Web 2.0 and the Health Care Market: Health Care in the era of Social Media and the modern Internet : Health Care in the era of Social Media and the modern Internet [1 ed.] 9783836647670, 9783836697675

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Sabrina Sturm

Web 2.0 and the Health Care Market

Copyright © 2010. Diplomica Verlag. All rights reserved.

Health Care in the era of Social Media and the modern Internet

Diplomica Verlag

Web 2.0 and the Health Care Market: Health Care in the era of Social Media and the modern Internet : Health Care in the era of Social Media and the modern Internet, Diplomica

Sabrina Sturm Web 2.0 and the Health Care Market: Health Care in the era of Social Media and the modern Internet ISBN: 978-3-8366-4767-0 Herstellung: Diplomica® Verlag GmbH, Hamburg, 2010

Copyright © 2010. Diplomica Verlag. All rights reserved.

Dieses Werk ist urheberrechtlich geschützt. Die dadurch begründeten Rechte, insbesondere die der Übersetzung, des Nachdrucks, des Vortrags, der Entnahme von Abbildungen und Tabellen, der Funksendung, der Mikroverfilmung oder der Vervielfältigung auf anderen Wegen und der Speicherung in Datenverarbeitungsanlagen, bleiben, auch bei nur auszugsweiser Verwertung, vorbehalten. Eine Vervielfältigung dieses Werkes oder von Teilen dieses Werkes ist auch im Einzelfall nur in den Grenzen der gesetzlichen Bestimmungen des Urheberrechtsgesetzes der Bundesrepublik Deutschland in der jeweils geltenden Fassung zulässig. Sie ist grundsätzlich vergütungspflichtig. Zuwiderhandlungen unterliegen den Strafbestimmungen des Urheberrechtes. Die Wiedergabe von Gebrauchsnamen, Handelsnamen, Warenbezeichnungen usw. in diesem Werk berechtigt auch ohne besondere Kennzeichnung nicht zu der Annahme, dass solche Namen im Sinne der Warenzeichen- und Markenschutz-Gesetzgebung als frei zu betrachten wären und daher von jedermann benutzt werden dürften. Die Informationen in diesem Werk wurden mit Sorgfalt erarbeitet. Dennoch können Fehler nicht vollständig ausgeschlossen werden und der Verlag, die Autoren oder Übersetzer übernehmen keine juristische Verantwortung oder irgendeine Haftung für evtl. verbliebene fehlerhafte Angaben und deren Folgen. © Diplomica Verlag GmbH http://www.diplomica-verlag.de, Hamburg 2010

Web 2.0 and the Health Care Market: Health Care in the era of Social Media and the modern Internet : Health Care in the era of Social Media and the modern Internet, Diplomica

TABLE OF CONTENTS

Table of Contents ................................................................................................ I List of Tables ..................................................................................................... IV List of Figures ..................................................................................................... V List of Appendices ............................................................................................ VII List of Abbreviations ........................................................................................ VIII 1. Introduction .................................................................................................. 1 1.1 Overall Aim of the Study ...................................................................... 2 1.2 Expectations ........................................................................................ 2 1.3 Introduction to the Topic of the Study .................................................. 3 2. Web 2.0 .......................................................................................................... 9 2.1 What is Web 2.0?............................................................................... 11 2.2 Principles of Web 2.0 ......................................................................... 13 2.3 Selected Technologies Supporting Web 2.0 ...................................... 24 2.4 Typical Web 2.0 Applications and Services ....................................... 28 2.4.1 BlogsǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤʹͻ 2.4.2 Social Communities & NetworksǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤ͵ʹ 2.4.3 Pod- & VodcastsǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤ͵͹ 2.4.4 WikisǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤ͵ͺ 2.4.5 Social Bookmarking & Social TaggingǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤ͵ͻ 2.4.6 (Cartographic) Mash-upsǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤͶʹ 2.4.7 Virtual WorldsǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤǤͶ͵ 2.5 Current Trends Concerning the Use of Web 2.0 & User Typography 44 3. The Health Care Market.............................................................................. 49 Copyright © 2010. Diplomica Verlag. All rights reserved.

3.1 Towards a “Health Society” ............................................................... 49 3.2 Definition and Classification: Health, Health Systems, and the Health Care Market ........................................................................... 52 3.3 Scope of the Health Care Market ...................................................... 56 3.4 Status Quo of the Health Care Market ............................................... 58   

Web 2.0 and the Health Care Market: Health Care in the era of Social Media and the modern Internet : Health Care in the era of Social Media and the modern Internet, Diplomica

3.5 Influence Factors of the Health Care Market ..................................... 63 3.6 Future Development of the Health Care Market ................................ 67 4. Introducing Web 2.0 to the Field of Health Care ...................................... 73 4.1 Virtualization of the Health Care Market ............................................ 74 4.2 Web 2.0 in the Realm of eHealth ....................................................... 75 4.3 Terms: Medicine 2.0 and Health 2.0 .................................................. 78 5. How Patients Can Benefit From Web 2.0 Applications ........................... 81 5.1 Coping with a Disease: Patient Blogs ................................................ 82 5.2 What Do Others Think: Patient Communities & Networks ................. 84 5.3 Becoming Educated via Health-Related & Medical Podcasts ............ 88 5.4 In Search of Information: Wikis for Patients ....................................... 90 5.5 Where to Find Reliable Information? ................................................. 92 Social Bookmarking & Social Tagging ............................................... 92 5.6 Receiving Information, Education and Promotion: ............................. 95 Strolling in Virtual Worlds ................................................................... 95 5.7 A Holistic Approach: Health Portals ................................................... 98 5.8 EPHRs: The Case of Google Health & Microsoft HealthVault.......... 102 6. How Health Care Providers Can Benefit from Web 2.0 Applications ... 104 6.1 Propagation of Information & Sharing of Knowledge: ...................... 105 Medical Blogs................................................................................... 105 6.2 Exchanging Professional Experiences: ............................................ 108 Medical Communities & Networks ................................................... 108 6.3 Collaboration & Education of Health Care Professionals: ................ 114 Wikis, Podcasts & Virtual Worlds ..................................................... 114 7. How Health Payer Can Benefit from Web 2.0 Applications .................. 117 Copyright © 2010. Diplomica Verlag. All rights reserved.

7.1 Branding, Marketing and Information: Blogs & Micro-Blogging ........ 120 7.2 Educating and Informing Customers: .............................................. 121 Pod- / Vodcasts & Virtual Worlds ..................................................... 121     

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8. Net Gains: Advantages Outweighing Disadvantages? ......................... 123 8.1 Advantages: Drawing Benefits from the Use of................................ 123 Web 2.0 in Health Care .................................................................... 123 8.2 The Downside: Identifying General Disadvantages ......................... 132 of Web 2.0 in Health Care ................................................................ 132 9. The Legal Framework for Web 2.0 in Health Care ................................. 138 9.1 Copyright Infringements ................................................................... 139 9.2 Online-Marketing and Competition Regulations ............................... 140 9.3 Protection of Private Data ................................................................ 143 9.4 Liability of Online-Providers for ........................................................ 145 User-Generated-Content and Hyperlinks ......................................... 145 9.5 Legal Effects of the “Prohibition of Remote Treatment” ................... 150 in Germany ...................................................................................... 150 10. Web 2.0 in the Health Care Market: Expert Apprails ........................... 152 10.1 Concept and Way of Proceeding ................................................... 152 10.2 Results and Interpretation .............................................................. 155 11. Conclusion & Future Outlook ................................................................ 161 References ..................................................................................................... 164

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Appendix ........................................................................................................ 181

  

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Table 1: Internet Activities for Private Purposes within the Last 3 Months (2007) Table 2: Web 2.0: Occasional and Regular Use 2007 to 2009 in % Table 3: Web 2.0 Use According to Age and Gender in % Table 4: Classification of Health Systems Table 5: Demographic Changes across the World Table 6: Advantages & Disadvantages of Virtual Patient Communities as Compared to F2F Self-help Groups

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Table 7: Comparison of the Features of Web 2.0 and Web 3.0

  

Web 2.0 and the Health Care Market: Health Care in the era of Social Media and the modern Internet : Health Care in the era of Social Media and the modern Internet, Diplomica

   

Figure 1: German households equipped with PC and Internet Figure 2: Internet usage according to age and gender 2007 Figure 3: Broadband connections in selected countries of the EU and tendencies in Germany Figure 4: Different Approaches to Define Web 2.0 Figure 5: Mind Cloud: The Realm of Web 2.0 Figure 6: Principles of Web 2.0 Figure 7: Graphical Depiction of Metcalfe´s Law Figure 8: Value Chain Models of Web 1.0 and Web 2.0 Offers Figure 9: Snapshot from HealthMap Figure 10: Elements of AJAX Figure 11: Common Web 2.0 Applications & Their Focus Figure 12: What Makes Twitter Special Figure 13: Example of a Disease-related Tag Cloud Figure 14: Distribution of Mash-ups According to Sources Used Figure 15: Kind of Use of Web 2.0 Applications in 2009 in % Figure 16: The Long Waves and Their Major Demand Areas Figure 17: Tasks of Health Care Figure 18: Stakeholders of the Health Care Market Figure 19: Primary and Secondary Health Care Market Figure 20: Overview of the Structure of the Health Care Market Figure 21: Health Care Spending in Selected Countries in 2007 as a Proportion of GDP

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Figure 22: Total Health Expenditures in Germany 2006 – Comparison of Official and Study Data Figure 23: The Market for Health Products in Germany: Expected Development until 2020 [in €] Figure 24: Projection of Health Care Expenditures as Proportion of GDP 2001 to 2070 in Germany   

Web 2.0 and the Health Care Market: Health Care in the era of Social Media and the modern Internet : Health Care in the era of Social Media and the modern Internet, Diplomica

Figure 25: Structural Change of the Health Care Market Figure 26: Web 2.0 in the Field of Health Care: Major Target Groups, Applications, & Purposes Figure 27: The Realm of eHealth and Web 2.0 Figure 28: Patients and Sub-groups with Corresponding Needs and Valuable Applications Figure 29: Screenshot from Medpedia: Example “The Eye” Figure 30: Example of a Social Bookmark List from “delicious”. Figure 32: Entry to the CDC Health Island Figure 32: Screenshot from the Health Factory Figure 33: How Do Physicians Assess the Value of Evaluation Portals? Figure 34: Health Care Provider and Sub-groups with Corresponding Needs and Valuable Applications Figure 35: Screenshot from VGR-D Blog Figure 36: Screenshot from the NeuroNetwork Figure 37: Screenshot from an Operating Theater in Second Health Figure 38: Health Care Payer and Sub-groups with Corresponding Needs and Valuable Applications Figure 39: Screenshot from HCC Medical Insurance Services Figure 40: Efficiency Gains Due to Web 2.0 Figure 41: Patient Groups and Their Transformation Figure 42: Overview of Applicable German Laws for Web 2.0 in Health Care Figure 43: Excerpt from WebMD, Demonstrating the Rule of Separation Figure 44: Is the Online Provider Liable for UGC? Figure 45: Responses to the Question of Meaningful Areas of Application

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Figure 46: Risks and Chances of Web 2.0 in Health Care in the Eyes of Experts

   

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Appendix

I: HONcode Principles

Appendix

II: List of Links to Patient-Centered Examples

Appendix

III: Results from the “Stiftung Warentest” Study

Appendix

IV: List of Links to Professional Examples

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Appendix V - IX: Interview with Experts from Industry

   

Web 2.0 and the Health Care Market: Health Care in the era of Social Media and the modern Internet : Health Care in the era of Social Media and the modern Internet, Diplomica

    

abbr.

abbreviated

API

application programming interface

approx.

approximately

B2B

business-to-business

B2C

business-to-consumer

C2C

consumer-to-consumer

CHI

compulsory health insurance

cp.

compare (to)

Ed.

Edition / editor

EMS

Emergency Medical Services

EPHR

Electronic Personal Health Record

EU

European Union

et. seq(q).

and the following (sg. and pl. respectively)

F2F

face-to-face

GDP

Gross Domestic Product

ICT

Information-/Communication Technologies

IT

Information Technology

LPM

Lightweight Programming Models

OECD

Organization for Economic Cooperation and

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Development OTC

over-the-counter

PHR

Personal Health Records

PMI

Private medical insurance

PR

Public relations

SL

Second Life

SNS

Social networking sites

UCC

User created content

UGC

User generated content

URL

Unified resource locator   



Web 2.0 and the Health Care Market: Health Care in the era of Social Media and the modern Internet : Health Care in the era of Social Media and the modern Internet, Diplomica

WHO

World Health Organization

WWW

World Wide Web

Legal Abbreviations

AMG

German “Arzneimittelgesetz”

BDSG

German „Bundesdatenschutzgesetz“

BGB

German “Bürgerliches Gesetzbuch”

Dir.

Directive (EU)

HWG

German “Heilmittelwerbegesetz”

MBO-Ä

German “Muster-Berufsordnung für Ärzte”

para.

paragraph (German: “Absatz”)

RStV

German “Rundfunkstaatsvertrag”

sec.

section (German: “Paragraph”)

StGB

German “Strafgesetzbuch”

TMG

German “Telemediengesetz”

UrhG

German “Urhebergesetz”

UWG

German “Gesetz gegen unlauteren Wettbe-

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werb” WCT

World Copyright Treaty

WPPRT

World Performers and Producers Right Treaty

  

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ͳǤ   

The following piece of research deals with Web 2.0 and the health care market. It will be examined how far value can be generated for the health care market by using Web 2.0 elements. Therefore first of all, major definitions within the field of Web 2.0 as well as its dominant applications and tools will be described as to create a common basis for further discussion. Second, the health care market will be roughly depicted in order to gain an understanding of its structure, its characteristics and potential influencing factors. In this context also the various segments like hospitals, pharmaceutical companies or health insurances will be taken into consideration. Moreover, this includes also the recognition of unsatisfied needs and unsolved problems within these sectors. Afterwards, it will be analyzed and discussed which role Web 2.0 plays in the health care market and how it may support this market and provide aid for needs and problems. This involves amongst others the depiction of possible applications, a discussion of major catchwords like “Health 2.0” and “Medicine 2.0”, and the question whether the use of Web 2.0 can lead to significant advantages and increased customer value as it is proclaimed. Within this context five expert interviews have been conducted in order to gain an additional external view on the topic with further suggestions as well as to underline the correctness of stated arguments. When selecting potential interview partners it has been put a strong focus on appropriate qualification and a suitable variety of interviewees (as to cover as many relevant industry branches as possible).

As another point, an eye will be put on the legal environment which has to be

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considered when dealing with the Internet, Web 2.0 and the health care market. This is considered to be important since infringements can happen often, especially in the field of user-generated content. Finally, the book will end up with a conclusion summarizing major findings and giving an insight into the future of Web 2.0 and the health care market.  ͳ 

Web 2.0 and the Health Care Market: Health Care in the era of Social Media and the modern Internet : Health Care in the era of Social Media and the modern Internet, Diplomica

ͳǤͳ  

The aim of this study is to provide a detailed description of the fields of Web 2.0 and the health care market and to gain new insights into the topic since it has not been examined completely for a long time yet. In addition, there is a need to show how those very different industries can fit together and how the health care sector can profit from Web 2.0. Moreover, it is expected that the expert interviews to be conducted will come up with some interesting points and remarks of real life practice which can be used for further investigation.

The concrete objectives of the research are defined as following (key points): x

Introduce major aspects of Web 2.0

x

Give an insight into the health care market and its characteristics

x

Interlink those two fields (Web 2.0 and health care) and show which combinations are yet existent and which can be imagined for the future

x

Identify the value which can be obtained by using Web 2.0 elements in health care

x

Find out about potential disadvantages and challenges

ͳǤʹ 

The author shares two major expectations with respect to Web 2.0 applications

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in the health care market. In this regard it is intended to give a profound insight into the topic in order to either approve or disapprove these expectations. Accordingly, the findings of research as well as the conducted expert interviews will be used to analyze the expectations. The author expects that it turns out that:  ʹ 

Web 2.0 and the Health Care Market: Health Care in the era of Social Media and the modern Internet : Health Care in the era of Social Media and the modern Internet, Diplomica

x

“The use of Web 2.0 Elements will provide significant value to all stakeholders of the health care market when used properly.” (Expectation 1)

x

“Web 2.0 applications are still used hesitantly within a professional health care setting; in contrast patients are willing to quickly adopt the new offers.” (Expectation 2)

ͳǤ͵    

Nowadays mobile phones, computers and the Internet are part of people´s daily life. Many could not imagine living without these media again. However, since the evolution of the Internet it had been a long way to reach this point. After many years having passed, it has to be recognized that the “invention” of the Internet had not been a static “one-point-in-time” event but is subject to dynamic advancements and continuous improvements. While in the beginning the Internet had been a medium only for few “specialists”, nowadays the Internet has become a mass medium for a large proportion of the population. This can be proven by the fact that the number of households owning a PC as well as Internet access is constantly growing (see Figure 1). In 2007 more than 60% of all German households had fallen into this category. However, also the number of individuals using the Internet is convincing: in 2008 more than 80% of all Germans aged 54 and younger had used the Internet on a regular basis; only those

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aged 55 and older are still somehow reluctant to the Internet (cmp. to Figure 2).        

 ͵ 

Web 2.0 and the Health Care Market: Health Care in the era of Social Media and the modern Internet : Health Care in the era of Social Media and the modern Internet, Diplomica

Figure 1: German Households Equipped

Figure 2: Internet Usage According to Age

1

and Gender 2008.2

with PC and Internet.

This development could only happen due to the improvement of speed and declining usage costs. When the Internet became popular in the mid-nineties, a 14.4 Kbit/s modem was standard, implying long loading times for web pages.3 At that time data transfer via the Internet was slow and inconvenient. Moreover, the costs for accessing and using the Internet had been tremendously high, allowing only few people to use the Internet on a broad basis. In those times one hour of daily surfing had led to costs of up to 180 Euro a month.4 Here it becomes evident that only the comprehensive offers of broadband connections as well as flat rates (available for about 15€ per month) for using the Internet have allowed the Internet to become what it is today. Nowadays, on average almost 50% of all households are already equipped not only with Internet access but also with a fast broadband connection with a tendency that this number will in-

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crease further within next years (see also Figure 3).

 1

Cp. Statistisches Bundesamt [1] (Ed.), 2009, p. 112. Cp. Statistisches Bundesamt [2] (Ed.), 2009, p. 21-22. 3 Cp. Alby [1], 2008, p. 4. 4 Cp. Alby [1], 2008, p. 7. 2

 Ͷ 

Web 2.0 and the Health Care Market: Health Care in the era of Social Media and the modern Internet : Health Care in the era of Social Media and the modern Internet, Diplomica

Figure 3: Broadband Connections in Selected Countries of the EU and Tendencies in Germany.5

It is the broadband connection with today´s data transmission rates of 1, 6, or 16 MBit (sometimes even higher rates up to 100 MBit) which allow using the Internet for a much wider range of activities than it had been possible in earlier times, especially when huge data volumes are included (e.g. pictures with a large resolution, music files, etc.). At present days the Internet supports people in various activities like information search, communication, or e-shopping, to name just a few. Moreover, these technical improvements made it possible to talk about e.g. Wikis, Blogs, Social Software, platforms for photo- or videosharing and communities when discussing the Internet. The thing is not that most of those applications have not existed in earlier times; it simply did not make much sense to use these if one had not the patience to wait for hours until a handful of photos had been uploaded to the Internet.

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When having a closer look to the various activities for which people make use of the Internet nowadays several facts have to be outlined: interestingly, 90% of all people using the Internet do this for communication purposes (e-mail, chats,  5

Cp. Bundesverband Informationswirtschaft, Telekommunikation und neue Medien e.V. (Ed.), 2008.

 ͷ 

Web 2.0 and the Health Care Market: Health Care in the era of Social Media and the modern Internet : Health Care in the era of Social Media and the modern Internet, Diplomica

forums, etc.) and even 96% are engaged in online information search. It is very astonishing that 53% of all “information seekers” specifically search for health care and related topics. Corresponding to these figures, Table 1 gives an overview of conducted Internet activities, distinguishing between male and female users.

Activities

Total

Male

Female

90

90

89

E-Mail

86

87

85

Telephone (VoIP)

17

20

14

Chat / Use forums

41

44

38

96

97

95

Information on goods and services

84

86

81

Use of travel services

58

57

59

Use of Internet TV / radio

20

26

14

Play / download music & games

31

36

24

Download software

39

52

25

Read / download Internet newspapers & magazines

27

32

21

Job search, sending of applications

21

20

23

Information search on health-related topics

53

45

61

Information / use of other online services

43

47

38

52

57

47

Internet banking

45

48

41

Selling of goods and services

27

31

22

Contact to authorities/ public institutions (E-Government)

54

56

52

Information search on websites of public institutions

50

52

48

Download of official forms

33

35

30

Sending of competed forms

22

24

19

50

48

52

Communication

Information search, Use of online services

Banking transactions, Selling of goods and services

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Further education

Table 1: Internet Activities for Private Purposes within the Last Three Months (2007).6

 6

Cp. Statistisches Bundesamt [3] (Ed.), 2008, p. 369.

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These data allow to draw the conclusion that modern information- and communication technologies (ICT) like the Internet have great significance in today´s modern world. The user has adapted to common Internet habits, has gained trust in the medium and has recognized its value.7 Moreover, obviously the combination of the Internet and health care seems to be highly interesting for Internet users. Two facts can be cited leading to the assumption that those figures will increase even further in the future. One of the major aspects is the fact that many people, especially younger ones, are using the Internet almost daily by now and the latter is taken for granted. Secondly, the industrial society is becoming a “health society“ with health and health care turning into fundamental concerns for an increasing number of people.8 Reasons are due to changes in lifestyle or consumption behavior, advanced understanding of the importance of health and wellness, and not to forget, due to the strict healthcare cut-backs of health insurance funds which enlarges the consciousness for one´s own health, for prevention and self-medication. People are forced to “do something on their own“ if they prefer a healthy life up to a great age. Not enough, they are even willing to pay on their own if this leads to an enhanced well-being. According to a study of Roland Berger in 2007, each German has spent around 900 Euro on average for health care and related services per year on his own in addition to the premium for a medical insurance. Consequently, the “second health care market“ (accounting for all privately financed health care goods and services) sums up to about 60 billion Euro a year with high growth rates to be expected in the future.9 Those facts show that individuals are very well interested in health care products and services, especially in the Internet, as well.

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Therefore the “new“ Internet provides not yet fully developed possibilities for further applications in the field of health and health care which add value for the  7 8 9

Cp. Alby [1], 2008, p. 11. Cp. Simmet, 2008, p. 1 et seq. Cp. Kartte, Neumann, 2008, p. 4.

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user and provide aid in this topic, not only for informational purposes but also for communication, health-related e-shopping, exchange of experiences or data sharing. Here, interactions in the field of B2B (e.g. interaction of two or more physicians or hospitals), B2C (e.g. interaction of physician with patient), and C2C (e.g. interaction of two or more patietens or health-interested people) are

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considered to be most valuable.

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ʹǤʹǤͲ

First of all, to provide a shared understanding for further discussion, this chapter tries to give a definition of the concept of Web 2.0, thereby also addressing the issue of defined principles. Here it is majorly referred to the principles stated by Tim O´Reilly since those are considered to be most appropriate (as he had been the inventor of the term Web 2.0); however it should not be neglected that other guidelines and principles exist, depending on the focus of examination. Moreover, the various elements and applications which are commonly included in the sphere of Web 2.0 will be outlined to give some examples.

When considering the above mentioned changes it becomes evident that a new term for the WWW is contemporary. Experts have derived at this conlusion, as well. This is why the term Web 2.0 has emerged. Web 2.0 has been initially coined by Tim O´Reilly, Dale Dougherty and MediaLive International during a brainstorming session in the year 2004. Aims had been to identify new trends and technologies of the WWW. Subsequently, they had arranged a conference, the first “Web 2.0 Conference”, where the identified news and trends had been presented to the interested public.10 

Right at the beginning, here it has to be pointed out that no “one-and-only“ definition exists. In literature and within bodies of experts various points of view can be recognized. Majorly, three different perceptions of Web 2.0 can be identified: a technical approach with people regarding Web 2.0 as an umbrella term for new applications or business models holding specific structural (technological)

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characteristics (e.g. the use of AJAX or RSS). These applications range in the sphere of online publication, communication, and creation of communities. The second group of people favoring the human approach put the human being into the center. According to their view Web 2.0 is (only) a new and modified  10

Cp. Lange, 2007, p. 6.

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perception and use of the WWW. They believe that the real changes lie in the fact that the WWW has become more interactive, allowing users to actively participate by e.g. publishing their own texts, photos, or videos online, to communicate with others, read their opinions regarding a specific topic and comment on those in return.11 In contrast to the former WWW, now the user is not only a receiver of content (i.e. a consumer) but increasingly often becomes a sender of content, as well (often refered to as a “prosumer“, a combination of “produce“ and “consum“). Due to that reason it is often refered to the importance and value-enhancement of “user-generated-content“ when talking about Web 2.0. Finally, there is a group of people who vehemently negate the existence of Web 2.0. For them it is nothing more than a new buzzword for the yet existing WWW.12

Figure 4: Different Approaches to Define Web 2.0.13

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However, in the eyes of the author this discussion does not change anything on the fact that due to enhanced technology and a varied user perception new  11

Cp. Lange, 2007, p. 8 et seq. Cp. Gehrke, Gräßer, 2006. 13 Own figure. 12

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possibilities to use the Internet, also in the field of health care, opened up leading to enhanced value for all involved parties; no matter which name this fact is given. Moreover, it has to be questioned whether it is really one approach being completely right instead of rather assuming a combination of several aspects out of each which have led to Web 2.0. The various approaches are depicted in Figure 4 above, also showing the (possible) overlap of approaches.

ʹǤͳ ʹǤͲǫ

Due to its many facets the term Web 2.0 cannot be defined with clear boarders but has to be seen as a gravitational center around which various concepts, principles and technologies are clustered. Some, which can be found close to the center are more related to Web 2.0 while others being more far away from the center are less related to Web 2.0. To gain a first understanding of what Web 2.0 actually comprises, it is pointed to Figure 5 which shows major catchwords, technologies and applications to be found in the realm of Web 2.0 in the form of a mind cloud. An explication of major aspects will be given later on. Here one can also see the major differences as compared to the former Web “1.0”: while in earlier times the WWW was more or less “read-only” (however some interaction has also existed in the Web 1.0 like forums but it had been strongly limited), the new Web 2.0 is a WWW of interaction and participation (blogs, social software, wikis, recommendation, etc.). Moreover, a strong focus is put on standardization, design and usability which had not been that much

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the case within Web 1.0. Formerly, pages had not been subject to standardized structure and organization14, therewith often enough confusing its users by unclear handling. In addition, with Web 2.0 new business models have emerged,  14

E.g. being compliant to the „principle of consistency“ (known from the world of PC applications), i.e. web pages should be consistent in it selves, with earlier versions as well as to the expectations of the user, see also www.useit.com.

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enabling companies and providers to address not only the mass but also the “long tail” (i.e. small niche customer groups).

Figure 5: Mind Cloud: The Realm of Web 2.0.15

In addition, many approaches to define the term Web 2.0 can be found within literature. For example, Alpar et al. have defined Web 2.0 in the following way:  “The term Web 2.0 characterizes applications and services which use the 

WWW as a technical platform on which the programs and user-

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generated-contents are provided. The collective use of those contents and interrelated references constitute relationships between users.”16

 15 16

Cp. Angermeier, 2005. Cp. Alpar, Blaschke, 2008, p. 5.

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While this definition puts emphasis on technical aspects, other definitions put the user into the center. Here e.g. the definition from Katarina StanoesvskaSlabeva can be instanced which tries to define Web 2.0 as cited hereafter:

“In the last years the Internet has changed stepwise from an “information platform” to a “participation platform”. Today users generate contents self-contained and create platforms by which they interact on their own initiative with each other, with their environment, and with companies.”17

To conclude it remains to allude that Web 2.0 does not only involve a technological progress but also a new way of communication and networking between users. Moreover it has to be noted that it is also the user himself who has matured concerning Internet usage. This becomes also evident in the following chapter, where the Web 2.0 principles defined by its inventor (Tim O´Reilly) will be described in detail. Those make an additional contribution to understand what Web 2.0 is all about.

ʹǤʹ   ʹǤͲ

Tim O´Reilly has identified several principles stated in his article “What is Web 2.0?” He has recognized that all those internet companies and dotcom-projects which have survived the “burst of the dotcom bubble” in the year 200118 have something in common which allows them to become and remain successful.

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Based on this cognition the following principles have been formed. In the eyes of O´Reilly these can be seen as “core competencies” of which a successful internet company/project possesses at least one. For a graphical depiction of  17 18

Cp. Stanoesvka-Slabeva, 2008, p. 14. Cp. O´Reilly, 2005.

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the principles and how they are related to each other, see also Figure 6 below. Here it can be seen that Web 2.0 is based on two pillars, i.e. people (participation) and technology (architecture).

At the end of each section the implications arising for the health care market in the Internet will be indicated to provide the reader with a first insight. Beyond, major applications for the health care market will be described and analyzed in

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detail within Chapters 5 to 7.

Figure 6: Principles of Web 2.0.19

 19

Adapted from Koch, n.d.

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The Web as (Service-) Platform

According to Tim O´Reilly, an internet application should use the Web as a platform.20 Viewed superficially, this statement seems to be nothing special since the WWW had been used as kind of platform within “Web 1.0”, as well. However, the real innovation (and actual meaning of this definition) which is ascribed to Web 2.0 is the fact that users do not need “common” desktop applications any longer in order to fulfill daily tasks like calendar management, project management or text / image processing. All these tasks can now be done via the WWW, with a web browser as single requirement. Advantages of this kind of use lie in the fact that the user need not install specific desktop software on his PC (the installation of software can lead to significant problems as we all might know), and that data sourced out to the WWW can be easily accessed, shared, modified and stored from any online place.21 Currently, the most prominent example where the Web is used as a platform might be Google with its various online applications like Google Search (search engine), Google Docs & Spreadsheets (online data processing), Google Mail (online E-mail management), to name just a view. Due to the above mentioned characteristics it is not astonishing that the user refers to a “service” rather than to “software” when thinking of Google – and exactly this is meant by using the Web as a platform. However here it should be pointed out that Google – by far – is not the only provider using the Web as a platform, at least the most consequent one.

Despite the fact that this new way of using the Internet does not provide new value for the online health care market directly, it can be assumed that eased use, as well as all other described advantages, may lead to new offers and way Copyright © 2010. Diplomica Verlag. All rights reserved.

of usage in the scope of online health care in an indirect way, as well. For example, “Google Health” (see also Chapter 5.8) may provide advantages for patients and physicians in storing and accessing patient health information.  20 21

Cp. O´Reilly, 2005. Cp. Friedman, 2008, p. 36.

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Collective Intelligence and Architecture of Participation

“Harnessing collective intelligence” (sometimes also called “wisdom of the crowds”) as it is named by Tim O´Reilly refers to the assumption (and reality proves that it is rather a fact) that the value of an internet application or website increases disproportionately high with the number of its users/members, each of them making a contribution to the network.22 In this context it can also be referred to “Metcalfe´s Law” which has proven that the value of a network increases proportionally to the square of the number of users of that network.23 The dynamics implied by this law have been demonstrated in the Figure presented below, as well.

Figure 7: Graphical Depiction of Metcalfe´s Law.24

Moreover, in Web 2.0 the users participate actively, thereby supporting the ongoing formation of the WWW. In this context it is often referred to “user generated content” (UGC) which is granted high significance within Web 2.0. User generated content (also known as “user created content” (UCC)) can be defined by means of the following characteristics: first of all, a publication in some conCopyright © 2010. Diplomica Verlag. All rights reserved.

text is required (e.g. on a publicly accessible website, a blog, or a social networking site), second some creative effort has to be spent (e.g. upload of pho 22

Cp. O´Reilly, 2005. Cp. Teubert, 2008. 24 Cp. CollabWorks, n.d. 23

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tos in a blog, writing a text on a certain topic, or making a music video), finally the creation has to be done outside of professional routines and practices (e.g. not having an institutional or commercial market context, and being produced without expectation of profit).25

To illustrate this, it is probably Wikipedia which can be cited as the most prominent example, showing how the use of collective intelligence and user generated content lead to enhanced value. Here, everybody can add any content which in turn is marked / completed by other users on a voluntary basis. The sum of those small changes by millions of users can be referred to as “networking effect”. Due to this collaboration the value of Wikipedia itself as well as the value for each of its users is increased tremendously. Another prominent example is Ebay which just provides the (technical) platform, the users add the content, and the value of the Ebay platform increases exponentially with the number of its members. This value chain model which is characteristic for Web 2.0 companies is also described in Figure 8 (as compared to the “standard” business

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model of Web 1.0).

Figure 8: Value Chain Models of Web 1.0 and Web 2.0 Offers.26

 25 26

Cp. Vickery, Wunsch-Vincent, 2007, p.17 et seqq. Cp. Gehrke, Gräßer, 2007.

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The above described architecture of participation and “collective intelligence” have also an impact on health care found in the WWW. Users are offered a broad range of interaction concerning this topic. For example, users are enabled to discuss health-related topics on specific platforms, share their experiences concerning various therapies and pharmaceuticals, they can write their own blog on health-related topics, receiving comments from other users in turn, or they can evaluate health professionals online to help others choosing the right therapist. By providing such information/experience (UGC), the user becomes part of the network thereby increasing its value.

Data as Next Intel Inside

Nowadays almost every considerable Internet application has a database running in its background (Google, Amazon, Ebay, etc.). Therefore database management can be considered as an important core competency of companies offering Web 2.0 applications. Tim O´Reilly states in this context that having control over significant databases can lead to strong market power which in turn is positively related to revenue. Moreover, having control over such databases is seen especially important if it is dealt with databases being expensive to create or which may lead to the generation of significant revenues due to networking effects. To underline the importance of owned data it is referred to as “data as next Intel inside”.27 Currently, most value is awarded to geographical (e.g. Google Maps), personal (e.g. in a database of a social networking website), and product-specific data (e.g. Amazon´s book-database). In addition, those huge data collections can be used to construct additional mash-ups Copyright © 2010. Diplomica Verlag. All rights reserved.

(combination of various sources to a new service/application; for a detailed description of the term please refer to Chapter 2.4.6). Although the creation of

 27

Cp. O´Reilly, 2005.

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mash-ups is still in an experimental phase, it can be assumed that they will gain in importance.

With respect to the health care market various approaches can be identified. On the one hand, the control of data may also lead to significant competitive advantages in this sector, especially when dealing with sensitive patient data (information on illnesses, therapy, etc.). Access to such databases may be of great value for pharmaceutical companies with respect to the recruiting of patients for clinical trials, for example. Moreover, for the creation of mash-ups within this realm many options are imaginable. One example which yet exists is the integration of “Google Maps” in an online-doctor-directory so that users cannot only identify a doctor suiting their needs but are also able to view the location of the doctor´s surgery immediately.

Software without a Lifecycle

This principle is closely related to the already described one “the Web as platform”. Due to the fact that software is not delivered as a product any longer but as a service within Web 2.0, various changes have to be done with respect to the underlying business model. Therefore the principle “Software without a lifecycle” refers to the vision that all software should be continuously improved rather than being updated every now and then in a new version. This vision has initially emerged from the “open source movement”; however it makes even a step further, viewing every user as a potential co-developer of the application. The advantages are obvious, on the one hand the user is not forced to “reCopyright © 2010. Diplomica Verlag. All rights reserved.

install” or update an application again and again after a new version has been published, on the other hand, the developers can test new features by providing it to the users for test purposes. Only if a new feature is accepted by a wide range of users it is integrated as an inherent part of the application. This implies that applications are developed according to the users´ needs and demands. As  ͳͻ 

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most Web 2.0 applications incorporate this principle it is often referred to as the “perpetual beta” signalizing a never ending continuous improvement.28

Linking this principle to healthcare it can be assumed that it is not the most important one. Nevertheless, it might increase user numbers of an online health offer due to enhanced usability and the omission of the installation of software. Moreover, the fact that users are viewed as co-developers guarantees that the offer fits the user´s needs. This might be of great importance, especially when dealing with online health offers since here sensitive topics come up very often (knowing what the user want constitutes a great advantage for providers in this case).

Lightweight Programming Models

Since the evolution of web services many companies started to develop highly complex applications, however often the desire of simplicity prevails. Therefore the approach of lightweight programming models has emerged. Characteristics of these include an easy structure with regard to “hackability” and “remixability”, i.e. low barriers for subsequent use (for example, providing open-source code). This implies that other developers can resort to the already developed programs and use them as a basis to create new online services (these services are also called “mash-ups”). The basic idea behind is that data are shared and distributed, it is not controlled what happens with those data. Lightweight programming models support this thinking as they allow for loosely coupled systems. In this context it has been found out that the most successful Web 2.0 services are Copyright © 2010. Diplomica Verlag. All rights reserved.

such which can be developed further in directions which the originator had not even thought of. Therefore the term “all rights reserved” is increasingly often modified to “some rights reserved”, indicating that data may be used by others.  28

Cp. O´Reilly, 2005.

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In addition, this procedure facilitates “innovation in assembly”, relating to the fact that new services are created by the simple combination of two already existing ones. The most prominent examples are those which use data from “Google Maps”, mix them with other data, and provide a new service (e.g. maps combined with a database about restaurants, or available real estate).29

The trend towards lightweight programming models has also an effect on health care on the Internet, as they enable the creation of new health-related online services as well, resulting from a mix of various sources, for example. Of course, it is comprehensible that the more services emerge the easier it is to create them. One example yet existent is “http://www.healthmap.org” which aggregates information from various sources to a new service (sources include amongst others “Google Maps”, information from the World Health Organization (WHO),

and

Euro

Surveillance).

According

to

the

developers,

“http://www.healthmap.org” and its value can be described as following:

“HealthMap brings together disparate data sources to achieve a unified and comprehensive view of the current global state of infectious diseases and their effect on human and animal health. This freely available Web site integrates outbreak data of varying reliability, ranging from news sources (such as Google News) to curated personal accounts (such as ProMED) to validated official alerts (such as World Health Organization). Through an automated text processing system, the data is aggregated by disease and displayed by location for user-friendly access to the original alert. HealthMap provides a jumping-off point for real-time information on emerging infectious diseases and has particular interest for public health Copyright © 2010. Diplomica Verlag. All rights reserved.

officials and international travelers.”30

 29 30

Cp. O´Reilly, 2005. Freifeld, Brownstein, 2007.

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In the eyes of the author this is a good example outlining one of the values for online health services, resulting from the use of Web 2.0 elements. In the following figure an image section from HealthMap is provided to receive an impression. In this case, Germany has been chosen as an example. One can see that on June 10th, 2010 a salmonella alert had been posted for Germany. In general the depiction of diseases can be arranged according to category, diseases last 30 days, or alerts by country. Moreover it is available in various lan-

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guages, unfortunately not in German yet.

Figure 9: Snapshot from HealthMap.31

  31

Cp. http://www.healthmap.org.

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Software above the Level of a Single Device

Web 2.0 often comprises another feature worthwhile mentioning, namely the fact that no longer limitations concerning the use of applications exist. They are not limited to be used on a PC platform anymore but can be rather accessed also on various mobile end devices, for example mobile phones or mp3-players (iPod).32 This opens up new possibilities for use of existent online services as well as it provides space for the development of new applications focusing on this aspect. Currently iTunes is the most known example which shows how applications can link different devices (in this case Web, PC, and iPod).

Coming back to the use of Web 2.0 in the health care market, the above described development leads to new chances of communication and interaction, too. While in earlier times a PC with an Internet connection was needed (which most often is bound to a certain location), the possibility to use the mobile phone for “going online” allows doing so from almost any place. They allow the user to have recourse to online health offers within every possible physical life situation when help or interaction is needed. First developments of this include “Moblogs” (composition of “Mobile” and “(We)blog”, enabling the user to write a “blog” from a mobile device), or mobile extensions of already existing Web 2.0 platforms. 33 To show an example, it can be referred to the above depicted HealthMap which is from now on also available as an iPhone application. Another example which seems to be mentionable is the “medicine reminder” from the health portal “Imedo”.34 They offer to remind the user to take his medicine according to his data (name of medicine, doses, time, etc.) deposited in his

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“Imedo-account” at no charge (of course, a prior registration is necessary).

 32

Cp. O´Reilly, 2005. Cp. Stanoesvka-Slabeva, 2008, p. 30 et seq. 34 Cp. http://www.imedo.de. 33

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Rich User Experiences

The term “rich user experiences” signalizes the evolution of multi-functional web applications, very similar to desktop applications concerning its functionality and usability (e.g. user interface). It provides a basis for global service platforms as well as the establishment of “online desktops” 35 (see also Chapter 2.2.1). The underlying technology enabling such applications has become known as “AJAX”; however it has to be pointed out that “AJAX” does not constitute a single technology but includes various technologies which have been linked in a new and efficient way (for a more detail description of “AJAX” please refer to Chapter 2.3). In the following years many new web applications, either created newly from scratch, or by re-implementing desktop applications, can be expected. Yet existent applications falling in this scope include amongst others Google´s “Gmail”, or online text processing applications which allow for collaborative writing.

The creation of rich user experiences allows providing encompassing web offers in the online health care sector, as well. The user can benefit from this development, due to enhanced functionality and design and collaborative functions which in turn facilitate a frequent and active use of such web offers.

ʹǤ͵   ʹǤͲ

In order to create Web 2.0 services according to the above mentioned prinCopyright © 2010. Diplomica Verlag. All rights reserved.

ciples, it has to be pointed out that not only the introduction of comprehensive broadband connections and flat rates for its use, as well as a more “sophisticated” users trusting the WWW and knowing about the potential of the Internet  35

Cp. Friedman, 2007, p. 37.

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had been necessary, in addition there was an urgent need both, to tap the full potential of already existing technologies, and to develop new technologies in order to convert Web 1.0 into Web 2.0. Therefore, the most important technologies which had a particular effect on the evolution of Web 2.0 are adumbrated in the following. Here it has to be pointed especially to AJAX, Ruby on Rails, and RSS. Of course, the initial basis is provided by the ability to create dynamic web pages which is the standard for Web 2.0 offers. Dynamic web pages are able to react to a user´s input. In order to create these, the use of certain programming- and script-languages is required. For this purpose it is very often made use of JavaScript, JSP, and PHP.36 Due to the fact that this piece of research is not located within the scope of information technology (IT), but is intended to provide an insight into the (potential) value for its users, the above mentioned programming- and script-languages will not be dealt with in greater detail. Moreover, the explanation of further mentioned technologies will be kept short and introductory.

AJAX

“AJAX”, the abbreviation of “Asynchronous JavaScript and HML”, cannot be considered a technology itself as it incorporates several modern web technologies. However, AJAX is mentioned most often when talking about Web 2.0. To illustrate the structure of AJAX it is pointed out to Figure 10, which shows the

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different components of AJAX and the corresponding applications.37

 36 37

Cp. Behrendt, Zeppenfeld, 2008, p. 29 et seqq. Cp. Lange, 2007, p. 17.

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Figure 10: Elements of AJAX.38

Basically, AJAX is responsible for the exchange of data between browser and server, allowing for a selection of certain desired data. This implies that specific contents can be re-loaded onto a web page without loading the whole web page again. Advantages of this process are that applications become faster, almost as fast as desktop installed applications. Moreover, AJAX facilitates mixing different web offers, as data can come from various sources. AJAX applications have typical characteristics which are strongly related to the characteristics of Web 2.0. When we have a closer look to these characteristics it becomes evident why Web 2.0 depends heavily on AJAX. These are depicted in the follow-

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ing39: x

The User Interface is becoming increasingly dynamic

x

Rich Internet Applications

x

Better precision of user interaction

x

Redundancy for a maximum of reach

 38 39

Adapted from Lange, 2007, p. 17. Cp. Friedman, 2007, p. 575 et seqq.

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x

Robust communication of applications

x

Web applications are becoming more and more similar to desktop applications

Ruby on Rails

Ruby on Rails (abbr. “Rails”) constitutes a working environment for the programming of modern, databank-based web applications. It is based on the programming language “Ruby”, with “Rails” programmers are enabled to create fast and fully-fledged applications. According to Tim O´Reilly, advantages lie in the fact that complex web applications can be developed within some days instead of months, or even years. This can be traced back to a simple programming with a minimum of code needed. In addition, frequently used standard activities are yet included which leads to a reduction of work load. Of course, those characteristics are especially important for programmers of Web 2.0 offers which are mostly quite complex. Despite of their complexity, Ruby on Rails allows programmers to develop such offers within a short period of time.40

RSS & Atom

The abbreviation “RSS” stands for “RDF Site Summary”, “Really Simple Syndication”, or “Rich Site Summary”, depending on the interpretation and version. Therefore an unambiguous assignment of this abbreviation is not possible.

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Moreover, due to various intricatenesses when using RSS, a new syndication format came up, being called “Atom”. It tries to take over the advantages of its forerunners and simultaneously suppresses the disadvantages of those.41 To 40 41

Cp. Lange, 2007, p. 18. Cp. Kantel, 2007, p. 11 et seqq.

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day it is made use of RSS 0.92/2.0 or Atom most often while RSS 1.0 has disappeared almost completely due to its complexity. RSS / Atom helps to simplify users´ activities in the WWW, making it obsolete to visit a specific web page again and again to see which information has been newly published. If a RSS service is provided by the web page it is sufficient if the user registers for this offer once, afterwards he will be informed every time new information has been stored on the server of the web page. The most important contents of a RSSFeed include a title, a short description of content, as well as a link to the location of the pertinent information.42 Therefore RSS-Feeds contribute to the success of Web 2.0 offers since the notification of new information is particularly interesting for users when, for example, being interested in new blog or forum entries regarding a certain topic. Then, the user must not canvass all web pages to find any new posts. Moreover, the user can make sure that he does not miss any important information.

ʹǤͶ ʹǤͲ   

Within this chapter the most typical / commonly known Web 2.0 applications and services are depicted. Of course, this explanation does not make a claim to be complete; it is rather intended to provide a deeper insight into the various possibilities which have been facilitated by the introduction of Web 2.0. Here it has to be noted that some applications cannot be clearly separated from each other due to some overlapping functions. The following figure depicts the most

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important applications and their focus (information, communication, or relationship building). The selected applications will be discussed in greater detail subsequently.

 42

Cp. Behrendt, Zeppenfeld, 2008, p. 67 et seqq.

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Web 2.0 and the Health Care Market: Health Care in the era of Social Media and the modern Internet : Health Care in the era of Social Media and the modern Internet, Diplomica

Figure 11: Common Web 2.0 Applications & Their Focus.43

ʹǤͶǤͳ 

It is assumed that currently more than 50 million blogs can be found in the Web. However, due to the fact that the blogosphere44 is growing every day, it is difficult to provide exact numbers. Moreover, many of the existent blogs are not updated on a regular basis which makes them nearly “worthless”.45 Many experts consider “blogs” as the root of Web 2.0 as they unify all relevant characteristics of Web 2.0.46 Despite of this importance, it is not possible to provide an integrative definition of blogs; 47 it can be expected that as many definitions for blogs exist as blogs itself can be found in the WWW. 48 However, it has been agreed on certain characteristics (those will be outlined in the following, as well)

Copyright © 2010. Diplomica Verlag. All rights reserved.

which determine if a blog is a blog (and not a “standard” web page).  43

Own source. Note: The term “blogosphere“ is referred to as “all existent blogs“. 45 Cp. Klappenbach, 2006. 46 Cp. Huber, 2008, p. 27. 47 Abbreviation for “weblog“ which is composed of the terms “web“ and “log“. 48 Note: Use, for example, http://www.technorati.com to find blogs of a certain topic. 44

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Commonly, a blog is a web page which is fed with information about any topic in written text alongside with pictures, and videos presented in diary style.49 Often, the presented information conveys a high degree of authenticity and subjectivity (every blogger having its own style), making blogs such an interesting thing for the public with a great influence on the opinion of others if a critical mass of readers is reached. Moreover, a blog´s user (i.e. its reader) is invited to comment on the provided entries, enabling a blog to be highly interactive. Communication and exchange of opinions and experiences is encouraged, which in turn guarantees that a topic is discussed in depth on the one hand, and that all opposing views can be presented to the public, on the other hand.50 Another advantage of blogs is that a person who wants to write his/her own blog need not have any programming skills any longer.

These aspects can also be found in the definition provided by Brian Aker and Dave Krieger which define (we)blogs as following:

“A weblog can be anything from a journal to a stream of consciousness commentary or even a full-blown news site. The important features are a steady stream of fresh content and a willingness to link to other existing sites as a raison d'être. […]For the most part, weblogs are simple and straightforward. People can publish their thoughts, even for the first time, with almost no training.”51

Although this definition provides a good interpretation of what blogs are about, it

Copyright © 2010. Diplomica Verlag. All rights reserved.

becomes evident, why defining blogs comprehensively is so difficult.

 49

Cp. Löwer, 2006. Cp. Schwarzer, Sarstedt, Baumgartner, 2007, p. 3. 51 Chromatic, Aker, Krieger, 2002, p.2 et seq. 50

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Therefore, a set of primary characteristics have been identified which allow to judge whether a web page may claim to be a blog. These characteristics include:52 x

Reverse, chronological journaling (diary format)

x

Regular, date-stamped entries (timeliness)

x

Links to related news articles, documents, blog entries within each entry (attribution)

x

Archived entries (old content remains accessible)

x

Links to related blogs (blog-rolling)

x

RSS or XML feed (ease of syndication)

x

Passion (voice)

By means of these characteristics it becomes quite easy to identify blogs in the WWW when looking at web pages. Apart from the above depicted characteristics, additional functionalities of blogs can be identified. Here “permalinks” and “trackbacks” have to be mentioned in particular. With permalinks (abbreviation of “permanent links”) each blog entry receives an own URL (unified resource locator) by which it can be identified. Due to the continuous addition of new entries, the URL of the welcome page points out to different contents, depending on the newest entry. Therefore a permalink, by which an entry is “permanently linked” to the given URL, allows to retrieve it again without search. Closely related is the function of trackbacks by which blog writers receive notice if another blog writer has referred to one of their own entries. Both functions support the

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networking of the blogosphere.53

Finally, the advantages and disadvantages of blogs are outlined to complete the explanation. Advantages of a blog lie in its fast spreading of information, the  52 53

Cp. Gill, 2004, p. 1 et seq. Cp. Alby [2], 2007, p. 2.

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Web 2.0 and the Health Care Market: Health Care in the era of Social Media and the modern Internet : Health Care in the era of Social Media and the modern Internet, Diplomica

easy use with low / no costs, and its independence from any location (i.e. a blog can be written at any time, from any place, either a PC, or a mobile device). However, certain disadvantages are existent which might prevent a user from blogging. It should not be forgotten that a blog is a visiting card for its writer; therefore the writer should think critically about which information to publish. In addition, it is argued that blogs may not have a “real” own content, as they just talk about, or link to news which are provided by another web page. Lastly, the writer must take care that he does not infringe copyrights when using citations and links.54

ʹǤͶǤʹ   Ƭ

Social communities (also called “social networks”) refer to a specific kind of online communities by which the establishment, depiction, and administration of social contacts is facilitated. 55 Most prominent examples are “Facebook” (http://www.facebook.com),

”XING”

(http://www.xing.com),

“LinkedIn”

(http://www.linkedin.com) or “StudiVZ” (http://www.studivz.net). They can be defined as:

“Social networking sites (SNS) enable users to connect to friends and colleagues, to send mails and instant messages, to blog, to meet new people, and to post personal information profiles. Profiles include photos, video, images, audio, and blogs.”56

Copyright © 2010. Diplomica Verlag. All rights reserved.

The most important aspect, apart from finding people, and communicate with them, is the facilitation of group building according to interests (formation of in 54

Cp. Przepiorka, 2005, p.16 et seqq. Cp. Hippner, 2006, p. 13. 56 Vickery, Wunsch-Vincent, 2007, p. 38. 55

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terest clusters) and the comprehensive linkage of profiles (also called “linkage of second order”).57

All social communities have in common that a prior registration is necessary in order to become an active member. Sometimes the registration may also be limited to certain groups of people (e.g. “students only” like in StudiVZ). Afterwards, the user is asked to create a personal profile, telling about private and / or business data, interests, hobbies, and so on. Often, a personal picture can be uploaded, as well. Now, the user can search for certain persons (e.g. the former neighbor Mr. X), for persons with same characteristics (e.g. same location or company), or same interests (e.g. diving as a hobby). Found people can be added to one´s “contact list” (functions as an address book), making communication even easier. Moreover, social communities provide certain functions which are intended to support the communication with others. Here it is pointed to the sending / receiving of private messages, participation in forum / group discussions, or the writing / reading of “guestbook entries” which are included on a user´s profile page.58

Social networks can be classified by means of various characteristics. First of all, it can be distinguished between “real life communities”, for example alumni organizations or expert circles where those relationships can be found in real life, as well, and “internet communities” which just exist in the Internet, used by people which may never meet in real life.59 Moreover, social networks can be classified according to their reach; here it is pointed to “local networks” as compared to “global networks”. Specific local ones focus on meeting people from the same region online (e.g. the network “Lokalisten”60); in contrast, global netCopyright © 2010. Diplomica Verlag. All rights reserved.

works are joined by people from all over the world. Another classification favors the differentiation of social networks according to the age of their target group  57

Cp. Friedman, 2007, p. 45. Cp. Alpar, Blaschke, Keßler, 2007, p. 49 et seqq. 59 Cp. Huber, 2008, p. 60 et seq. 60 Cp. http://www.lokalisten.de. 58

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(“age specific networks”) like “StudiVZ” (for students), “SchülerVZ” (for pupils), or “Feierabend.de” (for the generation 50plus). Finally, the most common classification is made by distinguishing between “identity-driven” and “topic-driven” social networks, or a mix of both.61 This classification is most universal and encompassing which is why this way of differentiation is preferred by the author.

A Special Case: Twitter

In consideration of the fact that Twitter constitutes a special case within the realm of Web 2.0 applications, it is devoted a separate explanation at this point. Twitter can neither be clearly assigned to the scope of blogs, nor to the category of social networks / communities. In fact, it appertains to both categories, overtaking the advantages from each. The creators of Twitter simply refer to it as a “communication service”. Twitter, launched in March, 2006, is a so-called “micro-blogging” service, 62 and combines elements from E-Mail, SMS, blogging, RSS, and social networks, to name just a view. This unique combination of elements can be considered the major driver for its success. The major characteristic of Twitter is the limitation of a post´s length to 140 characters, at maximum. The created posts are publicly accessible, and a user can subscribe to the posts / topics he is interested in (using RSS). In addition, posts can be edited and received through various channels, including SMS, E-Mail, Instant Messaging (IM), or the Web page. The posts created this way then become published in real-time, either on the Twitter homepage, or they can be included on the user´s profile at other social netCopyright © 2010. Diplomica Verlag. All rights reserved.

works (e.g. Facebook), or they are displayed at one´s own web page. 63

 61

Cp. Ahlers, 2008, p. 100 et seqq. “Micro-blogging“ is characterized by the length of a post which is limited up to 140 characters. 63 Cp. O´Reilly, Milstein, 2009, p.7. 62

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When using Twitter, people can communicate their activities or what they have currently in mind, on the one hand (“micro”-blogging); on the other hand, Twitter can also be used as a platform for chatting, thereby finding other users, and link to them (“social networking”). The advantages and characteristics of Twitter are also outlined in Figure 12 below.

Figure 12: What Makes Twitter Special.64

The depicted functions of Twitter are not only considered valuable for private purposes, as it might be expected at first sight. Nowadays, companies increasingly often recognize the potential value of Twitter for their business activities,

Copyright © 2010. Diplomica Verlag. All rights reserved.

being it for the communication with co-workers, being it for the communication with vendors, the press or customers, or being it for the information of interested people about new products or features. In which way Twitter can be efficiently used in the realm of the health care market is depicted in Chapter 6.1.  64

Cp. Unruh, 2008.

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A Special Case: Photo- & Video Communities

Photo- and video communities are probably the most known social communities. However, due to their special characteristics, they are described separately. To classify them is somehow difficult; various options to do so exist. On the one hand, photo- and video communities can be assigned to the realm of “topicdriven” social networks, on the other hand they can be regarded as “simple” content sharing platforms (here: pictures or videos). Nevertheless, since a certain degree of interaction of users can be found, they are regarded most often as a special case of social networks. Most prominent examples currently are http://www.youtube.com (video), and http://www.flickr.com (photos).

Photo- and video communities provide a platform for users to upload their individual photos or videos, assign keywords to those (so-called “tags”), group them according to topics, and share them with other interested users. Of course, this feature alone does not make a network. The character of a social network derives from the functions of commenting and evaluating on uploaded content of others, as well as linking to it. Due to this interaction, a network is created with its value again increased the more people use it. With respect to the upload and linkage of content it has to be pointed to the problem of copyright infringement (see also Chapter 9.1); here the user has to take care that he owns the required

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rights for the uploaded material.65

 65

Cp. Hess, Walsh, Kilian, 2007, p. 13.

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ʹǤͶǤ͵ǦƬ

The term “podcast” constitutes a new neologism from the well-known Apple “iPod” (mp3-player) and the noun “broadcasting”. 66 Podcasts are audio files which are uploaded and distributed via blogs and / or online platforms, and which can be, similarly to the text-based RSS feed, subscribed to.67 Although podcasts are primarily intended to communicate spoken text, also music, pictures, or videos can be included. If videos are the major component, it is referred to these as “vodcasts” (combination of “video” and “broadcast”).68 Concerning the contents of a pod- / vodcasts, as well as its formats, many different orientations can be recognized. A podcasts can contain an interview, sounds, and (live) recordings from shows, comments, or essays. Also the range of topics is endless, including amongst others, health, comedy, technology, politics, news, economy, education, or travel and sport.69 Due to this broad range, it can be expected that every user may find something according to own preferences.

Audio files in the WWW are not particularly new, however, due to certain factors, podcasts have attracted increasing attraction. Due to the compression of the mp3-format, audio files became smaller in its size, thereby increasing download speed and decreasing required storage space which makes its use significantly more comfortable. Moreover, the new devices like, e.g. iPods or other mp3 player, led to an increased demand for audio files. Those devices have been tremendously reduced in size, allowing the user to take the device around, having it ready at any time and any place. Finally, production methods of podcasts became eased, as well as the required means became affordable. This has led to an increased amount of private persons, creating their own podCopyright © 2010. Diplomica Verlag. All rights reserved.

casts.70  66

Cp. DATACOM Buchverlag GmbH (Ed.), 2009. Cp. Friedman, 2007, p. 61. 68 Cp. Ziff Davis Publishing Holdings Inc. (Ed.), 2009. 69 Cp. Huber, 2008, p. 45 et seqq. 70 Cp. Alby [1], 2008, p. 73 et seqq. 67

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Web 2.0 and the Health Care Market: Health Care in the era of Social Media and the modern Internet : Health Care in the era of Social Media and the modern Internet, Diplomica

Podcasts may not only play an increasingly important role for media companies. For example, TV stations, or print media already create podcasts to provide additional information to specific telecasts or articles. Often it is also possible to listen to the corresponding podcasts (or view the vodcasts), if a telecast has been missed by the user on TV. Despite, more and more commercial enterprises make use of podcasts to reach their customers, as well (e.g. for marketing purposes).

ʹǤͶǤͶ  

When thinking of wikis, the first thing which comes to mind is its probably most famous application Wikipedia (http://www.wikipedia.com). Despite, many other wikis can be found in the WWW.71 To gain an understanding about wikis and its function(s), it is pointed to the following definition, including major characteristics of wikis:

“A wiki is a website that allows users to add, remove and otherwise edit and change content (usually text). Users can change the content of pages and format them with a very simple tagging language. Initial authors of articles allow other users to edit “their” content. The fundamental idea behind wikis is that a large number of users read and edit the content, potentially enriching it and correcting mistakes.” 72

In addition, the advantages of wikis can be derived from this definition. A wiki is Copyright © 2010. Diplomica Verlag. All rights reserved.

an “open” system which facilitates collaborative working. A major emphasis is put on user-generated content, and the application becomes more valuable, the  71

72

For example, health related wikis: http://wiki.gesundheit-regional.de, or http://www.pflegewiki.de. Vickery, Wunsch-Vincent, 2007, p. 37.

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more people use it and participate with own content. Therefore major fields of application are located in the scope of online encyclopedias, documentation, project management, E-learning, and knowledge management.73

Despite, disadvantages should not be neglected. In contrast to other forms of online publication like blogs or community entries, in wikis an article is not clearly assigned to one author being responsible for the content. Since in wikis many people work on one article, the question has to be addressed in how far the articles constitute correct and trustworthy information. However, here it has to be pointed to various studies which have proven that wiki articles may differ with respect to their quality but most often incorrect information is identified quickly due to the huge number of people taking care (referred to as “self-healing effect”).74

ʹǤͶǤͷ   Ƭ 

 

Social bookmarking and social tagging are closely related which is why they are described within one and the same section. In both cases, “social” refers to a collaborative way of action, pointing again to the value of user generated content. Currently, the most known providers of social bookmarking services are Delicious75 (international focus), and Mr. Wong76 (German focus). The concept of social bookmarking does not constitute a completely new application since users saved and management their favorite links (“bookmarks”) in earlier times, as well. The new aspect of social bookmarking is that bookmarks are not stored Copyright © 2010. Diplomica Verlag. All rights reserved.

on the individual browser on a single device any longer, but in the Internet.77  73

Cp. Przepiorka, 2005, p. 21 & Ebersbach, Glaser, Heigl, 2008, p. 46. Cp. Stein, Hess, 2008, p. 109. 75 Cp. http://delicious.com. 76 Cp. http://www.mister-wong.de. 77 Cp. Ebersbach, Glaser, Heigl, 2008, p. 109 et seqq. 74

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Web 2.0 and the Health Care Market: Health Care in the era of Social Media and the modern Internet : Health Care in the era of Social Media and the modern Internet, Diplomica

This aspect is also strongly related to the Web 2.0 principle of “Using the Web as (service-) platform”. There exist two major advantages of social bookmarking. First, bookmarks can be managed online, thereby allowing the user to access his bookmarks from any place and any PC. Second, the user can categorize his bookmarks by assigning individual keywords (“tags”) to each link. Then, those individual bookmark lists become accessible for other users, as well. If many users do so, a huge public bookmark collection is created, which is expected to provide better search results than traditional search engines in many cases.78

Nevertheless, some disadvantages of social bookmarking have to be remarked. Here, it has to be pointed to the keywords (“tags”) which are assigned to bookmarks. Due to a missing standardization of terms, different people use different words (or word forms) for the same thing (e.g. singular or plural; is an automobile a car or a vehicle?). Due to this reason, searches within these bookmark collections for a certain keyword become more difficult. This problem can be minimized when the system suggests tags which other users have used for the same topic (then, the next user takes over the tag, thereby reducing the number of differing / redundant information). Finally, web pages which are frequently recommended to others may suffer from huge sudden traffic, possibly being not able to cope with that.79

As mentioned above, keywords, called “tags” are assigned to the individual links which lead over to the aspect of “social tagging”. Social tagging constitutes the activity of collaborative indexing of bookmarks. Within this context it is often referred to the term “folksonomy”, pointing to the difference as compared to earlier Copyright © 2010. Diplomica Verlag. All rights reserved.

links which had been classified by means of taxonomies. While the taxonomy approach implies that web pages are classified into a directory by means of a fixed, hierarchical scheme, the folksonomy approach makes use of collective  78 79

Cp. Stöcker, 2006. Cp. Ebersbach, Glaser, Heigl, 2008, p. 126.

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intelligence, allowing users to classify their bookmarks themselves on the basis of own tags.80

To visualize the result of social tagging it is often made use of so-called “tag clouds”. The principle of these is intuitive and facilitates a clear arrangement. The major aspect to know is that those tags which are used most often within all keywords are silhouetted against those words which are currently of minor interest. This is done by a larger font size, a different color, or a bold text.81 The figure below depicts an excerpt of such a tag cloud for the topic of diseases.

Figure 13: Example of a Disease-related Tag Cloud.82

Copyright © 2010. Diplomica Verlag. All rights reserved.



 80

Cp. Alby, 2008, p. 127. Cp. Ebersbach, Glaser, Heigl, 2008, p. 130. 82 Cp. Centers for Disease Control and Prevention (Ed.), 2009. 81

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ʹǤͶǤ͸ȋ  ȌǦ



To begin with, the term “mash-up” has to be explained. Mash-ups can be defined as applications which integrate data from different sources, thereby resorting to open APIs (application programming interface) which have been provided by other Internet applications (being conformant to the “lightweight programming model” explained within Chapter 2.2).83 Due to the fact that up to now most frequently a combination of “Google Maps” with any other source can be found in the WWW (more than 2000 mash-ups are existent), the focus of this section has been put on “cartographic mash-ups” (i.e. a mix of maps like provided by Google with other data). The percentage of mash-ups based on maps

Copyright © 2010. Diplomica Verlag. All rights reserved.

is also depicted in the following figure.

Figure 14: Distribution of Mash-ups According to Sources Used.84

 83 84

Cp. Back, Gronau, Tochtermann, 2008, p. 83 et seq. Cp. Programmable Web (Ed.), 2009.

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Web 2.0 and the Health Care Market: Health Care in the era of Social Media and the modern Internet : Health Care in the era of Social Media and the modern Internet, Diplomica

To

mention

an

example

it

is

pointed

to

“Who

is

sick?”

(http://www.whoissick.org), an interactive cartography combining “Google Maps” with current and local sickness information to see which diseases occur currently at a certain location. Unfortunately, it has to be remarked that, although the idea of this application is considered to be valuable, currently the value of it is limited due to a lack of current local sicknesses posted. Another example is HealthMap which has been introduced previously (see Chapter 2.2).

The major advantage of such cartographic mash-ups is, of course, the fact that information is visually prepared so that the user may gain a comprehensive impression. The fact that information is not only provided in written form, but also displayed on a map, allows the user to have an insight into the surrounding of the location, distances, or clusters of certain objects.

ʹǤͶǤ͹ 

Virtual worlds are defined as virtual environments, trying to replicate many elements of the “real world”. They constitute a computer-generated and mostly internet-based space of interaction. Here, user can create own avatars by which they can navigate and act within this virtual world.85

Recently, virtual worlds attract an increasing public attention. Even public media report about events in virtual worlds. In this context it is referred to the virtual world “Second Life” in the majority of cases. Nevertheless, it has to be noted Copyright © 2010. Diplomica Verlag. All rights reserved.

that this is, by far, not the only virtual world existing in the WWW. Its major competitors are “Gaia Online”, “Multi-User-3D-Online-Welt” or “Entropia Universe”, to name just a view.86 By now, many “real” companies and institutions  85 86

Cp. Lattemann, 2009. Cp. Winkler, 2007.

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Web 2.0 and the Health Care Market: Health Care in the era of Social Media and the modern Internet : Health Care in the era of Social Media and the modern Internet, Diplomica

have created their correspondent within “Second Life”. Companies use the virtual environment of “Second Life” to develop a new sales channel by which primarily young customers should be directly addressed. In addition, it is a good place for providing information, conducting market research, doing (online) advertising, or the testing of (potential) new products.87 Despite, potential problems should not be neglected. These do not only concern companies within “Second Life” but also individuals acting there. Major problems arise from legal aspects, as many users consider “Second Life” to be an unlegislated area, but rather the contrary is true: apart from the defined rules and regulation from the provider (Linden Lab), national law is applied, as well (e.g. in case of copyright infringements, identity misuse, or lacking protection of minors). Therefore companies and individuals have to think critically about their actions within virtual worlds.88 

ʹǤͷ   ʹǤͲ Ƭ 

The following chapter provides some information about trends in the use of Web 2.0 applications to assess the dimensions of diffusion amongst users. In this context it has to be stated that apart from the knowledge about the technical feasibility as well as the capabilities of Web 2.0 applications, it is important to know about its users, as well. A Web 2.0 application without users is worthless. Therefore providers must know about the (target) users and their (specific) needs. Due to this reason, the following paragraph will have a closer look to the Copyright © 2010. Diplomica Verlag. All rights reserved.

various Internet users, their behavior, and the resulting impact(s) for Web 2.0 applications.

 87 88

Cp. Martell, 2007. Cp. Nelles, 2007.

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The current number of Web 2.0 applications within the Internet cannot be determined for the reason that every day many new ones come up. However, this development is not astonishing if one has a look to the following table (Table 2). This table depicts the percentage of people using certain Web 2.0 applications, comparing the years 2007, 2008, and 2009. Here one can clearly identify a trend towards an increased use of these applications. Due to this development, it can be expected that these figures will continue to rise in future years.

Occasional use (in %)

Regular use (in %)

2007

2008

2009

2007

2008

2009

Wikipedia

46

60

65

20

25

28

Video communities

34

51

52

14

21

26

Private networks / communities

15

25

34

6

18

24

Photo communities

15

23

25

2

4

7

Job-related networks

10

6

9

4

2

5

Weblogs

11

6

8

3

2

3

Bookmark collections

3

3

4

0

1

2

Virtual worlds

3

5

-

2

2

-

Table 2: Web 2.0: Occasional and Regular Use 2007 to 2009 in %.89

In this context, the following remarks can be made: most notably, Wikipedia, video communities, as well as private networks, and photo communities attract the users´ interest. In contrast, job-related communities, weblogs, and book-

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mark collections still own only a low amount of (regular) users, indicating that either the demand for these applications does not exist, or that the offers are

 89

Cp. Busemann, Gscheidle, 2009, p. 358 et seq.

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not suitable to users´ needs. Finally, virtual worlds are expected to play a minor role within Web 2.0 applications so far.

In order to draw more precise conclusions about the importance of Web 2.0 applications, we have to consider the above depicted data more in depth. First of all, it has to be distinguished between users who are engaged in the use of Web 2.0 applications actively and those who consume passively only. In this context, a “passive use” refers to the fact that a person uses the applications, but does not provide any own content. In contrast, an “active use” indicates that a person is engaged in the further development, i.e. uploading own content, writing articles, uploading photos or videos, or creating a user profile within a social network. Here it has to be pointed to the following figure (Figure 15), showing the

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percentages of active and passive users.

Figure 15: Kind of Use of Web 2.0 Applications in 2009 in %.90

 90

Cp. Wilhelm, Magerhans, 2007.

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Web 2.0 and the Health Care Market: Health Care in the era of Social Media and the modern Internet : Health Care in the era of Social Media and the modern Internet, Diplomica

Based on the figures depicted above it can be suggested that the kind of use (active / passive) depends on the kind of application to some extent. However, it may be concluded that many people using Web 2.0 applications do this passively, i.e. they retrieve information from such web pages, but do not actively support content creation. This fact has to be considered by providers when new applications are created. Thus, providers should offer incentives for users to become active if they want to increase the value of their service.

In addition, the proportion of people using such applications is highly dependent on certain demographic factors. Therefore the following table sheds light on the distribution of usage with respect to age and gender.

Women 64

Men 67

14-19 years 94

20-29 years 77

30-39 years 70

40-49 years 62

50-59 years 50

60+ years 39

Video communities

45

58

93

79

55

45

27

12

Private networks

36

32

81

67

29

14

12

7

Photo communities

25

26

42

41

20

19

19

14

Job-related networks

8

11

6

16

13

8

7

1

Weblogs

6

10

12

16

10

5

4

1

Bookmark collections

4

4

9

6

4

2

2

2

Virtual worlds

-

-

-

-

-

-

-

-

Wikipedia

Table 3: Web 2.0 Use According to Age and Gender in %.91

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From those figures it can be derived that by trend the proportion of male users is slightly higher than those of females. In addition, it becomes evident that younger people are exceedingly engaged in the use of such applications, e.g.  91

Cp. Busemann, Gscheidle, 2009, p. 360.

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use more than 90% of the 14 to 19 years old Wikipedia and video communities (e.g. YouTube). In contrast, the older the users are the higher is the aversion to the use of Web 2.0 applications. This is particular noticeable in the groups of people aged 50 years and older. Here it has to be analyzed which underlying reason form the basis of this phenomenon and how this age group can be encouraged for extended use (e.g. providing seals of trust, or incentives for participation). The study “Web 2.0 and the generation 50+” 92, aimed at gaining an insight into the motives, needs, acceptance, and using barriers of users aged 50 and older, has proven the reluctant use of Web 2.0 applications within this age group. In addition, some reasons for their behavior became obvious. Although many of these people know the term Web 2.0 from media or press, a concrete examination of the possibilities and chances did not take place. Predominantly, these users are skeptical towards a “self-expression” within the Internet, they use the WWW almost only for information retrieval, and not for fun purposes. In this context the user group “50+” has different demands on web pages, i.e. they consider seriousness, reasonableness, a clear page structure, as well as an intuitively recognizable intention of the web page to be most important. Obviously, many Web 2.0 applications do not meet this need(s) (despite, many “Web 1.0” web pages may not be conformant to this demand, as well) which is why users 50 years and older still disapprove such applications. The trends concerning Web 2.0 applications, the use of such, as well as the different user profiles have to be taken into account when creating and offering new Web 2.0 services and applications. If providers fail to adapt to the differing needs and

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habits, even the best application will fail.

 92

Cp. Result GmbH (Ed.), 2007.

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͵Ǥ

After having outlined the principles and functionalities of Web 2.0, the following chapter is intended to provide a basic insight into the health care market. To have this insight into the health care market, including its characteristics, is important for assessing the potential value of Web 2.0 applications for this market in subsequent chapters. For this reason, the basic terms health, health system, and health care will be defined at first. In addition, since definitions of the term health care market vary with respect to the scope of it, it is necessary to agree on one definition which serves as a basis for further discussion. Afterwards, the significance and scope of the health care market will be discussed. Ongoing, the development of this market will be depicted. Relating to this, selected factors influencing the health care market will be outlined, as well. Finally, the different segments of the health care market which have been chosen as a focal point within this piece of research will be described.

͵ǤͳDz dz

For some years the trend towards a different stance over health and health care can be observed within society. Nowadays, health and wellness permeate a bigger part of our lives than ever before. Due to changes in people´s mindsets, an altered demographic structure, an extended offer in the realm of healthrelated goods and services, as well as health-related information in abundance Copyright © 2010. Diplomica Verlag. All rights reserved.

(offline, as well as online), health is gaining increasingly importance within the societies of highly developed countries. In this context the term “health society” has been coined by Ilona Kickbusch who defined health as an economic, social, political, and individual driving force within the modern 21st century society. The health society conveys a comprehensive, active, individualized, and reflationary  Ͷͻ 

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health understanding. 93 This leads to the fact that people value individual health differently, thereby becoming disposed to actively engage in activities which allow them to preserve or retain their health. Simultaneously, the role of the citizen / consumer or patient becomes ever more important, as an active and proficient contribution to the own health is expected. 94 However, due to complex health systems and the growing health care market with all its facets it is not always easy to find the right or wrong information, product, or service. Here it is pointed to the potential value of Web 2.0 within the health care market which can help the user to become an experienced, informed, and aware consumer and patient who is claimed. In turn, the new understanding and significance of health, as well as the corresponding behavior, enlarge and dynamize the market for health information technology and health services / products.95 But, in addition, it leads to the question how to reform medical care and its financing in a way as to accommodate the different societal behavior, values, and norms, counting for a sustainable financial feasibility, as well. Therefore it seems likely, that the health care market will not only be an important market in the future, but also that it will be subject to drastic changes and reorientation.

At this point a further piece of theory, the “Kondratieff Waves” are introduced; it corroborates the existence of a 21st century health society with different needs, desires, and demands, a change in thinking and behavior, as well as a significant growth and change within the health care market. The “theory of the long waves” can be traced back to the Russian economist Nikolai Dmitrijewitsch Kondratieff who recognized that the economic development is not only characterized by short and medium cyclical fluctuations, but that in addition, long economic cycles of 40 to 60 years exist. He published his “theory of the long Copyright © 2010. Diplomica Verlag. All rights reserved.

waves” in 1926; those waves became known as “Kondratieff Cycles”.96 In this  93

Cp. Kickbusch, 2007, p. 6 et seq. Cp. Kickbusch, 2008. 95 Cp. Fonds Gesundes Österreich (Ed.), 2008. 96 Cp. Wandschneider, Rösener, 2004, p.11 et seq. 94

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context, Leo A. Nefiodow (as well as other scientists) revisited this theory, stating that new long-term cycles emerge from path-breaking technological innovations (“basic innovations”) which are accompanied by a tremendous increase in productivity (please refer to Figure 16 below for a depiction of the Kondratieff Cycles, including major demand areas, as well as the corresponding basic innovations and time periods). Currently, we are in the 5th Kondratieff cycle, also called cycle of information and communication technology (ICT) with the digital computer as basic innovation. It can be expected that in the near future, this cycle will be over, becoming superposed by the 6th Kondratieff cycle. The 6th cycle is consequently built on the previous ones, resorting to the needs of the information and communication society.97 Nefiodow and others expect that the leading sector of the 6th cycle will be a holistic view of health, including basic innovations in the fields of information, environment, biotechnology, and medicine.98 Major changes include an integration of providers within the health care market, an increasing shift of health-responsibility to the consumers / patients, knowledge democratization (more transparency, and information sharing), as well as a gain in importance of health promotion. Due to that reason Leo A. Nefiodow stated that health and the health care market will be economic engines and the locomotive in the 21st century. From this statement the future significance of the health care market can be derived. Moreover, since the outcomes of the 5th Kondratieff Cycle (i.e. innovations in the field of information and communication) will keep their vital role within the next cycle, it is very interest-

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ing to see how Web 2.0 suits and influences the health care market.

 97 98

Cp. Lonsert, Schäfer, Harms, 2006, p. 6 et seqq. Cp. Geuenich, 2008, p. 10 et seq.

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Figure 16: The Long Waves and Their Major Demand Areas.99

Due to the aspects mentioned above, it is – by far – not enough to take the current status of the health care market into consideration for the subsequent analysis of the value of Web 2.0 applications for this market, but it is essential to identify major influence factors and their implications for future development.

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After having outlined the significance of health for individuals and societies, the following section provides a survey of official definitions of health, health systems, health care, and the health care market. This allows integrating the health care market in the realm of health, thereby gaining an insight into existent linCopyright © 2010. Diplomica Verlag. All rights reserved.

kages. It has been consciously decided that the underlying concepts of health and the various health systems will be defined, but not deeply discussed within this section, since a focusing on the health care market has been chosen. It  99

Cp. Wandschneider, Rösener, 2004, p.11.

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would extend the scope of research work for this purpose by far if these aspects would be described in great detail.

First of all, the most popular definition of health, to which it is still often referred, was provided by the World Health Organization (WHO) in 1948. The World Health Organization defined health as:

“[…] a state of complete physical, mental and social wellbeing and not merely the absence of disease or infirmity.”100

Here it becomes evident that health comprises more than the pure absence of diseases since this would not allow for the underlying complexity of this phenomenon. However, some critics on this definition have been raised. Major reproaches state that this definition is conceptualized in a too broad way, pointing to an idealistic and utopian state of health which may never be attained. Moreover the definition describes health as a static condition; this does not count for the fact that health is rather a changing process.101

Subsequently, we have to consider the health system which constitutes the framework and has a significant influence on the health care market. It is intended to facilitate the preservation and restoration of health. According to the definition provided by the WHO from 1998, a health system is defined as:

“A formal structure for a defined population, whose finance, management, scope and content is defined by law and regulations. It provides for services to be delivered to people to contribute to their health…delivered in Copyright © 2010. Diplomica Verlag. All rights reserved.

defined settings such as homes, educational institutions, workplaces, public places, communities, hospitals and clinics.”102  100 101 102

The European Observatory on Health Systems and Policies (Ed.), 2007. Cp. Schwartz et al, 2003, p. 26 The European Observatory on Health Systems and Policies (Ed.), 2007.

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In this context it has to be noted that various health system models exist, each having an own structure and priority. In general, it is differentiated between three basic models, i.e. the Beveridge Model (a national health insurance system), the Bismarck Model (a social insurance system), and a market-based health system (no / minimized governmental interference). The characteristics of those are also depicted within the following table (Table 4).

Beveridge Model

Bismarck Model

Market-based Model

Financing

State (taxes)

Social insurance (contributions)

Private (premiums, co-payments, self-payments)

Service provision

Public (central state, region, district, local authority)

Not for profit (charitable, non-profit organizations)

For Profit (private)

Table 4: Classification of Health Systems.103

Going one step further, we may then ask how the term health care can be interpreted; here it is pointed to the following definition:

“Any type of services provided by professionals or paraprofessionals with

an impact on health status.”104 To make this definition more specific it can be amended by the following statement: “Goods and services used as inputs to produce health. In some analyses, one’s own time and knowledge used to maintain and promote health are considered in addition to conventional health care inputs.”105

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The duties and responsibilities of health care are depicted in the following figure, identifying four major areas (prevention, cure, rehabilitation, and (medical) education).  103

Cp. Simon, 2005, p. 68 et seq. The European Observatory on Health Systems and Policies (Ed.), 2007. 105 The European Observatory on Health Systems and Policies (Ed.), 2007. 104

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Figure 17: Tasks of Health Care.106

Following the scope of health care depicted above, it becomes evident that the health care market is the “place” where the tasks of health care become realized. Accordingly, the health care market is defined as:

“A market on which supply and demand for goods and services which serve, directly or indirectly, the facilitation, preservation and restoration of health, as well as the alleviation of suffering caused by ill-health and pain, including the supply and inputs that are provided in order to produce the actual health-related goods and services, meet.” 107

This definition does not only underline the various aspects of the health care market, but also its complexity. Thus it becomes evident, that a clear and unCopyright © 2010. Diplomica Verlag. All rights reserved.

ambiguous definition about the inclusion or omission of certain aspects, goods, services, or situations may be difficult.

 106 107

Cp. Diegeler, 2009. Witherton, 2009.

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͵Ǥ͵ 

First of all, to define the scope of the health care market, the various stakeholders of this market have to be identified. Within the health care market many different actors can be found, each of them having own needs and demands which have to be considered when it is aimed at the provision of valuable Web 2.0 applications. Due to the size of the market, it is important that stakeholders communicate in order to guarantee a well-functioning market. The following figure represents the major stakeholders within this market. Here, the interaction und network character becomes evident, as well.

Figure 18: Stakeholders of the Health Care Market.108

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Another approach defining the scope of the health care market is “segmentation”. Due to the different facets of this market, the health care market is divided into several “segments”. Commonly, it is distinguished between the primary and  108

Adapted from Pauli-Bach, Lewald, 2007, p. 15.

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the secondary health care market which can be further subdivided in turn. The primary health care market includes all aspects of ambulant and inpatient treatments, as well as a person´s protection in case of illness. The goods and services provided by the primary health care market are mostly covered by health insurances (although it has to be noted that the portion paid by insurances is decreasing due to cost reduction programs and health reforms). In contrast, the secondary health care market counts for fields of health-related consumption (e.g. fitness, wellness, health tourism, bio food, etc.).109 Here it is the private person who has to defray the arising expenses. The following figure provides an overview of major sub-markets of the primary and secondary health care market, distinguishing between actors and goods & services. In this context it has to be emphasized that in recent times the primary and secondary market converge more and more which is why a clear separation of activities

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and actors cannot be guaranteed.

Figure 19: Primary and Secondary Health Care Market.110

 109 110

Cp. Grönemeyer, 2009. Adapted from Kartte, Neumann [1], 2008, p. 35 et seq.

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When having a closer look at the scope of the health care market, unfortunately it has to be pointed out that provided data for this market (e.g. expenditures, or number of people employed) vary, depending on the underlying definition of the market. Most official statistics do rarely count for the secondary health care market yet, including only some privately financed expenditures for OTC products or voluntary medical treatments. In contrast, many other institutions base their calculations on a much broader definition of the secondary health care market, including, for example, wellness treatments, health-related travel, or bio food, as well. Therefore the comparison of data coming from different sources is difficult. However, since the secondary health care market is subject to significant growth, it seems appropriate to include all data from this market to provide a comprehensive picture of the health care market in total.

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The health care market is not comparable to other markets. On the one hand, the health care market involves complex decision processes; on the other hand it shows a different structure. On a classic economic market, two market actors (i.e. supplier and consumer) interact, on the health care market, at least three of them can be identified: consumers (insurants and patients), health professionals (i.e. supplier, physicians, etc.), and payers (health insurances, public institutions, government, etc.).111 In addition, the government has a regulatory function to ensure a certain degree of medical care for all citizens. The structure of the health care market with its major market actors, its key functions, and prodCopyright © 2010. Diplomica Verlag. All rights reserved.

ucts can be viewed in Figure 20.

 111

Cp. PriceWaterhouseCoopers Health Research Institute (Ed.), 2005, p. 30.

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Figure 20: Overview of the Structure of the Health Care Market.112

Despite of this complex structure, nowadays, the health care market constitutes one of the largest industry sectors, based on employment and value creation.113 To underline the importance of the health care market, the following figure presents the proportion of health care spending with respect to the GDP of selected countries. Here it becomes evident that on average 10.4% of the GDP are spent for health. It ranges from 8.4% in the United Kingdom to 16% in the

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United States, with Germany being positioned in the middle with 10.4%.

 112 113

Cp. Heigl, 2003, p. 9 & Oberender, Hebborn, Zerth, 2006, p.175. Cp. Berkermann, 2007, p. 3.

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Figure 21: Health Care Spending in Selected Countries in 2007 as a Proportion of GDP.114

In this context it has to be noted that the health care spending as measured by the proportion of GDP may vary due to the underlying definition of the health care market. While the Federal Statistical Office of Germany states health expenditures of 245 billion Euro (approx. 10.5% of GDP) in 2006, a study by Roland Berger states 270 billion Euro (approx. 12% of GDP) for the same year. The figure below reveals the reason for this discrepancy. To a large extent it depends on the underlying definition of the secondary health care market and

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the corresponding inclusion or omission of expenditures.

 114

Cp. Organization for Economic Co-operation and Development (OECD) (Ed.), 2009, p. 8 et seq.

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Figure 22: Total Health Expenditures in Germany 2006 – Comparison of Official and Study Data.115

Despite of this mismatch it appears obvious that people value health highly and are willing to privately pay for health services, if necessary. Currently, it has to be observed that expenditures by the compulsory health insurance (CHI) still constitute the largest proportion; astonishingly it is directly followed by expenditures within the secondary health care market (private financing). Here a further shift in expenditures towards private financing can be expected.

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Whether this is a real voluntary action might be disbelieved since more and more benefits become excluded by health insurances and publicly financed benefits due to an increasing pressure to cut costs (ironically often coming  115

Cp. Müller, Böhm, 2009, p. 15 et seqq. & David, Neumann, Friedl, 2009, p. 8.

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along with so called “health care reforms”). Therefore people are faced with a Hobson´s choice if they do not want to abdicate certain benefits. In turn, if people increasingly have to finance health expenditures privately, a certain level of knowledge on existing benefits, possibilities and options is required to make a rational and reasonable decision. At present, a sufficient level of required knowledge amongst patients and consumers has to be questioned. Here – for example – Web 2.0 applications might support further education of this target group, as well as it might encourage people to engage and actively participate in health discussions online due to the appealing characteristics of such applications.

When looking at the status quo of the health care market, the attention has also to be drawn to the employment factor. The number of people employed within a sector provides an indication of the size and volume of a market. Currently, the primary health care market provides more than 4.4 million of jobs, accounting for about 10% of all jobs in Germany.116 x

3.655.000 persons employed in the ambulant and inpatient care

x

311.000 persons employed in intermediate consumption industries of the health care sector (e.g. pharmaceutical industry and medical laboratories)

x

403.000 persons employed in administration (including EMS 117 , public health, and other facilities)118

To make a correct estimate, a certain number of additional jobs, provided by the secondary health care market, have to be added to this 4.4 million; unfortunateCopyright © 2010. Diplomica Verlag. All rights reserved.

ly, this number cannot be specified further.  116

117 118

Basis: 43.410.000 persons employed in Germany in 2008; Federal Statistical Office Germany. EMS, abbreviation for Emergency Medical Service. Cp. Bundesministerium für Gesundheit (Ed.), 2009, p. 103 et seq.

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͵Ǥͷ    

As is has been stated before, the health care market is a complex market with many actors and functions. Thus, several influence factors can be identified which determine the future development of this market. These will be outlined in the following, prior to the discussion how the health care market might look in the future. Nowadays people value health differently than a decade ago. Of course, this has a significant influence on their behavior with respect to healthrelated goods and services, thereby influencing the further development of the health care market as such. However, in addition to this common adaption to changing needs, three major influence factors have to be considered as most important: the demographic change within the population, medical-technological progress, and political determining factors.

Demographic Changes: The Aging Population

Forecasts indicate a huge change with respect to age and structure of the population, not only for Germany, but also for most other developed nations. Here, two major tendencies can be identified: On the one hand, the birth rate will drop further, resulting in a total decline in population. For example, it can be expected that the population of Germany will decrease from 82.5 million in 2005 to 69-74 million citizens in 2050 (already considering migration effects). On the other hand, a shift in the relation of younger and older people will occur. In the future, the proportion of older people within a society will rise significantly; it is

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forecasted that in 2050 only half of the population in Germany will be in an employable age, in contrast, 30% of the population will be aged 65 years or older, and only 15% will be aged 20 years and younger. Comparing this to today´s figure an increase of people aged 65 and older of about 11% has to be

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marked.119 This development towards an “older” population can be traced back to both, an increase in life expectancy and the simultaneous decline in birth rates. Major worldwide demographic changes with respect to different continents can also be viewed in the following table (Table 5), underlining the above stated development.

Table 5: Demographic Changes across the World.120

Of course, this development has a significant effect on the health care market, as well. However, the direction of the effect depends on the perspective. Therefore, it has to be distinguished between the supply side (health providers), the demand side (consumers and patients), as well as the governmental perspec-

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tive.

From a supply perspective, the “demographic aging” is a positive trend due to a further growth of the health care market. However, it has to be distinguished between the consumption- and the provision-market. While in the provision  119 120

Cp. Statistisches Bundesamt [4] (Ed.), 2006, p. 5 et seqq. Cp. The Berlin Institute for Population and Development (Ed.), 2008, p. 3.

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market growth is limited by regulation, the consumption and “lifestyle-health” market is expected to experience a huge growth, especially in the field of pharmaceuticals and treatments for older people, as well as preventive goods / services.121

Having a look at the demand side, we have to consider the re-shaped health awareness on the one hand, and differing needs of elderly people on the other hand. Regarding this, it can be expected that the demand for products ranging in the secondary health care market, as well as for (long-term) care and treatment of chronic diseases will grow. People do not just want to live longer but do this with the best possible health condition. Therefore, people will be increasingly content to pay for benefits on their own if health care insurances do not cover certain treatments; this is especially the case since the elderly have a relatively high purchasing power.122 Here, the needs and demands of the elderly have to be considered when creating Web 2.0 applications for this target group, as well (see also Chapter 2.5 “User Topography”).

In contrast, from a governmental or health insurance perspective this aging trend is expected to constitute a further burden for the financing of the health care system. On the one hand, revenues will decrease due to a higher proportion of elderly people (who pay lower premiums), on the other hand the aging process may lead to higher total expenditures (however, whether this assumption is true is still controversially discussed).123 Against the background of this development, a reformation of the health care system seems to be urgent. If government and health care providers fail to succeed in decreasing costs and simultaneously increasing efficiency, thereby undergoing a complete structural Copyright © 2010. Diplomica Verlag. All rights reserved.

change, the health care system´s financial feasibility cannot be guaranteed for long.  121

Cp. Heigl, 2003, p. 16. Cp. Heigl, 2003, p. 12 et seq. 123 Cp. Stanowsky, Schmax, Sandvoß, 2004, p. 6 et seqq. 122

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Innovation: Medical and Technological Progress

Another important driver of the development of the health care market is constituted by innovative medical as well as technological progress.124 Those innovations lead to increased sales and production volumes on the one hand, and to enhanced quality and levels of provision on the other hand. However, medicaltechnological innovations are also the driving force for the increase in costs which in turn necessitate solutions in the fields of information technology, portability, process management, as well as communication and networking (Æ Web 2.0). If applied properly and / or in a wise combination, medical and technological innovations do not necessarily pushup costs, especially if gains in efficiency and effectiveness can be realized.125 This can be exemplarily outlined by the example of the virtualization of health care, often referred to as “eHealth” (see also Chapter 4.1 and 4.2). Making use of this innovation, suppliers, as well as consumers / patients can benefit from this trend, e.g. by an increased quality and efficiency, an eased process of administration, or reduced costs. New applications include online-monitoring of vital functions (replacing personal medical visits), online information search for health-related topics, collaboration platforms for medicals, and so on, naming just a view.126

Regulatory Affairs: Political Interventions

The third major influence factor determining future growth of the health care market are interventions made by government. In many cases, the health care market is strongly regulated by government which justifies this intervention by Copyright © 2010. Diplomica Verlag. All rights reserved.

the market failure of the health care market. Therefore, the government is expected to facilitate a suitable framework for a functioning market with free  124

Cp. Stanowsky, Schmax, Sandvoß, 2004, p. 6 et seqq. Cp. Berkermann, 2007, p. 7. 126 Cp. Heigl, 2003, p. 16. 125

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supply, demand, and competition.127 Therefore the scope of future interventions of government, especially in the fields of financing, budgeting, as well as rules & regulations setting, will partly determine the development of the health care market. In this context it is discussed in how far government should interfere. While some argue, that it is a core duty of government to do so, others would prefer a lower level of interventions to provide actors within the health care market with a higher degree of freedom. Similarly, a recent study by the health insurance provider “Continentale” found out that 52% of German citizens would prefer a lower level of government interaction, as well.128

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According to the expectations of experts, the health care market is supposed to grow within the following years. In addition, various studies have investigated this topic, confirming this impression of future growth. In this context, the influence factors depicted above play a key role for the identification of the structure and size of the prospective health care market. Major problems to be dealt with in the future will be the issue of coping with a new kind of patient / customer, their new claims, resulting from their new and more sophisticated understanding of health and health care, the assurance of a nationwide provision of health care (especially with respect to rural areas), and the issue of financing future expenditures (finding a financially feasible and fair way of allocation).

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Regarding the mental change of patients, it can be expected that patients increasingly convert to self-confident customers who need to be put into the center of health care and being treated appropriately. The “new” patient-customer  127 128

Cp. Stanowsky, Schmax, Sandvoß, 2004, p. 8. Cp. Continentale Krankenversicherung a. G. (Ed.), 2009, p.12.

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prefers a holistic satisfaction of his needs and demands with adequate service, not only the pure treatment of his illnesses.129 This is often referred to as “patient empowerment” indicating the tendency towards a self-dependent, critical, responsible, and well-informed patient who claims a larger influence on his medical treatment and care (see also Chapter 8.1). 130 This development becomes noticeable in the adapted and / or new products and services created for patients / customers, new marketing methods, and a changing doctor-patient relationship where the borders between health professionals and laymen become more and more indistinct. In this context it is not astonishing that major growth is expected within the secondary health care market. Market research has found out that in 2003, 49 billion Euro have been spent for secondary health care market products and services, in 2007 these private expenditures summed up to 60 billion Euro (with an additional willingness to pay for further 16 billion Euro), for 2020 expenditures of more than 75 billion Euro within this market are expected (conservative prognosis).131

With respect to the assurance of an area-wide health provision, it can be assumed that one tendency is constituted by an expanded virtualization of the health care market to cope with an increasing shortage of health professionals and financing problems on the one hand, and to increase value for all parties, enhance the information and education of patients / customers, as well as to support new and more convenient possibilities for the promotion and delivery of health, on the other hand.132 Amongst others, the application of Web 2.0 in the health care market ranges in this category, too.

With regard to the cost aspect, it can be anticipated that a structural change is Copyright © 2010. Diplomica Verlag. All rights reserved.

needed, resulting in a more efficient and effective health care management. According to a study of Roland Berger, the market for health and health-related  129

Cp. Sollmann, 2006, p. 141. Cp. Ziltener, 2008. 131 Cp. Kartte, Neumann [2], 2007, p. 5. 132 Cp. Fischer, Patzer, 2007, p.1 et seq. 130

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services will account for 453 billion Euro in Germany in 2020. This implies a rise of costs of about 74% as compared to 2003. How this figure has been derived can be viewed in Figure 23. It has to be noted, that not all private expenditures have been included within this calculation. Even if those figures are adjusted for potential cost reduction possibilities (e.g. efficiency gains, modernization of CHI benefit catalog), the health care market is expected to account for a volume of 398 billion Euro in total in the year 2020.133

Figure 23: The Market for Health Products in Germany: Expected Development until 2020 [in €].134

Here it becomes evident that if the expected development of expenditures – as Copyright © 2010. Diplomica Verlag. All rights reserved.

depicted in Figure 23 – comes true, it might not be possible to publicly finance the health care expenditures for long. As one can extract from Figure 24, a continuous rise up to 41% (worst case) or 21% (best case) in 2070 of the proportion  133 134

Cp. Kartte, Neumann, Kainzinger, 2005, p. 25. Cp. Kartte, Neumann, Kainzinger, 2005, p.11.

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of health care spending on GDP is forecasted. Of course, this development would not be financially feasible since health care expenditures would then grow at the expense of other important economic sectors. Options to counteract are, for example, efficiency gains, cost shifts to patients (“self-payment”), or finding a way to generally decrease production / servicing costs.

Figure 24: Projection of Health Care Expenditures as Proportion of GDP 2001 to 2070 in Germany.135

By now, a beginning change and reorganization can already be noticed within the health care market, entailing completely new exigencies. 136 However, it should not be neglected that the process of transformation can only be successful if it is guided by conscious actions and if the development is not left to its own devices. In this context, the following major critical principles have been

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identified by IBM:137

 135

Cp. Schlander, Schwarz, 2005, p. 184. Cp. David, Neumann, Friedl, 2009, p. 2. 137 IBM Global Services (Ed.), 2006, p. 2. 136

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x

Focus on value o Consumers, providers, and payers will agree upon the definition and measures of health-care value and then, direct healthcare purchasing, the delivery of healthcare services, and reimbursement accordingly.

x

Develop better consumers o Consumers will make sound lifestyle choices and become astute purchasers of healthcare services.

x

Create better options for promoting health and providing care o Consumers, payers, and providers will seek out more convenient, effective, and efficient means, channels, and settings for health promotion and care delivery.

Finally, the following figure sums up major developments and changes with respect to key drivers (Figure 25138). It becomes obvious that it is not as simple as

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it may seem to find an adequate solution.

 138

Cp. Sell, 2005, p. 63.

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Figure 25: Structural Change of the Health Care Market. Copyright © 2010. Diplomica Verlag. All rights reserved.

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ͶǤ   ʹǤͲ  

Figure 26: Web 2.0 in the Field of Health Care: Major Target Groups, Applications & Purposes.139

Within previous chapters the peculiarities of the health care market have been

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outlined. In this context, several problems and challenges have been identified. Since information and communication technology (ICT) in general, and the Internet in specific, find its way into more and more business as well as private  139

Own source.

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fields, its potential value should not be neglected for the health care market to keep up with the times. Here it is pointed to the famous saying: “If you don't go forwards you go backwards.”, i.e. only a continuous improvement by implementing modern innovations can help to bring the health care market forward, thereby keeping and making it attractive, functioning, and successful. The following chapters will discuss the possibilities and chances which open up by the use of Web 2.0 in the field of health care. The potential of Web 2.0 has to be viewed in a differentiated way, as several user groups, means and applications, as well as purposes and aims have to be considered. Here, the figure above (Figure 26) provides a first overview of major target groups, depicted outside the corners of the octagon, major means and applications (white area), as well as major purposes and values (grey area). Subsequently, these aspects will be discussed in greater detail.

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In recent years an increasing virtualization of the health care market can be noticed, i.e. more and more activities, as well as the creation and delivery of services, are shifted to the Internet. Online pharmacies spring up like mushrooms, pharmaceutical companies use the Web to inform about new studies or drugs, patients “google” their disease(s) and search for remedy in forums, almost every health insurance provider informs customers about benefits, selected health topics and news on their web portal, and physicians use the Internet to schedule appointments with their patients online. These are just a few examples of how the Internet finds its way into the health care market. Of course, online Copyright © 2010. Diplomica Verlag. All rights reserved.

offers have to be convenient (structure, design, layout, 24/7 availability), easily accessible and comprehensible to the layperson. Here, Web 2.0 does not only ease the way of content creation for the provider, but also makes the online service more attractive, valuable and useful for its visitors.

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The virtualization of the health care market constitutes a “mega-trend” and has far-reaching effects on all subdomains of this market. This trend influences and develops patients and customers by an immediate and ubiquitous provision of information. In addition, a direct exchange of experiences and opinions of ill people is supported by Web 2.0. Likewise, Web 2.0 allows a health provider to actively integrate the patient / consumer into the value creation. 140 The consumer / patient, becoming increasingly medically educated, critical and responsible, demands new voices concerning the preservation or restoration of his own health. There is talk of patient empowerment and shared decision making in this regard. In turn, boundaries between laypersons and experts become blurred, with patients turning to customers and physicians acting as service providers.141

ͶǤʹʹǤͲ   In the context of the above outlined virtualization, it is not only the term Web 2.0 to which it is often referred, but it is also “eHealth” which is pulled together. Despite of their coherence it is a wrong conclusion that “Web 2.0 in health care” and “eHealth” embody the same meaning. According to the WHO, eHealth can be defined as following:

“[…] eHealth aims to support countries in further developing their health systems by improving access, quality and efficiency, through the use of information and communication technologies.” Additionally it is stated that: “eHealth can support the different functions of the health system,

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providing a unique opportunity for strengthening the information, intelligence and knowledge processes.”142  140

Cp. Simmet, 2008, p. 4. Cp. Fischer, Patzer, 2007, p. 1. 142 Haas, 2006, p. 7. 141

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Here it becomes evident that Web 2.0 comprises only a part of eHealth, i.e. one could argue that it is a new variety of ICT used, facilitating an advanced performance of eHealth by supporting existing eHealth applications as well as creating new ones.143 This conclusion can also be derived from the figure presented below. As one can see, a healthy population has highest priority (mission). It is tried to reach this aim by the installation of a health care system which in turn has certain aims to reach the mission (e.g. a certain level of performance, customer orientation, or providing economic efficiency). On this basis, eHealth exhibits certain aims to support the achievement of the superior aims of the health care system. In this context, Web 2.0 can be seen as a supporting factor, for

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both, eHealth as well as the health care system itself.

Figure 27: The Realm of eHealth and Web 2.0.144

 143 144

Cp. Karkalis, Koutsouris, 2006, p. 3. Adapted from Fitterer, Mettler, Rohner, 2009, p. 9.

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The following major eHealth services have been identified which can be enhanced by Web 2.0 applications. 145 This outline is expected to serve as an overview; detailed information on the respective applications of Web 2.0 will be given subsequently. x

Tele-advice: Giving medical advice by bridging time and space between physician and patient (distant consultation), e.g. by using medical forums or direct doctor-patient chats (e.g. via Skype or MSN Messenger).

x

Tele-diagnostics: Making a diagnosis by bridging time and space, e.g. by using shared medical wikis.

x

Medical documentation: Collecting and administrating illness-related data of a patient, e.g. by using patient blogs.

x

Health portals: Provisioning health information and services for layperson via an aggregated platform in the Internet.

x

Personal health management: Collecting and administrating personal health information, e.g. by using “Google Health” 146.

x

Networks: Exchange of health-related information via the Internet, e.g. by using shared wikis, or medical virtual communities.

x

Professional directory-services: Central collection of health-related data of approved materials, individuals, or institutions, e.g. by using social bookmarking and tagging.

x

(Medical) literature management: Provisioning of evidence-based, medical knowledge for research and education purposes via the Internet, e.g. by using shared wikis.

x

E-Learning: Provision and procurement of medical basic- and expertknowledge for multi-media-based learning via the Internet, e.g. by using

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interactive “Web 2.0” applications.

 145 146

On the basis of Fitterer, Mettler, Rohner, 2009, p. 13 et seqq. See https://www.google.com/health for further information.

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x

E-Collaboration: Collaboration of all (some) actors by bridging time and space, e.g. by using shared wikis, Skype, health forums, or health portals.

ͶǤ͵ǣ  ʹǤͲʹǤͲ

When having a closer look to existing literature it is remarkable that various terms like “Medicine 2.0”, “Patient 2.0”, as well as “Hospital 2.0”, “Health 2.0” and a lot more can be found. These terms came up in the style of the term Web 2.0, whereby the “2.0” is intended to indicate a new version. Sometimes it is even already referred to “Health 3.0” and “Health 4.0”.147 However, the author has the impression that “2.0” is haphazardly added to each and every possible term and therefore shares the opinion of some experts in this field who state that:

“[…] “Medicine 2.0”, and “Health 2.0” are terms that should probably be avoided in academic discourse, any discussion and evaluations concerning the impact and effectiveness of Web 2.0 technologies should be framed around these themes.”148

In addition, up to now, no uniform definition(s) of these terms can be found within literature. Depending on the source(s) used, definitions vary. Despite, it is pointed to definitions of “Health 2.0” and “Medicine 2.0” to show their similarity

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and underline the statement(s) given above. According to Bos, Carroll, and Marsh, “Health 2.0” includes healthcare social networking communities with user-generated health care. Another source, defines “Health 2.0” as  147 148

Cp. McCabe Gorman, den Braber, 2008, p.1. Eysenbach, 2008, p. 3.

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“The use of Web 2.0 technologies within health care to affect health care for the better, particularly in terms of increased consumer participation in health provision.”149

Here one can see that definitions vary heavily with respect to the included scope. While the first definition by Bos, Carroll, and Marsh focuses on social networking communities within health care only, the second one includes a much wider range of applications.

Similarly, “Medicine 2.0” had been defined initially on the first Medicine 2.0 Congress in Toronto, 2008 as:

“Medicine 2.0 applications, services and tools are Web-based services for health care consumers, caregivers, patients, health professionals, and biomedical researchers that use Web 2.0 technologies and/or semantic web and virtual-reality tools, to enable and facilitate specifically social networking, participation, apomediation, collaboration, and openness within and between these user groups.”150

In contrast, others even do not make a significant difference between “Health 2.0” and “Medicine 2.0”, they just state that both subsume five major salient

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themes:151 x

the participants involved (doctors, patients, etc.)

x

its impact on both traditional and collaborative practices in medicine

x

its ability to provide personalized health care

x

its ability to promote ongoing medical education

 149

Doherty, 2008, p. 50. Eysenbach, 2008, p. 3. 151 Cp. Hughes, Joshi, Wareham, 2008. 150

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x

its associated method- and tool-related issues, such as potential inaccuracy in end-user-generated content

All these definitions have in common that they describe aspects of Web 2.0 in the field of health care in any context. One can imagine how complex and farreaching this topic can be understood. Some provide more comprehensive definitions while others focus on certain aspects only. For other catchwords like “Hospital 2.0” or “Physician 2.0” not even once proper definitions can be found. Therefore, since no uniformly agreed definitions can be provided yet, it has been decided to stick to the term Web 2.0 in the field of health care, allowing for

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the broadest possible scope of application.

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ͷǤ    ʹǤͲ  

Of course, different stakeholders exhibit different needs and expectations concerning health and health care. What is of great interest for one group might not be interesting for another group at all. This is why it must be outlined that “the scope of the health-related Internet applications is ´as broad as medicine itself´”.152 Thus, the following sections present the most valuable Web 2.0 applications distinguishing by type of user. In this context it has to be noted that only these applications adding value for the respective group are discussed.

The patient (or consumer respectively) is one of the most important – if not even the most important - stakeholder of health care in general, and Web 2.0 applications in the health market in specific. This has been underlined by the movement of health care towards a “consumer-centric health care”, as well. While in earlier times, physicians have been put into the center of health care, it is nowadays the patient who gains greatest attention. Therefore the following sections will outline and discuss major advantages and values a patient / consumer can draw from Web 2.0 applications. Of course, the stakeholder group patients / consumers is not a homogeny one but rather divided into further sub-groups (with specific needs and interests) like it is depicted in the following figure. It has to be distinguished between healthy consumers, patients with symptoms, patients with a validated illness, and finally those who are chronically ill. While a healthy consumer might just be interested in some information about preventive treatments and general information on health and health care, a chronically ill

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patient has a need for tailored and specific information about options of treatment, medicaments and advice. Therefore, Web 2.0 applications have to take into consideration the interests of its potential target group and adapt the offer  152

Cp. Cline, Haynes, 2001, p. 672.

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to these needs. Similarly, not every application does fit to every intention which .

is why the type of application has to be chosen diligently.

Figure 28 Patients and Sub-groups with Corresponding Needs and Valuable Applications.153

ͷǤͳ    ǣ  

According to blog search engines, hundreds of thousands patient blogs exist.

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Patient blogs refer to blogs which are written by patients (for a general definition of blogs please look at Chapter 2.4.1). Most often, patients writing a blog, have been diagnosed a chronic or severe prolonged illness. In this context, a blog dedicated to experiences and thoughts referring to this illness can help patients  153

Own source.

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in many respects. Up to now, only little research has been conducted about the effect of blog-writing on illnesses. However, one of the first studies (by Ohio State University) reveals that blogs may help fighting a serious illness and make patients feel they can cope with their condition.154 Therefore, it can be expected that on the one hand, they may provide a therapeutic experience. By blogging about opinions, feelings, and experiences, patients can share their knowledge with others who may come upon a similar situation.155 This is especially important when dealing with rare diseases where the number of persons concerned worldwide is very low. These patients can connect regardless of physical, geographical or other limitations. Thus, patient blogs provide a venue for personal expression and peer emotional support. On the other hand, personal patient blogs can provide valuable information to health professionals (e.g. attending physicians) receiving an insight into the mental, physical and emotional state, opinions, and habits of his / her patient(s).156 Despite their potential, the downsides of patient blogs should not be neglected. Major concerns include the possibility that people, being in a state of emotional instability, may reveal more of their thoughts than they really would like to. Another threat is potential misinformation157, given by fellow patients. Here one should always remember that blogs express personal opinions, and not necessarily medical truth. Therefore quality and accuracy have to be reviewed critically since blogs do mostly not follow certain quality guidelines.158 In this context, it is pointed to the “Health on the Net Foundation” (HON) which promotes and guides the deployment of useful and reliable online health information and its appropriate and efficient use. Their “HONcode” offers a multi-stakeholder consensus on standards to protect citizens from misleading health information.159 For a brief overview of the HONcode and its principles please refer to Appendix I. Finally, the most critical fact Copyright © 2010. Diplomica Verlag. All rights reserved.

concerning patient blogs - as considered by the author - is that patient blogs  154

Cp. Munshi, 2008. Cp. Cohen, 2007. 156 Cp. Reisman, 2009, p. 154. 157 Cp. Munshi, 2008. 158 Cp. Childs, 2005, p. 2. 159 Cp. Health on the Net Foundation (Ed.), 2009. 155

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may be abused by the pharmaceutical industry as it has been revealed in April, 2009, for example. It turned out some companies misused patient blogs for their own purposed by writing “faked” comments to blog entries, advertising and promoting their own drugs intrusively.160

Finally, to provide the reader with some examples of patient blogs, it is pointed to Appendix II which outlines some prominent patient blogs, including title, its links, as well as a short description.

ͷǤʹ ǣ   Ƭ

Nowadays, a huge number of different patient communities / networks can be found on the Web, some of them being more general and / or including many sub-groups, others being dedicated to a specific illness only. All have in common that they provide a place for patients with similar interests, enabling them to connect to fellows, thereby building up a virtual network. In addition, the way of communicating, interacting, and exchanging information with peer friends is eased. Of course, social networks are intended to facilitate new connections to people sharing the same interests, as well. Research has found indications that

“A stable and supportive social network improves health outcomes for people with a wide range of conditions […]. In addition, social networks

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have a palliative effect on preoperative pain and anxiety.” 161

To gain an impression, a small selection of examples of patient communities and networks are outlined in Appendix II. Patient communities are especially  160 161

Cp. Gulli News (Ed.), 2009. Sarasohn-Kahn, 2008, p. 4.

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valuable to these who suffer from a chronic or rare disease since here virtual networks sometimes constitute the only possibility to find fellow sufferers and to exchange experiences with them, thereby gaining valuable hints and tips. These people can resort to a wide international variety of perspectives and experiences by using patient communities which would offline not be the case.162

When dealing with patient communities / networks O´Reilly´s concept of “the wisdom of the crowds” has a strong effect (see also Chapter 2.2.2). The value of information increases disproportionately high with the number of patients sharing their experiences, information, ideas, symptoms and treatment options. Therefore it can be stated that a patient network lives on its members, even the best network is worthless when it is used by a few number of people only.

When comparing face-to-face (F2F) self-help groups (i.e. real life meetings with fellow sufferers), with virtual patient communities / networks it becomes obvious that benefits of virtual communities go far beyond those of F2F ones. Of course, virtual communities also incorporate exclusive disadvantages which cannot be found in F2F groups. Therefore the net benefit has to be weighted. However, if patients are educated about risks and benefits and how to behave in the virtual world, if they adapt to certain rules for online behavior and keep a critical attitude, knowing that not all information found on the WWW must be true, it can be expected that benefits are significant and outweigh risks and disadvantages. The following table provides a comparison of advantages and disadvantages in summary, thereby outlining the differences in F2F self-help groups and virtual

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patient communities/networks (Table 6).

 162

Cp. Seeman, 2008, p. 107.

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Advantages, being unique to virtual patient communities

Disadvantages, being unique to virtual patient communities

Convenience of access. The asynchronous virtual patient communities are available to members 24/7 and location-independently.

Technology issues. Membership in online communities is limited to people with access to computers and the ability to type. Learning how to access and participate in a desired online group may be far more complicated than showing up for an F2F meeting.

Increased access to diverse members. Geographical restraints do not exist, and the nature of text-based relationships removes most of the influence of status, age, gender, dress, weight, or other barriers.

Misunderstandings due to the nature of textbased relationships. There is a propensity for disinhibition, projection and transference, when there are no visual or auditory inputs that can place the text in its proper context, or assist the correct interpretation of the text.

People in rural areas now have access to a wide range of self-help support that was previously unavailable to them.

High signal to noise ration. There are few controls in virtual patient communities to prevent people from posting advertisements, erroneous information, or messages that are off-topic.

Online anonymity makes virtual patient communities members more comfortable in sharing sensitive or potentially embarrassing information.

The major baffler to the use of online support networks is the current lack of universal access to them.163

Advantages, common to virtual patient communities AND F2F self-help groups

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Groups help normalize the behavior or condition in question. The conditions, which have been marginalized and stigmatized, become acceptable by association with others for whom this condition or behavior is a common occurrence.

Disadvantages, common to virtual patient communities AND F2F self-help groups It is difficult to assess the therapeutic value or to predict which of the members are being helped. Virtual patient communities are similar to F2F groups in that there is a strong selfselected positive bias; the group is composed of people who found value in their membership.

 163

Cp. Madara, 1998.

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The members become empowered by exposure to the experiences and positive coping strategies of others. This empowerment initially manifests as hope, which is an important factor in effecting cognitive or behavioral change. Groups provide exposure to role models along with expanded opportunities for social interaction.

There is a potential exposure to misinformation, along with the possibility of raising false hopes. There is little data regarding the downside of F2F self-help groups, but the potential for the dissemination of false information is mentioned by several research articles.

The group tends to focus on the inner strengths of the individual, rather than on the person´s pathology (Riessman, 1997).

Table 6: Advantages & Disadvantages of Virtual Patient Communities as Compared to F2F Self-help Groups.164

A Special Case: ICYOU – A Video Community

A (smaller) sub-category of patient communities is constituted by video communities, providing only videos dealing with health and healthcare. One prominent example of such a health-related video community is “ICYOU”.165 ICYOU is a user-generated video community that empowers patients to make informed health decisions. It describes itself as:

” […] the Web’s only destination focused solely on bringing you the whole world of healthcare video. From important medical breakthroughs to the latest diets, from recipes for people with diabetes to vlogs from cancer patients, ICYOU is healthcare video.”166

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Patients are allowed to easily upload own videos, watch videos from others, as well as to comment on those. Only a prior (free) registration to the community is  164

Adapted from Storm A. King, 2004, p. 65 et seqq. Cp. http://www.icyou.com 166 Cited from http://www.icyou.com/about. 165

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necessary. The advantages of such a health video community are for sure the visualization of difficult or complex health aspects which facilitates a better understanding of a certain aspect by patients. However, due to the fact that no more health video communities followed in the WWW it has to be questioned whether patients accept this form of online communication. In addition, the question arises whether patients are willed to upload own videos with a sensitive content since these videos are normally highly private. Here it can be expected that more patients are likely to watch videos but are not disposed to upload videos themselves. Thus it is a moot point whether the value of the health video community is so great since it lives on user-generated content and a certain number of active patients (“critical mass”).

ͷǤ͵   Ǧ Ƭ 

Nowadays, an increasing variety of medical, health, and health-related podcasts can be found in the WWW. More and more companies, institutions, and organizations recognize the benefit of providing such podcasts to patients and consumers. However, it has to be confessed that the use of podcasts (creation as well as downloading) in the field of health and health care is still rather low. The podcast search engine “Podcast - Suche” (www.suche.podcast.de) offers 224 podcasts when searching for “Gesundheit”, 5 offers for “health”, 88 entries for “Medizin”, and 0 for “medicine”. The range of topics is never-ending and includes nutrition and other advice, new therapy information, advertisements, and

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information on current trends and topics. With the help of RSS (see also Chapter 2.3), patients / consumers can subscribe to a series of podcasts and are then informed as soon as a new episode is put online.

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As research has shown, podcasts can have a significant potential in the field of patient education.167 By using podcasts, health providers can easily inform their customers about relevant news or enhance customer loyalty as part of its marketing strategy. However, due to the podcasts´ nature of one-way communication only, they might not constitute the best choice, depending on the intention and topic. According to the ConSerT-Study from 2007 (“Web 2.0 Applications for Medicine and Health”)168, in which 52 health-related podcasts have been examined, most existent podcasts in the field of health came from private people (17%), the radio (15%), health providers (15%), and agencies (12%). Health insurance providers were responsible for 10% of all considered podcasts. Only 6% of all podcasts were produced by pharmaceutical companies; this is partly astonishing since they might gain the greatest benefit by marketing their new products indirectly and providing valuable information for patients suffering from specific illnesses (e.g. new treatment options with a newly approved drug from them). Concluding, it is doubted whether podcasts will become a major application in the field of health and medicine for patient education due to their somehow inconvenient nature (one-way communication only, recording of podcasts, etc.). Here, other applications might fit this purpose in a better way. Nevertheless, to provide the reader with some podcasts, considered to be inter-

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esting, Appendix II outlines some examples.

 167 168

Cp. Boulos, Wheeler, 2007, p. 6. Cp. ConSerT (Ed.), 2007.

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ͷǤͶ     ǣ    

The theory of wikis and the benefits they offer in general has been discussed within Chapter 2.4.4. In the following it is outlined in which ways wikis can be of value for patients. Up to now, only few “pure” patient wikis can be found on the Internet. Reasons for that can be expected to be up to the relatively high effort to keep wikis up-to-date. In addition, if one does not want to rely on the corrective power of the patient group (“wisdom of the crowd”), an ongoing monitoring of the wiki is needed in order to guarantee profound and correct information. Wikis are applied majorly for three reasons in the field of health care: sharing of knowledge (collaboration), provision of information, and for running community projects. Most wikis designed for patients are intended to provide information for these people and therefore play a vital role in the field of patient education. Collaboration between patients is not a great issue so far. A future vision might be the introduction of wikis for specific patient groups running a project together (e.g. a weight loss group, or patients enrolled in a certain clinical study) to facilitate the exchange of information and track their project progress.

With respect to patients, it has to be distinguished between wikis which are edited by patients and those which are “read-only” for them. Currently, the most prominent example of a “read-only” medical wiki is Medpedia169 (see screenshot below, Figure 29). Medpedia is a new project in cooperation with famous medical universities (e.g. Harvard Medical School, and Stanford School of Medicine), intended to provide a worldwide knowledge platform for medicine, health, and the human body, not only for health professionals but also the interested public

Copyright © 2010. Diplomica Verlag. All rights reserved.

(e.g. patients). For quality purposes, only health professionals are allowed to write articles. The public is allowed, for example, to read articles, suggest changes to articles, and follow important articles that they are interested in.170  169 170

Cp. www.medpedia.com, currently available in English only. Cp. Medpedia Website (Ed.), 2009.

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However, despite of its “read-only” nature, it must be pointed out that Medpedia may be of great help for patients, since they can find professional and reliable information with respect to their illness or other health topics.

Figure 29: Screenshot from Medpedia: Example “The Eye”.171

In contrast, there exist wikis which are edited by patients, as well. One example here is Diabetes Wiki172 which is open for everyone to join and write and / or edit articles. Furthermore, of course, the well-known “Wikipedia” 173 offers articles on health-related topics and illnesses, as well. Both approaches of wikis (read-only / read-write) have their advantages and disadvantages. Advantages for patients of read-only wikis lay in the expected higher accuracy and reliability Copyright © 2010. Diplomica Verlag. All rights reserved.

of information due to professionals writing the articles. In contrast, the quality of read-write blogs has to be questioned. However, here it is pointed to the hypo 171 172 173

Cp. http://wiki.medpedia.com/Eye (12/02/2009). Cp. http://diabetes.wikia.com/wiki/Diabetes_Wiki. Cp. www.wikipedia.de (German); www.wikipedia.com (English).

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thesis that the process of many patients writing the wiki leads to “Darwikinism”174, i.e. a finally high quality reached by the constant improvement of articles by fellow authors (“survival of the fittest (article)”).175 To prove this thesis, further research is necessary since the correctness and reliability of information is especially important in the field of medicine and health(care). Despite, readwrite wikis exhibit another advantage: patients might view a topic from a totally different perspective than professionals do. Therefore patients can add valuable information for other patients which professionals do not consider important, helpful or necessary. Finally, it remains to be seen if wikis will win a permanent fixture in the field of patient education, information and communication. In Appendix II, the reader can find a list of some wiki examples, to have a starting point for exploring patient wikis online.

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Since the amount of health information on the Internet is vastly growing day by day, the detection of relevant information for a specific problem constitutes a large searching effort for patients. Moreover, it may be difficult for them to assess the quality of information. Here, social bookmarking and tagging can make a contribution to the simplification of the search process. As outlined in Chapter 2.4.5, social bookmarking services allow users to collect, annotate (tag) and share their favorite web links in a virtual, open environment which others are allowed to read and use.176 Therefore social bookmarking tools are excellent Copyright © 2010. Diplomica Verlag. All rights reserved.

resource discovery tools, facilitating the creation of communities with same in-

 174 175 176

Darwikinism describes the “socially Darwinian process” that wiki pages are subject to. Cp. Boulos, Maramba, Wheeler, 2006. Cp. Boulos, Wheeler, 2007, p. 6.

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terests, as well.177 If now a significant number of patients / consumers provide their collection of bookmarks to a specific topic in the field of health(care) (e.g. websites on a certain illness) for others, one will see which links are bookmarked most often from the community. In turn, it can be assumed that these websites which provide greatest value exhibit a higher number of bookmarks. Therefore other patients seeking information to the same topic can resort to these link lists and follow the links which are expected to provide greatest value for them. Here, the activities of all patients / users function as a “collaborative filter”, allowing only valuable information to survive. The aspect of quality of information is especially important in the field of health since here the provision of false information may have tremendous effects. Social bookmarking can help to minimize the risk of receiving harmful information due to its power of participation and the “wisdom of the crowds”, two major principles of Web 2.0 applications. Another advantage of social bookmarking & tagging is constituted by the use of folksonomies. The medical language is not open to every patient which is why they might not understand all technical terms used by health professionals. When applying social bookmarking and tagging, users attach “own” catch words to a certain webpage or article. These “tags” are mostly drawn from common language which can be understood by most patients. However, the use of folksonomies can also lead to disadvantages since they are built from ordinary people, not professional indexers. This may lead to inconsistent tags (e.g. different people using different tags for the same resource, or different spellings), or even wrong tags (e.g. using a false catchword for a certain resource). Moreover, it has to be stated that social bookmarking lists are only as good as their creators. If only a small number of people participate, or if many errors are in-

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cluded, the value of this list decreases.

Up to now, only few “health-only” bookmarking services have been identified. Most often, traditional bookmarking services include health-related topics and  177

Cp. Barsky, Purdon, 2006, p. 66.

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link lists in good quality. Therefore the need for a specific health bookmarking services is questionable. To show an example, it is pointed to Figure 30 below, depicting a screenshot from the well-known bookmark service provider “delicious”178. It has been searched for a bookmark list for “peanut allergy”. In total 637 results have been found. Here one can see that within the example the “Food Allergy & Anaphylaxis Network” has been bookmarked by 224 people and the tags “food”, “health”, “allergies”, and “nutrition” have been used most often to tag this website. Since 224 individuals consider this website to be valuable, it can be expected that it provides helpful information as a starting point. The user is now able to further specify the results (e.g. searching for a specific tag only), or sort them according to needs. This has not been done within this example.

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Figure 30: Example of a Social Bookmark List from “delicious”. Example: Peanut Allergy.179

 178 179

Cp. http://www.delicious.com. Own Figure based on http://www.delicious.com.

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The rise of virtual worlds (e.g. the famous “Second Life”180) has given new opportunities for patient education and information, as well. It is the “gaming character” of virtual worlds which is expected to make patients more susceptible to (health-related) learning. Here, also the anonymous character of virtual worlds (i.e. the interaction via personal “avatars” only) plays a key role in patient interaction since it reduces feelings of shame and uncertainty. Moreover, virtual words may provide an appealing and convenient environment for other healthrelated Web 2.0 applications, like virtual self-help groups, communities, and so on. It has been decided to use the most famous virtual world Second Life (SL) exemplarily to demonstrate potential health applications and benefits, although other virtual worlds (e.g. Active Worlds181) may provide similar benefits. Since virtual worlds constitute a rather new phenomenon, its potential is by far not yet fully tapped. Some patients have told that the interaction in virtual worlds helped them to recover or cope with an illness by influencing their mental health. Stein (2007) tries to describe this phenomenon as following:

“Because the full-color, multifaceted nature of the experience offers so much more “emotional bandwidth” than traditional Web sites, e-mail lists and discussion groups, users say the experience can feel astonishingly real. Participants develop close relationships and share intimate details even while, paradoxically, remaining anonymous. Some say they open up in ways they never would in face-to-face encounters in real support

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groups, therapy sessions, or even with family and close friends in their true lives.”182  180 181 182

Cp. http://www.secondlife.com. Cp. http://www.activeworlds.com. Stein, 2007.

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Despite, up to now only little research about the effectiveness and possible implementation of virtual worlds in healthcare has been conducted. Here further research is necessary. Currently, major patient-relevant health-related activities in SL can be divided into five categories, all incorporating several applications:183 x

Education & Awareness: Offering information applications as well as exploratory e-learning/edutainment 184 applications about various health issues.

x

Support: Offering one-to-one discussion with real-life doctors, and other health professionals; some also facilitate peer support groups, events and meeting places.

x

Training: Focusing on educating people in health (care). Many offering lectures, discussions, simulations of health experiences, and patient interactions.

x

Research: Recruiting of participants & conducting research in SL and real world settings.

x

Marketing & Promotion of Health Services: Companies, promoting new or future health services, treatments, or drugs.

More and more well-known companies, institutions and organizations, as well as individuals recognize the potential of virtual worlds for their purposes. However, currently only few medical facilities are engaged in SL and the pharmaceutical industry remains completely unrepresented so far. Despite, experts see a high potential for marketing, selling, and customer interaction in this field. Whether the pharmaceutical industry will adapt to this trend remains to be Copyright © 2010. Diplomica Verlag. All rights reserved.

seen.185

 183 184 185

Cp. Beard, Wilson, Morra, Keelan, 2009. “Edutainment”, a composition of education and entertainment. Cp. Medizinagentur (Ed.), 2009.

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To provide the reader with an impression about what is yet existent, some examples are described in the following. One example to demonstrate how SL can be used for health purposes is constituted by the “CDC Health Island”, run by the US Centers for Disease Control and Prevention (CDC). The figure below provides a screenshot from CDC Health Island to gain an impression. 186

Figure 31: Entry to the CDC Health Island.187



CDC has recognized the need to present online information in a way which is tailored to the individual needs as well as to their online preferences. Information has to be presented appealingly in order to influence health behavior. Therefore they have created a huge health island, being professionally built with many interesting interaction options, including an “issue of the month” walk, a conference center, a virtual health career museum, and a virtual lab. Moreover, Copyright © 2010. Diplomica Verlag. All rights reserved.

they have introduced private spaces where patients can talk to CDC experts and they offer podcasts on several health issues. The island is continuously updated, improved, and stuffed with new features.  186 187

Cp. Boulos, Ramloll, Jones, Cohen, 2008, p. 298 et seqq. Own screenshot based on http://www.secondlife.com.

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Another example is represented by Jefferson´s Occupational Therapy Center. This center has been built by the Jefferson College of Health Professions in Philadelphia (USA). It includes a virtual home equipped with universal design elements and specific types of adapted equipment for persons with disabilities. The intention is to show people with physical and mental disabilities how to live safer and more satisfying in their real life by adapting their home environments. This is done by visualizing the options as well as enabling people to try out the remedies in the virtual world themselves. Here, the 3D-virtual world provides specific advantages since it is a model “close to reality”; experiences made here can be transferred to the real world. Moreover disabled people can access this offer 24/7 and without getting to a specific place to try out.188 Of course, this procedure is by far easier and more comfortable to disabled people and therefore likely to be used more frequently. In addition to this virtual home, Jefferson´s Occupational Therapy Center provides information on the human body, and other related topics via tutorials, videos, and quizzes.

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The most holistic approach of a Web 2.0 application for patients is constituted by so-called “health portals”. They combine several features, for example a blogging function, a live chat with health professionals, specific communities / forums or wikis. The activities of physicians within the WWW in this context (here: online advice) are conformable to the German Medical Association's pro-

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fessional code of conduct since the focus of their consulting service is prevention and education, and not a “real treatment” (see also Chapter 9.5 for more details). In addition, health portals provide health-related information on various topics (depending on its specification). Often, they include other interactive  188

Cp. Boulos, Ramloll, Jones, Toth-Cohen, 2008, p. 307 et seqq.

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functions like a SMS drug reminder (for free), online health TV, or applications for mobile devices. Frequently, a strong emphasis is put on user-generated content (patients help patients), as well. In the majority of cases, health portals are aligned in a more general perspective, providing information, help, and support to various different illnesses instead of focusing on one only. Therefore they provide an entry point for patients when searching for health information.

According to a study conducted within the USA, health portals range on second position when it comes to locating health information online. 46% of respondents have stated to use health portals for this purpose, only general search engines are used more frequently (67%).189 Within Europe, numbers do not differ much. Here not only the enormous potential of such health portals becomes evident, but also their potential of doing harm to many users by providing false information. Despite their importance for a patient´s search of information, they cannot substitute a real medical consultation. In addition, almost every day new health portals are launched which leads to an oversupply of information which not uncommonly alienates patients. Here a clear indication of sources and expert messages are to counteract this aspect. Health portals must have a clear structure, intention (“mission statement”), and the usability factor should be of highest priority.190 For this reasons, guides to educate patients about the correct use of health portals have been developed. These put emphasis on a healthy mistrust, knowledge about who provides the information and his interests, evaluate the author and his professional qualifications, focus on up-to-date information, and have a look for seals of quality (e.g. HONcode).191 In this context, a study conducted by “Stiftung Warentest” has proven that not all health portals provide correct, complete, and comprehensible information. Moreover, many Copyright © 2010. Diplomica Verlag. All rights reserved.

health portals gained negative points for usability, search options, or overall appearance (for detailed results please refer to Appendix III).192  189

Cp. Elkin, 2008, p. 12. Cp. Yougovpsychnomics AG (Ed.), 2009. 191 Cp. Seigel, 2009. 192 Cp. Stiftung Warentest (Ed.), 2009. 190

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The following screenshot (Figure 32) is made from the “Gesundheitswerkstatt” [Health Factory].

Figure 32: Screenshot from the Health Factory.193

Here one can see which Web 2.0 applications are included within this health portal; these have been market by circles. The general alignment of illness becomes evident, as well. The user can search for a specific illness on the right upper side; the most famous searches are marked bold and are put at the beginning. All other diseases dealt with are alphabetically ordered. The clear Copyright © 2010. Diplomica Verlag. All rights reserved.

structure and the usability factor are well realized. Further links to health portals can be found in Appendix II.  193

Cp. http://www.gesundheitswerkstatt.de/en.

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A Special Case: Evaluation Portals

A special form of health portals is constituted by so-called evaluation portals which gain an increasing attention. Here users are invited to “evaluate” health providers. In the majority of cases doctors are evaluated (doc check portals), but also hospitals, or other health-related institutions with respect to various categories, e.g. waiting time, friendliness, quality of treatment, degree of mutual trust, etc. can be valued. These evaluation portals have been heavily discussed within public press. While patients feel quite comfortable with these rating options, the contrary is the case with doctors. Doctors feel somehow insulted and treated like “objects”; that doctors question the value of such portals has been revealed in a study of the “Stiftung Gesundheit”, as well. They have asked 1869 doctors how they assess such “doc-check portals”. As it can be viewed in the figure below, most of them are skeptical. Despite the fact that they know that patients are susceptive for recommendations they do not believe that fellow pa-

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tients have the knowledge and ability to rate physicians properly.

Figure 33: How Do Physicians Assess the Value of Evaluation Portals?194

 194

Cp. Stiftung Gesundheit (Ed.), 2007, p. 7.

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Moreover, they question the benefit of these portals since they believe that an evaluation of a doctor cannot be done properly by a few given categories, only.195 Finally it has to be noted that the evaluation portals can only provide value for users if they have a certain number of active evaluators (“critical mass”). Up to now, the quantity of available evaluations per portal is insufficient in order to deliver significant value; the quality of such evaluations needs to be reviewed in further research.196 Nevertheless, a list of available evaluation portals is provided within Appendix II, too.

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EPHR, the abbreviation for “electronic personal health record” (also called electronic patient record), are gaining increasingly attention. EPHRs are intended to facilitate the collection, tracking and sharing of past and current information about one´s own health. Here it is pointed to the difference as compared to “standard” medical records. While standard medical records contain information about one´s health compiled separately by each health provider involved, an EPHR is compiled and maintained by one´s own. The EPHR is not for private purposes only (i.e. monitoring one´s own health), but can be shared with health professionals when it comes to potential health conditions, treatment options, costs of treatment, management of chronic conditions, healthy lifestyle choices, or preventive actions.197 Entirely in terms of Web 2.0, Google as well as Microsoft have brought their applications for EPHRs to market in 2008. Google offers Copyright © 2010. Diplomica Verlag. All rights reserved.

with “Google Health” an application where users can organize their health information all in one place, gather medical records from health providers, and  195

Cp. Sander, 2009. Cp. Stiftung Gesundheit (Ed.), 2008, p. 3. 197 Cp. AHIMA (Ed.), 2009. 196

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share the information securely with a family member, doctors or caregivers online.198 The same applies to Microsoft´s “HealthVault”.199 Advantages of EPHRs are primary the collection of all relevant health data in one place. The quality of received healthcare can be improved since the patient is better informed when visiting a doctor. Moreover, healthcare costs can be decreased (fewer redundant medical checkups since no previously collected data get lost), and medical errors can be reduced (no missing information at doctor´s side).200 Both applications, Google Health and Microsoft HealthVault, can be used for free; however, certain disadvantages should not be neglected. The most severe aspect is the question of data security and privacy. All data entered into the application are stored on a Google´s (or Microsoft´s or other provider´s) server. The user does not know what Google or someone else does with his stored data. Of course, the providers promise to be trustworthy and keep all data safe. However, what is about external hacking of servers? In the eyes of the author the trustworthiness of such (commercial) providers has to be questioned. EPHRs might be of great value if the underlying applications are provided by a trustworthy source,

Copyright © 2010. Diplomica Verlag. All rights reserved.

e.g. the Federal Office for Health.

 198

Cp. http://www.google.com/health. Cp. http://www.healthvault.com. 200 Cp. Daily Health Care News (Ed.), 2009. 199

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͸Ǥ   ʹǤͲ  

The second group of stakeholders, the providers of health and health care, including amongst others, physicians, hospitals, pharmacies, as well as pharmaceutical companies, have different needs and requirements as compared to patients. Of course, the health care providers do not form a homogenous group (similar to patients which are not a homogenous group either); however needs and benefits look similar which is why they have been put into the same category of stakeholders. The benefits healthcare providers can draw from Web 2.0 applications are outlined in the following sub-chapters in detail. In this context, some examples are provided in order to point up the outlined benefits. First of all, to provide a basic insight it is pointed to the following figure, identifying rele-

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vant stakeholders, their needs, as well as useful applications.

Figure 34: Health Care Provider and Sub-groups with Corresponding Needs and Valuable Applications.201

 201

Own source.

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Not only patients can make use of a blog, it is an interesting application for health professionals, as well. Medical blogs, i.e. blogs written by physicians, hospital staff, or other health providers, can serve various purposes. First of all, they may provide a good basis for the propagation of new (health) information. Here the kind of information does not matter; important is that such information provided by health professionals is expected to be more accurate and qualified. For physicians but also pharmacies, they provide a good opportunity to inform about news in the field of medicine (e.g. new drugs, or treatment options) and health care (e.g. description of preventive and healthy lifestyles), or to present new research results. It has to be remarked that in this context especially physicians should take care that they do not publish confidential information (e.g. comments on individual patients), or violate data privacy.202 Hospitals can blog about new treatment options within their hospital, provide background information to patients for treated illnesses, or appeal to more healthy lifestyles. Moreover, they can publish upcoming events like symposiums, patient meetings, or offer contact details to support groups or external health professionals. In addition, they can enhance their image by providing information on quality and efficiency measures used for evaluation. For pharmaceutical companies, blogs might be an especially valuable tool since pharmaceutical companies face a strong competitive market (especially in the field of OTC drugs). Moreover direct marketing is difficult for them since they have limited options to advertise their products direct to the consumer; in most cases a physician is set in between

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who has to prescribe drugs to his patients. Therefore it becomes even more important to do good marketing and communication with customers in the field of OTC drugs; here pharmaceutical companies can directly address the end  202

Cp. Lagu, Kaufman, Asch, Armstrong, 2007.

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customer and differentiate themselves from other providers by an effective and appealing (brand) image, good marketing campaigns, as well as profound and serious provision of information. By providing the customer with a deeper insight into the company (e.g. production processes), further background information (e.g. its employers) or observed adverse reactions (results from clinical studies) in a company blog, they might catch the customer and turn him into a more loyal one. In addition, physicians as well as companies can enhance their patient / customer relationships due to a better communication with them. Since blogs allow for comments to be written by its readers, customers can directly respond to a posted marketing article, for example. Here the physician or company can gain valuable insights into the needs of its customers or new ideas.203 However, despite all advantages it must be pointed to the fact that – in contrast to the US – German health providers have not yet recognized the potential of blogs, resulting in a very low number of professional medical blogs; that is why patients in Germany are not used to frequently visit such offers. A major problem has been recognized in the fact that blogging physicians are strolling on a narrow path between interesting stories and medical confidentiality. 204 Thus benefits are currently limited for both parties. The second way to use blogs in healthcare is like a “B2B application”, i.e. blogs not used for communication with patients but between health professionals themselves. Since blogs engage people in knowledge sharing, reflection, and debate, they often attract a large and dedicated readership. They can also facilitate the creation of small virtual groupings of individuals interested in co-constructing knowledge around a defined topic of interest within a community of practice. Here, a co-writing of a blog between several physicians can be imagined which leads to a better distribution of knowledge of a certain research area / topic. Mostly, those blogs are centered on a Copyright © 2010. Diplomica Verlag. All rights reserved.

particular research area. Moreover, blogs are also used in clinical practice; here blogs are used to share clinical cases across different departments or amongst

 203 204

Cp. Constantinides, Fountain, 2007, p. 239 et seqq. Cp. Lederer, 2007.

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physicians to solicit a second opinion (virtual collaboration). 205 For this case, the blog can be password protect in order to guarantee data security. To show an example it is pointed to the following figure which shows a blog in the field of dermatology, the VGR-D blog. The administrators of this blog describe their intention as: “One may want to ask a question about diagnosis or therapy, present an interesting clinical photo or post a micrograph. We are a group of clinical and academic dermatologists who believe that this form of web-based

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tele-dermatology can be both, personally and professionally enriching.”206

Figure 35: Screenshot from VGR-D Blog.207

 205 206 207

Cp. Boulos, Maramba, Wheeler, 2006, p. 2. http://www.vgrd.org/about/about.html. Cp. http://vgrd.blogspot.com.

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A Special Case: Medical Micro-Blogging via Twitter

The use of Twitter for professional purposes is still at its beginning. Up to now, only a limited number of health companies and professionals use Twitter. But more important, even a fewer number of those using Twitter provide regular “tweets” (messages). One tweet every half a year does not lead to a benefit. Only these communicating on a regular basis and providing interesting information, may obtain many followers208 on Twitter. If done properly, Twitter can support public relations (PR) and marketing, as well as it may serve as a new, modern and interactive communication channel with customers. Often, Twitter is used to communicate about company going-ons with journalists, as well. Currently, Boehringer Ingelheim, Novartis and Johnson & Johnson are among the most prominent “Twitterers” within the industry. While Novartis has the largest number of followers, the other two companies have a more well-known Twitter profile, tweeting almost daily, and engaging in chat with the Twitter community. The question why pharmaceutical companies as well as physicians use Twitter so reluctantly, may be partly answered by the fact that there is a lack of (legal) guidelines about what such companies are allowed to do and what not.209

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Similar to patients, exchanging experiences in patient communities, healthcare professionals can use (professional) medical communities to found other proCopyright © 2010. Diplomica Verlag. All rights reserved.

fessionals with same interests, build up a network of like-minded people, and share experiences and knowledge. It is important to note that these communi 208

209

“Followers” on Twitter are interested people who have subscribed to the new posts of a certain company; often the number of followers is used to measure the quality of posts of this company. Cp. Tyer (1), 2009.

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ties are only accessible for health professionals who have to prove their medical background, i.e. patients are not allowed to join. The major advantages are the easy use as well as the facilitation of exchange across time and space. Participants can instantly exchange information without considering different time zones or geographical locations. Moreover, it is kept record of discussions in a written form which allows participants to track the progress of research or medical discussions. Most often, medical communities are built around one specified topic, like “asthma” or “breast cancer”. This leads to a high quality network devoted to a defined area of interest, expected to bring about many benefits for its participants, as soon as the critical number of people joined is reached. It has to be noted that, since such communities live on user-created content, the value of the network is largely defined by the number of active participants providing content. To demonstrate one example it is pointed to “The NeuroNetwork”210, a community of health professionals concerned with various aspects regarding the human brain. This online community has been created by the publishing house “Springer” especially for neuro-scientists. According to the creators its intention can be described as following:

“The NeuroNetwork was built to allow students and researchers to find and interact with each other in a professional environment. One may create searchable profiles with one´s research interests; start a blog; upload poster presentations and videos; post and search job listings; create open and closed discussions; form a virtual "group" based on interests, geographical location, etc.; and view, post, and RSVP to upcoming meetings.”211

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The range of topics comprises all aspects related to the brain, including brain science, neurology, psychology and artificial intelligence. Up to now, more than 1.300 participants and 40 groups from more than 70 nations have joined this  210 211

Cp. http://www.theneuronetwork.com. Avouris, 2009.

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network.212 Obviously, the demand for such communities is existent which is why it can be expected that more and more professional communities will be created for various purposes in the future. Below, a screenshot from “The NeuroNetwork” welcome page can be found.

Figure 36: Screenshot from the NeuroNetwork.213

A Special Case: Photo & Video Communities

Health professionals begin to recognize the potential of photo- and videocommunities for their purposes. Photo / video communities constitute an excellent option to share clinical graphical material across distances and without loss of time. Major aims of such a platform include the mobilization of medical know-

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ledge by knowledge exchange, networking, and communication.214 The major difference with respect to other communities is the fact that its core is a huge image database, filled with images provided by health professionals. To ensure  212

Cp. Healthcare Marketing (Ed.), 2009. Cp. http://www.theneuronetwork.com. 214 Cp. Medizinwelten (Ed.), 2008. 213

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data quality and security, evidence of a clinical profession can be required for registration. This inhibits unqualified people to become part of the community. In addition, shared material can be password protected to allow only a limited number of selected people to access the material. One example of such a photo community is “Medizinwelten”

215

[“Medical Worlds”]. Medizinwelten is a com-

munity where physicians and other health professionals are able to exchange clinical images in combination with text. The use of this community as well as the provided information itself (images and text) is free of charge and the material can be further used without paying a royalty. Health professionals can use this community to ask others for a second opinion, but also borrow the provided material for own speeches or publications. To facilitate communication and discussion, a comment function is included. Moreover, the community provides medical podcasts about current topics. A new offer has been yet included to keep up with newly emerging trends: from now on, each published contribution on “Medizinwelten” is available on Twitter, as well; by this physicians are allowed to keep an eye on new contributions as not to miss interesting new posts. Therefore photo and video communities can be expected to become a powerful tool for health professionals in the future. Another option how video communities can be used by health professionals, is to resort to “general” video communities and publish, for example, advertising or informational videos for the broad public there. In this case, video communities can be used as a sales, marketing, and communication channel for company purposes. This has been done by the pharmaceutical company Boehringer Ingelheim, for example. They make use of YouTube to publish videos about their company, new products, or other informative topics. Most recently, they have

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added a video on YouTube devoted to the Parkinson's disease.216 Another example is constituted by Pfizer, having launched an own European YouTube

 215 216

Cp. http://www.medizinwelten.de. Cp. Comer, 2009.

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Channel to promote its European operations by showcasing some of its people.217

A Special Case: How Communities & Networks Help to Improve Clinical Trials

The use of (patient) communities for improving the quality and effectiveness of clinical trials constitutes a different way health professionals can draw benefits from the Web 2.0 development. In this case, patient communities can provide benefits for physicians and pharmaceutical companies that are engaged in clinical trials. While some use independent patient communities, e.g. PatientsLikeMe 218 , other companies develop own (patient-centric) communities to improve their clinical trials. This holds true for Pfizer, to name an example. Pfizer will launch an own online community for clinical trials (expected launch date is at the beginning of 2010) which is intended to help recruiting more participants for clinical trials.219

Major problems concerning clinical trials are the recruiting of eligible patients within a given time frame. Within the United States 80% of the approximately 50.000 current clinical trials are delayed for at least one month. A delay of a clinical trial due to a loss of test candidates can imply a loss of millions for a pharmaceutical company. While the amount of clinical studies conducted continuously rises, the number of participants declines.220 As a consequence, the cost of finding and enrolling patients onto trials has more than doubled between the years 2000 and 2005. This trend is expected to continue.221 In this context, it is especially problematic to find enough participants for Phase III trials since

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here some thousand patients are needed. Therefore it is of utmost importance  217

Cp. Tyer (2), 2009. Cp. http://www.patientslikeme.com. 219 Cp. InPharm (Ed.), 2009. 220 Cp. Allison, 2009, p. 895 et seqq. 221 Cp. InPharm (Ed.), 2009. 218

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for pharmaceutical companies to improve the recruiting process. The declining number of voluntary participants can be majorly traced back to a lack of knowledge of existent studies on the patient side, as well as a certain “fear” of being a “guinea pig” with unpredictable outcomes for the own body.

Here, it is expected that patient communities may partly help to resolve these problems. First initiatives to use communities for recruiting purposes have shown that this procedure might be successful in the future. By providing information about clinical trials in such communities, they are able to reach patients living far away from modern medical centers who otherwise would never get notice of the clinical studies. In addition, since potential participants are “clustered” in topic-driven communities, it is easier for pharmaceutical companies to contact potential participants, e.g. the company may write an invitational e-mail for a clinical trial of a new breast cancer drug to all members of the “breast cancer community”, knowing that all members face this illness and are therefore potential participants.222 Since personal profiles of members reveal further inclusion / omission criteria like age and gender, companies are able to address community members even more selectively. Up to now, various pharmaceutical companies, including Novartis (partnering with PatientsLikeMe), Merck (partnering with Inspire 223 ), and Pfizer (own community) have joined various cooperations with patient communities or created own ones to test this procedure of online recruiting. However, despite the fact that this process may seem easy and comfortable, certain drawbacks cannot be denied. On the one hand there is the question whether these studies become biased by this procedure from a research perspective. Due to the fact that patients, enrolled in the same study, may talk about it within the community, the study is unconsciously “deCopyright © 2010. Diplomica Verlag. All rights reserved.

blinded”.224 On the other hand, the author sees a psychological aspect, i.e. how do patients feel if they notice that companies capitalize on their disclosure of  222

Cp. Sander, 2009. Cp. http://www.inspire.com. 224 Cp. Kliff, 2009. 223

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highly private data because the patient does not find any other way to receive help with his illness?

͸Ǥ͵ Ƭ    ǣ   ǡƬ 

Collaboration is especially important in the field of medical research since the use of the collective power of many researchers may enhance results (“survival of the highest-quality article”). Here, wikis can make a valuable contribution. Major benefits which apply to the field of medicine in particular include the fact that the continuous update of a wiki allows reflecting new research and local realities for best practice instantly, as well as they facilitate a faster creation and dissemination of knowledge (in contrast to textbooks which are updated with every new edition, at most).225 So, professional medical wikis serve two major purposes: on the one hand, they facilitate collaboration and exchange of knowledge (also across national boundaries); on the other hand they serve for educational purposes and as a repository for information (i.e. knowledge management in a professional setting).226 In this context, it becomes obvious that, in addition, further education is especially important for health professionals due to the fast changing nature of the field of medicine. There exist little industries where new research findings may change the current state of knowledge so frequently and considerably. Wikis may also be supportive for medical students as a “reference book”. In addition, pod- / vodcasts and virtual worlds may play a

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vital role in the education of medical students as well as the postgraduate professional education of health professionals in the future. Amongst others, some universities have started to experiment with these tools, e.g. providing lectures  225 226

Cp. Shachak, et al., 2008. Cp. Eysenbach, 2008, p. 7.

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as a pod- or vodcasts to give students the possibility to review attended lectures again afterwards. Experts suppose that these tools enhance students´ and physicians´ learning experiences, and deepen levels of learners´ engagement; however further research has to be conducted to build evidence about the tools´ value. 227 Learning content provided in virtual worlds is expected to be better adopted, as well, since such worlds can provide an appealing learning environment due to their “gaming nature”. Another advantage of such tools lies in the fact that they can be accessed via several devices at any time from any place (e.g. via mobile phones, too), for examples, podcasts may be listened to during an occurring waiting time. This makes education / learning more flexible and therefore comfortable.



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Figure 37: Screenshot from an Operating Theater in Second Health.228

 227 228

Cp. Boulos, Maramba, Wheeler, 2006, p. 2 et seqq. Taken from NMC Virtual Worlds (Ed.), n.d.

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To mention an example it is pointed to “Second Health” located in SL. The underlying concept of “Second Health” is a fully equipped hospital simulation (including e.g. beds, sophisticated diagnostic equipment, offices of the British NHS, and operating theaters) and constitutes an outstanding example of the possibilities these environments can be used to improve the skills of physicians and demonstrate cutting-edge medical facilities.229 A screenshot of an operating theater can be seen in the figure above (Figure 37). Here, medical students and

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other health professionals can train their skills and receive further education.

 229

Cp. NMC Virtual Worlds (Ed.), n.d.

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͹Ǥ   ʹǤͲ  

Up to now, the use of Web 2.0 applications for health care payer has only been treated to a very small extent by literature and research. Here, further studies have to be conducted to measure the value of such applications for health insurance providers, and other paying institutions in depth. For the purpose of this piece of research, health payers have been defined as all health insurance providers (HIPs), either being private or compulsory, as well as health-related institutions and organizations like the “German Pension Fund” (being responsible for rehabilitation actions, for example) and the government. Of course, other actors may pay for health, as well (e.g. companies paying for preventive treatments); however it would be too comprehensive to discuss all of them in detail.

Web 2.0 applications might be of particular value for HIPs since the introduction of the “Gesundheitsfond” in Germany which took effect as from beginning of 2009. From these days on, HIPs have to offer, amongst other things, a uniform contribution rate and a fixed catalogue of benefits. Therefore it becomes even more important for them to differentiate themselves from other providers by advertising and communication activities.230 In this context Web 2.0 applications can make an important contribution due to their nature of communication and interactivity. Of course, health care payer can make use of wikis for internal knowledge management purposes, as well (in a similar way as described in Chapter 6.3 for health care providers). However, this way of using Web 2.0 applications is here considered to be a minor aspect which is why it is not further

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discussed in detail. The following figure provides an overview about the different health care payers, their needs, and suitable applications.

 230

Cp. Cision (Ed.), 2009.

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Figure 38: Health Care Payer and Sub-groups with Corresponding Needs and Valuable Applications.231

The author considers the offer “Kranke Kasse”232, a subsidiary of the German health care provider “City BKK” a good example to demonstrate how a HIP may make use of Web 2.0 to offer an innovative and appealing service for its customers. They have noticed that the topic “health care insurance” is not an appealing one for people, especially not for the younger ones. Moreover, they have arrived at the conclusion that the communication with its customers has to be urgently improved. Therefore they have created the “Kranke Kasse” which is expected to attract especially the younger generation. To communicate this offer properly, several Web 2.0 features have been included in the website. When visiting the website for the first time, the user is equally shocked, amazed, and confused to found such a website provided by a HIP. However, after having a

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closer look, it seems that this approach could have success.

Another, international example is constituted by “HCC Medical Insurance Services”, a leading insurance company, having offices in the USA, UK, Spain and  231 232

Own Source. Cp. http://www.krankekasse.de.

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Ireland, that develops strong business and customer relationships through social media. HCC hast re-designed its website to emphasize its new social media offerings. The result can be viewed in the screenshot provided below.

Figure 39: Screenshot from HCC Medical Insurance Services.233

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 233

Cp. http://www.hccmis.com.

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͹Ǥͳ  ǡ     ǣ  Ƭ Ǧ

 

As outlined above, health insurances face strong competition and need to differentiate themselves from their competitors. In this context, a blog may be a helpful supporting tool. Blogs become increasingly important in corporate communication since some research has proven that blogs have a greater impact on customers´ (purchasing) decision than a traditional website (or print media) due to their rapidly spreading “word of mouth”. Health Insurances may use blogs to provide the reader with various types of information, thereby positioning themselves in the desired light, increasing the awareness of their “brand”, as well as providing insights into the company, others may not provide. Moreover, a seriously written blog (i.e. a truthful one) may increase credibility and trust (which is of special importance within the insurance sector) and in turn facilitating customer loyalty.234 The same holds true for the use of micro-blogging services (e.g. Twitter). Thus, a blog, carried out professionally, can lead to a competitive advantage when reasonably combined with other communication means to provide enhanced customer service. Of course, a single blog on its own will not make the difference.

According to a study conducted by Cision (2009), German CHIs make extensive use of Web 2.0 applications (especially blogs and micro-blogs) whereby the activities of AOK and DAK are especially worth mentioning. The author has tried to follow this result, however the result seems questionable. The author could recognize only few German health care payers that are already engaged in

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blog-writing or micro-blogging. No company-owned blog could have been identified, apart from one exception, the “AOK-c@re Community Blog”.235 However, here it has to be noted that this is not a blog written by the company but “only”  234 235

Cp. Schmitz, 2009. Cp. http://blog.aok-care-community.de.

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the provision of space provided for customers to blog on sportive activities. In contrast, an outstanding example is considered to be the British NHS website236 which offers (amongst other Web 2.0 applications) a broad range of blogs, each of them dealing with a specified topic like asthma, diabetes, or heart conditions. The blogs are continuously updated, well written, and include interesting blog entries.

In addition, although some CHIs have own Twitter Accounts, the quality of these posts is questionable. This has been noted by other users, as well. When having a look at the AOK Twitter Account one can notice that AOK posts seem to be automatically created by a computer, including just links to AOK websites. In addition, it looks like that the AOK is not engaged in any discussion / two-way communication (obviously, this is the intended primary purpose of Twitter).237 The same criticism holds true for other health care payers like the DAK, as well. A bit better is doing the British NHS where at least sometimes a prepended “@” or “RT” can be found within their posts.238 Therefore it is disputable whether the majority of health care payers have already understood the purpose and value of such applications. In this context it can be definitely stated that it is does not add any value if the tools are not properly or only ineffectually used.

͹Ǥʹ      ǣ ǦȀƬ 

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Similar to health care providers, health care payers may use podcasts, vodcasts, or virtual worlds to inform and educate their customers. As mentioned  236 237

238

Cp. http://talk.nhs.uk. Whether a discussion takes place, can be identified by the prepended “RT” and/or “@” in a post. Cp. http://twitter.com/NHSChoicesTalk.

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beforehand it is expected that such types of learning offers are more appealing and comfortable for customers that is why they may be used more frequently. In addition, it is expected that knowledge derived with the support of hearing and / or watching articles in addition to interactive tasks is maintained in memory easier and faster. Moreover, these applications can be accessed via a mobile device (e.g. mobile phone or iPod), as well, which makes learning independent from time and place.

In this context, some health payers could have been identified which have already adopted some of these applications, for example is the number of podcasts provided by health care payers constantly rising, e.g. provided by the British NHS239, or German health insurances like DAK or BIG. They make use of podcasts to inform their customers about their provided benefits, new trends, or other current health-related topics (e.g. the “Swine Flu”). Up to now, no German health care payer could have been found that makes use of virtual worlds. Again, the British NHS acts more future-oriented and is represented by an office in SL where they – amongst other activities – offer medical consulting services or hold symposiums and (virtual) conferences.240 In addition, the NHS has been involved in the creation of “Second Health” (Second Health has been described in greater detail within Chapter 6.3).

Whether these learning offers are really used more frequently in reality, as well as their contribution for the improvement of a populations´ health has to be examined in further research. Of course, the arguments sound comprehensible; however, research is right now at its beginning in this particular area. Therefore

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a lot more of research has to be conduct to prove the efficiency of these tools.

 239 240

Cp. http://www.nhs.uk/Audio/Pages/medialibrary.aspx. Cp. Pasteur, 2007.

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ͺǤ  ǣ       ǫ

Previously, the benefits and disadvantages for selected user groups as well as the different applications have been outlined in detail. In addition to these “specific” strengths and weaknesses, the use of Web 2.0 applications in health care can provide further, more “general” benefits and downsides which are valid for the whole healthcare system, being not limited to certain user groups or single applications. Therefore, the following sections will discuss whether advantages can outweigh disadvantages from a general perspective.

ͺǤͳ ǣ      ʹǤͲ 

When having a look at potential advantages, three major or core fields could have been identified. These are covered within the following sections; they will explain how the use of Web 2.0 in health care can help to reduce costs, improve the quality of treatments, make the whole health care system more efficient, and how its use can facilitate the change from a physician-centric health care system to a more patient-centric one.

Keeping Health Care Affordable: Cost Reduction Effects Copyright © 2010. Diplomica Verlag. All rights reserved.

& Increase in Revenues

In previous chapters it has been outlined that one of the major problems of the health care market is constituted by the assurance of a long-term financing of health care in the future. Therefore the question of how Web 2.0 might help to  ͳʹ͵ 

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reduce costs in the health care market is an essential one. The costs for creating and maintaining a Web 2.0 offer have to be contrasted to the potential savings, to gain an insight into the real net gains, of course. To provide absolute numbers is difficult since therefore complex cost-benefit analyses for the single cases have to be performed. Moreover, the existence of reference values is limited since up to now Web 2.0 is used rather hesitantly within the health care sector; most applications are stand-alone solutions instead of fully-networked ones. However, despite the fact that the market for Web 2.0 applications is still at its beginning, the prospects are promising. Web 2.0 applications may enable patients, health care providers, as well as health care payers to save a significant proportion of costs. Moreover, the health care industry (especially the pharmaceutical one) may increase its obtained revenues.

For patients, the use of Web 2.0 applications can reduce costs from several perspectives: on the one hand, patients can safe time (and thereby costs) by finding suitable and high-quality information with the help of such applications faster (e.g. the “right” physician, or the best drug); on the other hand, they can inform themselves about health-related topics, thereby becoming more healtheducated, resulting in a healthier lifestyle and an increased action in preventive activities. This in turn may lead to a decreased spending for OTC drugs or other benefits which have to be paid by their own, for example.

For health care providers and payers, cost savings and revenue increases might have an even greater impact on current performance. Amongst other things, this has also been proven by a three-year study from McKinsey (20062009); Here, 69% of respondents across all industries have reported that “their Copyright © 2010. Diplomica Verlag. All rights reserved.

companies have gained measurable business benefits, including more innovative products and services, more effective marketing, better access to knowledge, lower costs of doing business, and higher revenues.”241 Cost reduc 241

McKinsey (Ed.), 2009.

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tions are implied by various aspects, for example the fact that the use of Web 2.0 in health care can lower transaction / administration costs for providers. In addition, a study conducted by SAP and Accenture, has found out that the German health care system can save up to 400 million Euro each year by integrating platforms by which hospitals and physicians are enabled to virtually collaborate; this includes that physicians can book appointments in hospitals for their patients online, share patient data online (in both directions: physician to hospital and hospital to physician), and communicate about specific cases. According to the expectations of the respondents of the study, the introduction of such a platform leads to a decrease of costs of 100€ per patient. The introduction of such “virtual collaboration-platforms” does not only reduce administrative costs (i.e. lower costs due to minimized paper-based communication), but also the number of redundant examinations / consultations or the avoidance of complications within medical treatments due to a higher information transparency.242 Another example of possible cost reductions can be found in the field of health insurances which can decrease their costs by taking an active role in influencing patients´ decisions which in turn affect insurance claims. Moreover, Web 2.0 supports the creation of effective, internet-based disease management programs. These programs perform preventive information as well as they can assure therapy-compliant behavior, thereby decreasing long-term costs for treatment and illness-related inability to work.243

An increase of revenues and a decrease of costs might be especially important for the pharmaceutical industry, as well. Providers of medical drugs and other medical equipment may increase their revenue by a better and more customertailored marketing strategy (“branding” and “imaging”), a more direct communiCopyright © 2010. Diplomica Verlag. All rights reserved.

cation, as well as an appealing provision of information about their products (including the motivation of patients to take necessary drugs on a regular basis). These aspects will lead to an increase of demand of pharmaceutical products in  242 243

Cp. Viola, 2008. Cp. Geiger, Eikemeier, Grütter, 2002, p. 64 et seqq.

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the long-term, thereby positively influencing sales figures. Moreover, the use of communities and blogs where customers can directly respond to new products or product features can lead to a decrease of product development time since providers gain a faster and better understanding of customer needs and demands.244 This will lead to a reduction of R&D costs. Of course, the above mentioned principles of cost reduction by the use Web 2.0 are valid for this industry branch, as well.

Considering the above depicted details, it can be concluded that the introduction of Web 2.0 applications in the health care market exhibits a significant potential for the urgently needed reduction of costs across all parties. The applications allow to deliver much value (i.e. highly patient-oriented care options) at relatively low costs.245 If reasonably applied, all stakeholders of the health care market are able to draw their (financial) benefits.

Making It Better: Efficiency and Quality Gains

Efficiency and quality gains in the health care market are closely related to the principle of cost reductions and increases in revenues since an increase in efficiency indirectly reduces costs. Moreover, an improvement of quality leads to a higher degree of customer loyalty and increasing sales figures, as well. Efficiency gains can be realized in the administrative processes of health and health care in particular. In addition, Web 2.0 may help to improve the efficiency of treatments. Possible efficiency gains in the health care system due the use of Web 2.0 have been exemplarily outlined by Katrin Keller and Dr. Alexander AlCopyright © 2010. Diplomica Verlag. All rights reserved.

scher, founders of the Samedi GmbH246, a company trying to bring Web 2.0 to

 244

Cp. Nadler, 2006. Cp. McCabe Gorman, den Braber, 2008. 246 Cp. https://www.samedi.de. 245

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the health care market. Their assessment of possible efficiency gains for physicians and hospitals can be viewed in the figure shown hereafter.

Figure 40: Efficiency Gains Due to Web 2.0.247



Here it becomes evident that Web 2.0 can be employed in various process steps. Often, the use of Web 2.0 can help to reduce a health provider´s time spent on administrative processes resulting in more “free” time for the treatment and interaction with patients / customers. Simultaneously, the perceived quality for patients can be significantly increased since they feel the physician dediCopyright © 2010. Diplomica Verlag. All rights reserved.

cates sufficient time for their appointment. Similarly, other health care providers (e.g. health insurances or pharmaceutical companies) can use Web 2.0 to make their administrative and communication processes more efficient. By enhancing  247

Adapted from Keller, Alscher, 2009.

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these processes, the quality of offers improves almost automatically. Apart from efficiency gains in the administrative processes, Web 2.0 can also help to create more efficient medical treatment options. Here it is majorly referred to collaboration activities (e.g. obtaining a second opinion or clinical case sharing), online disease management programs for chronically ill people and “virtual consultations”. Virtual consultations can support the resolution of medical supply bottlenecks, especially in times of crisis or in rural areas. Here Web 2.0 applications, i.e. the interactive communication with health professionals online, make allowance to a fast, comfortable and problem-oriented consultation/medical advice as well as more efficient health care. However, it has to be noted that in some countries, e.g. Germany, virtual consultations are strongly limited due to a prohibition of giving medical advice via print- or communication media, only (see also § 7 para. 3 of the Medical Association's professional code of conduct248; Chapter 9).

It can be concluded that the use of Web 2.0 can lead to significant efficiency gains on the part of health care providers if a fully networked Web 2.0 health landscape can be created. Although single isolated application may be beneficial for a few, they will - by far - not tap the full potential. If this is the case, patients and consumers will benefit from an increased quality of health-related communication and other services.

Shifting the Paradigm: Customer-Centric Health Care & Patient Empowerment

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Despite the fact that it can be expected that healthy people will turn to online health information more haphazardly while people with symptoms or diagnosed (chronic) illnesses will make conscious use of such applications, of course, all  248

Cp. Bundesärztekammer (Ed.), 2006.

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applications facilitate information search (in connection with health education), as well as they strongly encourage communication (interaction and exchange of experiences) between patients and / or with health care professionals. The quality of medical care could be increased by the use of Web 2.0 applications: due to the easy access to information, as well as the broad range of information available, patients become empowered. Now, they can inform themselves about health-related topics and discuss topics / questions with fellows without the need to personally contact health professionals. The gained knowledge improves a patient´s medical decision-making, increases his participation and therapy-compliance and reduces his dependency. A reduction of noncompliance also affects health-related costs; currently costs for non-compliance amount to about 70 billion Euro per year in Europe. Here it is expected that patient empowerment can lead to cost reductions in the health care sector. 249 Therefore the health care market should try to have the “empowered patient” on their agenda. In order to realize the “empowered patient” it has to be assured that information provided in the Internet is of high quality and therefore correct and reliable. Without high-quality information, a “real” patient empowerment will not take place. Moreover, it has to be noted that patient empowerment might not be realized across all patients and all stages of illnesses. The greatest effect will be obtained in the field of patients, suffering from a chronic or long-term illness. In addition, patients become more self-assured and dare to actively participate in health-related activities (especially in the field of prevention). In this context, it can also be referred to the use of EPHRs (see also Chapter 5.8). While “standard” electronic medical records are used in Germany for more than 10 years (even if they are not used comprehensively), EPHRs constitute – by far - not yet a common procedure; however they might lead to patient empoCopyright © 2010. Diplomica Verlag. All rights reserved.

werment, as well. Like it has been mentioned beforehand, the difference between “standard” medical records and EPHRs is the fact that a “standard medical record” is maintained by the physicians and hospitals that have been con 249

Cp. European Health Care Foundation (Ed.), 2005.

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sulted by a patient. Every physician / hospital keeps record of the treatments, but there is no consolidation of the various records of one patient across various providers. In contrast, the EPHR is maintained by the patient himself, i.e. the patient keeps record of his medical treatments and diagnoses across different providers on his own. This fact leads to a changed behavioral role of the patient. While the patient is an “object” only in the scope of provider-maintained records, he becomes the “subject” within the scope of EPHRs with an own responsibility, giving the patient more power and a say.250 The figure below (Figure 41) provides an insight into the empowerment process of patients, supported by the use of Web 2.0 applications. The figure is based on a study of the Boston Consulting Group which has defined 4 types of patients: x

“Accepting” patients: the physicians have the only authority.

x

“Informed” patients: mostly patients with chronic diseases and an increased personal responsibility for their illness.

x

“Involved” patients: people with a high engagement in health care and a demanding attitude towards the physician.

x

“Controlling” patients: self-assured patients, actively using the Internet for the verification of physicians´ decisions.

Here it becomes evident, that the behavior of patients is only partly influenced by the severity of his illness. A second influencing factor will be the use of Web 2.0 and EPHRs which are expected to transform patients from “accepting” pa-

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tients to “controlling” patients.

 250

Cp. Warda, 2005.

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Figure 41: Patient Groups and Their Transformation.251

Finally, patient empowerment facilitates a movement towards a “patient-centric” healthcare system: it is no longer the physician who is in the center with his knowledge and power to “dictate” treatments but rather the patient who critically challenges doctor´s evidence and who actively calls for certain treatments or actions.252 This way of interaction between patient and doctor leads to an endu-

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ringly changed “physician-patient-relationship”.253

 251

Adapted from Warda, 2005. Cp. Tovey, 2006, p. 741 et seq. 253 Cp. Bos, Carroll, Marsh, 2008, p. 3 et seqq. 252

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ͺǤʹ ǣ         ʹǤͲ 

As compared to Chapter 8.1, the following chapter will have a closer look to threats and disadvantages which have to be considered when creating and using Web 2.0 applications within the health care market. Here it has to be stated that Web 2.0 in general comes up with new threats and disadvantages which are not specific to the health care market. However, they play a key role in assessing disadvantages for the health care market, as well. Only few problems arise from the health care market itself but one can state that some of the general problems have a greater importance when dealing with health-related use instead of other industries or private use. The following sections are intended to demonstrate the key challenges in this context, including the issue of data quality and reliability on the one hand, and data privacy, data security and illegal reutilization on the other hand. Finally, the question of equal opportunities to access is discussed. With respect to legal problems it is pointed to Chapter 9. Within Chapter 9 the legal framework for Web 2.0 in the health care market is outlined in detail, pointing to critical aspects, as well.

Trust justified? Data Quality and Reliability within Web 2.0

When people turn to the Internet in search of health-related information, they want information they can trust and rely on. The aspect of data quality and reliability becomes especially important in the field of health care since here the

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publishing of wrong or poorly researched information can lead to tremendous and even killing effects. Moreover, wrong information may cause unneeded medical consultations (cost factor) due to patient-panic arising from fearmongering articles in the web.254 A study conducted by the Health on the Net  254

Cp. Forum Gesundheitspolitik (Ed.), 2009.

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Foundation (HON) has also proven the importance of this fact: 28% of all patients interviewed remarked that the most important aspect of online health information is accuracy of information; another 13% stated that trustworthiness is their major criterion.255 Since patients were asked to state only a single criterion to be most important, the fact that 41% agree that data quality and reliability is very important is a considerably high number.

In this context the question arises whether Web 2.0 applications, especially those relying on the “collective wisdom of the crowds” (e.g. patient communities or blogs) can lead to information with good quality and reliability. While detractors argue that patients do not have the knowledge to provide good medical information and advice, favorers point out that the collective intelligence leads to self-policing and community watchfulness, i.e. mistakes are rapidly detected by other users and become corrected. Thus, they believe that the collective wisdom leads to even higher quality / reliability of information.256 According to various studies, it has been proven that health information on the Internet is not necessarily true and reliable. Often, false, uncompleted or biased information could have been identified (with varying levels of error severity). Despite, only few cases have been reported where patients suffered from severe pain after relying on health-related online information. 257 However, here the author is in line with the favorers, although it cannot be denied that users of such information should critically think about the information provided and not just take its correctness for granted. In addition it can be helpful to rely not on a single opinion or advice, but rather crosscheck several communities in order to get best information results. To determine the quality of information one should also try to identify the author and his status (e.g. is it written by a professional physiCopyright © 2010. Diplomica Verlag. All rights reserved.

cian?), this can be of help when assessing the quality of information. Beyond that it can be expected that forums, chats, and communities that are expert  255

Cp. Boyer, Provost, Baujard, 2002. Cp. Eysenbach, 2003, p. 292 et seqq. 257 Cp. Cline, Haynes, 2001, p. 679. 256

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moderated, i.e. professionals are supervising the discussions, yield a higher quality.258 Therefore experts see most potential in Web 2.0 applications which can guarantee a high quality and reliability of information for its users, either being expert moderated, or being able to prove the correctness of information by means of quality seals (e.g. “HON” certified websites”) and well-known institutions as authors (e.g. the National Ministry of Health) or limiting the writing / editing of articles to health professionals, only. Despite this assessment of experts, the author believes that especially patient communities are of high value, in particular for those with rare and chronic diseases. Here persons concerned can exchange practical tips for the handling of the illness in daily life which health professionals might even not know.

Where Are my Data Gone? Data Privacy, Security and Re-Utilization

Another aspect dealing with the exposure to data and information in the Web 2.0 is the question of data privacy, data security, as well as illegal re-utilization. Of course, people publishing personal and sensitive health data in the Internet do this on a voluntary basis; nevertheless, it can be expected that they often do not think about possible consequences or that they publish these data because they do not know any other way of receiving help with a specific medical problem. Especially in the field of health data this can have unwanted effects since data being once published will never again disappear in the Internet. It has been reported about cases where pharmaceutical companies, being unauthorized for doing so, misused patients´ data in communities / blogs to gather data for clinical studies or contacted patients with spam or unwanted messages and inforCopyright © 2010. Diplomica Verlag. All rights reserved.

mation.259 Receiving spam messages due to published data can also occur if providers of such applications illegally sell patient data in order to finance the application. Here providers should take great care that patient data are kept  258 259

Cp. Seeman, 2008, p. 107 et seq. Cp. Gully News (Ed.), 2009.

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private and secure if this promise is made to its users, especially since national laws concerning data protection exist (see also Chapter 9). However, up to now many providers do not take sufficient (technical) action to prevent data misuse (e.g. from third parties).260 The issue of data security and illegal re-utilization is in particular a critical aspect when dealing with EPHRs, as well. In the case of Google Health, data protection experts criticize that such sensitive information should not be administered by a company following different interests than patients and physicians do. Moreover it is worried about the fact that insurance providers or employer may gain unauthorized access to personal health data for the purposes of informing themselves about the real health status of their members and employees. In this context, the psychologist Deborah Peel, founder of the patient protection association “patientprivacyrights.org”, conveyed her displeasure and stated: “This is the Wild West in an online format”.261 Therefore people should critically think about which health information to publish, and where to publish and store it in order to avoid surprises in the future.

Limitations to Access: From Digital to Social Divide?

A further problem or discrepancy when dealing with Web 2.0 applications in the health care market is constituted by the unequal access to such applications. In this context it is often referred to the “digital divide”, and discussion takes place whether the use of Web 2.0 likewise in the health care sector extends the digital divide further. The term “digital divide” aims at pointing to existent inequalities with respect to access to computers, internet, and other digital ICT. It is expected that this is highly dependent on social factors, like household income,

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education, age, and race and exhibits wide-ranging societal effects. Moreover, often it is not only the pure access or non-access to ICTs, but also the lacking

 260 261

Cp. Geiger, Eikemeier, Grütter, 2002, p. 71 et seq. Cp. Focus (Ed.), 2008.

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ability to efficiently use them.262 The digital divide cannot only be found between developing and industrial countries, but also within one society, as well.

The paradox in the field of health care is that on the one hand Web 2.0 applications are intended to further educate and inform patients about health-related topics, to provide space for interaction with fellows, communication with physicians and other health providers, generally to improve the individual health status and to enhance the outcomes of health care systems; on the other hand, it is obvious that patients who need further education / information in terms of health and health care most urgently, have the least chances to gain access to computers and the Internet. Trying to understand the reasons for this phenomenon it is pointed to the “inverse care law”, which has been described by Julian T. Hart already in 1971. He proposed that “the availability of good medical care tends to vary inversely with the need of the population served.”263 Although he had very little statistical evidence, nowadays further research has refined the statement but has also approved its correctness.264

When dealing with Web 2.0 applications in health care in industrial nations, the major problem is expected to occur in low-income households since these people – even if they have access to the Internet – may not have profound knowledge about how to use it. Here literacy plays a key role, as well. Without a certain level of (health) literacy, people are not able to find and understand the needed information.265 Therefore critics argue that an extensive use of Web 2.0 in health care discriminates the people of lower income and education, thereby facilitating a two-tiered medical care. The question arises which path to follow: either to stop following an “e-strategy” in health care due to the lacking skills of Copyright © 2010. Diplomica Verlag. All rights reserved.

some classes of population, thereby disposing of all potential benefits Web 2.0 applications might entail or to ensure a sufficient training for those currently not  262

Cp. Brodie et al., 2000, p. 262 et seqq. Cp. Hart, 1971. 264 Cp. Watt, 2002, p. 252 et seqq. 265 Cp. Bos, Carroll, Marsh, 2008, p. 8. 263

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having adequate skills to use such applications in order to facilitate equal chances for all people in the long-term. The author believes that if it is not made a serious effort to equalize the problem of digital divide, the future development may turn the digital divide into a social one where a consequent two-tiered medical care is just the beginning. It has to be positively alluded to the European Commission which has established a “broadband gap policy” to overcome the digital divide. Their goal is to: “achieve 100 % high-speed internet coverage for all citizens (of Europe) by 2010 as part of the European Economic Recovery Plan.”266 Of course, a lot more needs to be done, however it is a good step to-

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wards the right direction.

 266

Cp. European Commission (Ed.), 2009, p. 3 et seqq.

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ͻǤ   ʹǤͲ 

Figure 42: Overview of Applicable German Laws for Web 2.0 in Health Care.267

For the creation and use of Web 2.0 applications in health care it is of utmost importance to consider the legal framework as not to violate law. Therefore the following chapter will give an overview of the most important legal aspects which have to be taken into consideration. Majorly, the legal framework for Web 2.0 applications in health care comprises four “dimensions”. On the one hand, the applications have to be compliant to general law; secondly, internet-related rules in general, and Web 2.0 rules in particular have to be taken into account. Copyright © 2010. Diplomica Verlag. All rights reserved.

On the other hand, it has to be assured that no health-related laws are violated. This leads to the creation of very complex situations; moreover, the use of Web 2.0 is a rather “young” phenomenon which is why currently not yet comprehen 267

Own source.

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sive and uniform agreements and laws / regulations exist. The figure above (Figure 42) provides a basic overview of the four perspectives and the corresponding national laws for Germany. Subsequently, the most important legal aspects for the use of Web 2.0 in the health care market will be discussed in greater detail.

ͻǤͳ     

In the field of Web 2.0 copyright infringements can be frequently noticed. This is due to the nature of such applications, i.e. users generate and publish their own content. Often, they thereby neglect existing copyrights (both, intentionally or unintentionally), e.g. when uploading pictures or videos to a blog. Of course, this holds true for medical images and clinical cases, too. In Germany, copyright aspects are dealt with in the “German Copyright Law” (UrhG). Here it is specified which opuses are worthy of protection (§ 2 UrhG), amongst other this counts for the protection of written material, photographic works, cinematographic work, tables, drafts, or cartographic material. The Copyright Law awards the creator of the opus a publication right and determines possible exploitations. It is especially pointed to § 31 UrhG; here the right of reproduction is determined. This section states that: “The creator may provide others with the right to use his opus in one or all types of use (“right of usage”).” If this is not the case, people publishing this content anyway infringe copyrights and according to sections §§ 97-105 UrhG the creator of the opus has an entitlement to dam-

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ages and injunctive relief. Here § 823 BGB (general liability for damages) and § 1004 BGB (injunctive relief) are applied, as well. In addition, the sections §§ 106 – 111 UrhG define the penologic consequences. For example, it is stated that the publisher is sentenced to a monetary penalty or to a custodial sentence for up to three years (§ 106 UrhG). Here it has to be noticed that already any attempt will be punished.  ͳ͵ͻ 

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Since national boundaries become blurred in terms of communication, transactions, and business, especially facilitated by the use of the Internet, the original German “Urhebergesetz” as of September 11th, 1965 has become modified in order to allow for adaption which has been made necessary by the evolution of the Internet. New regulations, especially in the field of international copyright law, had to be added amendatory. Here it is pointed to the “World Copyright Treaty” (WCT) and the “World Performers and Producers Right Treaty” (WPPRT), as an example. Moreover, the European Commission has tried to harmonize the copyright standards, as well as the corresponding property rights within the EU. Therefore the member states have agreed on an EU-informationdirective 268 which is intended to uniformly put the specifications made within WCT and WPPRT Europe-wide into practice. The EU Information-Directive deals with the common rights of the creator, i.e. the right of reproduction (which is of utmost importance in times of the digital age), the distribution right, as well as the communication to the public.269

ͻǤʹ Ǧ      

Online marketing and advertising plays a vital role in the field of Web 2.0 and health care, as well. Basically, here no other rules apply than those being specified for other advertisements in print, press, radio, or TV. Therefore, the “German Competition Law” (UWG), in particular the sections §§ 3, 5 UWG, have to

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be marked. 270 Those paragraphs prohibit unfair competition (§ 3 UWG) and deceptive advertising (§ 5 UWG). Here it is pointed to the fact that the UWG has been amended as of December 30th, 2008 to account for various European  268

Directive 2001/29/EC as of May 22nd, 2001. Cp. Hoeren, 2003, p. 5 et seqq. 270 Cp. Baumann, 2008. 269

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Directives (amongst others the Directive 2005/29/EC as of May 11th, 2005 on unfair business practices between employers and consumers). 271 Thereby, amongst others, § 5 UWG has been concretized and a “black list” of business activities has been included (activities on the list will always lead to breach of law).

For the use of Web 2.0 in health care, most important, the “rule of separation” has to be followed. The rule of separation states that advertisements must be clearly separated from editorial content as not to mislead customers. Therefore, health professionals have to take care that they behave compliant to this rule when publishing content in blogs, communities, or health portals. Especially health portals/communities or (private) health-related blogs are often financed by advertising revenue. Here it is of utmost importance that those advertising offers are clearly distinguishable from editorial content for its users. The rule of separation is contained in various regulations, e.g. in § 4 para.3 UWG (deception of the advertising character) in conjunction with the general norm of § 3 UWG or in a more direct form in § 1 RStV in conjunction with § 58 para.1, clause 1 RStV (“German State Treaty on Broadcasting”). Moreover the rule of separation is anchored in § 6 para.1 clause 1 TMG (German Teleservices Act). To show an example, the following figure provides an excerpt from the “WebMD” website (http://www.webmd.com), here advertising can be clearly dis-

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tinguished from editorial content (marked with an arrow).

 271

Cp. Ulbricht, 2009.

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Figure 43: Excerpt from WebMD, Demonstrating the Rule of Separation.272

In addition, all marketing / advertising activities in health care – not only but also in the Internet – have to be compliant to the “Law on Advertising in the Health Care System” (HWG) and the “Medical Association's Professional Code of Conduct” (MBO-Ä). According to § 1 HWG, those regulations apply to the advertising of pharmaceuticals, medical products, and other remedies, processes, treatments, or items as long as the advertising refers to the recognition, elimination, or palliation of diseases, bodily injuries or disorders of humans and animals. Section 2 HWG specifies who is expected to belong to medical expert groups. The following aspects are considered most important and are outlined

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in greater detail. It has to be noted that misleading advertising is prohibited (§ 3 HWG), as well as the advertising for pharmaceuticals which are subject to the duty of market authorization and are not (yet) authorized (§ 3a HWG). Moreover, a strict separation of advertising for expert groups and “patients” is made,  272

Cp. http://www.webmd.com.

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for example are companies not allowed to advertise pharmaceuticals outside expert groups which deal with the recognition, prevention, elimination, or palliation of some illnesses, e.g. cancer or complications during pregnancy (§ 12 HWG). Prescription pharmaceuticals may only be advertised within expert groups, this holds true for drugs eliminating insomnia or mental disorders, as well (§ 10 HWG). If advertisements are not compliant to the HWG, section 14 specifies possible fines (monetary penalty or custodial sentence up to one year). Therefore, health professionals have to ensure that their blog / forum / community articles do not violate the above depicted legal aspects. In this context the critical question arises what is needed to give a statement an “advertising character”. Is the pure mentioning of a pharmaceuticals´ name in an article already advertising?

Finally, the “Code of Medical Ethics” (MBO-Ä) outlines the prohibition of misleading advertisements for physicians in particular. Section 27 para. 3 MBO-Ä declares that physicians are not allowed to initiated, conduct, or tolerate promoting, misleading, or comparative advertising. Within a European Frame the advertising for pharmaceuticals has been governed by the Directive 2001/83/EC as of November 6th, 2001, here in particular §§ 86 – 100 of this Directive.

ͻǤ͵   

Data privacy protection is especially important when dealing with highly sensi-

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tive personal data on health status, diagnosed illnesses, chronic diseases, treatments, etc. Therefore data privacy protection has to be ensured, especially when those data are put online. Online patient data can be found in a majority of applications (e.g. blogs, communities, or EPHRs), distinguishing between health data which have been uploaded by the patient himself, and those data being put to the Internet via a health professional (maybe even without inform ͳͶ͵ 

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ing the patient). If patients put their health data online themselves, they should consider possible disadvantages of this behavior. Moreover, they should carefully read the GTCs (general terms and conditions) of the provider where data are uploaded. Here especially the section dealing with data privacy and protection is of great importance. How are data handled by the provider, are they handed on to third parties?

In contrast, health professionals should take great care when uploading patient data to the Internet (e.g. to ask for a second opinion) as well as providers of applications should act conformant to law. Otherwise, §§ 43, 44 BDSG are applicable, implying high penalties. Here, in Germany violations to the “Federal Data Protection Act” (BDSG) or the “German Teleservices Act” (TMG) are a common mistake. In Germany, the legal framework for data protection and security is the BDSG and the TMG, whereby it has to be noted that the BDSG is always applicable as long as the TMG does not contain a particular regulation. Both, the BDSG and the TMG require the principles of appropriation (§ 31 BDSG and § 12 para.1 TMG), system data protection and data avoidance/minimization (§ 3a BDSG). For example, § 12 para.1 TMG postulates the principle of appropriation, i.e. the person concerned has to be informed about the kind, scope, location, and purpose of the collection of his personal data prior to the collection. Moreover, §§ 28, 29 BDSG define in which case and how personal data may be collected, processed, and used by non-public bodies.

In addition, health professionals have to consider § 203 StGB (“German Criminal Code”), as well. This section refers to the violation of private secrets and prohibits physicians or members of another healthcare profession to “unlawfully Copyright © 2010. Diplomica Verlag. All rights reserved.

disclosing a secret of another, in particular, a secret which belongs to the sphere of personal privacy”. Here, in addition it is pointed to § 823 para. 1 BGB, which aims at protecting general personal rights. Those regulations apply to the publication of clinical cases / private patient data in the Internet, too. Thus, phy-

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sicians have to make sure that the “real” patient concerned cannot be concluded from by means of the uploaded material.

From a European Perspective it became clear that the EU has to undertake serious action in the field of data protection, in order to guarantee Europe-wide proper data handling as well as transnational data exchange. Therefore the European “Data Protection Directive” (Dir. 95/46/EC) had been established in 1995, entailing an adaption of the German BDSG, as well. A second European Data Protection Directive (Dir. 2002/58/EC), which came in effect in 2002, regulates the processing of personal data and the protection of privacy within electronic communication in particular. Although the levels of data protection and security within Europe converge, it has to be pointed to the fact that outside Europe different standards and regulations exist, e.g. in the USA where the level of data protection is considered to be significantly lower (from a European perspective). Here, a further convergence of regulations is desirable.273

ͻǤͶ     Ǧ   Ǧ Ǧ 

The question of liability of online providers for user generated content is a very challenging but also important one. For the provider of a health portal, for example, the answer to this question may have far-reaching effects. The same holds true for professional (medical) blogs which allow users to write comments

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or which have a guestbook feature included. Here the same question applies, is the provider of the blog liable for user comments or guest book entries?

 273

Cp. Baumann, 2008.

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The subsequent figure tries to clarify the initial situation. The service provider (i.e. of a health portal, a community, or a blog) provides space for interaction (i.e. the platform or blog). The community members interact on this platform. Now, a user posts articles, videos, images, or comments, thereby behaving not conformant to rules and regulations and violates another person´s rights. It has to be determined who is liable for this infringement, solely the user who has put content online (“interferer”) and/or the service provider (“co-interferer”), too?

Figure 44: Is the Online Provider Liable for UGC?274

In accordance with § 2 TMG, a service provider is every individual or entity which provides own or external telecommunication media for use or which pro-

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vides access to its use. Here the TMG distinguishes between a content provider, an access provider and a service provider. The TMG determines different forms of liability for the three types. The content provider keeps available own  274

Adapted from Ulbricht, 2008.

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information for use (“information supplier”) and is therefore according to § 7 TMG fully liable correspondent to the general regulations of civil and criminal law (i.e. a blogger is fully liable for his own published articles on his blog). Thus, a provider is liable for incorrect content in accordance with the “product liability law” (ProdHaftG) or § 823 para. 1 BGB. When dealing with medical information a damage to body or health (both legally protected by § 823 para. 1 BGB) may occur more frequently than in other fields which is why a high liability risk is expected when providing health advice or health-related advertising. 275 In contrast, the access provider that only provides access to the use of information, is not liable for the content (§ 8 TMG).

The service provider (i.e. also providers of health portals and communities), is not liable for content stored on behalf of a user as long as he does not have cognizance of the illegal action (§ 10 para. 1 TMG) and as long as they immediately remove or block unlawful information after they have received notice (§ 10 para. 2 TMG). Thus they do not act as a “co-interferer” and are therefore not liable for users´ infringements as long as they comply with this principle of “notice and take down”. As a result, a provider of a health community will not be charged liable for a user´s harmful health tip as long as he had not yet taken notice of it. The same holds true for (health-related) blogs, i.e. a blogger has to remove harmful / unlawful information in reader comments as soon as he receives notice of it; if he does not so, he will be held liable for potential damages.

Independent of the type of provider, the liability for manually set hyperlinks has to be considered. Here, on the one hand the questions arises whether providers allowed to link to external content without the permission of the external providCopyright © 2010. Diplomica Verlag. All rights reserved.

er. To answer these questions it has to be distinguished between deep links and surface links (i.e. links where the user directly notices that he has been led to an external website) and inline links (i.e. the user has the perception that the  275

Cp. Hoeren, 2009, p. 452 et seqq.

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linked content belongs to the initial provider). When dealing with deep / surface links, generally the provider can set those links without permission and without violating the law (in particular UrhG and UWG). In cases of inline links, the risk of infringing those laws is by far higher. Here it is important to have the permission of the external provider to set links to the external content. On the other hand, it is questionable whether the provider who has set links to external content is considered liable for this (external) content, as well. The jurisdiction does not uniformly evaluate this problem. Majorly it depends on the degree to which the provider who has set the hyperlinks adopts the content as his own. If doing so, this may be illegal in terms of copyrights, or – if the link leads to illegal content – may result in law enforcement. Therefore provider of links to external content should clearly dissociate himself from the content provided by the external links, e.g. by a statement like: “The following links refer to external content only. We do not take any responsibility for this content.”276

With respect to European regulations dealing with the liability of providers for UGC and hyperlinks, it is pointed to the E-Commerce Directive of the European Union (Dir. 2000/31/EC as of June 8th, 2000). In particular it is referred to §§ 12 – 15 of this Directive. Here, the liability of the different types of online providers is governed. The specifications of this Directive have also been put into national legislation by amending the German TMG (see also §§ 7 – 10 TMG). Finally it has to be noted that not only in Germany the liability of providers for hyperlinks is not uniformly ruled but also no regulations standardized within the EU could have been agreed on. 277 Therefore this branch of law remains uncertain for

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now.

 276 277

Cp. Baumann, 2008. Cp. Hoeren, 2009, p. 516 et seqq.

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A Special Case: Medical Evaluation Portals from a Legal Perspective

Whether medical evaluation portals are compliant to law has been frequently discussed within the public. In general, the evaluation of physicians, hospitals, or other medical facilities is protected by § 5 para. 1 GG (“Fundamental Law for the Federal Republic of Germany”) which states that: “every person shall have the right freely to express and disseminate his opinions in speech, writing, and pictures and to inform himself without hindrance from generally accessible sources. […] There shall be no censorship.” Since the evaluation criteria on evaluation portals constitute value judgments, they are protected by § 5 para. 1 GG. This assessment has been verified by verdicts from the Federal Court of Justice (BGH), e.g. by the well-known “Spickmich-Urteil”.278 It turns out to be more critical if evaluation criteria are not objective, or if users post untrue, offending or defaming comments on physicians (“damage to one´s reputation”). Then, the personality rights of the evaluated person can be violated and the culprit (i.e. the author of the post) may be sentenced to an indemnity according to § 823 para. 2 BGB. With respect to the liability of the platform provider (“service provider”) for the user´s post, the “notice and take down” principle applies here, as well (see also section above), i.e. he is not hold liable as long as he did not have cognizance of unlawful content and has immediately blocked it after receiving notice. Here § 15 para. 1 Dir. 2000/31/EC (“E-Commerce Directive”) is

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applied mutatis mutandis.

 278

Verdict Az. VI ZR 196/08 , BGH.

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ͻǤͷ   Dz    dz  

The last aspect which is dealt with in greater detail within this work is the “prohibition of remote treatments” for health professionals and its legal effects on the use of Web 2.0 in the health care market. According to § 7 para. 3 MBO-Ä, German physicians are not allowed to exclusively provide individual medical treatment and advice by letter, via journals and magazines, neither may they provide individual medical treatment or advice exclusively by means of telecommunication media or computer communication networks. By this, it is ensured that the physician fulfills his due diligence (§ 9 para. 1 MBO-Ä). Similarly, § 9 HWG prohibits advertising for remote treatments. Therefore, physicians interacting with patients in health communities, blogs, or health portals have to behave compliant to § 7 para. 3 MBO-Ä and § 9 HWG (in addition to the provision for data protection requirements). Within § 7 para. 3 MBO-Ä, the term “exclusively” is of utmost importance, since by this definition the communication between a physician and a patient via Web 2.0 applications after an initial personal contact, remains unproblematic (e.g. for purposes of medical supervision or communication in the framework of an after-treatment).279 Many health portals and communities advertise with a slogan like “get answers from experts to your medical questions”; here it has to be distinguished between answers from health professionals which are kept general without a direct reference to a concrete patient and those answers which directly provide advice (diagnosis, treatment options) to a concrete patient request referring to concrete symptoms. While the response to general medical / health-related questions, as well as

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advice to preventive actions, is permitted according to § 7 para. 3 MBO-Ä, a concrete provision of individual diagnosis and therapy in a particular case is prohibited. When answering patient questions in forums, blogs or communities health professionals have to consider this aspect. Moreover, it is not only the  279

Cp. Dierks, 1999, p. 41 et seq.

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respondent physician who can be sentenced if behaving unlawfully; it is also the provider of such platforms / offers who can be prosecuted if he had notice of this action. However, when studying the offers of “medical expert advice”, infringements to the prohibition of remote treatments can be noticed on a regular basis.280

From an international perspective it has to be stated that pure remote treatments are not prohibited worldwide, this depends on the nationally varying medical codes of conduct. For example, are remote treatments permitted within the USA.281 On a European Basis, this is governed, similar to Germany, within the European Directive 2001/83/EC as of November 6th, 2001 which aims at the creation of a common codex for human pharmaceuticals within the EU (in par-

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ticular § 90 para. 1 of this Directive).

 280 281

Cp. Glökler, 2010. Cp. Initiative Gesundheitswirtschaft e.V. (Ed.), 2010, p. 10 et seq.

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ͳͲǤʹǤͲ ǣ  

After having discussed and outlined the theoretical background of the use of Web 2.0 in health care, existing applications and options for implementation have been depicted. Within the following sections it is aimed at providing a view on the topic from an individual “expert” perspective. Within the scope of the conducted expert interviews it was intended to gain an insight into the individual valuation and considerations of this topic by the “experts”, i.e. from those who professionally use, provide, or create Web 2.0 applications for the health care market. Here it was not aimed at gaining “hard facts” but rather expectations, feelings, and impressions from a practical perspective.

ͳͲǤͳ   

The process of conducting the expert interviews followed five successive steps, which are listed below and which are shortly described within subsequent sections:

1. Deciding on the way of realization 2. Constructing the questionnaire 3. Selecting appropriate experts and contact them

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4. Conducting the interviews 5. Analyzing the results and drawing conclusions

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Deciding on the Way of Realization

Since it turned out that many experts have reacted reluctantly when being asked for a personal (face-to-face) interview, being it either time restrictions or personal concerns, it has been decided to conduct the expert interviews on a written basis, knowing well that this may lead to more imprecise or short answers than in a face-to-face situation.282 In order to partly overcome the downsides of E-mail based surveys, like a low response rate, the initial contact has been established via telephone in order to make the situation more personal, to explain the purpose and kind of this survey, and to give the respondents an individual impression, thereby increasing the response rate and quality of answers. If the expert has agreed on participation, the questionnaire has been sent via E-mail to the contacted person. The written way has also been chosen due to various advantages: on the one hand, a verbatim reproduction of answers is ensured (this would not have been the case via a telephonic interview), on the other hand, it leaves the freedom to choose the experts independently from location (the search for experts therefore has not been limited to a particular region). 283 Therefore an E-mail based, written interview process seemed most promising to the author. All interviews have been conducted according to the above depicted procedure in order to increase comparability.

Constructing the Questionnaire

The underlying questionnaire contains 11 open questions, i.e. questions for which the respondent is given no pre-defined answers to chose from; open Copyright © 2010. Diplomica Verlag. All rights reserved.

questions allow for “longer” and more detailed answers, as well as they elicit the respondent´s opinion, considerations and evaluation of the topic. Since it is dealt with personal opinions and expectations, there are no “wrong” or “right”  282 283

Cp. Gläser, Laudel, 2009, p. 153 et seq. Cp. Schnell, Hill, Esser, 2008, p.358 et seqq.

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answers. After having decided on the written way of realization, the questions have been designed in a way so that they are easy to understand and selfexplaining. Moreover, within the questionnaire general questions have been placed first, to give the respondent an entry point to the topic, proceeding then with more specific questions towards the end. The questions focus on the various aspects of Web 2.0 in health care in dependence on those which have been addressed throughout this study. Respondents were asked to freely express the potential of Web 2.0 in health care, its advantages and benefits, as well as the corresponding risks and downsides from their perspective.

Selection of Experts and Realization of Interviews

Potential respondents have been chosen in accordance with the following prior considerations. First of all, the respondent should have a profound level of knowledge and expertise of this topic to ensure high-quality answers. Moreover, the intention was to get respondents across the different stakeholder groups (i.e. health care providers & health care payers), as well as different “branches” of the health care market (e.g. pharmacies, hospitals, health insurances, communication consulting companies and pharmaceutical companies). Although patients constitute one of the major stakeholders of Web 2.0 applications in health care, it has been intentionally decided to omit these within the interviews since most patients do not have a conscious knowledge of this topic. Moreover, here a large sample of some hundred patients would have been needed in order to draw high-quality results from the answers.

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However, during the telephonic contacting it became obvious that in practice respondents from a diversity of “branches” could not be realized. Here, despite of an intensive contacting, especially in the field of hospitals, physicians, and health insurance providers (either being compulsory or private), the reluctance of participation was tremendous. While physicians and hospitals refused to take  ͳͷͶ 

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part majorly for the purpose of lacking knowledge, health insurance providers stated a lack of time or the outsourcing of the communication process to a PR agency in the majority of cases. The author considers this to be a great pity since thereby results become more biased towards certain “branches”. Of course, this does not increase the value and expressiveness of results. However, this behavior underlines the fact that the use of Web 2.0 applications in the (professional) health care market is not yet very far-reaching.

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The following section sums up the most important findings from the conducted expert interviews. The findings may be regarded as trend statements; however, they cannot be generalized for all stakeholders. For the original interviews please refer to Appendix V to IX.

Unsurprisingly, experts see major problems in the future of the health care market in cost pressure and financing issues, an increasing demand due to the future demographic development (“aging population”), and a lack of care especially in rural areas and for the chronically ill, as well. These statements are conformant to literature, and can be supported by various articles in newspapers, for example the “Wiesbadener Kurier” stating: “Germany is running out of doctors.” 284 or the “Frankfurter Allgemeine Zeitung” (FAZ) which titles: “Doctors complain about health care rationing.”285 Moreover, legal issues, a consolidation Copyright © 2010. Diplomica Verlag. All rights reserved.

of the market leading to less competition in the long-term, and the urgent need to create more options for individual prevention possibilities are addressed by the respondents. Experts consistently grant the use of Web 2.0 applications a  284 285

Cp. Wegener, 2010, p. 11. Cp. Nienhaus, 2010.

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long-term development within the health care market. In their eyes, it is by far more than a temporary fashion, despite the fact that not all applications are equally valued, and a higher benefit is expected to come from wikis, communities and forums while the use of Twitter or blogs is considered less beneficial. However, it must be pointed to the fact that this opinion might not be shared by all stakeholder groups depending on the particular needs. Moreover, experts believe that Web 2.0 applications can definitely help to overcome the challenges to which the health care market currently is exposed to. From the answers provided it can be derived that experts see a possibility of cost savings, in particular. Moreover, they expect that the creation of better communication and information possibilities for patients is highly beneficial since a better informed patient is expected to be more therapy-compliant which in turn facilitates cost reductions in health care. A better informed and educated patient may lead to an improvement in the physician-patient relationship, as well. Moreover, a better health care for the chronically ill and those who need home care can be provided by the use of such applications, as well as the online treatment of little sicks and pains is considered to be helpful in terms of cost reductions and improved health care provision.

When talking about cost savings for the health care market, it is not enough to regard the costs saved only, rather a more comprehensive view is needed, considering the costs spent for the introduction of Web 2.0 applications as compared to the benefits obtained from these applications. Here, experts are not in complete agreement. While all experts certify Web 2.0 applications a benefit, an agreement on costs could not be made. On the one hand it is argued that the costs for the creation of such offers are rather low since technical requirements Copyright © 2010. Diplomica Verlag. All rights reserved.

are yet given; therefore benefits clearly outrange costs. On the other hand it is believed that it is not the creation but the “maintenance” of such applications which is expensive. The term maintenance refers to the fact that it is not enough to build such applications, but continuously monitor its content to guarantee reliable information in the long-term; this is especially time-consuming when deal ͳͷ͸ 

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ing with patient-created content published in communities that has to be reviewed by “experts”.

When thinking of possible and meaningful situations of use, experts see the exchange of information between patients on first place, followed by interactive applications facilitating further medical training and education of health professionals. In general it can be stated that all answers lie in the scope of communication/interaction and provision of information and experiences, for example also to serve the purpose of customer-tailored marketing via blogs or Twitter. Of course, here the interactive nature of Web 2.0 applications is most accommodating. The complete range of answers can be found in the figure provided be-

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low.

Figure 45: Responses to the Question of Meaningful Areas of Application.286

 286

Own figure based on expert responses.

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As a result it can be concluded that greatest benefits are seen for patients and their relatives; however benefits for health professionals cannot be denied either, for example in the field of virtual medical education, as outlined beforehand. When considering the most well-known Web 2.0 applications for patients as compared to those for health professionals, this opinion can be confirmed since the number of patient-centered applications is by far higher than the number of applications provided for health professionals. However, this might change in the future when Web 2.0 applications further develop into a “common standard”.

Subsequently, experts have been asked about their assessment of implied chances and risks of using Web 2.0 in health care. The following figure provides

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a summary of responses given.

Figure 46: Risks and Chances of Web 2.0 in Health Care in the Eyes of Experts.287

 287

Own figure based on expert responses.

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Especially in the field of data quality serious concerns have been raised. Apart from one expert referring to the “self-correcting” effect of communities, most of the experts consider the assurance of high-quality and correct information to be problematic. Of course, when dealing with health information this is of greatest importance. To counteract this risk it is proposed to make compliance to the HONcode or another independent seal of quality compulsory. By this, a certain level of quality can be assured, and patients directly know if they can rely on the provided information or not. Moreover, it is taken care that provided information is not biased towards the provider of the service (e.g. consciously filtering information to convey a particular image or message). With respect to legal problems or difficulties the opinions of experts vary. While some argue that legal difficulties are not specific for Web 2.0 applications (e.g. data security is a concern outside the Internet, as well) or that they are easily solvable at least, others see here a major challenge to behave conformant to law. This is partly due to a non-uniform jurisdiction on the one hand, and the imprecise laws, especially in the field of advertising in health care (HWG) and provider liability for UGC (TMG in particular). Both facts do not facilitate a more frequent adoption of Web 2.0 applications in a professional health care setting. Despite data quality issues and legal challenges, some further aspects have been identified which facilitate a broader adoption and acceptance of Web 2.0 applications amongst patients and health care professionals in the eyes of experts. First of all, the trustworthiness and quality of provided information must be demonstrated, e.g. by the HONcode. This is considered to be most important in the eyes of the respondents. Moreover, information has to be up-to-date and themed to the relevant target group(s). Here a clear distinction between layper-

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sons and medical experts should be underlined. Moreover, a major criterion for the acceptance of Web 2.0 applications is the “usability factor”. This includes an easy-to-understand language (e.g. the avoidance of medical terms), a design supporting accessibility (e.g. being free of barriers), and options for interaction. In addition, from a technical perspective, data security should be ensured by all  ͳͷͻ 

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means, as well as no automatic standard replies or the automatic integration of RSS-Feeds should be provided. Finally, the respondents have been asked whether they are currently undertaking projects in the scope of Web 2.0 in health care. It has been tried to assess the current importance of such applications in management practice. In this context, answers vary; majorly the consulting companies help to create Web 2.0 applications for companies, also in the field of health care and telemedicine. With respect to the pharmaceutical companies it can be concluded that a trend can be recognized but the implementation is performed rather hesitantly. However, the observation of the topic shows that companies are not completely ig-

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norant towards this topic; it just may take a while to come into practice.

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ͳͳǤ Ƭ 

To conclude the findings of this piece of research it can be stated that Web 2.0 applications have a potential for the health care market by all means. If the level of penetration increases within the next years, thereby leading to a comprehensive interconnectedness of all parties, all stakeholders of the health care market can draw their benefits from this development. This conclusion is conformant to the author´s expectation, expressed within Chapter 1.2. It has to be noted that Web 2.0 applications might be especially useful for the purpose of informing, educating and communicating with patients, as well for the purpose of professional collaboration between health care providers. The fact that currently health professionals use Web 2.0 to a lower degree than patients had been expected by the author, as well; however this should change in the future.

Moreover, cost reductions, revenue increases, as well as efficiency gains can be realized, supporting the overcoming of current problems of the health care market in particular such as the problems of future financing, good provision of health care for all patients, and the demographic aging of the population, leading to an increased demand for (home) care services which may be realized more efficiently with the help of Web 2.0 applications. Of course, the downsides should not be neglected. Here major problems arise from the anonymity in the Internet, the question of high-quality, reliable and trustworthy information, as well as data protection / security issues. Moreover, legal aspects like potential copyright infringements or questions of liability have to be considered. However, these downsides do not constitute insurmountable obstacles but rather can be

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overcome by certain mechanisms like an independent website quality certification (“HONcode”) to ensure quality, a required registration prior to use to overcome anonymity, or technical mechanisms to guarantee data security. Therefore it is assumed that advantages will outweigh disadvantages if Web 2.0 applications are properly created and are not thoughtlessly used. To a very great extent, this valuation is shared by the experts that have been interviewed, as  ͳ͸ͳ 

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well. Certainly Web 2.0 cannot be regarded as a universal remedy against all problems but as a good supporting instrument.

Table 7: Comparison of Major Characteristics of Web 2.0 and Web 3.0.288

Beyond that, it should not be forgotten that users and technology will develop further, thereby leading to completely new or more advanced possibilities for its use. Already, trends show that Web 2.0 will not be the end of technological progress, referring yet to “Web 3.0”. The benefit of this notation may be ques-

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tionable; however the underlying concepts show promising developments. While, generally speaking, within Web 2.0 it is all about participation (usergenerated content), interactivity, connectivity, and communication, Web 3.0 is also called “the semantic web” and enables computers to communicate with  288

Cp. Giustini, 2007, p. 1273 et seq.

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each other, making use of “artificial intelligence”. Here it is all about metadata (data about data) which allow machines to understand and meaningfully link the data. However, currently no uniformly agreed definitions can be found for the term Web 3.0, neither a common standard has been yet developed.289 The major progresses from Web 2.0 to Web 3.0 are outlined in the table below.290

Experts assume that Web 3.0 will have an even greater impact on health care than Web 2.0 does because it allows computers to recognize information that is trustworthy and then return validated information to people, thereby overcoming some of the largest disadvantages of Web 2.0. Within literature some experts go one step further and do not only refer to “Health 2.0” (a synonym for Web 2.0 in health care) and “Health 3.0” but even to “Health 4.0”. 291 However, the development of Web 2.0 in general as well as in the field of health care depends on a large number of influencing factors. Finally it must be concluded that it remains to be speculative if and how the use of “Web X.0” will further change the

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way of provision of health care in the future.

 289

Cp. Wilke, Stumbek, Dell, n.d. Cp. Giustini, 2007, p. 1273 et seq. 291 Cp. McCabe Gorman, Braber, 2008. 290

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Back, Andrea; Gronau, Norbert; Tochtermann, Klaus: Web 2.0 in der Unternehmenspraxis. 1. Ed., München: Oldenbourg 2008. Barsky, Eugene; Purdon, Michelle: Introducing Web 2.0: social networking and social bookmarking for health librarians. Journal of the Canadian Health Libraries Association, Toronto, Vol. 27, (2006), P. 65-67. Baumann, Sibylle: Skript IT-Recht. Vorlesung IT-Recht WS 08/09, Fachhochschule Ludwigshafen, 2008.  ͳ͸Ͷ 

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Brodie, Mollyann et al.: Health Information, The Internet, And The Digital Divide. Health Affairs, Bethesda, Vol. 19 (2000), No. 6. P. 255-265. Bucher, Stefan (2005). Webseiten im Abo mit RSS (JPG-File, Version: 10/01/2005). Internet: http://www.stefanbucher.net/tutorial/rss/ (lastly accessed: 02/12/2010). Bundesärztekammer (Ed.): (Muster-)Berufsordnung für die deutschen Ärztinnen und Ärzte (Stand 2006). 5. Ed.: Bundesärztekammer 2006.  ͳ͸ͷ 

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CollabWorks Inc. (Ed.) (2008). Metcalfe´s Law. (JPG-File, Version: 10/12/2009). Internet: http://www.collabworks.com/Main_WhatIsOpenIT/Metcalfe.htm (lastly accessed: 10/12/2009). Comer, Ben (2009). Boehringer Ingelheim broadens YouTube, Twitter efforts. (Online Article, Version: 08/26/2009). Internet: http://www.mmmonline.com/boehringer-ingelheim-broadens-youtube-twitterefforts/article/147349/ (lastly accessed: 12/28/2009).

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Stiftung Gesundheit (Ed.) (2007). Ärzte im Zukunftsmarkt Gesundheit 2007. (PDF-File, Version: 07/15/2007). Internet: http://www.stiftunggesundheit.de/PDF/studien/Studie%20%C3%84IZG %202007_kurz.pdf (lastly accessed: 12/31/2009). Stiftung Gesundheit (Ed.) (2008). Arztbewertungsportale – Eine Beobachtung der Angebote im deutschsprachigen Internet (PDF-File, Version: 02/07/2008). Internet: http://www.stiftung-gesundheit.de/PDF/studien/Arztbew.pdf (lastly accessed: 12/16/2009). Stiftung Warentest (Ed.): Gesundheitsportale – Die besten Infos im Netz. Test, Berlin (2009) No. 6, P. 86 – 89.  ͳ͹͸ 

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Stöcker, Christian (2006). Menscheln statt googeln (Spiegel Online Interview, Version: 11/07/2006). Internet: http://www.spiegel.de/netzwelt/web /0,1518,446749,00.html (lastly accessed 10/31/2009). Storm A. King (2004). The Therapeutic Value of Virtual Self-Help Groups. (Dissertation, Version: 11/2004). Internet: http://webpages.charter.net /stormking/dissertation.pdf (lastly accessed: 11/30/2009). Sutter Health (Ed.) (2009). Physician Creates Podcasts for Patients (Online Article, Version: 05/29/2009). Internet: http://www.sutterhealth.org/about /news/news09_safh-podcasts.html (lastly accessed: 12/28/2009). Teubert, Silvio (2008). Internetgesetze (5): Metcalfe´s Law (Blog Entry, Version: 02/12/2008). Internet: http://www.bloggas.de/internetgesetze-5-metcalfes-law/ (lastly accessed: 10/30/2009). The Berlin Institute for Population and Development (Ed.): Europe´s Demographic Future – Growing Imbalances. 1. Ed., Berlin: The Berlin Institute for Population and Development 2008. The European Observatory on Health Systems and Policies (Ed.) (2007). Glossary (Online Glossary, Version: 03/05/2007). Internet: http://www.euro.who.int /observatory/Glossary /TopPage?phrase=H (lastly accessed: 11/01/2009). Tovey, Dave: The informed patient. Singapore Medical Journal, Singapore, Vol. 47 (2006) No.9, P. 741-746. Tyer, Dominic (2009) (1). We're playing catch up on Twitter, admits Pfizer (Blog Entry, Version: 09/30/09). Internet: http://www.inpharm.com/news/were-playingcatch-twitter-admits-pfizer (lastly accessed: 12/28/2009).

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Tyer, Dominic (2009) (2). Digital Pharma: Pfizer launches European YouTube channel (Blog Entry, Version: 02/12/09). Internet: http://www.inpharm.com /news/digital-pharma-pfizer-launches-european-youtube-channel (lastly accessed: 12/28/2009). Ulbricht, Carsten (2009). Neues Marketing - und Werberecht - Aktuelle Änderungen des UWG und deren Auswirkungen. (Online Article, Version: 03/04/2009). Internet: http://rechtzweinull.de/index.php?/archives/93-NeuesMarketing-und-Werberecht-Aktuelle-AEnderungen-des-UWG-und-derenAuswirkungen.html#extended (lastly accessed: 01/25/ 2010). Unruh, Peter (2008). Why we love Twitter. (JPG-File, Version: 10/30/2009). Internet: http://www.peterunruh.de/wp-content/uploads/twitter_love.gif (lastly accessed: 10/30/2009).

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Vickery, Graham; Wunsch-Vincent, Sascha: Participative Web and Usercreated Content – Web 2.0, Wikis, and Social Networking. 1. Ed., Paris: OECD Publications 2007. Viola, Gerald (2008). Gesundheitswesen: Einsparpotenziale von 400 Millionen Euro pro Jahr (Online Article, Version: 08/11/2008). Internet: http://www.egovernment-computing.de /projekte/articles/147764/?icmp=aut-listartikel Wagner, Jürgen (2009). The ultimative guide for everything Twitter. (Blog Entry, Version: 12/09/2009). Internet: http://fremdsprachenundneuemedien .blogspot.com/2009/09/ultimate-guide-for-everything-twitter.html (lastly accessed: 10/30/2009). Wandschneider, Ulrich; Rösener, Carin: Chancen und Perspektiven für die Gesundheitswirtschaft am Beispiel von Hamburg. In: Medizin – Menschen – Marken – Marketing für die Gesundheitswirtschaft. Ed.: B. Seidel-Kwen, U.-A. Ludwig, J. Finsterbusch. 1. Ed., Wegscheid: Wikom 2004. P. 11-18. (Klinik Management Reader Band 4). Warda, Frank (2005). Patienten-Empowerment durch den Einsatz elektronischer Gesundheitsakten (Online Article, Version: 10/13/2005). Internet: http://www.telemedizinfuehrer.de/ free/2006/warda_374_378.pdf (lastly accessed: 01/19/2010). Watt, Graham: The Inverse Care Law Today. The Lancet, New York, Vol. 360, (2002) No. 9328, P. 252-254. Wegener, Basil: Deutschland gehen die Ärzte aus. Wiesbadener Kurier. Nr. 2 as of January 4th, 2010. P. 11. Wilhelm, Thorsten; Magerhans, Alexander: Web 2.0: Nutzung, Nichtnutzung und Erfolgsfaktoren. 1. Ed., Göttingen: eResult 2007. Accessible also via Company Homepage: http://eresult.de/downloads/downloads/Web_20 _Nutzung_Nichtnutzung_und_Erfolgsfaktoren.pdf (lastly accessed: 10/31/2009).

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Wilke, Stephanie; Stumbek, Sebastian; Dell, Michael (n.d.). Semantic Web + Web 2.0 = Web 3.0? (Powerpoint Presentation, Version: 02/02/2010). Internet: http://www.ag-nbi.de/lehre/07 /S_MWT/Material/10_Web_3_0.pdf (lastly accessed: 02/02/2010). Winkler, Lars (2007). Virtuelle Welten – Vier Alternativen zu Second Life (Online Article, Version: 05/24/2007). Internet:http://www.welt.de/webwelt/article 888759/Vier_Alternativen_zu_Second_Life.htm (lastly accessed: 10/31/2009).

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Witherton, Peter G. (Ed.) (2009). Gesundheitsmarkt (Online Encyclopedia, Version: 11/02/2009). Internet: http://www.wirtschaftslexikon24.net/d/gesundheits markt/gesundheits markt.htm (lastly accessed: 11/02/2009). Yougovpsychonomics AG (Ed.) (2009). Zum Thema Gesundheit fragen Sie Ihren Arzt oder das Internet (Press Article, Version: 10/27/2009). Internet: http://www.presseportal.de/pm /25608/1500348/yougovpsychonomics_ag (lastly accessed: 12/12/2009). Ziff Davis Publishing Holdings Inc. (Ed.) (2009). Encyclopedia – Definition of: podcast (Website, Version: 10/31/2009). Internet: http://www.pcmag.com /encyclopedia_term/0,2542,t=podcast&i=49433,00.asp (lastly accessed: 10/31/2009). Ziltener, Erika: Gesundheitswesen im Umbruch: Die Rolle der Patientin in Zukunft!. In: Gesundheitswesen Schweiz im Umbruch: Das interdisziplinäre Handbuch mit der prozess- und praxisorientierten Sichtweise. Ed.: W. Oggier et. al. Sursee: Trend Care 2008. Chapter 9.5.

Law Books

AMG (1976): Gesetz über den Verkehr mit Arzneimitteln [German Medicines Law] from August 24th, 1976 (as amended on September 28th, 2009). BDSG (1990): Bundesdatenschutzgesetz [Federal Data Protection Act] from December 20th, 1990 (as amended of January 14th, 2003). BGB (1896): Bürgerliches Gesetzbuch [German Civil Code] from August 18th, 1896 (as amended on January 2nd, 2002).

Copyright © 2010. Diplomica Verlag. All rights reserved.

HWG (1965): Gesetz über die Werbung auf dem Gebiete des Heilwesens [Law on Advertising in the Health Care Market] from July 11th, 1965 (as amended on April 26th, 2006). MBO-Ä (1997): Muster-Berufsordnung für die deutschen Ärzte und Ärztinnen [German Code of Medical Ethics] from the 100. German Medical Assembly (as amended on November 24th, 2006). RStV (1991): Staatsvertrag für Rundfunk und Telemedien [Interstate Treaty on Broadcasting] from December 31st, 1991 (as amended on July 31st, 2006). StGB (1871): Strafgesetzbuch [German Criminal Code] from May 15th, 1871 (as amended on April 13th, 2007).  ͳ͹ͻ 

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TMG (2007): Telemediengesetz [German Teleservices Act] from February 26th, 2007. UrhG (1965): Gesetz über Urheberrecht und verwandet Schutzrechte [Copyright Act] from September 9th, 1965 (as amended on November 10th, 2006). UWG (2004): Gesetz gegen den unlauteren Wettbewerb [Act Against Unfair Practices] from July 3rd, 2004 (as amended on December 21st, 2006). WCT (1996): WIPO-Urheberrechtsvertrag [WIPO Copyright Treaty] from December 20th, 1996. WPPRT (1996): World Performers and Producers Right Treaty from December 20th, 1996.

EU Directives Directive 95/46/EC (1995): Directive on the protection of individuals with regard to the processing of personal data and on the movement of such data from October 24th, 1995. Directive 2000/31/EC (2000): Directive on certain legal aspects of information society services, in particular electronic commerce, in the Internal Market from June 8th, 2000. Directive 2001/29/EC (2001): Directive on the harmonization of certain aspects of copyright and related rights in the information society from May 22nd, 2001. Directive 2001/83/EC (2001): Directive on the community code relating to medicinal products for human use from November 6th, 2001.

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Directive 2002/58/EC (2002): Directive concerning the processing of personal data and the protection of privacy in the electronic communications sector from July 12th, 2002. Directive 2005/29/EC (2005): Directive concerning unfair business-to-consumer commercial practices in the internal market from May 11th, 2005.

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Appendix I: HONcode Principles292  Principle

Statement

Explanation

Authoritative

Indicate the qualifications of the authors.

Any medical or health advice provided and hosted on this site will only be given by medically trained and qualified professionals unless a clear statement is made that a piece of advice offered is from a non-medically qualified individual or organization.

Complementarity

Information should support, not replace, the doctorpatient relationship.

The information provided on this site is designed to support, not replace, the relationship that exists between a patient / site visitor and his / her existing physician.

Respect the privacy and confidentiality of personal data submitted to the site by the visitor.

Confidentiality of data relating to individual patients and visitors to a medical / health Web site, including their identity, is respected by this Web site. The Web site owners undertake to honor or exceed the legal requirements of medical / health information privacy that apply in the country and state where the Web site and mirror sites are located.

Copyright © 2010. Diplomica Verlag. All rights reserved.

Privacy

 292

Adapted from http://www.hon.ch/HONcode/German

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Attribution

Justifiability

Transparency

Financial disclosure

Copyright © 2010. Diplomica Verlag. All rights reserved.

Advertising policy

Cite the source(s) of published information, date and medical and health pages.

Where appropriate, information contained on this site will be supported by clear references to source data and, where possible, have specific HTML links to that data. The date when a clinical page was last modified will be clearly displayed (e.g. at the bottom of the page).

Site must back up claims relating to benefits and performance.

Any claims relating to the benefits / performance of a specific treatment, commercial product or service will be supported by appropriate, balanced evidence in the manner outlined above in Principle 4.

Accessible presentation, accurate email contact.

The designers of this Web site will seek to provide information in the clearest possible manner and provide contact addresses for visitors that seek further information or support. The Webmaster will display his / her E-mail address clearly throughout the Web site.

Identify funding sources.

Support for this Web site will be clearly indentified, including the identities of commercial and non-commercial organizations that have contributed funding, services or material for the site.

Clearly distinguish advertising from editorial content.

If advertising is a source of funding it will be clearly stated. A brief description of the advertising policy adopted by the Web site owners will be displayed on the site. Advertising and other promotional material will be presented to viewers in a manner and context that facilitates differentiation between it and the original material created by the institution operating the site.

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Appendix II: List of Links to Patient-Centered Examples  Patient Blogs Blog Title

Link

Description

http://www.clldiary . blogspot.com/

David Arenson, the author of the blog, describes his personal experiences with his diagnosed illness – “chronic lymphocytic leukemia (CLL)” and provides support for other persons concerned.

http://www.diabet esmine.com/

Amy Tenderich, the author, describes her experiences with diabetes, shows new treatment options, and writes about other topics related to diabetes. Comments of other persons concerned are welcomed.

Tumor Diary

http://news.bbc.co .uk/2/hi/health/42 11475.stm

In this blog, Ivan Noble, has written about his emotions, experiences and thoughts during fighting his brain tumor. This blog has been stopped in January, 2005; however, when reading the blog, it might become understandable why the author considers this blog worth mentioning.

Biography of Breast Cancer

http://biography ofbreastcancer. blogspot.com/

Jeff Gartin talks about her impressions and feelings concerned with her diagnosed illness: breast cancer.

The New Life of e-Patient Dave

http://patientdave. blogspot.com/

Dave reports on his way to beat the cancer.

Anastasia's Cancer Experience

http://anastasiasc ancerexperience. blogspot.com/

Here, Anastasia Spiecker documents aspects of her encounter with Hodgkin's Lymphoma.

CLL Diary – Living with chronic lymphocytic leukemia, and everything else

Copyright © 2010. Diplomica Verlag. All rights reserved.

Diabetes Mine – A gold mine of straight talk and encouragement for people living with diabetes

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Patient Communities

Copyright © 2010. Diplomica Verlag. All rights reserved.

Community Name

Link

Description

Leukämie Online

http://www.leukaemie-online.de/

Community for people suffering from leukemia.

Patienten Wie Ich

http://patientenwieich.de/

Community divided into subgroups, each dealing with a specific illness.

Leben mit MS

http://www.leben-mit-ms.de/mscommunity/

Community for people suffering multiple sclerosis.

Daily Strength

http://www.dailystrength.org/

Community divided into many sub-forums each dedicated to a specific illness.

Patients like me

http://www.patientslikeme.com/

Community with many subforums.

MedFriend

http://www.medfriend.de/

Community divided into many sub-forums and dealing with various illnesses.

Inspire – together we´re better

http://www.inspire.com/

Community divided into many sub-forums and dealing with various illnesses.

Novel Patient

http://community.novelpatient.com/

Community, created for patients with chronic diseases.

Parkinson´s Disease Community

http://www.wellsphere.com/parkinsons-disease-community/267262

Community for people suffering from Parkinson.

My Cancer Place

http://www.mycancerplace.com/

Community for people suffering from any kind of cancer.

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Podcasts for Patients Editor

Link

Description

BIG

http://www.big-direkt .de/services/infoservice/ podcast/aktuelle_pod cast_sendungen.html

BIG, a health insurance provider, offers a monthly podcasts, informing patients / customers on current trends and aspects in the field of health care (e.g. in November 2009: back therapy)

Healthy Living

http://dergesundepodca st.de/podcast/healthylivi ng.xml

The healthy living magazine from Gruner + Jahr has started a new podcast series. Listeners are provided monthly with current trends and highlights from the (paper) magazine.

Deutschen Grünen Kreuz (DGK) e.V.

http://dgk.de/presse/tvra dio/podcast.html

The „German Green Cross“ provides various podcasts. Those include health tips, expert interviews, book presentations, and information on events.

HSS ( Hospital for Special Surgery ) 

http://www.goomedic.co m/hss-hospital-forspecial-surgerypodcasts-for-patientsand-professionals-andmedical-students.html

These podcasts are comprised of interviews, patient testimonials, condition or treatment highlights, surgical videos, and many other subjects presented by the team at HSS

http://www.vaughanmd.c om/podcast.html

Dr. Vaughan is one of the first physicians in the region to create audio podcasts for his website, www.vaughanmd.com. These podcasts provide information on a variety of subjects ranging from H1N1 (swine flu) to heat related illness.293

http://www.cvmd.org/

The CVMD offers podcasts with various topics related to cardiovascular diseases, e.g. prevention or treatments.

http://my.clevelandclinic. org/patients/publications /podcasts.aspx

Cleveland Clinic podcasts offer breaking news from the cutting edge of medicine, in-depth information on diseases and treatments, and moving real-life stories.

Mark Vaughan

CVMD - Cardiovascular Multimedia Information Network

Copyright © 2010. Diplomica Verlag. All rights reserved.

Cleveland Clinic

 293

Sutter Health, 2009

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California Health Institute

http://www.chi.org/basic page.aspx?id=6004

The series examines patient experiences throughout the healthcare continuum, and touches on topics ranging from access to information and care, to breakthrough research improving quality of life, to solutions to the problems of rising healthcare costs and bureaucracy.

CDC – Center for Disease Control and Prevention

http://www2c.cdc.gov/po dcasts/index.asp

CDC offers various health-related podcasts; topics deal with H1N1, Salmonella, or Mumps, for example.

Wikis for Patients Wiki Title

Link

Description

http://www.fluwikie.com/

This is a wiki including articles related to the “flu” (Swine flu, Avian flu, etc.), including general information, news, and remedies.

http://www.wikihealth.com

This is an open general health wiki with articles on health conditions, mind/body & spirit, and health remedies. Everyone is asked to share his knowledge by creating or editing an article.

SelbsthilfeWiki

http://www.selbsthilfewiki.de/

This wiki is intended to become a comprehensive work of reference for health care.

Diabetes Wiki

http://diabetes.wikia.com

This is an open wiki for information on diabetes, including e.g. articles on symptoms, treatments, and complications.

http://www.mamaherb.com

This is a wiki which deals with the use of natural ingredients for healing illnesses. Everyone can write about his experiences with home remedies. They see themselves as "The Largest Free Home Remedies and Natural Health Resource" (official website statement).

http://quitsmoking.wikia.com

This wiki is for everyone trying to quit smoking, and for those who, we already succeeded, to share their experiences, advice, information, stories, and opinions (official website statement).

Flu Wikie*

WikiHealth

Copyright © 2010. Diplomica Verlag. All rights reserved.

Mamaherb – What actually works.

Quit Smoking

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Fitness Wiki

http://fitness.wikia.com

This wiki is for all forms of fitness; running, combat sports, mountain climbing, cycling, team sports, swimming, athletics, body building, dieting, yoga, anything, if it involves making you a better you (official website statement).

Ganfyd*

http://www.ganfyd.org

Read-only wiki which covers nearly all fields of medicine, and health.

Medpedia*

http://www.medpedia.com

Read-only wiki which includes articles to a broad range of health- and medicine-related topics.

Wikipedia**

http://www.wikipedia.de /.com

The most famous wiki in the web, including health-related articles as well.

* Those wikis can only be edited by health professionals, thus they are “read-only” for the interested health public. ** A general wiki, which is offering health and health-related articles, as well.

Health Portals for Patients Health Portal Title

Health Portal Online

Copyright © 2010. Diplomica Verlag. All rights reserved.

EmpowHer. Improving Health. Changing Lives.

Onmeda – Für meine Gesundheit.

Link

Description

http://www.healthportalonline .com/

Experts proving information to various health- and wellness-related topics, in addition a health store is included, as well as a medical library.

http://www.empowher.com/

The health portal „EmpowHer“ is dedicated to women's health and well-being, offering a community, a media library, news and health events, articles from experts and patients. The German health portal Onmeda offers information and news on health and health care, diseases, symptoms, and drugs. Moreover, services like chats, self-tests, or a physician search are included.

http://www.onmeda.de

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WebMD. Better information. Better health.

Sanego

Health-EU Portal

NHS Choices

http://www.webmd.com/

“WebMD provides valuable health information, tools for managing your health, and support to those who seek information. You can trust that our content is timely and credible.”

http://www.sanego.de

They claim to be an independent and freely accessible portal at which patients and their carers may exchange experiences about drugs, diseases, and physicians. A focus is put to reports on unwanted side-effects of drugs. Also physicians, care providers, selfhelp groups or other persons concerned are welcomed users.

http://ec.europa.eu/healtheu/index_en.htm

”This is the official public health portal of the European Union with a wide range of information and data on health-related issues and activities at both European and international level. The main objective of this thematic Portal is to provide European citizens with easy access to comprehensive information on Public Health initiatives and programs at EU level.”

http://www.nhs.uk/Pages/Ho mePage.aspx

This is the official health portal from the British NHS (National Health Service). Here the user can find health-related information, medical advice, blogs, videos, as well as health news, contact details from physicians and health tools (e.g. a “supermarket health checker”).

Evaluation Portals for Patients

Copyright © 2010. Diplomica Verlag. All rights reserved.

Evaluation Portal Title

Link

Description

Rate MDs

http://www.ratemds.com

Physician ratings for the USA, UK, Ireland, Canada, Australia, New Zealand, and India

Dr. Score

http://www.drscore.com

Physician ratings for the USA

http://www.vitals.com/

Physician ratings for the USA

Vitals

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Web 2.0 and the Health Care Market: Health Care in the era of Social Media and the modern Internet : Health Care in the era of Social Media and the modern Internet, Diplomica

I want great care Jameda

Check the doc Patienten bewerten Ärzte.

Copyright © 2010. Diplomica Verlag. All rights reserved.

Docinsider

http://iwantgreatcare.org

Physician ratings for UK

http://www.jameda.de

Physician ratings for Germany

http://www.checkthedoc.de

Physician ratings for Germany

http://www.docinsider.de

Physician and health professionals ratings for Germany

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Web 2.0 and the Health Care Market: Health Care in the era of Social Media and the modern Internet : Health Care in the era of Social Media and the modern Internet, Diplomica

Appendix III: Results from the “Stiftung Warentest” Study294

 

Copyright © 2010. Diplomica Verlag. All rights reserved.

              294

Adapted from http://www.test.de/themen/gesundheitkosmetik/test/Gesundheitsportale/1780855/1780855 /1781846/1781928/

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Appendix IV: List of Links to Professional Examples

Professional Medical Blogs Medical Blog Title

Link

Description

http://drugscope.wordpress.com/

Drug Data Update is a service from DrugScope and helps health professionals to keep up to date with drug information, thereby minimizing drug related harms.

http://dLnet.blogspot.com

Blog run by the Digital Libraries Network (DLnet) aiming at health librarians and trainers in the UK, interested in promotion and training.

http://www.nutrapharma.com/blog

This blog is edited by the Nutra Pharma Corp. and informs about activities and issues related to the company.

AZ Health Connections

http://www.azhealthconnections.c om/

This is the official blog from the pharmaceutical company Astra Zeneca. It informs interested users about company issues as well as general health, disease, and drug news.

More Than Medicine Blog

http://www.morethanmedicine.us. gsk.com/blog/

This blog is edited by GlaxoSmithKline and is intended for US residents, only.

Drug Data Update

DLnet

NPC Blog

Balding Blog

Copyright © 2010. Diplomica Verlag. All rights reserved.

KevinMD

Skin Deep - A Dermatology Blog

http://www.baldingblog.com/

http://www.kevinmd.com/blog

http://www.gulfdoctor.net/blog

“BaldingBlog.com began in April, 2005 by William Rassman, Medical Director and Founder of the New Hair Institute, with the goal of educating about hair loss and hair restoration.” This is a professional medical blog, edited by the physician Kevin Pho who provides provocative physician commentary on breaking medical news. This blog is for dermatologists to post interesting cases.

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Web 2.0 and the Health Care Market: Health Care in the era of Social Media and the modern Internet : Health Care in the era of Social Media and the modern Internet, Diplomica

JNJ BTW – Our people and perspectives

This is the official blog from Johnson & Johnson, edited by staff. “On JNJ BTW, there will be talk about Johnson & Johnson — what we are doing, how we are doing it and why. There will be comment on the news about our company and the industry — occasionally correcting any mistakes or simply providing more context.”

http://jnjbtw.com/

Podcasts for Health Professionals Podcast Title NEJM This Week - Audio Summaries McGraw-Hill's AccessMedicine Weekly Podcasts

Description

http://podcast.nejm.org/nejm_audi o_summaries.xml

Those podcasts contain audio summaries from the New England Journal of Medicine (NEJM).

http://books.mcgrawhill.com/podcast/acm/

These podcasts provided by Mc Grawhill are updated weekly and include for example online updates, cases of the month, or online grand rounds.

http://www.podcastdirectory.com/ podcasts/6373

This directory for podcasts provides podcasts on various topics, e.g. how to establish an online therapy practice or how to build a thriving fee-for-service practice

CME Podcasts

http://www.clevelandclinicmeded. com/online/podcasts/

These podcasts are provided by the Cleveland Clinic and deal with a variety of topics in various field like cardiology, emergency medicine, nursing, or palliative medicine. It is a very comprehensive directory of medical podcasts for health professionals from a serious provider.

NIH Podcasts

http://www.nih.gov/Subscriptions. htm#podcasts

Those podcasts deal with various medical topics and are provided by the National Institutes of Health (US).

Marketing For Mental Health Professionals

Copyright © 2010. Diplomica Verlag. All rights reserved.

Link

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Communities for Health Professionals Community Name

The Neuronetwork

Coliquio

Sermo

Medi-Learn

DocsConnect

Copyright © 2010. Diplomica Verlag. All rights reserved.

Community of Doctors

Link

Description

http://theneuronetwork.com

“The NeuroNetwork is a multidimensional professional networking site devoted to those working, studying, or simply interested in the study of the brain”

http://www.coliquio.de/

“Coliquio is an independent internet platform which facilitates a fast and direct exchange of individual medical knowledge and experiences between German-speaking physicians within Europe.”

http://sermo.com/

“Sermo is the largest online physician community in the US. It’s where practicing US physicians—spanning 68 specialties and all 50 states— collaborate on difficult cases and exchange observations about drugs, devices and clinical issues.”

http://www.medi-learn.de/

Medi-Learn offers a portal for Germanspeaking medical students and young physicians.

http://www.docsconnect.com/

A social community dedicated only to physicians from Germany, Austria and Switzerland. Here physicians can create their own profile, present their medical practice and socialize with other physicians.

http://www.communityofdoctors.c om

“Community of Doctors is a medical communications company. We offer many things to busy professionals within the medical community. We provide current information on a variety of topics, including the latest news, drug information, educational events, and public affairs policy.”

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Web 2.0 and the Health Care Market: Health Care in the era of Social Media and the modern Internet : Health Care in the era of Social Media and the modern Internet, Diplomica

Healthheva

Doc2Doc

Biomed Experts – your scientific match point

Health Professionals Portal

Merlot Health Sciences

http://www.healtheva.com

“Healtheva allows collaborating with physicians, researchers, residents, interns, and medical students. With Healtheva, one joins a private community interested in basic science research, clinical research, paper collaboration, and startup & commercialization opportunities.”

http://www.doc2doc.bmj.com

Another social community dedicated to physicians, only. The intention is to connect doctors worldwide.

http://www.biomedexperts.com/

“BiomedExperts is the first literaturebased scientific social network - brings the right researchers together and allows them to collaborate online.”

http://www.hpp.moh.gov.sg/HPP/ HPP_Home.html

http://healthsciences.merlot.org/

“HPP is a one-stop portal for the healthcare professionals to access multiple secure e-services and information using a common password entry and interface.” “The MERLOT Health Sciences Portal is an educational resource for teaching and learning. One can join and contribute to this growing community of instructors, professionals, and students and use the health science learning materials and/or submit one´s own modules for evaluation and learning ideas to support teaching and learning.”

   

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Photo & Video Communities for Health Professionals Community Name

MEDTING

Medicalpicture

VideoMD

Medizinwelten

Link

Description

http://mdpixx.com/

“MEDTING is an interactive platform on web for the medical professionals over the world to share their knowledge. MEDTING is a best tool for a physician for sharing medical images, videos and discuss them with a large community of physicians.”

http://medicalpicture.de/ OR http://medicalpicture.de/cont_8.la ng_en.home.php

Medicalpicture is a community where to find an amazing amount of clinical images.

http://www.videomd.com/

The goal of VideoMD’s is to have the most comprehensive library of health videos

http://medizinwelten.de

Medizinwelten is a clinical image database for physicians and other health providers. Currently, it is available in German only, but it can be expected that is accessible in English soon.

Wikis for Health Professionals Wiki Name

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Ask Dr. Wiki

HL Wiki Canada

Link

Description

http://www.askdrwiki.com

A medical wiki with the goal of creating a collective online memory for physicians, nurses, and medical students.

http://hlwiki.slais.ubc.ca/index.php /Allied_health_professionals

This is a wiki for health librarians and is run by the University of British Columbia.

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Web 2.0 and the Health Care Market: Health Care in the era of Social Media and the modern Internet : Health Care in the era of Social Media and the modern Internet, Diplomica

Medpedia

Health Impact Assessment Wiki

The Adult Literacy Education Wiki

MentalHealthWiki

http://www.medpedia.com/

http://www.healthimpactassessme nt.info/

“The Medpedia Project is a long-term, worldwide project to evolve a new model for sharing and advancing knowledge about health, medicine and the body among medical professionals and the general public.” “This HIA wiki aims to provide up-todate information, knowledge and, hopefully, wisdom on HIA theory, policy and practice from across the world.”

http://wiki.literacytent.org/index.ph p/Health_Literacy

A wiki dealing with all aspects of health literacy.

http://www.mentalhealthwiki.org/

“Mental Health Wiki is a guide to mental health problems. Mental Health Wiki is run by a team of researchers at the University of Melbourne in Australia. Contributors to Mental Health Wiki include health professionals, academic researchers, consumer carers or advocates and health service administrators.”

   

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Appendix V: Interview with a Health Consulting Company Date of Completion: December 11th,2009

1. Please outline shortly the major problems and challenges of the healthcare market in the future. x x x

Cost pressure Consolidation, i.e. less competition in the long-term Strong legal integration, i.e. no uniform case law

2. In how far the use of information- and communication technology within the healthcare market is feasible and reasonable (catchword: eHealth) is still under discussion. Do you concretely see the use of Web 2.0 (blogs, wikis, twitter, communities, etc.) within the healthcare market as a temporary „fashion” or as a long-term development? x x

If a consolidation and a creation of a single uniform interface, “Web 2.0” applications may be “more” than a temporary fashion The market of “Web 2.0” providers is still very heterogeneous and coined by temporary fashions

3. In how far can Web 2.0 support the necessary transformation process of the healthcare market by solving existent problems? A future vision: Does a patient someday need not come to the doctor´s practice at all? x

Breaking-up of the in Question 1 stated major problems

4. How do you evaluate the cost-benefit-ratio of Web 2.0 applications within the healthcare market?

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x x

Due to a multiplicity of different providers, currently quite low Here, a consolidation would be necessary and welcomed, or at least a uniform transferable interface. Catchword: Open Source!!!

5. Which fields of application of Web 2.0 within the healthcare market do you consider reasonable? (catchwords: e.g. communication, information exchange, information provision, medical education, collaboration, or interaction/participation/networking, etc.) x x x

Information exchange Medical education Customer-controlled marketing  ͳͻ͹



Web 2.0 and the Health Care Market: Health Care in the era of Social Media and the modern Internet : Health Care in the era of Social Media and the modern Internet, Diplomica

6. Which benefit and to whom (physicians, hospitals, patients, medical institutions, health insurance provider, etc.) do you see by this development? x

A benefit can be obtained for all participants when correctly implemented

7. Which chances and risks open up due to the use of Web 2.0 within the healthcare market? x x

Wrong information Negative reporting about companies

8. Do you see a problem of quality / reliability of health-related information in the Internet? x

Yes ++ HON-criteria should be compulsory

9. How do you assess legal problems with respect to this topic (catchword: data privacy, copyright, liability)? x x

Due to national legislative legal problems are considered to be serious Especially in the context of the very heterogeneous jurisdiction in the field of “HWG” and health-legal aspects in general

10. a.) In your opinion, which (quality-) characteristics must a Web 2.0 health service have in order to be successful? x x x

HON-certification People interact with people, i.e. no automatic integration of RSSfeeds into “Web 2.0” applications Clear separation of layperson- and expert information ++ Catchword: DocCheck

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b.) What is further necessary to facilitate a broad adoption of Web 2.0 applications within the healthcare market? x x

Uniform interface, i.e. several “Web 2.0” applications can be operated with one tool Central control mechanisms

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Web 2.0 and the Health Care Market: Health Care in the era of Social Media and the modern Internet : Health Care in the era of Social Media and the modern Internet, Diplomica

11. Do you currently conduct projects in your company / institution with respect to this topic or are any planned? If so, which ones and for which purpose? x x

Too many to mention them all We serve distinct customers (dimension > 50 million revenue) in the field of “Web 2.0”

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Again great thanks for answering my questions!

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Web 2.0 and the Health Care Market: Health Care in the era of Social Media and the modern Internet : Health Care in the era of Social Media and the modern Internet, Diplomica

Appendix VI: Interview with a Consulting Company Date of Completion: December 22nd, 2009

1. Please outline shortly the major problems and challenges of the healthcare market in the future. x x

x

Demographic development (an increasing number of elderly people, thus increased demand for care) Questions of financing: sustainable financing of the health care system, the financial crisis intensifies this aspect; especially the public holdings, being financed by the states and communes, become increasingly pressurized. The positive aspect is that this level of suffering increases the readiness for reforms. Structural aspects: in Austria a fragmentation of competences (federal government, states, and communes) and a “regionalthinking” (federalism) exists. Therefore comprehensive nationwide solutions are hard to realize.

2. In how far the use of information- and communication technology within the healthcare market is feasible and reasonable (catchword: eHealth) is still under discussion. Do you concretely see the use of Web 2.0 (blogs, wikis, twitter, communities, etc.) within the healthcare market as a temporary „fashion” or as a long-term development? In my opinion, “Web 2.0” solutions will be increasingly deployed. It can be expected that this is a long-term development. Current research clarifies this trend; almost 60% of patients inform themselves already via the Internet when searching answers to medical questions.

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3. In how far can Web 2.0 support the necessary transformation process of the healthcare market by solving existent problems? A future vision: Does a patient someday need not come to the doctor´s practice at all? The physician will remain to be the central contact person for patients in the future. Especially in the case of health-related questions, as well as in the medical supervision, a certain degree of trust and confidence plays a vital role. “Web 2.0” solutions support both, the patients and the physicians. Consultations and medical care communication may take place via telemedicine. I cannot image an entirely virtual treatment approach.  ʹͲͲ 

Web 2.0 and the Health Care Market: Health Care in the era of Social Media and the modern Internet : Health Care in the era of Social Media and the modern Internet, Diplomica

When dealing with other sectors, e.g. in the field of care, this is imaginable. The supervision of patients can be supported by “Web 2.0” technologies, in order to ensure home-care as long as possible. 4. How do you evaluate the cost-benefit-ratio of Web 2.0 applications within the healthcare market? In my own sight, “Web 2.0” technologies offer a variety of approaches for cost reductions. Especially due to the high penetration of Internet and mobile phones in Austria, the technical requirements are existent. 5. Which fields of application of Web 2.0 within the healthcare market do you consider reasonable? (catchwords: e.g. communication, information exchange, information provision, medical education, collaboration, or interaction/participation/networking, etc.) x x x x x x x x

Exchange of information between relevant stakeholders (patients, physicians, ect.) Communication (e.g. publication of quality reports) Medical consultation (ward rounds, question times) Evaluation of hospitals, physicians, etc. Applications to health insurance providers Medical education (virtual networks) Supervision of patients with chronic diseases (e.g. tele-medical applications like diabetic diaries) Physicians´ accounting

6. Which benefit and to whom (physicians, hospitals, patients, medical institutions, health insurance provider, etc.) do you see by this development? x x x x

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x x

Improvement of communication (patient, physician, health insurance provider) Improvement of quality of care and supervision (patient) Better information on quality within the field of medical care (patient) Shifting of processes to the customer (applications, print-out of evidence, one-stop-shop) (health insurance providers) Up-to-date information 24/7 (patient, physician, health insurance provider) Increased transparency

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Web 2.0 and the Health Care Market: Health Care in the era of Social Media and the modern Internet : Health Care in the era of Social Media and the modern Internet, Diplomica

7. Which chances and risks open up due to the use of Web 2.0 within the healthcare market? Chances: increased transparency, increased efficiency within the system, cost savings, more information Risks: data misuse 8. Do you see a problem of quality / reliability of health-related information in the Internet? Basically not, the problem of quality of published health information exists in all media. Especially within the Internet the option exists that wrong information is replaced quickly. One should consider how quickly errors are corrected at Wikipedia. 9. How do you assess legal problems with respect to this topic (catchword: data privacy, copyright, liability)? The aspects of data privacy and data security do not only concern the “Web-Area”. One should think of the data scandals at the German, as well as Austrian, Railway. Within this scope clear rules and guidelines on the part of the legislative body are needed. If certain applications do not offer the needed security (trust of the involved), this will be regulated by the market, the user will not accept the offer. 10. a.) In your opinion, which (quality-) characteristics must a Web 2.0 health service have in order to be successful? x x

Interesting and up-to-date offers Data protection & Information quality

b.) What is further necessary to facilitate a broad adoption of Web 2.0 applications within the healthcare market? x

Interesting and useful offers for the relevant target group(s)

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11. Do you currently conduct projects in your company / institution with respect to this topic or are any planned? If so, which ones and for which purpose? We advice out clients in the scope of strategic consulting projects in the field of “Web 2.0” solutions and tele-medical approaches, too. Currently, we develop a concept for the supervision of diabetics on the basis of “Web 2.0” approaches. Again great thanks for answering my questions!  ʹͲʹ 

Web 2.0 and the Health Care Market: Health Care in the era of Social Media and the modern Internet : Health Care in the era of Social Media and the modern Internet, Diplomica

Appendix VII: Interview with a Health Care Marketing Consulting Company Date of Completion: January 6th, 2010

1. Please outline shortly the major problems and challenges of the healthcare market in the future. x

x x

Solving the financing problem: increasing benefits (demographic factor, medical-technological progress, etc.) with constant revenues at the same time - cannot work and cannot solved by the pure saving of costs Aging of the population, thus an increase of dementia and other age-related diseases Lack of physicians turns into a problem

2. In how far the use of information- and communication technology within the healthcare market is feasible and reasonable (catchword: eHealth) is still under discussion. Do you concretely see the use of Web 2.0 (blogs, wikis, twitter, communities, etc.) within the healthcare market as a temporary „fashion” or as a long-term development? Patients or their (younger) relatives will make an increasing use of the Internet when searching for health- and disease-related information in the future. I expect greatest growth in the field of reference works (Wikipedia) and forms/communities. In the case of Twitter and blogs I do not see any demand. 3. In how far can Web 2.0 support the necessary transformation process of the healthcare market by solving existent problems? A future vision: Does a patient someday need not come to the doctor´s practice at all?

Copyright © 2010. Diplomica Verlag. All rights reserved.

The major problem is the “mature” patient, thus make the patient more informed, increase the compliance. This content has to be published by experts. I see less chances for content created by users for users. 4. How do you evaluate the cost-benefit-ratio of Web 2.0 applications within the healthcare market? I cannot say anything to that aspect.

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Web 2.0 and the Health Care Market: Health Care in the era of Social Media and the modern Internet : Health Care in the era of Social Media and the modern Internet, Diplomica

5. Which fields of application of Web 2.0 within the healthcare market do you consider reasonable? (catchwords: e.g. communication, information exchange, information provision, medical education, collaboration, or interaction/participation/networking, etc.) See above: information, forums, and communities – especially for chronic diseases. In how far the second health care market will play a real role??? I refer to health nutrition, health-related quality of life, etc. 6. Which benefit and to whom (physicians, hospitals, patients, medical institutions, health insurance provider, etc.) do you see by this development? The informed and educated patient is more motivated, more therapyadherent, and saves a lot of costs for the system in the long-term (see also problem of compliance). However, this kind of patient is more stressful to the physician since he is more informed and educated. 7. Which chances and risks open up due to the use of Web 2.0 within the healthcare market? Chances: cost savings (compliance) Risks: high degree of technical effort, content may eventually not be accepted, continuous skilled / content-related supervision is expensive 8. Do you see a problem of quality / reliability of health-related information in the Internet? General problem, yes. Moreover, medical information is differently presented by different physicians. Complex contexts, complications have to be examined for the single case. There is the danger of a generalization and thus the risk of a false advice 9. How do you assess legal problems with respect to this topic (catchword: data privacy, copyright, liability)?

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Resolvable 10. a.) In your opinion, which (quality-) characteristics must a Web 2.0 health service have in order to be successful? On-topic, supervised by the corresponding association, at best.

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Web 2.0 and the Health Care Market: Health Care in the era of Social Media and the modern Internet : Health Care in the era of Social Media and the modern Internet, Diplomica

b.) What is further necessary to facilitate a broad adoption of Web 2.0 applications within the healthcare market? Create offers and test, what is used by people; then analyze why it is used or why not respectively. Then build on this further. 11. Do you currently conduct projects in your company / institution with respect to this topic or are any planned? If so, which ones and for which purpose? No.

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Again great thanks for answering my questions!

 ʹͲͷ 

Web 2.0 and the Health Care Market: Health Care in the era of Social Media and the modern Internet : Health Care in the era of Social Media and the modern Internet, Diplomica

Appendix VIII: Interview with a Large Pharmaceutical Company Date of Completion: January 19th, 2010

1. Please outline shortly the major problems and challenges of the healthcare market in the future. As major challenges in Germany the following aspects have to be mentioned, amongst others: x accommodation and care of dementia and cancer patients whose number will significantly rise in the future due to the demographic development x reasonable distribution and use of funds in health care x Creation of an innovation-friendly framework and deregulation of the health care market x Increasing the possibilities of individual medical prevention x prevention 2. In how far the use of information- and communication technology within the healthcare market is feasible and reasonable (catchword: eHealth) is still under discussion. Do you concretely see the use of Web 2.0 (blogs, wikis, twitter, communities, etc.) within the healthcare market as a temporary „fashion” or as a long-term development? The use of “Web 2.0” is a long-term development. The importance of modern ways of communication, establishing a connection between participants, is given in the health care market, as well.

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3. In how far can “Web 2.0” support the necessary transformation process of the healthcare market by solving existent problems? A future vision: Does a patient someday need not come to the doctor´s practice at all? The communication models of “Web 2.0” will for sure not substitute a visit to the doctor in the future. But especially patients with chronic diseases have a high demand for information. When choosing information sources, the Internet ranges on first place for most patients and their carers – even ahead of TV and professional literature. The direct exchange between patients is an important additional benefit of “Web 2.0” offers. Often, it is not sufficient time to discuss aspects of daily life and very individual concerns during a physician-patient ʹͲ͸ 

Web 2.0 and the Health Care Market: Health Care in the era of Social Media and the modern Internet : Health Care in the era of Social Media and the modern Internet, Diplomica

conversation. Another aspect of acceptance of medical online-offers is rooted in the anonymity of the users within the Internet. 4. How do you evaluate the cost-benefit-ratio of Web 2.0 applications within the healthcare market? A benefit always exists if patients are helped with the coping with their illness. Communication means like Blog, Twitter, and Communities are variable in their effort and costs due to advancing technological possibilities. 5. Which fields of application of Web 2.0 within the healthcare market do you consider reasonable? (catchwords: e.g. communication, information exchange, information provision, medical education, collaboration, or interaction/participation/networking, etc.)

The provision of complex medical topics necessitates a current exchange, no matter whether it is dealt with medical expert groups or patients. Despite, the fast and accurate provision of information for the press is an aim when using “Web 2.0” applications like Twitter. 6. Which benefit and to whom (physicians, hospitals, patients, medical institutions, health insurance provider, etc.) do you see by this development? For patients, communities offer a contact point for questions around their disease. Caring relatives have a great demand for exchange of information and experiences with other peoples concerned, as well. For medical expert groups internet-based communication methods offer a high benefit, too, since they can be flexibly integrated into the professional daily routine. 7. Which chances and risks open up due to the use of Web 2.0 within the healthcare market?

Copyright © 2010. Diplomica Verlag. All rights reserved.

Chances: online communication channels are accurate, goal-oriented and capture interested people most often there where they stay. Risks: there is a need to professionally operate online communication channels (e.g. up-to-datedness, high-quality content); otherwise they will not be accepted by the public.

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Web 2.0 and the Health Care Market: Health Care in the era of Social Media and the modern Internet : Health Care in the era of Social Media and the modern Internet, Diplomica

8. Do you see a problem of quality / reliability of health-related information in the Internet? Due to the vast amount of medical information on the Internet, not all Internet users are capable to distinguish between reputable and dubious offers. Therefore, disease- or treatment-related information should be majorly drawn from reputable sources. 9. How do you assess legal problems with respect to this topic (catchword: data privacy, copyright, liability)? As a drug company we are – as everyone else - liable for the content and technical security of our online offers. Data privacy is an important aspect. Data privacy has been exactly defined within the data privacy regulations at each website. 10. a.) In your opinion, which (quality-) characteristics must a Web 2.0 health service have in order to be successful? Up to date information, coherent language, thematic relevance for the target group, emotionality, accessibility (barrier-free offers), interaction options b.) What is further necessary to facilitate a broad adoption of Web 2.0 applications within the healthcare market? Advertisements, recommendations from friends or physicians, increasing usage of mobile devices (e.g. iPhone) 11. Do you currently conduct projects in your company / institution with respect to this topic or are any planned? If so, which ones and for which purpose? Amongst others, discussion forums/expert advice for patients with psoriasis; Twitter for specialized journalists

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Again great thanks for answering my questions!

 ʹͲͺ 

Web 2.0 and the Health Care Market: Health Care in the era of Social Media and the modern Internet : Health Care in the era of Social Media and the modern Internet, Diplomica

Appendix IX: Interview with a Large Pharmaceutical Company Date of Completion: February 1st, 2010

1. Please outline shortly the major problems and challenges of the healthcare market in the future. The financing of the German health care market in the future. 2. In how far the use of information- and communication technology within the healthcare market is feasible and reasonable (catchword: eHealth) is still under discussion. Do you concretely see the use of Web 2.0 (blogs, wikis, twitter, communities, etc.) within the healthcare market as a temporary „fashion” or as a long-term development? Long-term development which will gain continuously in importance since all people being born in 1980 and later have been grown up with the Internet and consider Web 2.0 as “normal”, as well. 3. In how far can Web 2.0 support the necessary transformation process of the healthcare market by solving existent problems? A future vision: Does a patient someday need not come to the doctor´s practice at all? No, this will not happen. The health of the human being is a very sensitive topic and the relationship between physician and patient is of great importance. Especially when dealing with serious illnesses. However, chances are there that harmless “little aches and pains” will be resolved via communities etc in the future.

4. How do you evaluate the cost-benefit-ratio of Web 2.0 applications within the healthcare market?

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The costs for creating Web 2.0 applications are very low. However, much time has to be spent for the seriousness of the offer. It must not happen that wrong information is passed to the patient; that is why here much time, manpower and money needs to be invested.

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Web 2.0 and the Health Care Market: Health Care in the era of Social Media and the modern Internet : Health Care in the era of Social Media and the modern Internet, Diplomica

5. Which fields of application of Web 2.0 within the healthcare market do you consider reasonable? (catchwords: e.g. communication, information exchange, information provision, medical education, collaboration, or interaction/participation/networking, etc.) Information exchange between patients, networking 6. Which benefit and to whom (physicians, hospitals, patients, medical institutions, health insurance provider, etc.) do you see by this development? First of all, for the patient since a faster exchange of information is facilitated; but also for health-related institutions which can catch a disposition within the relevant population, e.g. via a blog. Moreover, smaller requests can be dealth with fast and straigthforward. 7. Which chances and risks open up due to the use of Web 2.0 within the healthcare market? See question 3 and 4; Risks: wrong/incorrect information may not be published in reputable blogs, wikis, etc.; to ensure this is hardly possible. Chances: catching dispositions/opinions; fast provision of information 8. Do you see a problem of quality / reliability of health-related information in the Internet? See question 4 and 7. 9. How do you assess legal problems with respect to this topic (catchword: data privacy, copyright, liability)? Very difficult to handle. Theoretically, everybody can publish anonymously information on the Internet. 10. a.) In your opinion, which (quality-) characteristics must a Web 2.0 health service have in order to be successful?

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See above, certificate that the blog, wiki, etc. is resputable. b.) What is further necessary to facilitate a broad adoption of Web 2.0 applications within the healthcare market? It will automatically happen when the upcoming generations that have been grown up with Web 2.0, engage in the topic of health (care).

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Web 2.0 and the Health Care Market: Health Care in the era of Social Media and the modern Internet : Health Care in the era of Social Media and the modern Internet, Diplomica

11. Do you currently conduct projects in your company / institution with respect to this topic or are any planned? If so, which ones and for which purpose? No. However, the topic is observed with great attention and is planned to be realized at some day in the future.

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Again great thanks for answering my questions!

 ʹͳͳ 

Web 2.0 and the Health Care Market: Health Care in the era of Social Media and the modern Internet : Health Care in the era of Social Media and the modern Internet, Diplomica

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