The Internet has been around for more than thirty years, and for many of those years, it was used primarily by research scientists and the military for defense. But with the advent of the invention of “hyperlinking,” it has become widely available. Linking creates the World Wide Web (WWW) and allows users to navigate from page to page with the click of a mouse. The Web ties together information from around the world that can be accessed by anyone with a computer and the ability to log on.

It has only been during the past five years that the mental health and addiction field met the Internet and became familiar with it. Many of us are now learning to work in an electronic world. Because so many activities in the field are about sharing information, healthcare stands to reap huge gains as Web technology is more widely used.

Much of healthcare involves the sharing of patient information with stakeholders, including primary-care providers, specialists, payors, labs and hospitals. (The term patient is used generically in this article to include patients and clients.) The Web provides a remarkable solution to linking these entities together. In addition to publishing patient education and improving patient care, continuing education for professionals will also become easier through online courses dealing with issues relevant to each practitioner’s specific needs.

Practitioners must learn about online technology in order to meet the needs of today’s empowered, e-health consumer. It is estimated that almost one third of the $1.3 trillion spent on healthcare today is wasted by the inefficiencies of the current paper-dependent system. As practitioners learn to use the Internet, their practices and the treatment they offer will become more cost-effective. Today, the WWW brings a marvelous, desktop tool to the field that can be used to improve the quality of care to patients. For the first time in history, with the use of this electronic teaching tool, practitioners have instant access to “best treatment” information, expert consultations and established treatment guidelines. By providing access to more efficient care for patients and timesaving tools for practitioners, e-health holds the promise of driving down traditional healthcare costs.

The term “e-health” encompasses  any form of healthcare information made available over the Internet. For some consumers and/or patients, e-health includes searching for health-related information at Web sites like OnHealth.com, filling their prescriptions at drugstore.com, or taking depression assessments online at Prozac.com. For others it means interacting with practitioners via e-mail or directly through videoconferencing.

The high-tech healthcare network is expected to grow dramatically in the next few years and there are several major factors to consider as it does, including:

• Consumers

• Connectivity

• Public policy

• Technology

Record numbers of Internet users are rushing to find health information from health-related Web sites. The number of U.S. adults seeking health information on the Internet surpassed 98 million this year, twice as many as just two years ago. Over 50 percent of all Internet users seek health information on the Web and after finding the information, the top three actions they take are:

1. Urge a friend or family member to see a doctor.

2. Ask their doctor about a specific medication.

3. Make a treatment decision.

Studies show that more than 60 percent of those seeking online health information express a desire to communicate by e-mail with their practitioners. One study predicts that the “competition for e-health consumer mind share will be fierce.” Cyber Dialogue reports that 29 percent of respondents to one of their e-health studies said, “They would be likely to switch doctors to use a Web site operated by their physician’s office.”

According to Laurie Flynn, executive director of the National Alliance for the Mentally Ill (NAMI), mental health sites are among the five most popular health sites on the Web. Flynn states, “The anonymity appears to allow people to seek information and move more rapidly toward diagnosis and treatment.” Some of these people become empowered patients, and as they become savvier they expect more from their practitioners. Even seasoned practitioners, who do not recognize this fact, risk losing patients to their colleagues who endorse the e-health movement and who welcome increased patient participation in treatment decisions.

Some believe the baby boomers that have been so successful at changing other areas of our economy will lead the charge to change healthcare from practitioner-centric to consumer-driven. Speaking of the baby boom generation, Regina E. Herzlinger, PhD, professor at Harvard Business School and author of “Market-Driven Health Care,” said, “They’re the ones who have changed the rest of the economy and they’re very interested in healthcare. There’s no reason for any rational person to believe that they’re going to say, ‘Oh no, leave healthcare in the hands of these people who are going to tell me what to do.’ Today’s consumers simply won’t accept that.”

Web-based search engines and niche health portals furnish patients access to the same scientific databases, clinical information and other sources that their practitioners often lack sufficient time to study. Practitioners should be reminded that, in contrast to the many conditions of which they must demonstrate expertise, patients usually have only one disorder to study. Some practitioners refer to patients who become particularly knowledgeable about their conditions as “board-certified patients.”

Sean Nicholson, professor at Wharton School of the University of Pennsylvania, recently reported about patients who visit their doctors carrying health information they have retrieved from the Internet. Nicholson says, “What’s interesting is the number of times the patient walks away with a lower evaluation of the doctor. Why? Perhaps because he or she doesn’t think the doctor is up-to-date. In some cases patients say they are thinking about finding a new physician because of that impression.”

As mentioned previously, a majority of patients would like to receive their health information from their practitioner’s Web site. However, only a minority of practitioners offer a personal Web page to their patients. Internet companies like the WebMD provide Web pages for their physician and nurse members. Our company, athealth.com specializes in publishing comprehensive online directory pages to help mental-health practitioners meet the needs of their patients.

Whereas it took television over 25 years to reach mass penetration of consumers in the United States, it took the Internet only seven years. Two factors adding impetus toward the building of a “wired world” are advertising and investment dollars. Advertisers focused on health-related Web sites expect their total spending to exceed $265 million by 2002. Investors also provide capital to entrepreneurs with solid business plans for companies promising to deliver e-health more efficiently than traditional forms of care.

Another major driving force toward e-health is the increasing amount of personal dollars consumers are spending for their healthcare. Trends show that consumers are picking up a larger percentage of the price of their healthcare and it is believed that this movement will increase as care becomes more managed and employers introduce defined contribution plans. In the end, as employees contribute more of their personal dollars toward their healthcare, they will demand more cost-efficient, high-quality care from their practitioners.

As parity for mental healthcare works its way through state and federal legislatures access to and demand for care is likely to increase. The Internet and its Web technology may provide anonymity and easier access to mental-health information, assessment and treatment to a large segment of our population that presently is not receiving care. Online tools may provide major benefits to practitioners wanting to broaden the reach of their traditional office practice.

Because healthcare is very complex, e-health will come of age through evolution, not by revolution. All of the major beneficiaries of e-health recognize that it is essential to weave online e-health tools into the “information technology challenged” healthcare system. However, because of complexities it will take longer for healthcare to adopt Web technology than other sectors of our economy. Some of the main obstacles facing e-health include privacy, security, authentication and professional standards.

The specific technical aspects of privacy, security and authentication are beyond the scope of this article. However, patients have the right to expect that their online health information remains private and they must be guaranteed that those who provide e-health are qualified professionals. Acknowledging these facts, technology companies are spending huge sums of money to ensure that online interactions between patients and their practitioners will be secure. Already, much of the technology is in place to ensure that the patient’s paperless medical chart will be more private than the traditional paper chart.

Currently, as the chart moves from the file cabinet to exam room, laboratory, front and back office, it can be read by many healthcare staff, many of whom are not directly involved in patient care. Online technology permits medical personnel various levels of password-protected privileges. For instance, the front office staff privileges only allow viewing of the patient’s demographic and billing information but not the clinical record.

Professional organizations are developing standards that will allow practitioners to safely use online e-health technology with patients. The International Society for Mental Health Online (ISMHO), promotes “the understanding, use and development of online communication, information and technology for the international mental-health community.” The ISMHO, in conjunction with other professional organizations such as the Psychiatric Society of Informatics (PSI), published the “Suggested Principles for the Online Provision of Mental Health Services.” Included in the report are topics dealing with informed consent, standard operating procedures and emergencies.

Last July, the American Medical Association (AMA) published the “Guidelines for Patient-Physician Elec-tronic Mail.” The report addresses the main obstacles to the usage of e-mail between practitioners and their patients, which include:

• Ensuring privacy and confidentiality of patient information

• Establishing appropriate standards for security

• Developing patient education material about using e-mail in their care

Because of the enormous amount of resources being invested, benefits will begin to outweigh the obstacles associated with e-health. Some of those benefits include:

• self-help

• risk assessment

• early intervention

• treatment adherence

It will become easier for patients to find information about their illnesses and disorders on the Web as new user-friendly search tools are developed. Currently, about 50 percent of homes in America have Internet access. Already, many patients visit their practitioners with articles they printed from their favorite health-related Web sites. These patients want and they need help interpreting the online information they find. They look for practitioners willing to partner with them in their healthcare decision-making process. This new proactive information-seeking patient stands in stark contrast to patients of a former era, who were more passive and less involved and who expected their practitioners to direct their care.

Web sites providing online assessments are beginning to be used by e-health users. In addition to Web resources like Prozac.com, which offers brief depression assessments, there are sites like Paxil.com, which provides an online version of SPIN, the Social Phobia Inventory. CopeWithLife.com, according to its authors, “is for people who want to cope with their depressive symptoms, as well as the stresses and anxieties that hamper their emotional health. It helps them when they need it, on their own schedule, with or without a doctor’s care.” COPE was developed by nationally recognized psychologists and psychiatrists Lee Baer, PhD, Associate Professor of Psychology, at Harvard Medical School; John H. Greist, MD, Clinical Professor of Psychiatry, University of Wisconsin Medical School; and Isaac Marks, MD, from the University of London. COPE is reported to be an “effective, confidential and convenient” self-help program to aid those using the program.”

By ensuring security with the use of encryption and authentication, e-mail will become increasingly important to practitioners. For example, Joel Yager, MD, Department of Psychiatry, University of New Mexico, uses e-mail with some of his patients with eating disorders. Many of his patients live in rural New Mexico and they drive long distances for their appointments. Dr. Yager receives an enthusiastic response from many of his young patients who utilize e-mail to communicate with him between their scheduled office visits. Younger people, who are growing up with the personal computer, find fewer obstacles with online technology associated with healthcare.

Newsletters and mailing lists are popular forms of e-mail to enhance the exchange of health information between patients and practitioners. Athealth.com publishes a free, weekly e-newsletter, Friday’s Progress Notes, for more than 44,000 mental-health practitioners. Each issue focuses on a specific mental-health topic. An issue dedicated to drug abuse can be viewed online at the newsletter archives. The e-newsletter, which will soon offer continuing education, is delivered to the practitioner’s desktop and saves important research time by providing professionals with current Web resources related to each week’s topic. Mailing lists such as one offered by the International Society of Mental Health Online provides its subscribers with daily e-mails containing the dialogue of professionals discussing issues associated with e-health. Professionals interested in subscribing to the free service should send an e-mail to This e-mail address is being protected from spam bots, you need JavaScript enabled to view it Include the word “subscribe” without quotes in the subject line and include your e-mail address in the body of the e-mail.

Many people, especially those under 25, are comfortable with the use of live chat or online discussion groups. An increasing number of patients find valuable support online from others suffering from the same mental disorders. An example of this popular discussion forum is the alcoholism discussion in about.com where participants trade information about their disorder, its diagnosis and its various forms of treatment. On about.com, at least four online AA meetings are scheduled each day. One of the meetings, called “Serenity by the Cybernet AA Chat,” offers four online rooms to meet the needs of alcoholics seeking help.

Martha Ainsworth is the host of the Web site Metanoia.com, whose mission is “to dissolve barriers that separate people who need help from caregivers who could provide it.” The site emphasizes that, “Online counseling is not a substitute for traditional psychotherapy. If you can visit a therapist in person, you should.” Metanoia does not have online professionals on their staff, but there are links to practitioners who do offer online counseling, and an online tutorial is provided to help patients search for competent therapists.

Although the value of using Internet tools to augment face-to-face treatment in the office setting is widely recognized, “online therapy” remains controversial for a majority of mental-health practitioners. Ethical issues abound as professionals struggle to set legitimate standards for e-health. Many patients are willing to share personal health information online even though their privacy may not be secure. Worse yet, vulnerable patients might use some Web services where the credentials of the “professional” have not been authenticated and/or certified. For instance, the online practitioner, who is bound by the rules of the state in which he or she resides, may be engaging with a patient in another state in which the practitioner is neither licensed nor certified. Also, when using today’s online tools without proper safeguards, the severity of a patient’s depression or suicidal intent might be missed or, without accurate authentication, a child or adolescent, who claims to be an adult, could engage an online counselor in inappropriate “sex therapy.”

The British Journal of Guidance and Counseling reported a situation where a male therapist named “Alex” disguised himself as a female therapist named “Joan.” After gaining the trust of online patients, “Alex” revealed himself and his “experiment” much to the dismay and hurt of those with whom he interacted.

TheCounselors.com offers phone consultation and online chat sessions. They publish lists of their online counseling and consulting staff. After selecting an online counselor, site visitors may click to the “Lobby” where they can schedule a phone call or Internet chat with the professional. A charge of $20 is made to their credit card for the first 20 minutes of the chat session. Here2Listen.com offers “e-counseling.” At this site online therapists’ names are published along with their degree, the institution where they studied, state license number, areas of expertise, theoretical orientation, and the fee for a one-half hour online session. eTherapy.com recently opened to manage mental-health services of the “highest levels of legal and ethical responsibility” for online practitioners. Therapists manage their own Web practices and eTherapy.com generates revenues by charging a small administrative fee for each session. Therapists are restricted to working only with clients from states in which they are licensed and are required to complete an online practice-training program.

DrGoodwell.com, labeled the “virtual clinic,” is an online videoconferencing tool being developed for family practitioners. The application, which will be tested using tech-savvy Microsoft employees later this year, is designed to be “an accessible, trusted mentor and provider of health information and medical services for employees who work in a high-tech corporate environment.” In a recent demonstration, a mock patient seated at his personal computer in his office interacted with Bill Crounse, MD, co-founder of this e-health venture. The total time spent by the patient to “see” his doctor was less than ten minutes. The online interaction saved more than two hours of work time that the employee would normally spend driving to and from the doctor’s office and the time waiting for his appointment. A very important component of DrGoodwell.com is that the practitioner will be paid a fee for his or her time online. Employers are likely to endorse this type of e-health, which promises to improve employee productivity. If employers and employees sign on, it is also very likely that practitioners will learn to use the technology.

In spite of these examples, some experts in e-health agree that practitioners are wise to wait for their professional organizations to develop standards before assuming the risk of providing e-health care. To facilitate this process, the U.S. government’s Health Insurance Portabil-ity & Accountability Act (HIPAA) is scheduled to take effect over the next couple of years. HIPAA addresses much of the privacy, security and authentication issues of e-health.

Currently, with the use of online applications, practitioners can receive continuing education with a steady stream of daily information. We can already benefit from Internet tools permitting us to focus on topics that are highly relevant to our practice settings and clinical interests. In addition to receiving our education from traditional sources such as textbooks, home study and live conferences, practitioners can log on to our favorite Web resources between patients to check the latest references relating to the “best practices” or expert treatment guidelines relating to a particular disorder. For instance, the American Psychiatric Association (APA) publishes several guidelines including, “Practice Guideline For The Treatment Of Patients With Substance Use Disorders: Alcohol, Cocaine, Opioids” on their Web site. These guidelines can provide a source of reassurance to the practitioner that he or she is providing care within a standard recognized by experts in the field.

Many clinicians find mailing lists delivered by e-mail to be extremely useful as a noncredit source of continuous education. During the last two years of my outpatient psychiatric practice, I subscribed to several mental health-related mailing lists. One of these, called the “Psychopharmacol-ogy Mailing List,” was an ongoing source of very practical information. Each day, the mailing list provides the e-mail dialogue between experts pertaining to the use of psychotropic medications. These experts included not only academicians but also many clinicians, who were “in the trenches” practicing psychiatry. Ivan Goldberg, MD, from New York, moderates the list and he helps to keep the subscribers’ discussion focused on psychopharmacology.

Many other mailing lists relevant to mental disorders and their treatment can be found at Web sources such as L-Soft Visitors to the site can search for mailing lists dealing with their favorite topics. For instance, a search for “addiction” yields eight specific mailing lists including, “Academic and Scholarly Discussion of Addiction Related Topics,” “Breaking Free: Newsletter of the Addiction & Recovery Forum,” and “Women and Addiction Research Network.” The number of subscribers to each of these lists number from 27 in “Women and Addiction” to 7,714 in “Breaking Free.”

Several Web sites offer accredited, online, continuing education (CE) courses. Sites specifically offering courses for mental health professionals include the Distance Learning Center for Addiction Studies (DLCAS), athealth.com, and Behavioral Healthcare Community’s Continuing Education Online. DLCAS, in association with Hazelden Foundation, presents instructors, including Dennis Daley, Melody Beattie and Craig Nakken, to its online audience. About 30 courses pertaining to addiction are listed in their catalog. Athealth.com and Behavioral Healthcare Community’s Continuing Education Online are Web sites that provide CE for a broad range of mental-health topics professionals. Athealth.com links its weekly newsletter, Friday’s Progress Notes, directly to some of its CE/CME courses and will be adding online discussions moderated by experts to enhance their courses.

Online CE allows practitioners to receive an important part of their education conveniently from their office or comfortably from their home day or night. Additionally, by saving travel expenses and time out of the office practitioners are showing a rapidly growing demand for online CE.

Healthcare, including mental health, is struggling with the introduction of Web technology into practitioner’s lives and the lives of his or her patients. With the desire to provide high quality care to those we serve, practitioners are increasingly endorsing online information and education. E-health will grow as practitioners are assured that when they engage with their patients online they will “do no harm.”

John L. Miller, MD, is president and founder of At Health, Inc.
(www.athealth.com), a Web site that provides mental health information
for practitioners and consumers. He is trained in pediatrics and psychiatry and practiced
adolescent and adult psychiatry for 20 years before joining athealth.com full-time in 1999.

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