eHealth usage patterns of European general practitioners: A five-year (2002–2007) comparative study

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Abstract

Purpose

This paper provides a five-year (2002–2007) comparative segmentation analysis of how the Internet and dedicated health networks are used by European general practitioners (GPs) and the extent to which external factors affect their use of various eHealth services.

Methods

Two cross-national sets of survey data collected in 2002 (n = 3512) and 2007 (n = 3948) have been analyzed. These databases provide information on physicians’ eHealth uses in EU-15 countries, including sociodemographic indicators such as country, age, sex, location, and size of the medical practice.

Results

A total of 3512 and 3948 physicians, respectively, participated in the 2002 and 2007 studies. The percentage of GPs accessing the Internet or a dedicated health network increased from 64.5% in 2002 to 77.1% in 2007. Only these physicians were included in the latent class cluster analyses performed on both datasets, yielding three segments of eHealth users plus a group of non-Internet users. Thus, the following four final segments were identified in the years 2002 and 2007: ‘Information Searchers/Average Users’, ‘Advanced Users/Adv. Users (ePrescribers)’, ‘Laggards’, and ‘Non-Internet Users’. Contingency table analyses relating external indicators to physicians’ usage patterns of eHealth services confirmed strong country differences, low to moderate age influences reflecting a cohort effect, and moderate effects of practice size, both in 2002 and 2007. Conversely, very weak influences were observed for physicians’ sex and location of the medical practice.

Conclusion

A positive evolution is clearly observable in European primary care physicians’ use of eHealth, mainly with regard to online medical information searches, use of electronic health care records, and (to a lesser extent) electronic transfers of patient data. The international comparative profiling of European GPs’ eHealth usage patterns contributes to more efficient and continually adapted promotion strategies, aimed at fostering the diffusion of eHealth applications among medical professionals of the analyzed EU-15 countries.

Introduction

The term eHealth is commonly used to refer to “health services and information delivered or enhanced through the Internet and related technologies” [1]. A literature review conducted in 2005 identified 51 different definitions of eHealth, all showing clear references to health and technology [2]. The broad scope and interdisciplinary characteristics of eHealth have also been acknowledged. Key elements of this field include the use of networked digital and Internet technologies, especially for communication purposes, and “its application to all health stakeholder groups” [3].

Previous studies have examined both physicians’ [4], [5] and patients’ [6], [7] eHealth-related attitudes and behavior. In general, patients have shown a more optimistic view than physicians regarding the benefits of using eHealth services (e.g., patient–physician email communications) [4], [8]. Patients’ health-related Internet uses have focused mainly on searching for health information online [7], [9]. In the US, estimates of citizens’ Internet use to seek health information have ranged from 73% to 83% of Internet users [10], [11]. A study carried out in seven European countries has reported similar estimates (71% of Internet users) for European citizens’ use of Internet health information [12].

Patients’ use of the Internet for health information has been shown to provide them more benefits than problems [13], [14]. In this regard, most physicians believe that the benefits provided by patients’ online health information seeking depend highly on the quality of consulted Internet health information [8]. Nonetheless, patients still verify and discuss Internet health information with their physicians [14]. Therefore, doctors continue to be patients’ first option to make an informed decision about their own medical care [15]. More active eHealth uses, such as exchanging emails with physicians or providing telemonitoring services, have reported much lower (though slowly increasing) adoption rates among patients [6], [8].

A large majority of US and European physicians access the Internet on a daily basis [16], [17]. Physicians use the Internet mostly to search for medical information [16], in sources such as online journals or literature databases (e.g., Medline) [17], [18]. Conversely, physicians are quite skeptical about the potential benefits provided by patient–physician email communication [16], [19]. Less than 25% of US and European physicians have been reported to exchange emails with their patients [17], [20]. Perceived benefits include easier chronic-disease management [20] and increased flexibility in responding to patients’ requests [21]. Perceived risks include concerns about the effective integration of patient email into daily workflow, confidentiality issues, lack of time, and reimbursement for provided patient care communication [21], [22], [23].

Electronic health care records and other related concepts such as electronic medical, health, or patient records, can refer to a variety of health information systems differing in their definition, content, structure, and usage context [24]. Nonetheless, all these information systems serve as digital repositories of patient identifiable data [24], [25]. Consistent with a recent review of the literature on electronic health records [24], in most health care settings (including primary care), electronic health care records (EHCR) are viewed as information systems for electronic recording and storage of individual administrative, medical, or both types of patient information [26], [27]. These systems have been argued to be a “central component of health information technology” [22] and to contribute to increased efficiency of physicians’ professional activities [18].

In the US, estimates for physicians’ adoption of electronic health care records have ranged between 13% and 27% in private medical practices [23], [26], and between 20% and 25% in hospital settings [28]. Higher estimates between 65% and 85% have been reported for European physicians, both for digital storage of administrative and medical patient identifiable data [17], [29]. Worth noting, nearly all general practitioners in the United Kingdom currently use electronic health care record systems in their medical practices: between 95% and 100% of UK physicians have been shown to electronically store administrative and medical patient data [27], [29], [30].

The adoption of other eHealth services and technologies has been uneven. Higher adoption rates (59%) have been provided for physicians’ computerized access to laboratory results [26]. Adoption estimates of handheld mobile devices or PDAs have ranged from 45% to 85% for US physicians [4] and one third of European physicians [17]. However, physicians’ widespread use of online prescribing services has faced numerous problems [31], [32], with reported usage estimates of 27% among US physicians [26].

Previous research has also shown significant differences, both at the national and regional level, with regard to the development and adoption of Internet-related technologies in various sectors [33], [34]. These differences are even observable among developed countries in the European Union [27]. In this regard, individuals from Northern European countries show higher rates of Internet adoption, as well as far more developed digital infrastructures [35]. The unequal access to Internet technologies and slower Internet adoption processes in technologically backward countries (‘digital divide’) limit the potential positive effects of Internet technologies on the provision of health services in such regions.

Diverse studies have also dealt with the influence of other external variables (e.g., sex and age) on citizens and patients’ Internet use [14], [36], as well as physicians’ professional use of eHealth services [25], [37]. Patients’ Internet access and online searches of health information have shown significant associations with age, sex, race, education, and income [7], [12]. According to previous studies, male (compared to women) and older patients (especially those aged 65 and over) are less likely to search for health information on the Internet [7], [30]. Additionally, white patients (compared to African American individuals), with college education (compared to less-educated individuals), and higher income (compared to citizens at lower income levels) have shown significantly higher rates of Internet access and use of the Internet to seek health information [7], [14].

Physicians’ eHealth use has shown significant relationships with variables like size of the medical practice, age, medical specialty, or geographic location [4], [19], [25]. Higher usage rates of eHealth services have been observed in larger medical practices –i.e., practices with more physicians (compared to single-physician or small practices) [4], [5], [29]. With regard to physicians’ individual traits (age and medical specialty), previous research has shown declines in eHealth use with physicians’ age (lower use among older physicians—especially practitioners aged 65 years and above, compared to younger individuals) [19], [26], [37], whereas physicians from family medicine or a surgical specialty (compared to other medical specialties) should be more likely to use eHealth services [5], [19]. Mixed evidence exists for differences in physicians’ eHealth use based on location of the medical practice –i.e., usage differences between urban, mixed, and rural settings) [5], [19], [37].

Nevertheless, previous research has also suggested that the influence of specific external indicators (e.g., age) on eHealth use differs across specific eHealth services [5], [25] or that such indicators may become less relevant in explaining technology use over time [5], [36], [38]. The demographic differences between adopters and non-adopters of more mature media and technologies have been argued to become less and less significant [38]. The characterization of eHealth services as technologies in early stages of diffusion suggests that, as the use of different eHealth applications becomes more widespread among physicians, demographic traits should progressively become less helpful in explaining their eHealth-related behavior [5].

To effectively promote the use of Internet technologies for the provision of health care services, it is important to understand the nature of physicians’ professional uses of the Internet or dedicated digital networks. The results of such studies should be taken into account by European, national, and regional authorities, in order to develop the suitable policies aimed at further integrating health information technology among European health professionals. Such public or private eHealth strategies should be adapted to specific segments with differing eHealth-related attitudes and behavior [23].

This paper provides a five-year (2002–2007) comparative analysis of how the public Internet and dedicated networks are used by European general practitioners, and how external factors affect the degree of physicians’ usage of eHealth services. First, two separate segmentations of European general practitioners will be carried out, based on their adoption and professional uses of the Internet and dedicated health networks in the years 2002 and 2007. Behavioral indicators of the most relevant eHealth applications have been selected for the characterization of segments. Next, the study will examine the effects of external variables (country, sex, age, location, and size of the medical practice) on the previously identified groups of eHealth users.

The findings of the empirical analyses will clarify the existence and behavioral characteristics of the different segments (more vs. less advanced eHealth users) over the analyzed five-year period (2002–2007). Owing to existing national and regional differences in Internet adoption, these segments are expected to be differently distributed across European countries [27]. Accordingly, because of strong effects observed in previous studies, age is expected to show a significant decreasing association with physicians’ eHealth use [4], [25]. The other covariates included in the study (sex, location, and size of the medical practice) are expected to provide less stable and weaker effects on the identified segments of eHealth users [5], [25].

Section snippets

Samples

The empirical analyses are performed on two cross-national databases of survey data collected in European countries in 2002 (‘Flash-Eurobarometer N° 126—General Practitioners and the Internet’) and 2007 (‘Benchmarking ICT use among General Practitioners in Europe’).

The first survey was conducted at the request of the European Commission to examine European GPs’ use of various eHealth services and applications. The fieldwork was carried out between May and June 2002 by the national institutes

Identification of segments

From the initial samples of 3512 and 3948 respondents, respectively, in 2002 and 2007, the authors selected general practitioners who use Internet-enabling devices in their private practices (e.g., personal computers, laptops, or PDAs) for inclusion in subsequent statistical analyses. Computer equipment was available in most of doctors’ private offices (3503 or 88.7% of responses in the 2007 study, up from 2862 or 81.5% in 2002). With regard to Internet use in the medical practice, the

Segmentation of European physicians

This study has classified EU-15 GPs into four distinct groups reflecting the sophistication of their eHealth usage patterns in 2002 and 2007 –i.e., ‘Information Searchers/Average Users’, ‘Advanced Users/Adv. Users (ePrescribers)’, ‘Laggards’, and ‘Non-Internet Users’. Several studies have illustrated the higher effectiveness of IT policy measures and promotion strategies targeted at user groups such as light users, heavy users, current users, or non-users [42], [43], groups with differing

Acknowledgements

The authors gratefully acknowledge the Central Archive for Empirical Social Research (University of Cologne, Germany), Empirica (Bonn, Germany), and the Information Society and Media Directorate General of the European Commission for their support and providing access to the datasets used in this study. The authors also thank the editor and reviewers for insightful suggestions to improve the quality of this paper.

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