It is difficult to ascertain the proportion of Americans who have used computerized applications related to health. But it is clear that there are many millions of individuals who have gone online for at least one of these health applications. Several indications suggest that the number of consumers engaging in e-health has been increasing.
Before describing the frequency with which consumers go online for health reasons, it is useful to put this in the context of the potential universe of health IT users. Some individuals may lack health literacy skills or access to the computer or internet to take advantage of these applications. Differences by population group in health literacy and computer/internet access may also help to explain variation in consumer use of computer applications for health. (See “Health IT Prerequisites: General Trends in Health Literacy and Internet Access.”)
Another useful baseline comparison is other types of consumer use of IT. The most frequent online activities among respondents who had gone online the day before include using search engines (49%), viewing news media (39%), and looking up the weather (30%).
Many of the experts we consulted drew an analogy between health IT and online banking, in part because the two fields face similar challenges related to privacy and data security. Despite past resistance, a substantial population conducts its banking online. In 2007, the Pew Internet & American Life Project reported that 53% of internet users had at some point banked online, and that 21% said they had done so the day before.
A final point to consider before delving into the prevalence of consumer use of health IT is the nature of the data available to investigate this question. Although several studies address who goes online looking for health information, there are fewer available data on other health applications. In 2006, one report decried that with the exception of studies on penetration rates within large, closed health care systems, “little is known about the actual uptake and use of e-health tools.”
There are two primary sources of rigorous data on the topic:
- Health Information National Trends Survey (HINTS) – Biannual survey conducted by the National Cancer Institute, first administered in 2003.
- Pew Internet & American Life Project – Surveys on health topics have been administered on a two-year cycle starting in 2000. The Project tracks other online behavior more frequently.
(A sample of the questions that are asked in these and a handful of other surveys is available in the appendix.) In addition to these surveys, there are a number of private companies that follow trends in internet use—particularly related to transactions like purchasing drugs—but a subscription or payment is often required to access the findings.
The findings across different surveys are not always consistent. This may reflect the rigor of the sampling process. (For example, some studies conduct all of their recruitment online, thus excluding people who do not use the internet.) Also, questions that are asked in slightly different ways may yield different results.
Health IT Prerequisites: General Trends in Health Literacy and Internet Access
To understand the universe of who might be in a position to take advantage of consumer health IT, it is helpful to understand some potential barriers to online health activities. In this section, we focus on two factors that could slow the uptake of consumer health IT—health literacy and access to computers and the internet—and how these barriers differ by subpopulation.
Health literacy is defined as the “degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions."
In the general population, many experience limited health literacy levels. One study places 53% of the population at an intermediate level of health literacy, 22% basic, and 14% below basic, leaving only 12% of adults with a proficient level of health literacy. A large majority of health information materials are written at a 10th grade reading level or higher, well out of the range for a large portion of Americans. Low levels of health literacy are associated with being less likely to have undergone preventative measures such as screening and higher rates of illness and mortality.
Health literacy is lower in most racial groups other than white and Asian/Pacific Islander. Hispanic and African American adults are far more likely to have the lowest health literacy levels and this is particularly the case among those Spanish speakers who spoke only Spanish before starting school. Studies also consistently show that younger age groups and individuals who have achieved higher degrees of educational attainment have stronger health literacy skills.
According to a Pew Internet & American Life Project poll conducted in 2008, 75% of Americans use the internet. These finding are consistent with a total of eight previous surveys that Pew conducted; since 2005, the percentage of overall usage has not dropped below 69%.
Internet and computer use varies by population.
- Age - Surveys consistently show that younger Americans are more likely to use the internet. For example, the most recent Pew study found that 91% of individuals ages 18-29 use the internet, as do 86% of 30-49-year-olds, and 74% of people ages 50-64.A dramatic decline in internet use occurs among individuals over the age of 70; while 53% Americans ages 60 to 69 use the internet, only 22% of individuals who are 70 and above do. Similarly, only 28% of respondents 65 and older said they use a computer.
- Socioeconomic status - Internet users are more likely to have higher incomes and be more educated than their offline counterparts. Americans with household incomes less than $30-thousand annually are the least likely to use the Internet (56%). Conversely, higher earners, who make $75-thousand or more, are the most likely to use the internet (95%). Less than half of those who have not completed high school use the internet (38%), while the majority of high school graduates are internet users (66%). Over 95% of individuals who have at least one degree are internet users.
- Race - Whites and Hispanics are the most likely to use the internet. In the most recent Pew survey 75% of white, nonHispanics, 80% of English-speaking Hispanics, and 70% of nonHispanic African Americans use the internet. Not only do Hispanics lead in internet use, they are also one of the most rapidly growing internet demographics.
- Health - Research shows that Americans without internet access are more likely to suffer from chronic health conditions.
- Gender - In the August 2008 Pew survey, slightly more men and women use the internet.
- Geography - Rates of urban and rural internet use vary by 11 percentage points. Even though they lag behind their urban counterparts, the majority of people from rural areas (64%) do use the internet.
High-speed internet access
Not only does whether one goes online or not play a role in this discussion, but the type of the connection may also be crucial. Researchers have identified a “broadband effect” by which individuals who have access to a broadband connection, even accounting for other demographic characteristics, are more effective at using the internet to address problems. According to Pew, broadband access at home has become increasingly widespread. Currently 55% of Americans have broadband access to the internet. This represents a 17% increase from 2007 to 2008.
Some demographic groups once thought to be slow to adopt broadband are showing significant rates of growth between 2007 and 2008. Currently 50% of older Americans ages 50 and above have home broadband, as do 45% of people with annual incomes between $20-thousand to $40-thousand, and 38% of individuals living in rural areas. Other groups, in contrast, did not experience significant growth since 2007. Only 25% of Americans making less than $20-thousand a year said they had broadband and 40% of African Americans said the same.
The 2008 Pew survey also seeks to learn why respondents do not have broadband. Among those who report that they still do not have high-speed access, 62% say they are interested in adopting broadband. The most prevalent reason for not adopting was the price of broadband (35%). Another 19% said they simply don’t want broadband. Twenty-four percent of rural dial-up users said that broadband was not offered where they lived.
In addition to the above prerequisites, the ability for individuals to gain something meaningful from e-health resources may also be tied to these five factors proposed by the Institute of Medicine (IOM): Access, Availability, Appropriateness, Acceptability, and Applicability of content. 
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. For example, in the 2003 HINTS survey only 50.7% of respondents said they had looked for health or medical information online about themselves, while two years later that number had increased by 7.7 percentage points. Among internet-using adults, one survey found that about 80% have looked for information about at least one major health topic online, a statistic that has remained relatively consistent since 2002.[*] Extrapolating out, this implies that approximately 113 million American adults visit websites for health information. Among internet-using adults, an estimated 7% report looking for health information online on a typical day, comparable to the percentage who use the internet to pay bills or look up a phone number or address on a given day.
Different studies paint different pictures of the internet’s role as a source of information relative to other sources. One study found that among those looking for information about health, 69% mentioned the internet as a source, compared to 59% who mentioned their own physicians, and 39% who cited other health care professionals. However, only a small number of individuals mention the internet as themain source of their health information.
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. For example, the HINTS survey found that in 2005 nearly the same percentage of respondents were looking for medical information for others as were looking for that type of information for themselves—59.5% and 58.4%, respectively. Another study found that about one-third of caregivers have sought information online.
Individuals are interested in a range of health topics. About 64% of all internet users said they were looking for information on a specific disease or medical problem. Wellness topics appear to be quite compelling, with about half of internet users reporting looking online for information about diet, nutrition, and vitamins; and a similar share seeking information on exercise or fitness. About a fifth (22% of internet users) go online to learn about mental health issues, with smaller percentages looking for information on dental health (15%), sexual health (11%), quitting smoking (8%), or problems with drugs or alcohol (8%). In addition to learning about specific medical issues, many go online to find out about health care topics, with 28% interested in health insurance and 13% seeking information on Medicare or Medicaid. In another survey, finding out information about treatments was a goal of 72% of people who went online seeking health related information, only a slightly smaller share than the 84% who were looking for general information on a condition.
Research and purchase prescription drugs
One aspect of treatment that sparks some interest among online searchers is prescription drugs. In a 2004 study, 21% of adults said they had looked online for that type of information, 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. Part of the reason for these relatively low numbers may be that only 5% of those surveyed who were insured reported that they were required to use mail-in or online systems to order certain prescription drugs. A small number of individuals reported using the internet for other drug-related purposes. Only 2% of individuals in a 2003 survey who had taken at least one prescription drug in the past year said they had contacted their physician over email or secure message to ask for a prescription. (However, conversations with representatives from provider groups that offer the ability to request prescription refills online state that it is a popular feature.)
Take action to monitor and improve health
It is difficult to discern how many individuals are using applications that allow them to take action on their health. For example, a 2002 study found that about 7% of doctors who reported going online said they engaged in remote disease monitoring, but it is possible that a larger proportion of individuals were monitoring their own symptoms without interacting online with their providers. It is also difficult to ascertain how many individuals are using decision aids; several producers of these products estimated that they were used approximately nine million times in 2006, primarily through the internet.
Communicate with relatives, friends, and other patients
Online support groups appear to only attract a very small number of individuals. In the 2003 and 2005 HINTS surveys, 3.9% of respondents reported participating in online support groups. Research on PatientsLikeMe yields similar results; a year and a half after its community for individuals with ALS was launched, about 4% (1,140 individuals) of the estimated U.S. population of individuals with the condition, had enrolled. However, even if not formally participating in a support group, the web allows individuals to connect with others around health issues. Almost one-quarter of adults use the internet or email as a means of communicating with relatives or friends about health or health care and 11% had used online communications to interact with people with similar health issues.
Interact with the health care system
Using email or secure messaging to communicate with providers is a less common practice than communicating with friends and peers, although many individuals express interest in electronically contacting their providers. 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. Other studies have developed a range of estimates of the proportion of patients who are emailing their health care providers from 6% to 37%.[†] The percentage of people communicating with providers online has experienced a slow, but statistically significant increase over time.
One of the key factors behind the disparity between the number of patients who would like to email their providers and the number who actually do so is whether individuals are seeing providers who offer this service. Although one study found that roughly one-quarter of doctors are communicating with patients online, other estimates are lower. The number of consumers who said they had access to online communications with their physicians increased from 12 million in 2004 to 15 million in 2005, but these numbers still account for a small share of the 100 million US patients who would like to communicate electronically with their providers. Despite the fact that online communications between physicians and providers is apparently growing at a slower rate than other forms of online use, many doctors predict that it will become increasingly common in coming years, particularly because of the large demand from patients.
Visiting insurer websites is also growing in popularity. By one estimate, 26 million individuals visited the website of their health plan in 2005—a dramatic increase from the estimated 4 million who did so in 2001. Yet using the web to learn more about providers is still not a widely embraced practice. In one study, 18% of people who seek health information were in search of information on physicians who specialize in treatments and 13% sought to learn about hospitals.
It is not clear how many consumers consult online provider quality data. Two surveys found that twice as many individuals report being likely to gather information about the quality of providers from friends, relatives, and other health care providers, compared to individuals who would look to publicly available sources, including the internet. These studies found that 19%-36% of respondents say they would likely use the internet as a source of quality information.
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. It is difficult to determine the number of patients who see providers that offer patient portals; although one article pointed out that the potential reach is not insubstantial because some of the early adapters of patient portals—like the VA and Kaiser Permanente—have large patient rolls.
Even among patients who see providers with portals, the extent to which individuals decide to take advantage of them and log on to the system varies widely. Two provider organizations boasted enrollment or login rates of around 50% of their total patient population. However, results from two other providers had penetration rates hovering around 10%. This type of disparity may reflect, in part, the fact that some practitioners advocate use of the web resources more than others do. 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.
It is important to note that merely signing up for a portal does not necessarily translate into using it. One provider estimated that nearly one-third (31%) of individuals who sign up for an account on its portal actually activate the account. Among those who do login, another one-half do not make a request or otherwise communicate with providers. A study of one portal provides insight on which aspects of the site are most popular. The most common use is reviewing medical test results (54 out of every 1,000 patients enrolled in the site), followed by medication refills (44 of 1,000), summaries of office visits (32 of 1,000), and clinical messaging with providers (31 of 1,000). These numbers may appear low, but some patients may not have had a need to use those resources in the period studied. For example, looking only at individuals who actually had taken a lab test and are enrolled in the portal, one expert estimated that more than 90% of individuals reviewed the test result.
It is more difficult to find data on PHR use in the population as a whole, yet most studies suggest that it is very limited. An online survey conducted in 2003 found that only 1.5% of respondents said they use a computer to manage their health records, with an additional 0.5% saying they go online to do so. (The same survey found that almost three-quarters of respondents would be interested in using a least one of the features of PHRs.) In 2005, two experts in the field estimated that fewer than 1% of Americans are using fully functional PHRs. A 2007 survey estimated that 4% of the population uses a PHR in some form.