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.