Promising consumer opportunities. The Haight/Ashbury stage of the Internet is nearing an end. Free but undifferentiated content will give way to filtered, structured content. Hundreds of millions of dollars in equity capital are being invested in creating medically related Internet applications, many of which target consumers directly.
The gold standard that these firms seek is for their site/search engine/portal to become the Yahoo! of health care - that is, the first place consumers go to seek information or advice about health problems.11 Aggregating “eyeballs,” the odd Dali esque e commerce jargon for audience size, presumably creates leverage for selling advertising to firms (such as pharmaceutical and consumer products companies) that are eager to insert their commercial messages into the search process.
Another important area is giving patients access to information on quality. This information is now limited to data reported to Medicare and from consumer satisfaction surveys.12 However, it is reasonable to expect the volume of this information to grow to include licensure and medical disciplinary files on physicians and institutions, as well as information on medical error rates. How this information is gathered, validated, and presented will be the subject of fierce controversy and contention in the coming years.
However, the most significant consumer application of the Internet is the ability to aggregate patients with common problems into “virtual communities.”13 The Internet often is the first destination of a patient newly diagnosed with a serious, chronic health problem. The patient who types "lupus" into the search box of an Internet portal is within minutes of discovering an online community of fellow lupus sufferers, which brings a framework for collective learning about how to cope with the disease independent of one's physician.
Colleagues who follow these activities closely believe that virtual communities of sufferers from various diseases eventually will pool their resources and hire clinical consultants to help them navigate the health system, as well as lobbyists to help them confront Congress, state legislatures, and health plans on coverage and payment issues.14 This aggregation also will have significant political consequences and will complicate the already complex politics of resource allocation for research and treatment of diseases.
Patients' access to this emerging capability is predictably maldistributed by race, age, and income class. A recent U.S. Department of Commerce report found that although personal computers are in 80 percent of American homes with incomes over $75,000 a year, only 16 percent of homes with incomes less than $20,000 have them. The racial gap in Internet use is large and widening: Almost one-third of white homes are “wired,” compared with less than 12 percent of black households.15 Only 15 percent of the population over age fifty five is online. This population's online access is particularly crucial, because the elderly not only use health services heavily but are also more likely to be isolated from one another and from caregivers.
Access through schools and libraries does mitigate some of the socioeconomic barriers to Internet access, but differences in educational level will hamper persons in lower income strata in using this powerful new tool. Strengthening access to public computing sites is the most important short term palliative measure, but it will not be enough. Technical assistance by reference librarians, teachers, counselors, and others also will be needed. Teaching young people how to use the Internet to answer health questions probably will become a staple of health education in elementary and secondary education.