Doctors Without Modems?

Technology Historian Nathan Ensmenger checks the pulse of the e-health revolution.
December 29, 2008

From shopping and bill-paying to media consumption and socializing, Americans engage in dozens of routinized, Internet-mediated activities every day. And while the wired world may still skew young, Internet usage is becoming steadily more prevalent across all demographic lines. With most Americans accustomed to conducting personal business online—and 62 percent of employed adults using the Internet or email at work—clicking send is the new norm for getting things done. So why, then, are the vast majority of Americans prohibited from communicating with their doctors via email?

“There are huge industries that have not been changed much by the Internet, or not changed in obvious ways,” says Nathan Ensmenger, an assistant professor in the Department of History and Sociology of Science. In a paper titled “Resistance is Futile?: Reluctant and Selective Users of the Internet,” published this year in The Internet and American Business, Ensmenger explains why some industries—health care in particular—have not yet been radically transformed.

“Industries are not being uncritical about the Internet,” says Ensmenger. “We can’t talk about industries that don’t ‘get’ technology. They’re making very deliberate choices, and there are often quite legitimate reasons for resisting technology coming from the outside.”

Ensmenger found that comprehensively answering the question of why most doctors don’t use email produced a sort of case study in thinking about information technologies in a sophisticated way—moving beyond what he describes as the simplistic economic and technological determinism that often dominates discussions about Internet commerce. “We can’t talk about email, or the Internet, or computers as if they’re one thing,” Ensmenger argues. “We have to talk about them in particular business, economic and legal contexts.”

According to Ensmenger’s research, never in the past decade has the rate of email interaction between physicians and patients increased above six percent, despite the fact that national surveys indicate that as many as 90 percent of respondents would welcome the opportunity to communicate with their doctors via email, with 37 percent stating that they would be willing to pay for such access. The short explanation as to why this demand remains largely unsatisfied comes down to money, but there are pertinent noneconomic factors as well.

"We can't talk about email, or the Internet, or computers as if they're one thing. We have to talk about them in particular business, economic and legal contexts." - Nathan Ensmenger

“Physicians are rarely reimbursed for Internet-based activities,” writes Ensmenger. “This is certainly a powerful disincentive. And yet reimbursement is rarely cited by physicians as their principal reason for avoiding the Internet. Rather, concerns about privacy, liability, and patient safety and well-being are described as being primary.”

Even allowing for a degree of calculated disingenuousness, Ensmenger reasons, physicians’ collective wariness of Internet-based medicine seems to also stem from significant legal, professional and ethical concerns. “For most people, email is a very casual thing,” he says. “But for physicians email cannot be casual. They have to worry about HIPAA regulations, so there has to be an infrastructure for keeping information secure. There are concerns about patient care—doctors asking, Can I adequately diagnose someone without seeing them? Email is also not something that can be easily delegated to a nurse in the same way as certain kinds of tests or paperwork.”

Doctor-patient email is just one form of interactive communication that many would like to see widely adopted by the health care industry. As a historian of technology, Ensmenger will be curious to see whether, and how, the e-health revolution that seemed imminent to so many dot-com investors in the 1990s will actually materialize in the near future. “With the exception of information gathering, prescription refilling, and the occasional purchase of health-related equipment,” writes Ensmenger, “most patients do not, and cannot, access traditional medical services online.”

Perhaps change will occur more swiftly under a new presidential administration. The health care plan that President-elect Barack Obama put forth during his campaign calls for investing “$10 billion a year over the next five years to move the U.S. health care system to broad adoption of standards-based electronic health information systems, including electronic health records.” This same plan cites a study by the Rand Corporation that found that up to $77 billion in savings could be realized annually through efficiencies such as reduced hospital stays and avoidance of duplicative and unnecessary testing.

“There’s been a lot of talk about what electronic medical records would do to streamline the health care industry,” says Ensmenger. “In the 1980s in particular, there was this claim that the problem with health care was the bureaucracy, but this was in part an argument for increased privatization by the Reagan administration and various interested corporate actors.”

Ensmenger sees other issues weighing more heavily on people’s minds today. “The conversation about health care, in the United States at least, has shifted away from saving money by making the system more efficient,” he says. “There’s this sense now that the larger problem with health care is something other than paperwork—it’s the insurance-based system, or the third-party payer system, or new technologies or chronic care.”

Ensmenger also points out that for most medical interactions, having one’s complete medical record accessible on demand doesn’t offer a substantial benefit. “Most of us don’t visit the doctor because we’ve been hit by a car and need our full medical history,” he explains.  “Most of us are going to our general practitioner, or to specialists who we’re seeing for chronic conditions, and they know everything they need to know about us already.” When you do need a copy of your full medical record, he says, this can usually be accomplished by utilizing an existing technology: the telephone.


Click to listen:

Ensmenger on his research and forthcoming book, The "Computer Boys" Take Over

Ensmenger on the SAS undergraduate major in Science, Technology, and Society