reject intrusive or cumbersome measures

Suppliers need to employ more effective pricing strategies

Policy: Intellectual Property (2) Database protection laws create a

new form of intellectual property in the EU and are being debated in the U.S. (There are ethical, legal, and economic aspects to this policy issue.)

(Note: encryption policy is related to both intellectual property policy and privacy.)

ICD-9

CPT-4

Who Is an Authority?

The Internet appears to have a “leveling” effect• Anyone can set himself up as a judge of others• Many claims and criticisms may appear

equally valid to untrained observers

These disputes can be especially difficult for patients and consumers who want results even if they may be problematical

Non-traditional medicine raises many difficulties (not just for the Internet)

Control of Information

The Internet may decrease the control traditional sources have over the flow of information.

• “Quackwatch” is a site that seeks to expose fraud and misinformation.

• The second example comes from the American Diabetes Association.

Exposing Quackery

Early Release of Information

Licensure (1) The Internet makes it easy to “practice” across

traditional political or licensing boundaries• AMA reported 300% increase in “telehealth”

consultations 1n 1997• most common category (20%) was mental health

The traditional provider-patient relationship will change

(Licensure and liability are inter-related)

Licensure (2) PL 105-33 requires Medicare Part B payments for

telehealth professional consultations by 1 Jan. 1999

But it is sometimes difficult to distinguish between formal consultations and informal advice, especially when contact is remote

The examples that follow start with mental health and pharmaceuticals; we then look at an example that includes internal medicine specialties

An Attempt at Online Consultation

Liability (1)

General rules (which may be contentious)

•Providers should be licensed everywhere they provide service

•A harmed patient should have the right to sue where he is harmed

Liability (2) Does professional competence include “technical

competence” if new technologies are utilized to a substantial degree?

Who, if anyone, should be responsible for content in online forums and “chat rooms”?• Computer Decency Act (Sec. 509) provisions

required online services to take “reasonable measures” or be liable for defamation

• Should this apply to practitioners?

Do Disclaimers Work? (1)

Do Disclaimers Work? (2)

Summary

The Internet is a mature technology in an immature economy

Fundamental legal, economic, organizational issues are still to be solved

Critical choices should not be made prematurely

The Internet is already affecting the delivery of health and medical information and of services.