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Gibbons MC, Wilson RF, Samal L, et al. Impact of Consumer Health Informatics Applications. Rockville (MD): Agency for Healthcare Research and Quality (US); 2009 Oct. (Evidence Reports/Technology Assessments, No. 188.)

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Impact of Consumer Health Informatics Applications.

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Summary of Key Findings

We have presented here the results of a systematic review of the literature regarding the impact of CHI applications. The CHI field is new and still evolving. As such, the literature in this field is very heterogeneous and challenging to summarize in well-described categories. Our review identified a total of 162 articles, of which 137 addressed Key Question 1 and 31 addressed Key Question 2. Overall, despite the heterogeneity and limited nature of the literature, the following themes emerged.

First, while there may be a role for CHI applications to reach consumers at a low cost and obviate the need for some activities currently performed by humans, it is likely that a more important role is to enhance the efficacy of interventions currently delivered by humans. Several studies compared the use of a CHI application with traditional therapy against traditional therapy alone. Many found that both groups exerted a significant effect on the outcome of interests, yet the CHI group had even more benefit that traditional therapy alone.

Secondly, in the aggregate, the studies evaluated in this review tended to support the finding that at least three critical elements are most often found in those CHI applications that exert a significant impact on health outcomes. These three factors are 1) individual tailoring, 2) personalization, and 3) behavioral feedback. Personalization involves designing the intervention to be delivered in a way that makes it specific for a given individual. Tailoring refers to building an intervention, in part, on specific knowledge of actual characteristics of the individual receiving the intervention. Finally, behavioral feedback refers to providing consumers with messages regarding their status, wellbeing, or progression through the intervention. These messages may come in many different forms. They can be motivational (You did great today!) or purely data driven (You completed 80 percent of your goal today). Interestingly, it is not clear from this literature that CHI-derived behavioral feedback is any better than feedback originating from human practitioners or others. Rather, it appears that the feedback must happen with an appropriate periodicity, in a format that is appealing and acceptable to the consumer, not just the provider.

This systematic review found that RCT evaluations to date suggest that CHI applications may positively impact healthcare processes such as medication adherence among asthmatics. CHI applications may also positively impact intermediate outcomes across a variety of clinical conditions and health behaviors, including cancer, diabetes mellitus, mental health disorders, smoking, diet, and physical activity. CHI applications may not have much impact on intermediate outcomes among individuals who are obese or suffer with asthma or COPD. The currently available RCT evidence is more equivocal regarding the impact of CHI applications on relationship-centered outcomes, while the evidence appears relatively strong in support of the positive impact of CHI on selected clinical outcomes. (Mental Health) The data are insufficient to determine the impact of CHI on economic outcomes.

Of note, studies have identified several barriers to utilization of CHI applications. The barriers include incompatibility with current care practices, professional staff perceptions of increased workload, poor social support, limited IT knowledge and literacy of consumers, cultural issues, and concerns about time, privacy, security, and control.

While the use of CHI applications offers significant promise and potential, the nascent literature has important knowledge gaps that currently preclude claims of proven efficacy or unquestionably support a value proposition for the use of CHI applications. In the final analysis, the early work cited in this review is encouraging, but clearly more research is needed to substantiate these early findings and close the identified gaps in knowledge.


This review has several important limitations. First our initial search for eligible studies proved to be challenging because of inconsistent use of terminology in the literature. We minimized this problem by searching multiple databases and supplementing our search with a review of selected journals and querying experts. The most important limitation was marked heterogeneity of interventions, populations and outcomes, making synthesis across studies difficult, and precluding meta-analysis. Inconsistent definitions and reporting of outcome measures further limited our ability to synthesize data, as many studies did not report enough data to support calculation of effect sizes. Another limitation is related to the design of CHI tools and applications. Because development involves an iterative process, it is sometimes difficult to synthesize results across studies. Two studies my have evaluated the same CHI tool or application however the tool itself may have been adapted or otherwise changed during the period of time after the first study but prior to the second study. Methodologic limitations of many of the RCTs limit the strength of conclusions. We evaluated the quality of the study using the criteria proposed by Jadad.4 We also graded the strength of the body of the scientific evidence on each section. For a variety of reasons, the strength of the body of evidence was often graded as low. Because the distinction between CHI and patient-centered HIT has not been clearly articulated, it was at times challenging to distinguish between consumer HIT and patient-centered HIT. Patient centered HIT studies were excluded because they will be addressed in a separate evidence report. Finally, as indicated in the Research in Progress section of the Results chapter, several studies of CHI applications have been initiated or completed but not yet reported. The evidence report may need to be updated when the results of these studies are available.

Future Research Needs

The results of this review indicate that the scientific evidence base regarding the impact of CHI applications is at a nascent and evolving state. As such, several future research needs can be identified. More work needs to be done to confirm the preliminary findings identified in this review. In many areas, only one study has been done on a given question or issue, precluding definitive conclusions. Across studies, the reporting of the evaluations is non-uniform, often with critical features of the evaluation methodology or application details entirely lacking. To facilitate uniform reporting and improve the quality of the work in this field, consideration should be given to development of a national CHI applications design and development registry and CHI applications trials registry with uniform reporting requirements. However, the developers of these applications come from a wide and diverse array of backgrounds. Some have significant technical expertise while others do not. Furthermore, these studies are reported in a variety of journals with editors and editorial boards of widely differing technical expertise and reporting requirements. Research in this multidisciplinary field would be greatly enhanced by an accepted vocabulary, nomenclature, or ontology. Currently there is much confusion and blurring of the lines between the technical platform upon which the application is built along with the technical specifications of the CHI application in question with both the goals and functions of the application and the educational or behavioral content included in the application. While a strict rendering of the current definitions of these elements allows for little conceptual overlap, the literature is replete with examples of investigators who describe the technical platform employed in a CHI application (cell phone) when describing the application, which by itself, sheds little light, regarding the nature of the CHI application. More work will need to be done to explicate the role of human factors, socio cultural factors, human computer interface issues, literacy, and gender.

The findings of this review indicate that most CHI research is being primarily conducted among white/Caucasian adult patients, and it is not clear how the findings apply to non-white populations. The importance of this limitation is heightened by the fact that the internet will be the primary means of the consumer’s ability to use and take advantage of CHI tools. While technological platforms may vary, most CHI applications will, in one way or another, rely on the internet to perform its functions. Consumer internet familiarity and utilization trends will have significant impact on the ability of CHI applications to be successful across all consumer populations. Recent data suggests the internet and technology experiences of whites may not be the same as individuals from other racial/ethnic backgrounds. Differential experiences across racial groups may be associated with differential efficacy of a given CHI application and result in outcomes that are unexpected or unseen among white consumer groups. The evidence suggests, for example, that Internet and technology utilization has not yet become as essential or appealing to African-Americans as to whites. Just 36 percent of African-Americans with Internet access go online on a typical day compared to 56 percent of whites. Whites and blacks even have differing attitudes toward the internet with online African-Americans not being as fervent in their appreciation of the Internet as online whites.173 African-American Internet users are also somewhat more likely than whites to have their Internet access come exclusively through their jobs. Finally, while online privacy has become a significant concern for a majority of Internet users, African-Americans tend to be less trusting than whites. They are also more concerned about their online privacy than whites and these heightened privacy concerns are reflected in what they choose to do online. Online African-Americans are less likely to participate in high-trust activities like auctions or to give their credit card information to an online vendor. They are also less likely than white Internet users to trade their personal information for access to a Web site. 173 The CHI and health implications of these findings are unclear.

The problem extends beyond African Americans. Fifty-six percent of Latinos in the U.S. use the Internet. This compares to 71 percent of non- Hispanic whites and 60 percent of non-Hispanic blacks who use the internet. 173 Among Latinos, the information and communications revolution is not limited to the computer screen. Some Latinos who do not use the internet are connecting to the communications superhighway via cell phone. Almost 60 percent (59 percent) of Latino adults have a cell phone and 49 percent of Latino cell phone users send and receive text messages on their phone.173

Finally, the issue is not just one of under-utilization or access. Asian-Americans who speak English are the most wired racial or ethnic group in America. They are also the Internet’s heaviest and most experienced users. Over 5 million Asian Americans (75 percent) have used the internet. This compares to 58 percent of whites, 43 percent of African- Americans, and 50 percent of English-speaking Hispanics. 173 Typically Asians spend more time online than other racial and ethnic groups. In addition, they engage the internet at a much higher level of intensity on a typical day than other groups and, as such, the internet represents an extremely important and fundament component of daily living for Asian-Americans. Overall, Asian-American men engage in online activities more than Asian-American women.173 Even beyond race and ethnicity issues that may affect CHI mediated health outcomes; the importance of family, neighborhood, and environmental determinants of many clinical health outcomes is increasingly realized. We need to understand how these factors (social determinants) may impact CHI access, utilization, efficacy, costs, and/or outcomes at the individual level and healthcare disparities at the population level. The results of this review indicate that the realities and implications of these differences have not been adequately evaluated in the current scientific literature and much more formative and experimental work needs to be done to fill these critical knowledge gaps. The results of this review also indicate that because most of the evaluative research being done is being conducted among middle aged adult populations, significant opportunities exist for additional research among other age groups of consumers. It may even be that the impact of CHI applications may be greater among non middle aged adult consumers because these consumers may be most likely to adopt CHI applications (children, adolescents, and young adults) and they may have the most to gain from using effective CHI applications (elderly).

Similarly, the results of this review indicate that most CHI applications evaluated to date are designed to run on desktop computers. More work will need to be done to understand the role of other technological platforms including cell phones, PDA’s, TV, satellite, on Demand, Health Gaming platforms (Wii, XBOX, Gamecube etc). Related to technological platforms used for CHI applications is the potential role of social networking applications. Very few currently evaluated CHI applications explored the dynamics and potential utility of using social networking applications (Skype, Twitter, MySpace, Facebook, You Tube, blogs, Second life, Yoville and Farmville etc) to support behavior change or improve health outcomes. While it may be challenging to envision the elderly twittering, use of these applications may open opportunities to address health problems impacted by trust, social isolation, cognitive stimulation and low literacy) This type of research may inevitably lead to a broader array of interactivity among patients and their caregivers with measurable psychological and physiological health benefits for users and patients. In so doing, CHI applications may accrue greater appeal and effectiveness among patients because these applications are assisting patients to address real life issues that in the past may have been unrecognized barriers to achieving optimal health.


The results of this review have several important implications. In terms of the currently engaged and activated consumer, CHI applications and tools may in the future provide additional tools to facilitate efforts to optimize their health status. The rapid growth and development of the internet combined with the rapid rise in the use of the internet to search for health related information suggest that individuals are drawn to use convenient and anonymous technologies for health purposes. If CHI applications and tools become available in a wider array of platforms, it may become easier to engage more people who are not actively managing their health. Although CHI tools and applications, as we have defined them, do not require the involvement of a healthcare provider, it is likely that significant growth in the utilization of CHI tools will necessitate increasing provider and healthcare system competency with these emerging tools. Consumers will increasingly want more interactivity and functionality and the ability to work interactively with traditionally collected health information at the time and place of their choosing. Providers and healthcare systems that are seen as not equipped to handle or address these issues are unlikely to be seen as the highest quality or highest performing providers and systems.

There are may be important implications for health policy decision makers, such as the National Coordinator of IT. To the extent that CHI applications help improve healthcare process and clinical outcomes, they cannot be considered outside the domain of the healthcare system or direct medical care. Growth in this area may necessitate the development of policy positions which support diffusion of HIT tools and applications among providers and healthcare systems, but also facilitate the diffusion of CHI tools and applications among healthcare consumers. In like fashion many state officials and governments have or are currently considering supporting regional Health Information Exchanges, state wide Electronic Medical Records systems and other medical technologies. These state level health leaders may soon need to consider supporting patient use of CHI tools as one strategy to facilitate health promotion. Yet, as the results of this review indicate, the current state of the scientific literature is promising, but largely preliminary and thus not able to provide evidence based guidance regarding cost effective utilization of scarce public or private resource dollars with respect to CHI.

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