3.2 PUBLIC RESPONSE TO A CHANGING CLIMATE: THE PRE-HITECH
3.2.1 General Public Response Patterns: The Emerging Climate
Indeed change already was in the making by the early 1990’s from a general technological point of view as increases in public use of online communication surged, especially with the implementation of the smartphone: The development of the first smartphone prototype emerged with IBM’s “Simon” in 1992.99 The term “smartphone” itself was coined with the introduction
of Ericsson’s Penelope GS88 in 1997.100 The Apple iPhone and the LG Android101 came into
98 As stated earlier, the choice of using the term “mediums” as opposed to “media” is purposeful in that a strongly
media ecology perspective is herein taken to set apart the definition of “media” as a specific form of public entertainment such as a radio or TV show as opposed to the space through which messages are being transmitted. Meaning is derived as much through the message written/spoken as it is through the medium itself. As Marshall McLuhan so popularly stated, “the medium is the message” and therefore when various mediums are used, various messages of the same content can be delivered while implying multiple different meanings.
99 See http://mail2web.com/blog/2011/05/smartphone-revolution-growth-smartphones-exchange-activesync/ for a
list of landmarks of the smartphone. It is important to note that “Simon” was not distributed widely at this early point in time but acted more like a protocol, though it was purchasable at the then quiet unaffordable and impractical price of $899.
100 The term “smartphone” was patented in 1997, right around the time when guidelines for online communication
were coming into place. See Kane & Sands (1998) for guidelines. The patient information may be found at U.S. Patent #3,812,296/5-21-1974 (Apparatus for Generating and Transmitting Digital Information), U.S. Patent #3,727,003/4-10-1973 (Decoding and Display Apparatus for Groups of Pulse Trains), U.S. Patent #3,842,208/10-
popular play beginning around 2007.102 From the time smartphones took form until they reached
public popularity, a span of a little over 10 years passed; and within this span of time the public technology users included both patients and physicians who themselves were general public participants using this medium for day-to-day use. This means that the mechanism for change (i.e., the medium of the smartphone which facilitated increased use of the Internet, texting, FaceBook, Twitter, etc.) existed well before the application to healthcare even started. In advance of outside government forces mandating online medical communication, the medicological environment was primed for such change to take place. In a sense technology drove the use of online medical communication even before the need was realized by the healthcare community and the population at large.
Perhaps one could go so far as to say that the smartphone alone was the single most important medium in this entire process; but that would be an over simplification. It did introduce continuous communication between the vast majorities of ever-growing users in a wide variety of settings from everyday situations like parents tracking their children’s behavior and location to online banking or shopping needs. But to say that the smartphone single handedly thrust healthcare into the world of technology would be to disregard the true essence of the medicological environment. The stage may have been set, but the transformative nature of the interlocking factors of social acceptance, legal ramifications, security issues, economic restrictions, and the like all fell into synchronized, parallel play within the medicological environment. The smartphone was a significant factor; but it alone did not propel the acceptance
101 “LG” is the company that produces Android. The acronym stands for “Life’s Good.”
and development of online communication in healthcare today. No, the entire dynamic force erupting within the medicological environment did.
Certainly, the government mandates of the HITECH Act of 2009 (whose effects will be discussed more in section 3.3 below) propelled implementation forward for most practicing physicians and hospitals who were expected to provide public electronic communication within the new space of healthcare. Interestingly, from yet another perspective, this dynamic climate of electronic messaging in healthcare likewise helps to compel overall public use of Internet-related technologies and resulting online interactions. That is, when the market for online medical communication surged, the public yet again gained another access point to increased online communication. In a sense the entire adoption of online medical communication and secured portals not only reflects the existing demands of the public’s desire for online access, but it creates an even greater need for it. More specifically, it may be assumed that as more and more people realize the availability and convenience of online medical communication, they indeed may increase their own amount of online interactions because of experiencing the effects of this new application.103 For instance, if a psychiatrist treats a teenaged patient through a virtual eVisit that utilizes the medium of FaceBook or Skype, it might more effectively enable him or her to save a life by more directly halting an attempted suicide. In such a case, the medium (e.g., online eVisits through smartphone FaceTiming) influences its overall user-friendliness and - attractiveness. With public media dissemination of such “rewards” within healthcare, the medium therefore has the potential of becoming more acceptable and perhaps even more desirable. Therefore, the perpetuation of the medium in healthcare may very well increase the usage of the medium itself (with or without medical information as the content of that message)
within the medicological environment. With or without medical content, the technological environment exists; but the medicological environment (which includes health-related content) affects and is affected by this environment while interacting with multiple other environments as well (again such as legal, political, economic, social, and so forth).
In short, as stated earlier, the IOM states that patients have the right to communicate through various mediums with their healthcare professionals, including but not limited to face- to-face communication (Institute of Medicine, Committe on Quality Health Care in America, 2001); and, by demonstrating this right, the public finds itself curiously exploring new health- related technologies through the mediums of the computer and smartphones alike. Indeed when President Barack Obama first took office on January 20, 2009, he promised “change” for the American people with healthcare transformation as one of his top priorities. One might wonder whether or not the President realized the actual extent of his sweeping proposals which helped create the impetus for new forms of technology and more wide-spread, accessible Internet services. The system sustains itself and thrives. As technology evolves, so does the medicological environment; and with this evolution, so do all the other players within this environment also evolve.
As stated earlier, although “email” through secured health portals has been named one of the key “new” forms of physician/patient communication, it is but one of many related mediums that allow for electronic health communication. The smartphone, for instance, acts as a telephone, a texting mechanism, and a computer for Internet access. By using the Internet on the smartphone, phone calls can be made and text messages transmitted without using cellphone “minutes” but instead using Internet “data” (as when using the iphone/ipod application, “Viber”). The physician can be reached by phone, texting, email, FaceBook, Instagram, Snapchat, or
Twitter (adhering to HIPAA regulations or not) all through the same smartphone that draws from texting allowances, cellphone minutes, and/or Internet data allotments, depending on which is preferred.
Again such multi-purpose uses of the same medium transform the notion of separate communication spaces into continuous, multi-channeled mediums, a concept best described by Bolter and Grusin (1999) as “remediation.” If “a medium is that which remediates,” then all the mediums being used to communicate through electronic health messages (or any form of electronic messaging for that matter) never “operate in isolation” but instead “enter into relationships of respect and rivalry with other media” (p. 65). The space created therefore creates an environment that transformatively utilizes these interrelated mediums to the point that one cannot separate the “representational power of a medium except with reference to other media” (p. 65). Paul Levinson in The Soft Edge refers to this as the “anthropotropic” process (1997). That is, new media continue to improve upon themselves and all prior technologies. These forms of media thus refashion old media and begin to take on each other’s characteristics as forms of human communication (McLuhan M. , 1964). In effect, over time all mediums used to transmit information between patients and physicians become extensions or remediations of other forms of human communication (as in “face-to-face” communication through Skyping during virtual eVisits with physicians). The point is that the medicological environment provides a “hotbed” of continuously morphing technologies that adapt and reconfigure old technologies into “new” mediums of communication. Again the best example of this is the “old” technology of the telephone being transformed into the cellphone and then the smartphone. With each transformation the applications become more overlapping and complex and in effect closer to other forms of media.
While these multifaceted usages exist for many users, some technologies are limited in accessibility to some members of the population due to various superimposed restrictions. Due to location, socioeconomic levels, education levels, media literacy, and learning impairment, many in this country may not have had the opportunity nor means to become avid Internet users. Time, cost, and familiarity certainly have a profound effect on adoption. Despite these apparent roadblocks, availability has begun to increase significantly as access to the Internet improves through the FCC Broadband expansion to rural areas, as free services in public places such as libraries and senior centers emerge, and as the Lifeline government-funded cellphone program for low income Americans helps even the underprivileged obtain cell phone access to Internet and electronic messaging services.104
In short the public response exists as a powerful entity in this medicological environment, affecting and being affected by the many forces in play throughout this complex and ever- changing space. As supported through various public opinion polls and government reports discussed in this section, change started early on with the introduction of new electronic messaging mediums (such as the smartphone) and then accelerated with the recently mandated EHRs promoted by the Obama Administration. Again, it is important to emphasize that this change simultaneously affects both the physician/provider and the patient/consumer in this medicological environment. Finally, it must be further noted that physicians often are also patients and find themselves at times in the consumer role, experiencing the very same
104 Much controversial publicity has surfaced surrounding the Lifeline services for what many call “Obama phones.”
As stated in The Washington Examiner (Spiering, 2012), this program actually started in 1984 “as a means of subsidizing landline phone services for low income Americans.” In 2008 the program expanded to include cellphones. This resulted in a cost increase from $772 million in 2008 to $1.6 billion by 2011 with approximately 269,000 wireless Lifeline subscribers. All users now could potentially access text messaging and Internet services readily and easily through cell phone service. The website, Obamaphone.net, leads to the website https://qlinkwireless.com/ which shows how one can obtain this “free” cellphone service that is funded by
challenges as their patients.105 Indeed, multifaceted influences and remediated mediums exist
simultaneously within this transformative space.