Chapter 8: Health Resources in the Information Age

Health Care on the Internet
Medication Online
Medical Data Revolution
Health IT

Before the Internet, finding the latest information on a health issue typically required access to a university or medical library. Most medical studies and information existed in expensive books and journals, which were generally written for those with formal training. The Internet gave rise to a plethora of accessible, informative Web sites that average consumers could comprehend. The rise of online pharmacies also allowed people the convenience of ordering and receiving prescription drugs and medical supplies from home. Despite some problems such as the online sale of counterfeit medications and the existence of faulty medical information on the Internet, Americans' experiences with online health care information have been positive. According to Susannah Fox and Deborah Fallows of the Pew Internet & American Life Project (Pew/Internet), in Internet Health Resources (July 16, 2003, http://www.pewinternet.org/pdfs/PIP_Health_Report_July_2003.pdf), 82% of online Americans who searched for health information in 2001 found what they were looking for at least most of the time. Those who sought health resources on the Internet appreciated the convenience, the breadth of information, and the anonymity of online medical sources.

The Internet has benefited those who work in health care fields as well. The Internet allows medical researchers to share information as never before. Enormous databases accessible on the Internet contain references to nearly all published medical papers, sparing researchers the frustration of hunting through print indexes. The Internet also provides the perfect medium for posting health care research data, such as statistics on disease prevalence, and research organizations can post data from thousands of disease studies. The availability of the research data has fostered a new era of scientific cooperation wherein medical results from labs halfway around the world can be brought together with a click of a mouse.

Health Care on the Internet

Susannah Fox of the Pew/Internet notes in Online Health Search 2006 (October 29, 2006, http://www.pewinternet.org/pdfs/PIP_Online_Health_2006.pdf) that as of 2006, 80% of U.S. adult Internet users (113 million people) had gone online at least once to reference medical and health information. This represented close to half of the adult American population in 2006 and made searching for health care the second-most popular online activity (next to e-mailing). In addition, the number of people engaged in this activity was growing at a rapid rate. In The Online Health Care Revolution (November 2000, http://www.pewinternet.org/pdfs/PIP_Health_Report.pdf), Susannah Fox and Lee Rainie of the Pew/Internet estimate that in 2000 only 55% of adult Internet users (fifty-two million people) had researched a medical or health related topic at that time.

However, most of the people who went online for health information in 2006 did it infrequently. Fox reports that only 7% of health seekers (eight million adults) reported going online in search of health information on a typical day in 2006. Nearly half (48%) of all people turning to the Internet for medical advice said they went looking on behalf of someone else, such as a relative, spouse, or friend.

A smaller percentage of online men (77%) surfed the Internet for health and medical information than online women (82%). (See Table 8.1.) Elderly Americans were less likely to have sought Internet health advice than those under sixty-five years of age. In fact, 84% of Internet users aged thirty to forty-nine had searched for medical knowledge online, as opposed to 68% of seniors aged sixty-five and older. This age discrepancy did not have as much to do with disease prevalence in the two groups as it did with the fact that far fewer seniors were online in 2006. As the general population ages, the percentage of seniors seeking health information online

should grow. Not surprisingly, online Americans with higher incomes and education levels were more likely to search for health information online than were those with less education and income; discrepancies among races could be attributed to differences in income and education levels among these groups. Finally, adult Internet users with high-speed connections (86%) searched for medical information more often than those with dial-up access (75%).

Types of Health-Related Searches Made by Americans

Table 8.2 lists the types of health care searches Americans engaged in by topic in 2002, 2004, and 2006. Nearly two-thirds (64%) of adult Internet users searched for facts on a specific disease or medical problem in 2006, which was down slightly from 2004 (66%). The percentage of people who conducted searches on preventive health topics increased between 2002 and 2006, as did the percentage of those who sought information about a particular doctor or hospital. Forty-nine percent of online adults used the Internet to find facts about diet, nutrition, vitamins, or nutritional supplements in 2006, as opposed to 44% of wired Americans in 2002. Online women (53%) were more likely than men (45%) to seek out information on this topic. (See Table 8.3.) Health insurance and prescription drugs were also concerns in 2006. Internet users aged thirty to forty-nine (34%) were more likely to search for health insurance information online than those aged fifty to sixty-four (27%) or those between the ages of eighteen and twenty-nine (23%). In Health Information Online (May 17, 2005, http://www.pewinternet.org/pdfs/PIP_Healthtopics_May05.pdf), Fox notes the higher per-

centage of those seeking health information online during their thirties and forties and suggests that it might have to do with the fact that online adults with children living at home were significantly more likely to conduct searches on health insurance than Internet users without children living at home (38% to 26%). Conversely, Table 8.3 shows that younger Internet users aged eighteen to twenty-nine (14%) were more likely to search for information on alcohol, drug, and tobacco addiction than those thirty to forty-nine years old (6%).

Effects of Internet Health Care Information

For the most part, Americans think favorably of the health information available to them on the Internet. According to Fox and Fallows, 73% of online health-information seekers said the Internet had improved the quality of health care they received. This number was up from 2001, when Fox and Rainie reported in Vital Decisions (May 22, 2002, http://www.pewinternet.org/pdfs/PIP_Vital_Decisions_May2002.pdf) that only 61% of those seeking online medical advice believed the Internet improved their health care. Forty-four percent thought that information gleaned from the Internet affected a decision on how to treat an illness, and 25% said the information changed the way they coped with pain. Fox and Rainie concluded that those typically in the most need obtained the greatest benefits from e-medicine.

In Online Health Search 2006, Fox assesses the results of online health searches and finds that three-quarters (74%) of survey respondents felt reassured that they “could make appropriate health care decisions” based on what they learned online. (See Table 8.4.) More than half were eager to share what they had learned with others (51%) or were comforted by the information they had found online (56%). Ten percent expressed fear about what they learned online, and 18% said their Internet health search had left them confused. In The Engaged E-Patient Population (August 26, 2008, http://www.pewinternet.org/pdfs/PIP_Health_Aug08.pdf), Fox notes that nearly one-third (31%) of survey respondents in 2007 said they or someone they knew benefited appreciably from online Internet health information. However, 3% of those who searched for health advice online said they knew someone who was seriously harmed by following medical information gleaned from the Internet.

Many health care officials worry that Americans use the Internet to diagnose their own ailments in the hope of avoiding time-consuming but necessary visits to the doctor's office. The biggest problem with self-diagnosis is that it is rarely objective. Using advice from online Web sites is especially problematic in that it is often incomplete. In “A User's Guide to Finding and Evaluating Health Information on the Web” (July 25, 2008, http://www.mlanet.org/resources/userguide.html), the Medical Library Association (MLA) provides a list of recommendations that those seeking health information on the Internet should follow. These include identifying each site's sponsor, checking the date of information on the site, and verifying that the material is rooted in fact, as opposed to opinion. In addition, Gretchen K. Berland et al. suggest in “Health Information on the Internet: Accessibility, Quality, and Readability in English and Spanish” (Journal of the American Medical Association, vol. 285, no. 20, May 23, 2001) that online Americans looking for health information should take their time searching for advice, go to at least four to six sites, and discuss what they find with a doctor before taking action. According to Fox, in Online Health 2006, most people surveyed in 2006 did not adhere to these guidelines. Sixty-one percent of respondents reported visiting two to five Web sites during their search, but only one-quarter checked the source and date of the information they found, and only one-third later discussed the information with a physician. Fox finds that Internet users who had visited a doctor in the previous year were more likely to seek health information online than those who had not been to the doctor. Eighty-four percent of those who went to the doctor also said they searched for online health information, whereas only two-thirds (66%) of survey respondents who did not see a doctor said they had gone online for health information.

Top Web Sites for Health Information

According to the MLA, in “A User's Guide to Finding and Evaluating Health Information on the Web,” the ten most useful medical Web sites in 2008 were:

• Cancer.gov, National Cancer Institute (http://www.cancer.gov/)
• CDC.gov, Centers for Disease Control and Prevention (http://www.cdc.gov/)
• Familydoctor.org, American Academy of Family Physicians (http://familydoctor.org/)
• Healthfinder, National Health Information Center (http://www.healthfinder.gov/)
• HIV InSite, University of California, San Francisco Center for HIV Information (http://hivinsite.ucsf.edu/)
• KidsHealth, Nemours Foundation (http://www.kidshealth.com/)
• Mayo Clinic (http://www.mayoclinic.org/)
• Medem (http://www.medem.com/)
• MedlinePlus, U.S. National Library of Medicine (http://www.medlineplus.gov/)
• NOAH: New York Online Access to Health (http://www.noah-health.org/)

These Web sites were evaluated in part on their credibility, content, sponsorship/authorship, purpose, and design. General medicine Web sites noted by the MLA include Healthfinder.gov, Familydoctor.org, Medem.com, MedlinePlus.gov, Noah-health.org, and Mayoclinic.com. Like MedlinePlus, these sites contain information on many medical diseases and conditions. The not-for-profit Kidshealth.org (2008, http://www.kidshealth.org/parent/kh_misc/about.html) focuses on health care for children from prenatal care through adolescence. This Web site maintains separate areas for kids, teenagers, and parents, and in 2008 it received more than five hundred thousand visitors per day.

Facts on the human immunodeficiency virus (HIV) are available at HIVInsite.com, and Cancer.gov presents information on cancer types, causes, and treatments. Cancer.gov also maintains a database of clinical trials being conducted all over the country for those who seek information on alternative treatments. Finally, CDC.gov, which is operated by the Centers for Disease Control and Prevention (CDC), contains information on communicable diseases, immunization, and disease prevention.

MedlinePlus, the most comprehensive general medicine site, made its debut on the Internet in October 1998 with twenty-two health topics in its library. The site received over 682,000 page hits in its first three months. By the second quarter of 2007 the site recorded 245 million page views, an all-time high, and contained information from the National Institutes of Health (the largest medical research institution in the world) as well as other top medical institutions. (See Figure 8.1.) All in all, the site held information on more than 750 diseases and conditions. Content from the A.D.A.M. medical encyclopedia and Merriam-Webster's Medical Dictionary are integrated onto the site. Users of the site can also obtain current facts on most prescription and nonprescription drugs. The site displays no advertising, and experts in the medical profession review all the information on MedlinePlus. Content is available in more than forty languages. A search on MedlinePlus for a disease typically yields definitions, fact sheets, drug information, the latest news on the disease, and links to places where further information can be found. A record 37.7 million unique visitors logged on to the site in the second quarter of 2008.

A survey conducted among users of both the English-and the Spanish-language MedlinePlus Web sites found in 2005 that more than one-quarter (27%) of visitors to the English site and one-fifth (20%) of those visiting the MedlinePlus Spanish site were patients with a specific disease or condition. (See Figure 8.2.) The second largest group using the Spanish site was college students (19%), whereas health care professionals (14%) and friends or relatives of patients (14%) were the next largest groups of users logging on to the English site. About one-quarter of visitors to the MedlinePlus Web sites in 2005 believed their session led to improved understanding of the disease or treatment they were researching, and 4% indicated they or someone else made a doctor's appointment based on information learned on the site. (See Figure 8.3.)

Medication Online

Since the late 1990s the online pharmacy business has been growing at a steady rate. Most major online pharmacies, such as Drugstore.com and Wal-Mart's online

pharmacy, are legitimate. They carry the Verified Internet Pharmacy Practice Sites seal of approval (VIPPS, issued by the National Association of Boards of Pharmacy), meaning they comply with all state and federal laws. Much like traditional pharmacies, these online drug stores require that a prescription be faxed or called in by a doctor. Such pharmacies also send the drug to the patient complete with dosage and warning information on the bottle. However, unlawful virtual pharmacies, which do not follow U.S. state and federal regulations, have begun operating on the Internet as well. Some of these pharmacies are based in the United States and some operate on foreign soil.

The lure of illegal pharmacies is their low cost and convenience. Many illegitimate pharmacies will send patients prescription drugs without a prescription. Pharmacy Web sites located in other countries typically sell their drugs for much less than U.S. pharmacies. Many foreign pharmacies that cater to the U.S. market are located in Canada. Clifford Krauss reports in “Internet Drug Exporters Feel Pressure in Canada” (New York Times, December 11, 2004) that in 2004 the 270 online Canadian pharmacies made more than $800 million from U.S. customers. Even though many of the Canadian pharmacies follow the same strict standards as U.S. pharmacies, it is illegal for individuals in the United States to buy pharmaceuticals from foreign countries.

Safety Risks of Internet Pharmacies

Illegitimate online pharmacies have generated a great deal of concern among health care professionals and government lawmakers in the United States. One problem is that state medical boards, which typically oversee brick-and-mortar operations, have difficulty monitoring pharmaceutical Web sites. Even though some of these pharmacies follow many of the same standards as legitimate operations, others disregard them altogether. Besides providing drugs without a prescription, many send patients drugs without warning labels or dosage information. Such a practice is exceedingly dangerous. Accutane, an acne treatment medication, has been known to cause severe birth defects and mental problems in select patients. If a pregnant woman were to receive an unlabeled bottle of Accutane and did not know of the warnings, the results could be disastrous. Another concern is that many of these sites have been known to deal in counterfeit drugs with diluted ingredients or no ingredients at all. Counterfeit heart or cholesterol medication could result in a patient's death. When federal and state agencies become aware of one of these illegitimate pharmacies in the United States, they attempt to shut it down. However, government regulators can do little about controlling pharmacies outside of U.S. borders.

During the first six months of 2004 the U.S. General Accounting Office (GAO; now the U.S. Government

Accountability Office) conducted a study of Internet pharmacies. The investigators placed up to ten orders for each of thirteen different drugs from online pharmacies located in the United States, Canada, and other foreign countries, including Argentina, Costa Rica, Fiji, India, Mexico, Pakistan, and Turkey. (See Table 8.5.) When the GAO investigators received the drugs, they forwarded them to drug manufacturers for chemical verification.

The results were reported in Internet Pharmacies: Some Pose Safety Risks for Consumers (June 2004, http://www.gao.gov/new.items/d04820.pdf). All the Canadian Internet pharmacies required prescriptions from a patient's physician. (See Table 8.6.) Only five U.S. Internet pharmacies followed this convention. The other twenty-four sent out prescriptions based on questionnaires that asked about a patient's history—a practice condemned by the U.S. Food and Drug Administration

(FDA), the American Medical Association, and many state medical boards. Most of the foreign Internet pharmacies outside of Canada did not even require a questionnaire.

Some of the sites, particularly in Canada and the United States, followed every rule that brick-and-mortar pharmacies did in the United States. In one case, a U.S. pharmacy refused to send the investigators a prescription for Accutane because the doctor who wrote the prescription was not on an official list of doctors qualified to do so. Table 8.7 lists some of the problems encountered with the sixty-eight online pharmacies that did send drugs to the GAO investigators. For the most part, the samples that were sent from U.S. online pharmacies had only a few problems, including improper labeling. Many Canadian pharmacies sent versions of popular U.S. drugs that were not licensed for sale in the United States. Much like generic medications, these drugs have the same medicinal ingredients as their U.S. equivalents and pose no additional threat to those taking them.

However, drugs sent from foreign countries other than Canada were riddled with problems. Five foreign pharmacies took the investigators' money and sent them no drugs. Of the drugs received from these other foreign countries, none of them had an instruction label, and only six out of twenty-one had warning labels. Some of these drugs, particularly narcotics, were packaged in strange ways to disguise the contents of the package. The supposed shipment of the painkiller OxyContin arrived in a used CD case wrapped in brown packing tape. Several of the foreign drugs were counterfeit as well, including the OxyContin, which did not contain any of the actual drug oxycodone. When the GAO investigators attempted to track down the origin of the foreign packages, they came up with some bizarre locations. A sample of Lipitor from Argentina was apparently shipped from a shopping mall in Buenos Aires. An order of Humulin N and Zoloft was traced to a private residence in Lahore, Pakistan.

In the press release “FDA Operation Reveals Many Drugs Promoted as ‘Canadian’ Products Really Originate from Other Countries” (December 16, 2005, http://www.fda.gov/bbs/topics/NEWS/2005/NEW01277.html), the FDA reports another significant issue with online prescription orders. Online consumers who order from Canadian Internet pharmacies may be the victims of a bait-and-switch operation, in which the Web presence of an illegitimate drug seller is represented as Canadian, but the drugs are actually shipped from India, Israel, Costa Rica, or another foreign country. Out of 4,000 pharmaceutical packages intercepted and reviewed by FDA agents at major airports in August 2005, 43% (1,700) had been ordered through what consumers believed were Canadian pharmacies. However, only 15% of the “Canadian” packages proved to be actually of Canadian origin. The remaining 85% originated in other countries and included products that were improperly labeled or counterfeit.

Because of the many unethical and illegal practices encountered by consumers making pharmaceutical purchases online, the FDA published “Buying Prescription Medicine Online: A Consumer Safety Guide” (August 14, 2008, http://www.fda.gov/buyonlineguide/) to reduce

or eliminate many issues surrounding Internet pharmacies. The FDA recommends that patients use only sites that require a prescription, have pharmacists available to answer questions, and adequately protect the privacy of customers. The FDA also recommends that online consumers use only state-licensed U.S. pharmacies. Finally, the FDA stresses physicians' oversight and advice: “Talk with your doctor and have a physical exam before you get any new medicine for the first time.”

Who Is Ordering Online Medications?

Though the number of people purchasing drugs online has grown since the turn of the twenty-first century, the overall percentage of Americans buying pharmaceuticals on the Internet was still fairly low as of 2004. According to Fox, in Prescription Drugs Online (October 10, 2004, http://www.pewinternet.org/pdfs/PIP_Prescription_Drugs_Online.pdf), only 4% of American adults had bought prescription drugs online for themselves or others in 2004, compared to the 64% of American adults who took prescription drugs regularly or lived with someone who did. Predictably, most people who bought online drugs said convenience and savings were the two biggest reasons they bought drugs online. Seventy-five percent of people who made an online drug purchase bought a drug for a chronic medical condition such as high blood pressure. The rest said they went online to purchase a drug for other purposes such as weight loss or sexual performance.

According to Fox, the vast majority of people surveyed who bought online drugs said they had a prescription from a doctor. Almost all these people received their prescription drug from an online pharmacy based in the United States. Only a few people said they found their online pharmacy by responding to a spam e-mail advertisement. In the end, most people who went online for their drugs were happy with their experience. Ninety percent of those who purchased online pharmaceuticals said they planned to do it again. The biggest complaint people had was that their packages were lost in the mail. However, 62% of Americans surveyed still believed that purchasing prescription drugs online was more dangerous than buying them at a local pharmacy. Only 20% thought online purchases were as safe.

Medical Data Revolution

Since the 1980s information technology (IT) and the Internet have transformed the field of medical research. Before launching a medical research project, a scientist must first know what has been done in the area he or she plans to study. For example, the initial step for a researcher who wants to find a cure for Alzheimer's would be to analyze previous data on the subject. Only then could the researcher formulate new theories and design experiments that advance the field. Before the Internet and the widespread use of computer databases, researchers seeking such information were required to spend days at medical libraries, sifting through thick journal indexes that cataloged thousands upon thousands of past journal articles by subject. The advent of computer databases changed all that. Huge medical indexes were put in digital form, which allowed researchers to compile a full list of research articles in minutes instead of days. MEDLINE/PubMed, which is maintained by the National Library of Medicine, is one of the most comprehensive and widely used of these databases. The National Library of Medicine (April 22, 2008, http://www.nlm.nih.gov/pubs/factsheets/dif_med_pub.html) states that in 2008 MEDLINE contained citations and abstracts summarizing papers published in nearly fifty-two hundred biomedical journals in the United States and eighty other countries. By simply going online to MEDLINE and typing a query, a researcher can track down every published paper on most medical topics.

The ability of computers and the Internet to store and transmit scientific data has also transformed the way medical research is conducted. The Internet allows scientists from all over the world to share data on diseases and patient attributes. Computers can then perform statistical analyses on disease data in relation to various aspects of patient histories, such as age, geographic location, and even the presence of other diseases.

The CDC's National Center for Health Statistics (NCHS, http://www.cdc.gov/nchs/) database contains statistics on a variety of diseases including arthritis, heart disease, HIV, and even tooth decay. All this information is freely available for scientists to use in their research. For example, in 2003 researchers at West Virginia University, the University of South Florida, and the CDC combined data from the NCHS and the U.S. Census to create Atlas of Stroke Mortality: Racial, Ethnic, and Geographic Disparities in the United States (http://www.cdc.gov/DHDSP/library/maps/strokeatlas/index.htm). Among other things, the atlas confirms earlier studies that revealed that African-Americans have higher death rates from strokes than whites, Hispanics, or Asian-Americans. The atlas also provides a reference resource for government officials and health care workers, letting them know exactly where their time and money should be spent on stroke awareness programs.

Computer databases and the Internet have also become invaluable resources for organ and tissue donor programs. For example, treatments for leukemia (a type of cancer) sometimes destroy the bone marrow, which produces red and white blood cells and platelets. To replace the bone marrow, a transplant from another person is needed. However, finding compatible bone marrow is difficult. Typically, a match will not even exist within the same family. The National Bone Marrow Donor Registry is a computer database of people who have agreed to donate their bone marrow to those in need. A doctor with a patient in need of a transplant can simply log onto the registry via the Internet and pull up all possible matches in the country. The Organ Procurement and Transplantation Network (OPTN) maintains a similar database for internal organ transplants,

including kidney, pancreas, heart, lung, and intestine. The OPTN's secure transplant information database keeps track of exactly which patients are in need of a transplant. Table 8.8 displays the number of candidates who were waiting on the OPTN in August 2008. All necessary forms and patient histories are also included in the database. Should a donor's heart become available in a medical facility anywhere in the United States, the attending physician can access the database to find patients who are waiting for a new heart.

Health IT

IT is changing the way patients interact with their health care providers and the way health care providers interact with one another to ensure prompt, safe, and effective treatments. Electronic health records are expected to improve health care by keeping all information about a patient's health history, including medications, immunizations, laboratory and test results, allergies, and family history in one accessible online location. As U.S. health care systems become networked, information about a patient will be immediately available regardless of the treatment location.

As of 2008, the Agency for Healthcare Research and Quality (AHRQ) of the U.S. Department of Health and Human Services (HHS) reports in “Medical Errors & Patient Safety” (2008, http://www.ahrq.gov/qual/errorsix.htm) that each year approximately seven thousand people die from medication errors. The AHRQ believes that by using IT to integrate health history with medication information many of these deaths can be prevented. Computerized health record systems would provide attending doctors with dosage information about medications already prescribed for each patient, check for potential interactions with other medications, and alert physicians to patient allergies. Anticipated benefits of integrated health IT include electronic health records for patients that can be easily shared by health care providers; electronic transmittal of

medical test results; and electronic prescription messaging, which will improve efficiency and reduce human errors in reading paper prescriptions.

To facilitate the development of a nationwide electronic health system, President George W. Bush (1946–) established in April 2004 the office of the National Coordinator for Health Information Technology within the HHS. This office provides leadership in developing standards, policies, and the necessary infrastructure that will allow the flow of health information nationwide. Figure 8.4 shows how medical data will be shared among agencies and health care providers on the proposed Nationwide Health Information Network. In The ONC-Coordinated Federal Health IT Strategic Plan: 2008–2012 (June 3, 2008, http://www.hhs.gov/healthit/resources/HITStrategicPlan.pdf), the Office of the National Coordinator discusses its strategic plan for the development of the network. The plan identifies the interim goals and objectives necessary to achieve two overarching goals: to improve individual patient care through the advantages and efficiencies inherent in electronic communication and to use this information access to advance the overall health of the U.S. population. Figure 8.5 presents strategies for achieving the necessary privacy and security to exchange confidential health data. To use and share information in an efficient, secure manner, technical standards must be established and applied throughout the system. Figure 8.6 shows strategies for achieving interoperability, including the development of a system by 2011 that will allow swift access to population health information in the event of an emergency or epidemic. Electronic health information is expected to become standardized and more widely accessible by 2010, thereby increasing its usefulness and value to health care providers and patients. Figure 8.7 shows the timeframe for the adoption of electronic health records (e.g., those maintained traditionally in paper form in a physician's office) and personal health records (i.e., an individual's electronic health record that begins at birth, remains with him or her throughout life, and contains information from multiple sources). Finally, Figure 8.8 presents an outline of the goals necessary to coordinate and govern such a wide-ranging system of individual and population care.

In The Future of the Internet (January 9, 2005, http:// www.pewinternet.org/pdfs/PIP_Future_of_Internet.pdf), a survey of 1,286 technology experts, Susannah Fox, Janna Quitney Anderson, and Lee Rainie of the Pew/

Internet note that 39% of those surveyed agreed with the prediction that within ten years the increasing use of online medical resources will have a favorable impact on many of the issues currently facing the U.S. health system, including “rising health care costs, poor customer service, the high prevalence of medical mistakes, malpractice concerns, and lack of access to medical care for many Americans.' Summarizing one view, Ezra Miller of Ibex Consulting wrote, “Tele-medicine is already having a significant impact on remote communities. Streamlined insurance processing, elimination of prescription mistakes, better and confidential accessibility to records including longer-term archiving (medical imaging, test results) are all on the way to improving health care—though there are still hurdles to overcome (e.g., getting the insurance companies to cooperate).” However, others, such as Peter W. Van Ness of the Van Ness Group, were more cautious: “This is far too optimistic. Some improvement will ensue, particularly in the areas of customer service, information sharing and eventually with remote surgery (i.e., one seasoned surgeon walking a remote, less-experienced surgeon through a procedure live). However, serious attention needs to be paid to privacy concerns now, or a backlash of mistrust could prevent people from going to doctors for fear of having their illness made public.”