Major Strategies

In deliberating about the initiatives that could move the field of IHC forward and achieve the vision proposed in this chapter, the Panel was impressed with the need for a multidisciplinary, multipronged approach.

The Panel proposes four overarching strategies to achieve the Panel’s vision for IHC:

1. Strengthen evaluation and quality of IHC

2. Improve basic knowledge and understanding of IHC 3. Enhance capacity of stakeholders to develop and use IHC 4. Improve access to IHC for all populations

The Panel chose to put a primary emphasis on promoting evaluation because it believes that widespread evaluation and dissemination of results will drive the widespread availability of high-quality and effective applications. Because of the newness of the field, scientific knowledge about many aspects of IHC is very limited. Greater knowledge is needed to improve the effective- ness of IHC, inform application design and implementation, and, ultimately, further appropriate public policy. The Panel also identified major gaps in resources available to application developers and shortcomings in the skills of users. These deficiencies will need to be addressed to ensure the continued development of innovative applications and the ability of intended users to take full advantage of IHC. Finally, enhancing access to IHC for all populations is essential because, without equitable access, evaluation efforts will be incom- plete and the potential for IHC to provide benefits to entire communities is not likely to be realized.

In the remainder of this chapter, the Panel identifies the major areas within each strategy and outlines specific tactics that could be used to achieve a preferred future for IHC. The main recommendations of the Panel within each area are in bold italics.

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Evaluation of Applications

The Panel believes that promoting widespread evaluation of IHC applica- tions should be a central strategy for improving their quality and effectiveness. Because of the emerging nature of the technology and the potential for harm, there is a need to adapt an evidence-based approach to IHC. However, in applying this approach, it should be recognized that it may not be sufficient in all situations and that all types of data and evidence, not just statistical signifi- cance, should be considered when appropriate. There also is a need to define what is a “gold standard” for adequate evidence. Ultimately, a balanced approach to evaluation—one that promotes quality and considers the potential risks of an application—is indicated.

In light of these issues, the Panel believes that evaluation of IHC applica- tions should: 1) be practical in that evaluation methods reflect real-world limitations; 2) be proactive in that it seeks to prevent problems; 3) have a clear purpose of how results will be used to improve application quality; 4) be a shared responsibility in that all stakeholders participate; and 5) be integrated into the product development cycle in that evaluation methods are used to strengthen the software quality assurance process and are implemented through- out the product development process, from conceptualization through post-marketing surveillance.

To spur widespread evaluation activities, new evaluation models that facilitate evaluation for developers and that help users and purchasers assess quality and appropriateness need to be developed. These approaches may be necessary because current evaluative strategies were developed for relatively static health interventions that do not lend themselves well to the dynamic nature of new and emerging media. Agile evaluation methods that can adapt to the evolving field of IHC are essential. It is possible that appropriate evaluation systems will need to rely on many of the same advanced technologies that IHC applications are using. For example, software agents may be used to detect system changes and alert potential users. They may be used to extract or iden- tify specific changes so that users, developers, and others can periodically examine the modifications without having to evaluate the whole system again. These technologies could identify, assuming accurate and timely reporting, when changes occur in an application, including sponsorship, content, and skills of the development team.

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development process to prevent the release of ineffective or harmful applications. To encourage evaluation, prototype evaluations of applications at all levels within select topic areas (e.g., topics where there is substantial potential to do harm) could be made available to developers to serve as a template for future evaluations in similar areas. In situations where developers are unwilling to implement such controls or evaluation methods, health professionals (as individuals and through professional organizations), purchasers, consumers, and consumer advocates will need to exert pressure on them to do so. Similarly, consumers should insist on using only evaluated products. These practices will encourage the IHC industry to conduct evaluations and promote a norm of evaluation. In return, purchasers must be willing to implement and pay more for evaluated products. It should be noted that frequently purchasers, rather than developers, have ultimate control over product implementation, and they should work closely with developers to ensure that products are implemented appropriately. Because knowledge about effective implementation is limited, more research is needed in this area. Those who deploy applications should recognize that assessment of a product independent of its context might not be fully informative or adequate.