Analysis of Internet Use in Catalonia Health System: Webs, Doctors and Citizens

1. Analysis of Internet Use in Catalonia Health System: Webs, Doctors and Citizens Brown Bag Seminar Series SATSU 23rd June 2009 Visiting Researcher at SATSU Researcher at i2TIC – Internet Interdisciplinary Institute IN3 Lecturer Information and Communication Science at Open University of Catalonia Dr . Francisco Lupiáñez-Villanueva [email_address] [email_address] http://ictconsequences.net Dr . Francisco Lupiáñez-Villanueva

3. Catalonia http://www.gencat.cat/catalunya/eng/ Overview Catalonia is an autonomous community within Spain and exercises its self-government . Decentralized Health System: almost universal coverage and high quality network of hospital and primary care centers . Nowadays, Catalonia has more than seven million inhabitants. The Catalan Government has earmarked €9,412,900,000 for Catalan health care in 2009 ( 7% GDP ). Catalan Health Service ---> National Health Service UK http://www10.gencat.cat/catsalut/eng/coneix.htm

4. Technological Modernization, Organizational Change and Service Delivery in the Catalan Public Healthcare System directed by Prof. Castells and funded by Government of Catalonia (May 2005 – June 2007) Citizens, Health and the Internet directed by Prof. Castells and funded by Government of Catalonia (September 2007 – October 2008) Internet, Health and Society. Analysis of the uses of internet related to health in Catalonia Thesis (2009) Author: Francisco Lupiáñez-Villanueva Director: Prof. Castells Background Research Projects - IN3

5. Castells, M. (2004). Informationalism, Networks, and the Network Society: A theoretical blueprint. In The Network Society: a cross-cultural perspective. MA: Edward Elgar. Greenhalgh, T.; Robert, G., et al. (2005). Diffusion of Innovations in Health Service Organizations. A systematic literature review. Oxford: Blackwell Publishing Hardey, M. (2001). “E-Health”: the Internet and the transformation of patients into consumers and producers of health knowledge. Information, Communication & Society, 4(3), 388–405. Nettleton, S., & Burrows, R. (2003). E-scaped medicine? Information, reflexivity and health. Critical Social Policy, 23(2), 165–185. Pickstone, J. V. (2001). Ways of Knowing. A New History of Science Technology and Medicine. Chicago: University of Chicago Press. Pickstone, J. V. (2003). Production, Community and Consumption: The Political Economy of Twentieth-Century Medicine. In Companion to Medicine in the Twentieth Century. London: Routledge. Rice, R. E. (2001). The Internet and Health Communication: A framework of Experience. In E. R. Rice, & J. E. Katz (Eds.), The Internet and Health Communication. Experiences and Expectations. (pp. 1–46). California: Sage Publications. Webster, A. (2002). Innovative Health Technologies and the Social: Redefining Health, Medicine and the Body. Current Sociology, 50(3), 443–457. Background Multidisciplinary approach

6. http://www.wordle.net/gallery/wrdl/957924/Main_references Background

7. All references available at: http://www.ictconsequences.net/2008/12/06/the-definitive-references-collection-of-my-thesis/ http://www.wordle.net/gallery/wrdl/957899/References_thesis Background

9. Overview of whole project Methodology Healthcare actor Tools Universe / Population Sample / Rates Date WWW and Health Matrix Criteria 1,240 URLs September – December 2005 Health webmasters Identified online survey 388 emails 112 (28.8%) March 2006 Patient support groups Identified online survey 215 groups 52 (24.1%) October 2005 Internet users No-identified online survey 435 June 2006 Citizens Telephone survey Catalonian population 2.000 (M.E. 2.5% - C.I. 95%) October – December 2007 Physicians Identified online survey 16,531 Barcelona (COMB Professional Association) 2,199 (13.3%) June - July 2006 Nurses Identified online survey 13,583 Barcelona (COIB Professional Association) 1,170 (8.6%) October - November 2006 Pharmacists Identified online survey 7,648 Barcelona (COFB Professional Association) 898 (11.7%) November - February 2007

13. Health Websites Health Websites

14. What type of quality information and applications related with Health are offered on the Internet? Health Websites Content Telephone number 72.6 % Postal Address 70.6 % Health content 55.9 % Advertising 13.7 % Interaction Communication email 78.9 % Electronic forums 9.2 % Email list 8.8 % Online surveys 6.4 % Chat 2.3 % Services Electronic formulary 14.6 % Login - password 10.1 % Electronic Commerce 4.1 % Physicians appointments 4.8 % Other 4.8% Library services 3.5% Healthcare services 1.4% Online learning 0.4% Payments 0,5%

15. 5/43 What type of quality information and applications related with Health are offered on the Internet? Health Websites Quality Contents Author 66,3% Professional profile 60,6% Date 50,2% Communication and services Privacy – Legal advices 20,8% Web resources More than one language 37,6% Aim of the web 35,9% Search 16,9% Web Map 12,6% Accreditation 11,5% Help 4,9% FAQ: Frequent Asked Question 4,3% Technological Standards 1,2% Agents Professional Associations 25% Healthcare professionals 22.2 % Patient Support Groups 17.1 % Healthcare providers 12.8 % Personal Web 5.9 % Public Administration 5 % Teaching Centres 4 % NGO 2.4 % Research Centres 2.3 % Other providers 2.3 % Media 1 %

16. What type of quality information and applications related with Health are offered on the Internet? Figure 27. Variables of classification related to Information, Communication, Services and Quality (percent) Figure 28. Catalan Web health resources characterization (Method analysis: no hierarchical cluster, centre of clusters) Font : Self made Font : Self made Health Websites Criteria Information (Health content, postal address, telephone number and advertising) Communication (email, forum, email list, online surveys and chat) Services (Electronic form, Intranet, eCommerce, other services) Quality (Standards, Legal issues, Accreditation, Aim) 0 criteria 5.1 19.8 68.9 50.6 1 criteria 20.6 65.6 21.6 32.5 2 criteria 38.1 7.7 5.6 13.9 3 criteria 29.6 3.2 3.8 2.8 4 or more criteria 6.7 3.7 0.0 0.2 Clusters 1. High quality information oriented websites n=132 12,6% 2. Low quality information oriented websites n=301 28,8% 3. Medium quality interaction oriented website n=67 6,4% 4. Unusable websites n=545 52,1% ANOVA F Information 3 3 3 1 415,309* Communication 1 1 3 1 583.212* Services 1 1 2 0 238,022* Quality 2 1 2 0 627,556* *p<0,001

17. Analysis of Health websites and publishers Figure 30. Health Web resources orientation and Information, Communication, Services and Quality (percentages) Font: Self made 13/43 Health Websites Clusters 1. High quality information oriented websites n=132 12,6% 2. Low quality information oriented websites n=301 28,8% 3. Medium quality interaction oriented website n=67 6,4% 4. Unusable websites n=545 52,1% p Users 18,2 26,6 22,4 22,4 ,000 Healthcare providers 25,0 15,3 4,5 13,9 ,000 Healthcare professionals 32,6 47,5 59,7 49,0 ,000 Government 19,7 4,0 1,5 2,4 ,000 Others 4,5 6,6 6,6 12,3 ,000

18. 1. High quality information oriented websites Health Websites

20. 3. Medium quality interaction oriented website Health Websites

21. Health websites … still Web 1.0 The WWW is constituted mainly as a space of contents with little presence of applications of communication and services, therefore with a little degree of interaction. The presence in the Internet of the Catalan health care system is led by the professionals who offer mainly information and contents on health and few applications related to interaction . Quality is still a challenge Healthcare providers and the Government are more information providers than service providers on the Internet Health Websites

22. Physicians Physicians

23. What are the uses of ICT, especially the Internet, by physicians and how can they be characterized? Table 1. Most frequently used Information sources Factor Analysis (Analysis of the correlation matrix: Kaiser-Meyer-Olkin 0.723; Bartlett’s test of sphericity p=0.000; Varimax Rotated Matrix) FACTOR 1. Emphasis on international information FACTOR 2. Emphasis on national information FACTOR 3. Emphasis on institutional information Physicians

24. Physicians Table 2. Internet utilisation Factor Analysis (Analysis of the correlation matrix: Kaiser-Meyer-Olkin 0.676; Bartlett’s test of sphericity p=0.000; Varimax Rotated Matrix) FACTOR 1. Emphasis on the Internet for participation FACTOR 2. Emphasis on the Internet for produce information FACTOR 3. Emphasis on the Internet for communication.

25. Physicians Table 3. Most frequently ICT and Internet task Factor Analysis (Analysis of the correlation matrix: Kaiser-Meyer-Olkin 0.825; Bartlett’s test of sphericity p=0.000; Varimax Rotated Matrix) FACTOR 1. Emphasis on ICT for research and medical practice FACTOR 2. Emphasis on ICT for interaction and dissemination FACTOR 3. Emphasis on ICT for institutional information

26. What are the uses of ICT, especially that of the Internet, by physicians and how can they be characterized? Table 110. Advanced and intensive Internet use characterization ( Method analysis: no hierarchical cluster, centre of clusters ) Table 111. Advanced information system use practice characterization ( Method analysis: no hierarchical cluster, centre of clusters ) Physicians Clusters 1. Integrated ICT Physician n=597 (38,6%) 2. Utilized ICT Physician n=949 (61,4%) ANOVA Emphasis on international information ,538 -,399 447,790* Emphasis on national information ,265 -,197 87,390* Emphasis on ICT for research and medical practice ,383 -,265 171,911* Emphasis on ICT for institutional information -,103 ,055 9,693* Emphasis on ICT for interaction and dissemination ,408 -,257 181,693* Emphasis on the Internet for produce information ,599 -,377 452,151* Emphasis on the Internet for communication. ,293 -,184 88,603* * p<0,001 Conglomerados 1. Utilized information system physician n=1.502 (94,3%) 2. Integrated Information system physician n=90 (5,7%) ANOVA Information system - inside of the organization oriented -,01104 ,18425 3.243** Information system - outside of the organization oriented -,20352 3,39655 3567.423* Postal information system oriented -,05571 ,92982 86.927* * p<0,001 **p<0,01

27. Physicians

28. Physicians

29. What are the consequences of the use of these technologies by doctors with respect to their patients? Fuente : Elaboración propia Table 116a. Consequences of the use of the Internet (Dimension, percentage and Chi-square significance) 26/43 Physicians Dimensions Consequences of the use of the Internet 1. Integrated ICT Physician n=597 (38,6%) 2. Utilized ICT Physician n=949 (61,4%) Significance How do you consider health information available on the Internet? ,008 - Very relevant 12,3 7,4 - Relevant 69,1 69,9 - Litle relevant 18,0 21,0 Do you think that patients go online for health information… ,000 - Improve a lot their autonomy and quality of life 11,0 3,9 - Improve their autonomy and quality of life 42,8 36,1 - Improve a little their autonomy and quality of life 32,4 39,4 - Do not improve their autonomy and quality of life 7,9 12,0 - Make their autonomy and quality of life worse 6,0 8,6 Do you recommend your patients to go online for health information? ,000 - Yes, I usually do it 2,6 ,5 - Yes, I often do it 9,5 4,0 - Yes, I sometimes do it 44,9 36,0 - No, I never do it 43,0 59,5

30. What are the consequences of the use of these technologies by doctors with respect to their patients? Fuente : Elaboración propia 27/43 Physicians Dimensions Consequences of the use of the Internet 1. Integrated ICT Physician n=597 (38,6%) 2. Utilized ICT Physician n=949 (61,4%) Significance Do your patients discuss or share with you their Internet health information findings? ,000 - All of the patients do it 1,4 ,6 - Most of the patients do it 14,4 7,4 - Some of the patients do it 53,2 54,6 - A few of the patients do it 25,6 27,6 - Patients don’t do it 5,5 9,7 Do you think patients seeking for Internet health information improve their knowledge and facilitate their treatment ,000 - A lot 13,6 8,8 - Quite 47,4 43,0 - A little 28,9 38,3 - Nothing 10,1 9,8 The use of the Internet in you daily work… ,000 - Improve communication with other healthcare professionals 87,5 76.7 - Improve efficiency and productivity of your work 83,6 78,2 - Improve patients attention 55,8 48,9 - Improve communication with patients 35,9 20,3

32. What are the determinants (technological and non-technological) of the uses of the Internet by professionals? Table 118. Determinants of Integrated ICT Physician ( regression analysis: Logit model; dependent variabl e: Networked physician: value 1, YES, value 0, NO; standar coeficients ; n=1.056; % predicted observed 79,2%) 28/43 Physicians Variables Estimated coefficient Standard Error Wald Sig. Exp (B) Emphasis on international information 1,511 ,122 154,148 ,000 4,532 Emphasis on ICT for research and medical practice ,953 ,086 122,001 ,000 2,595 Emphasis on national information -,296 ,087 11,545 ,001 ,744 Information system - outside of the organization oriented ,267 ,085 9,806 ,002 1,306 Research activities ,655 ,203 10,418 ,001 1,925 The use of the Internet in you daily work improve communication with patients 1,095 ,179 37,242 ,000 2,990 Work on public and private healthcare organizations ,411 ,185 4,934 ,026 1,509 -2 Log-likelihood 951,749 R 2 Cox-Snell ,363 R 2 Nagelkerke ,490 Hosmer-Lemeshow ,035

34. Integrated ICT Physicians (38.6%) same analysis carried out for: Physicians Integrated ICT Nurses (4.5%) and Integrated ICT Pharmacist (8.6%)

35. Citizens Citizens

36. Health information sources and participation Figure 44. Identification of intensive use of health information sources (Factorial analysis; % total variance 61,5) Figure 45. Intensive use of health information characterization (Method analysis: no hierarchical cluster, centre of clusters) Figure 48. Participative Healthcare Expectations index (percentages) 17/43 Citizens Health Information sources Variables Factors Nurses (37.5%) Pharmacist (38.1%) Newspaper, Journals, Books (38.9%) TV and Radio (40.9%) Relatives and Friends (42.7%) 1. Intensive use of Mass media communication, family, friends as health information sources 2. Intensive use of healthcare professional as health information sources Clusters 1. Intensive users n=806 (59,7%) 2. No intensive users n=1.194 (40,3%) ANOVA Intensive use of Mass media communication, family, friends as health information source 1,08111 -,72979 7488,418* Intensive use of healthcare professional as health information sources ,17355 -,11715 41,486* *p<0,001 More Participative - good health 41,2 More Participative - bad health 10,0 Less Participative - good health 35,7 Less Participative - bad health 13,0

37. Tabla 51 . Tipología de usuarios de las Tecnologías de a Información y la comunicación (método de análisis: cluster no jerárquico centro de los conglomerados finales) Figure 51. Typology of ICT users (Method analysis: no hierarchical cluster, centre of clusters) Excluded Citizen n=428 22,25% Disconnected citizen n=341 17,73% Basic Connected Citizen n=271 14,09% Connected Citizen social oriented and medium equipped n=289 15,02% Connected Citizen personal oriented and high equipped n=242 12,58% Networked Citizen n=252 13,19% Internet access 0 0 1 1 1 1 Email use 0 0 1 1 1 1 Participate in online forums 0 0 0 0 0 1 Create or work on your own webpage or blog 0 0 0 0 0 0 Participate in web or blogs from others 0 0 0 0 0 1 Share online photos, videos, works 0 0 0 0 0 1 Take material you find online - like songs, text or images - and remix it into your own artistic creation 0 0 0 0 0 1 Desktop computer 0 0 1 1 1 1 Laptop computer 0 0 0 0 1 1 Mobile phone 0 1 1 1 1 1 Blackberry, Palm or other personal digital assistant 0 0 0 0 0 0 MP3 player 0 0 0 1 1 1 Digital or video camera 0 1 1 1 1 1 Webcam 0 0 0 0 1 1 I like that cell phones and other mobile devices allow me to be more available to others 0 1 0 1 1 1 When I get a new electronic device, I usually need someone else to set it up or show me how to use it 0 1 1 0 0 0 I believe I am more productive because of all of my electronic devices 0 1 0 1 1 1 How much, if at all, have these communication and information devices improved.. - Your ability to inform by yourself 0 1 0 1 1 1 - Your ability to work 0 1 0 1 1 1 - Your ability to learn 0 1 1 1 1 1 - Your ability to keep in touch with people 0 1 0 1 0 1 - Your ability to share your ideas with others 0 1 0 1 0 1

38. E-readiness to Network Society Citizens AGE Gender Work - Education (self-programmable vs. generic)

40. What are the uses of ICT with respect to health by citizens and how can they be characterized? Table 54. Health information and Empowerment characterize by Typology of ICT users (Dimension, percentage and Chi-square significance) Table 58. ICT users typology characterize by access to the Internet to inform or make procedures related to health or health services (Dimension, percentage and Chi-square significance) Citizens Dimension Health information and empowerment Excluded Citizen n=428 22,25% Disconnected citizen n=341 17,73% Basic Connected Citizen n=271 14,09% Connected Citizen social oriented and medium equipped n=289 15,02% Connected Citizen personal oriented and high equipped n=242 12,58% Networked Citizen n=252 13,19% More health information now than two years ago 53,5** 60,6** 52,9** 51,9** 55,4** 65,0** Intensive health information user 34,1* 47,5* 42,4* 37,5* 38,8* 42,5* Participative Healthcare Expectations 38,6* 39,8* 45,4* 58,2* 56,7* 61,6* Healthy Less Participative 26,9* 39,3* 35,1* 37,1* 37,9* 35,9* Healthy More Participative 20,4* 28,4* 28,7* 51,8* 50,7* 55,1* No healthy Less Participative 34,5* 20,9* 19,5* ,4* 5,4* 2,5* No healthy More Participative 18,1* 11,4* 16,7* 6,4* 6,0* 6,6* *p<,0001 **p<,001 Dimension Tipolgy of ICT users Have you ever accessed to the internet to look for information or make procedures related to health or health services? (24,3% of the population) Significatividad NO YES 1. Excluded Citizen 22,5 ,0 ,000 2. Disconnected Citizen 20,1 1,7 ,000 3. Basic Connected Citizen 18,4 2,2 ,000 4. Connected Citizen social oriented and medium equipped 14,7 30,2 ,000 5. Connected Citizen personal oriented and high equipped 15,8 37,1 ,000 6. Networked Citizen 8,6 28,7 ,000

42. What are the determinants (technological and non-technological) of the demand of healthcare services via the Internet? Table 68. Determinats of healthcare system access via the Internet or email (regression analysis: Logit model; dependent variable: healthcare system access via the Internet or email; cvalue 1, YES, Value 0, NO; standar coeficients; n= 1.279; % predicted observed 85,6%) 22/43 Citizens Variables Estimated coefficient Standard Error Wald Sig. Exp (B) Networked Citizen – Advanced Connected Citizen 3,868 ,525 54,330 ,000 47,842 Have visited physicians during this year ,480 ,197 5,931 ,015 1,611 Age ,074 ,102 ,526 ,468 1,077 Participative Healthcare Expectations ,314 ,176 3,190 ,074 1,369 -2 Log-likelihood 859,234 R 2 Cox-Snell ,141 R 2 Nagelkerke ,251 Hosmer-Lemeshow ,045

44. Conclusions Conclusions

45. Network Citizen Integrated ICT Healthcare Professional MEDIATED ICT – INTERNET PARTICIPATION EDUCATION - SKILLS USE WORK ORGANIZATION TIME INCENTIVES ACCESS ASSESSMENT SKILLS AGE INNOVATION FLEXIBILITY INTEGRATION From Industrial Health Age to Network Health Age Conclusions

46. HEALTHCARE TRANSITION – POLICY MAKING Peña-López, I. (2009) “Measuring digital development for policy-making: Models, stages, characteristics and causes. The role of the government” In ICTlogy, #68, May 2009. Barcelona: ICTlogy. Retrieved month dd, yyyy from http://ictlogy.net/review/?p=2176 Conclusions

47. THANK YOU INDEED FOR YOUR ATTENTION Brown Bag Seminar Series SATSU 23rd June 2009 Visiting Researcher at SATSU Researcher at i2TIC – Internet Interdisciplinary Institute IN3 Lecturer Information and Communication Science at Open University of Catalonia Dr . Francisco Lupiáñez-Villanueva [email_address] [email_address] http://ictconsequences.net Dr . Francisco Lupiáñez-Villanueva