As a growing number of health applications are available online, it is important to understand how and to what extent individuals are taking advantage of these applications. Given the existence of disparities in health status among individuals of different ethnic, racial, and socioeconomic backgrounds, it is useful to examine whether use of health-related information technology (IT) also varies by these dimensions. Finally, to the extent that such applications have been demonstrated to have a positive impact on patients’ behaviors and health, it is worthwhile to understand barriers to wider use and potential opportunities to address them. Informed by an extensive literature review and a series of discussions with thought leaders in the consumer health IT field, this paper focuses on those issues.
What consumer health needs can be addressed using health IT?
Individuals can use IT to address a number of health needs and can access health applications through several pathways. Many resources, particularly information sites, are available online for anyone who is interested in them. Other individuals come in contact with these web tools through their relationships with their medical providers. A final entrance point is through entities that pay for health care—insurers and employers. Consumers use health IT to:
- Seek health information:A variety of commercial, nonprofit, and government sites provide articles, tips, and other information about disease and wellness topics.
- Take action to monitor and improve health: Computerized applications can help consumers make decisions, monitor their chronic conditions, or receive assistance in engaging in healthier behaviors. Common topics for computerized tools are nutrition, weight management, tobacco cessation, and cancer and diabetes prevention and management.  A variety of products are available, including decision aids, games to promote healthy behaviors, and health monitoring systems.
- Communicate with relatives, friends, and other patients: Individuals use email to exchange information about their health conditions with friends and relatives—for example, adult children can keep an eye on their infirm parents from afar. Individuals can also participate in online communities where they can learn about the symptoms and treatment of individuals with similar conditions.
- Interact with the health care system: Individuals can go online to select an insurance plan, to learn about the benefits covered by that plan, and to find medical providers. To help them make health care decisions, consumers can gain information about the quality of health care providers and insurance plans. Some patients can also use the websites of their providers to schedule appointments, re-fill prescriptions, or otherwise communicate with physicians and office staff.
- Use a personal health record or multi-function portal: Some individuals see physicians who provide access to patient portals which, in addition to allowing for the functions described above, can be associated with an electronic health record (EHR), allowing patients to view part or all of their medical charts. A popular component of many of these portals is that the ability to view the results of lab and other diagnostic tests and view lists of their medications, immunizations, and allergies.  Another approach to monitoring one’s health data is the personal health record (PHR), through which individuals have control over their own health data and can integrate information from a variety of providers and other sources.
- Emerging trends in consumer health IT: Several of the experts consulted as part of this project highlighted social networking—including blogging—as an increasingly important trend. One expert talked about a growing interest in wellness and speculated that as consumers are paying a larger share of their health care costs they may express a greater interest in maintaining their good health. This may lead to further development of consumer driven products that are accessible through PDAs and cell phones. Products that can remotely track health and health care costs are also just emerging.
How are consumers currently using these resources?
It is difficult to ascertain the proportion of Americans who have used health-related IT, but it is clear that many millions of individuals have gone online to use at least one of these health applications. In order to understand the scope of potential online health IT engagement it is important to note that about three out of every four Americans use the internet.  Access to high-speed internet connections may also determine consumer health IT use.
Seek health information: Estimates for the proportion of American adults that have used the internet to look for information about health range from approximately 40% to around 60%.  Some evidence suggests that this use has grown over time. In understanding the reach of online health information seeking, it is important to consider the fact that many of the individuals who are looking online for health information are doing so on behalf of someone else. A 2005 survey found that the percentage of respondents looking for health information for themselves was equal to the percent looking for others—59.5% and 58.4%, respectively. 
Research and purchase prescription drugs: In a 2004 study, 21% of adults said they had looked online for information on prescription drugs, while another 5% said someone else had conducted such a search on their behalf.  Yet only 4% or 5% of Americans say they have purchased prescription drugs online. 
Take action to monitor and improve health: It is difficult to discern how many individuals use applications to take action on their health, but studies suggest modest use of IT applications like remote disease monitoring and decision support tools.
Communicate with relatives, friends, and other patients: Online support groups appear to only attract a very small number of individuals.  Although support groups are not widely used, 11% of adults use online communications to interact with people with similar health issues and almost one-quarter use the internet or email to communicate with relatives or friends about health or health care. 
Interact with the health care system: Although many individuals express interest in electronically contacting their providers, using email or secure messaging to communicate with providers is not a common practice. One survey found that over 80% of adults said they would favor or strongly favor being able to email their physicians; yet the same survey found that only 8% currently do so. 
Use a personal health record or multi-function portal: There are few good estimates of the number of individuals who manage their health data through a PHR or use a provider-sponsored web portal. Even among patients who see providers with portals, the extent to which individuals decide to take advantage of them varies widely from approximately 10% to 50%. This disparity may reflect the degree to which a practitioners advocates use of online resources. It has been estimated that between 15-20% of patients who have the option to access a PHR through their health plan will decide to sign up. 
Evidence on effectiveness: The majority of evaluations on the quality of online health information identify problems with accuracy and completeness; yet due to a lack of consensus on evaluation criteria and other methodological concerns it is difficult to draw concrete conclusions from this research. While many users report satisfaction with electronic health tools, in most studies only a minority of respondents say that those tools have changed their behavior. More rigorous studies that involve randomized control trials have linked applications to positive results; however such evaluations have not been conducted on many of the health tools that are most commonly used.
Differences in use by demographic group
Few data are available comparing the use of different health IT applications across subpopulations. The information that is available primarily focuses on information seeking. Evidence suggests that individuals who have lower educational attainment, are male, lack health problems, and are either young (and healthy) or older (and less comfortable with computers) are less likely to go online looking for information about health.
Socioeconomic status: Efficacy in using online health tools may have more to do with likelihood of seeking health information online than does economic status.
Race and ethnicity: One study found that 59.5% of nonHispanic white respondents had looked for medical information for themselves, while around 53-54% of Hispanic and nonHispanic black respondents had. 
Gender: Women are more likely to engage in consumer health IT activities than are men.  One expert attributed this to the fact that women often become large consumers of health information when they are pregnant or as they help care for family members.
Health: Health status repeatedly is an important factor in consumer health IT use. When individuals are facing a health problem, an estimated 46% turn to the internet. 
Age: The relationship between age and health IT use is not linear. Individuals in the middle years (their 30s to early 60s) are more likely to go online than are their younger and healthier or their older and less computer-savvy counterparts.
Computer and internet use: The likelihood of looking for health information online also varies by individual’s online access and experience. A study shows that 86% of internet users who had been online for at least six years have looked for health information online, compared to just 62% of those who had two or three years of experience online. 
Other e-health activities: A 2006 report remarked on the lack of data about how use of many consumer health tools varies by subpopulation —a finding that one of the experts confirmed still rings true today. Also, due to the low overall levels of use of some of these resources—like online support services—it is hard to identify distinctive patterns by demographic group.  For some of these activities, the patterns above still hold true. However, in other cases there are fewer subpopulation gaps. For example, in 2005, educational attainment no longer was associated with communicating online with providers.
What is necessary to expand health IT use?
There is interest from the federal government and individual consumers to increase the prevalence of consumer health IT use. Yet, several challenges must be addressed to bolster verall use and fill gaps among demographic groups:
- Consumers need the resources to access computerized applications, including the relevant technology and the skills to use it.
- Consumers need to be aware of the applications.
- Economic and technical problems must be addressed to encourage the use of these applications.
- Applications must guarantee privacy and be of high quality so they will be appealing to consumers and health care providers.
These items are, of course, related. Consumer demand might drive the creation of more high-quality e-health tools. At the same time, the presence of more high-caliber resources might increase the likelihood that physicians promote their use and make consumers more aware of them.
Access to technology and skills: “Health policy makers should follow developments in telecommunications carefully,” remarked one researcher interviewed as part of this project. As so many health applications require the internet—and most perform better with high-speed access—the importance of ensuring access to such technology cannot be understated. Although gaps in internet and computer access have been closing in recent years, they still remain.
In addition to ensuring access to technology, several steps could increase ability to use it. First, more appropriate tools could be designed to take into account the reading level of users and to be more relevant and culturally competent for diverse populations.  Second, individuals could be better prepared to use applications, for example, through health education, possibly at hospitals, in order to help them use online resources upon discharge. Third, there could be a larger role for friends, family members, and community health providers to use online applications on behalf of others who are less able to do so.
Lack of awareness: Many e-health resources are new and evidence suggests there is limited awareness of applications like remote disease monitoring and PHRs. Word of mouth may be one of the most powerful tools propelling individuals to health web sites, and providers may be one of the most important means to convey these messages. Representatives from three provider groups all emphasized the critical role of physicians in encouraging patients to use their online resources. As one noted, “most of what draws people to the portal is what happens in the exam room.”
Financial and technical barriers: Because of the perceived benefits of messaging, PHRs, and the ability to exchange health data, large integrated health care delivery systems may be willing to absorb the costs involved in building these applications and compensating providers for the time spent using them. Practitioners who are not in a closed system may struggle more with low or nonexistent reimbursement for responding to patients’ messages. One survey of physicians noted that 80% claimed they would be willing to exchange secure messages with patients if they received payment for that service. Identifying a party willing to pay for consumer health IT is a critical issue, as patients are unlikely to be willing to pay for it. 
There are technical obstacles as well. The ability to exchange lab results and other information to make PHRs most useful and appealing to consumers may depend on the development and implementation of standards for data security, permissions for sharing information, and interoperability.  Addressing these challenges is a central component of the work of the Office of the National Coordinator for Health Information Technology in DHHS.
Privacy and quality: Assuring the privacy of personal health information is a key component of developing the demand for online resources among consumers. More than half of respondents to one survey said they were very concerned about their information falling into the hands of employers or health insurers.  Privacy concerns and related legal issues may also limit the take-up of some applications among providers.  It is unclear the extent to which privacy concerns will continue to be a barrier for consumers. As one interviewee pointed out, many individuals have overcome their concerns about the privacy of their financial information and engage in online banking.
Providers may also resist recommending online tools if they are uncertain of the quality of the information available online. Indeed one researcher suggested that the quality barrier may be more of an issue for health professionals than it is for consumers.
Conclusions and policy areas requiring actions
Consumer health IT has the potential to allow users to be more informed about their health and take a more active role in monitoring chronic conditions and tracking wellness behaviors. To address the above challenges, the engagement of many stakeholders may be required. 
- Providers play a key role in granting access to portals and encouraging the use of an array of e-health tools.
- Payers may drive provider behavior by shifting reimbursement policy.
- The vendors and developers of health IT products could also affect uptake by focusing on tools’ design and fit with consumers.
- The federal government could continue to help to establish standards to promote interoperability and safeguards to ensure privacy.
The government could also support or promote research on who is using e-tools and what characteristics make them most accessible and appropriate to users across subpopulations. As new technologies emerge to give individuals greater ability to manipulate their health data and to interact and learn from other online patients, it is important to understand who is already part of that trend, which groups are being left behind, what the obstacles appear to be for greater uptake, and what policies can help overcome those barriers.