Online Health Searches and Their Perceived Effects on Patients and Patient-Clinician Relationships: A Systematic Review

Jane Wang; Tamara Ashvetiya; Emmanuel Quaye; Kapil Parakh; Seth S. Martin

doi:10.1016/j.amjmed.2018.04.019

Online Health Searches and Their Perceived Effects on Patients and Patient-Clinician Relationships: A Systematic Review

Jane Wang, Tamara Ashvetiya, Emmanuel Quaye, Kapil Parakh, Seth S. Martin

School of Medicine

Research output: Contribution to journal › Review article › peer-review

10 Scopus citations

Abstract

Online health searches are common and may be impacting patients and their relationships with their clinicians in ways that are not fully understood. We searched PubMed, Embase, Cochrane Reviews, Cochrane Trials, Scopus, and CINAHL from January 1, 1990 to January 29, 2016 for studies in which patients searched online for any aspect of health care and then visited their clinician. We extracted data pertaining to either patients’ or clinicians’ perceptions of the effects of these online searches on patients and the patient-clinician relationship. Searches seemed to induce patient anxiety but more often led to patient reassurance, clinical understanding, and empowerment. Patients tended to perceive that online health searches had a positive effect on the patient-clinician relationship, although the nature of the effect could depend on the clinician's response to patient queries about the information. Clinicians generally perceived neutral effects on patients and the patient-clinician relationship and commonly raised concerns about the accuracy of online content. Significant methodologic heterogeneity prevented quantitative synthesis. Accuracy of online health search content was not assessed, and randomized controlled trials were notably lacking.

Original language	English (US)
Pages (from-to)	1250.e1-1250.e10
Journal	American Journal of Medicine
Volume	131
Issue number	10
DOIs	https://doi.org/10.1016/j.amjmed.2018.04.019
State	Published - Oct 2018

Keywords

Health search
Internet accuracy
Internet health search
Online health search
Patient-clinician relationship

ASJC Scopus subject areas

General Medicine

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10.1016/j.amjmed.2018.04.019

Cite this

@article{0f1ec8f91cf549f889baeb1e78a64862,

title = "Online Health Searches and Their Perceived Effects on Patients and Patient-Clinician Relationships: A Systematic Review",

abstract = "Online health searches are common and may be impacting patients and their relationships with their clinicians in ways that are not fully understood. We searched PubMed, Embase, Cochrane Reviews, Cochrane Trials, Scopus, and CINAHL from January 1, 1990 to January 29, 2016 for studies in which patients searched online for any aspect of health care and then visited their clinician. We extracted data pertaining to either patients{\textquoteright} or clinicians{\textquoteright} perceptions of the effects of these online searches on patients and the patient-clinician relationship. Searches seemed to induce patient anxiety but more often led to patient reassurance, clinical understanding, and empowerment. Patients tended to perceive that online health searches had a positive effect on the patient-clinician relationship, although the nature of the effect could depend on the clinician's response to patient queries about the information. Clinicians generally perceived neutral effects on patients and the patient-clinician relationship and commonly raised concerns about the accuracy of online content. Significant methodologic heterogeneity prevented quantitative synthesis. Accuracy of online health search content was not assessed, and randomized controlled trials were notably lacking.",

keywords = "Health search, Internet accuracy, Internet health search, Online health search, Patient-clinician relationship",

author = "Jane Wang and Tamara Ashvetiya and Emmanuel Quaye and Kapil Parakh and Martin, {Seth S.}",

note = "Funding Information: To our knowledge, this is the first systematic review of online health searches and their perceived effects on patients and patient-clinician relationships. A major theme emerging from our analysis is that patients and clinicians seem to hold distinctly different perceptions of Internet health searches. Patients generally reported that they felt more reassured and empowered, engaged more with clinicians during clinical encounters, and took steps toward positive lifestyle modifications following online searches. However, clinicians frequently doubted the utility and accuracy of online information and reported greater strain on the patient-clinician relationship, particularly if they perceived patients as challenging their authority. Clinician concern about content accuracy is valid. Patients frequently lack a medical background to accurately distinguish between factual and spurious health information or to interpret information about clinical trials, novel therapeutics, and reputable health guidelines. Furthermore, patients may lack the insight to discern which diagnoses have a higher likelihood of causing particular symptoms and may bring in information on a topic that has little probability of being their underlying diagnosis. Therefore the information patients bring to clinical encounters may serve as a starting point for discussion but require guidance on accuracy and pretest probability from their clinician. No study within our final article list assessed the independent accuracy of online health information that patients brought in, which complicates analysis of the impact on the patient-clinician relationship. This is an important area for future study. There are several implications of these findings on clinical care. Internet health searches seem to have ushered in a new era of clinical negotiation and patient empowerment. Specifically, greater access to health information to patients may present an opportunity for increased health activation through open engagement between the clinician and the information-seeking patient. However, clinician skills and insight are likely necessary to direct this momentum into a productive and collaborative clinical encounter. If, as our findings suggest, the perceived effect on the patient-clinician relationship is dependent on the clinician's response, providers may benefit from being cognizant of their projected reactions to patients who present information from the Internet. It may be worthwhile for clinicians to validate patient concerns, acknowledge patient efforts in playing a more active role in their health, and encourage patients to further engage with their health by guiding them to validated sources of online information. Patient satisfaction has become an increasingly important metric in measuring clinical quality of care and has been incorporated into the Institute for Healthcare Improvement's {\textquoteleft}Triple Aim{\textquoteright} as a component of the patient experience of care. 73 Patient satisfaction has been linked to patient adherence to clinician recommendations, loyalty to clinicians, and decreased malpractice rates. 74 Because online diagnostic searches are now commonplace and may influence the patient-clinician relationship, they have potential to impact patient satisfaction, translating into changes in hospital reimbursement rates and patient health outcomes. Despite the potential for advancing patient well-being and engagement, our study also raised possible negative consequences of online health information seeking. These included unrealistic patient expectations, requests for unreasonable diagnostic studies, and alterations to treatment plans. These occurrences seemed to be few and did not seem to influence clinicians{\textquoteright} perceptions of patient outcomes, but they suggest a need for additional high-quality contemporary data. The accuracy of online health information is a point of concern during clinical encounters, and multiple articles cited significant clinician distrust of the online information patients solicited. In Provost et al, 56 only approximately 20% of physicians in the United Kingdom believed that online information was usually reliable, and in Murray et al, 84% of surveyed clinicians rated patients as fair or poor (rather than good, very good, or excellent) at appraising the quality of online information. Most articles included within our study did not list the websites that patients visited, which is a key limitation to address within future work. In the survey of oncology patients by Newnham et al, . Given the frequent lack of validation and oversight of health guidance websites, it is prudent of clinicians to probe the veracity of the online information that patients bring. 52 the most commonly searched websites were those of the Cancer Council of Victoria, the National Cancer Institute, and the American Society of Oncology. 52 In Cooley et al, 75 the most commonly visited websites were search engines (eg, Google, Yahoo, MSN), health websites (eg, eMedicine, WebMD, iVillage), and news websites (eg, CNN, MSNBC, Fox News). 75 A full tabulation of website domains recorded in articles examined in this study is provided in Table 2 Although patients may not solicit medically accurate information from the Internet, it may still be important to recognize their effort in being more active and involved in their health. It is critical to partner with them in this effort. Clinicians can aid patients by recommending credible sources for online health information sponsored by entities such as the National Institutes of Health, the American Heart Association, and the American Cancer Society. Hospitals and health systems may consider hosting physician-verified health information on their websites or online portals or linking to verified online health information. There were several notable limitations to our systematic review. First, there was significant methodologic heterogeneity across the studies in the quantification of the percentage of patients who conducted online searches. This, in addition to the bimodal distribution of the study sizes and heterogeneity in outcome ascertainment, prevented formal quantitative synthesis. Second, geographic variance in study groups may have introduced cultural biases in our results and may be responsible for some of the seemingly contradictory findings. Third, a disproportionate number of studies focused on oncologic conditions, which may have also colored responses from both patients and providers. Fourth, most of the studies endorsed a certain outcome rather than a null result, raising the question of selective reporting or publication bias. Furthermore, the nature of this study requires that patients have Internet access, so included articles may have only surveyed a particular subset of the population. Last, because elderly populations are less likely to use the Internet, this study may not have adequately captured their experiences. 76 Investigations of the relationship between online health information seeking and health outcomes are relatively new. As more studies are performed, the field may benefit from greater consideration of the accuracy of online health information, harmonization of outcomes, and study designs that use randomization. About the latter point, RCTs might be performed that randomize patients to online searching vs no searching or to different types of searching, and then evaluate outcomes such as relevance of search results, patient understanding, patient engagement, patient anxiety, or quality of the patient-clinician relationship. Such RCTs may be performed at different time points in the workflow of patient care and may consider potential effect modification on the basis of age, sex, socioeconomic income, medical condition, and geographic location. One example is an RCT of online health searching in the emergency department waiting room of patients presenting with new symptoms (NCT03073746). The trial randomized patients 1:1:1 to no searching vs usual Google search vs Google Health search, the latter being a dedicated symptom search tool that provides curated information, with accuracy verified by medical doctors, and presented based on probability. The trial's primary outcome is accuracy of the patient's previsit differential diagnosis compared with the clinician's postvisit differential diagnosis, and secondary outcomes include patient anxiety and quality of the patient-clinician relationship. Publisher Copyright: {\textcopyright} 2018",

year = "2018",

month = oct,

doi = "10.1016/j.amjmed.2018.04.019",

language = "English (US)",

volume = "131",

pages = "1250.e1--1250.e10",

journal = "American Journal of Medicine",

issn = "0002-9343",

publisher = "Elsevier Inc.",

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TY - JOUR

T1 - Online Health Searches and Their Perceived Effects on Patients and Patient-Clinician Relationships

T2 - A Systematic Review

AU - Wang, Jane

AU - Ashvetiya, Tamara

AU - Quaye, Emmanuel

AU - Parakh, Kapil

AU - Martin, Seth S.

N1 - Funding Information: To our knowledge, this is the first systematic review of online health searches and their perceived effects on patients and patient-clinician relationships. A major theme emerging from our analysis is that patients and clinicians seem to hold distinctly different perceptions of Internet health searches. Patients generally reported that they felt more reassured and empowered, engaged more with clinicians during clinical encounters, and took steps toward positive lifestyle modifications following online searches. However, clinicians frequently doubted the utility and accuracy of online information and reported greater strain on the patient-clinician relationship, particularly if they perceived patients as challenging their authority. Clinician concern about content accuracy is valid. Patients frequently lack a medical background to accurately distinguish between factual and spurious health information or to interpret information about clinical trials, novel therapeutics, and reputable health guidelines. Furthermore, patients may lack the insight to discern which diagnoses have a higher likelihood of causing particular symptoms and may bring in information on a topic that has little probability of being their underlying diagnosis. Therefore the information patients bring to clinical encounters may serve as a starting point for discussion but require guidance on accuracy and pretest probability from their clinician. No study within our final article list assessed the independent accuracy of online health information that patients brought in, which complicates analysis of the impact on the patient-clinician relationship. This is an important area for future study. There are several implications of these findings on clinical care. Internet health searches seem to have ushered in a new era of clinical negotiation and patient empowerment. Specifically, greater access to health information to patients may present an opportunity for increased health activation through open engagement between the clinician and the information-seeking patient. However, clinician skills and insight are likely necessary to direct this momentum into a productive and collaborative clinical encounter. If, as our findings suggest, the perceived effect on the patient-clinician relationship is dependent on the clinician's response, providers may benefit from being cognizant of their projected reactions to patients who present information from the Internet. It may be worthwhile for clinicians to validate patient concerns, acknowledge patient efforts in playing a more active role in their health, and encourage patients to further engage with their health by guiding them to validated sources of online information. Patient satisfaction has become an increasingly important metric in measuring clinical quality of care and has been incorporated into the Institute for Healthcare Improvement's ‘Triple Aim’ as a component of the patient experience of care. 73 Patient satisfaction has been linked to patient adherence to clinician recommendations, loyalty to clinicians, and decreased malpractice rates. 74 Because online diagnostic searches are now commonplace and may influence the patient-clinician relationship, they have potential to impact patient satisfaction, translating into changes in hospital reimbursement rates and patient health outcomes. Despite the potential for advancing patient well-being and engagement, our study also raised possible negative consequences of online health information seeking. These included unrealistic patient expectations, requests for unreasonable diagnostic studies, and alterations to treatment plans. These occurrences seemed to be few and did not seem to influence clinicians’ perceptions of patient outcomes, but they suggest a need for additional high-quality contemporary data. The accuracy of online health information is a point of concern during clinical encounters, and multiple articles cited significant clinician distrust of the online information patients solicited. In Provost et al, 56 only approximately 20% of physicians in the United Kingdom believed that online information was usually reliable, and in Murray et al, 84% of surveyed clinicians rated patients as fair or poor (rather than good, very good, or excellent) at appraising the quality of online information. Most articles included within our study did not list the websites that patients visited, which is a key limitation to address within future work. In the survey of oncology patients by Newnham et al, . Given the frequent lack of validation and oversight of health guidance websites, it is prudent of clinicians to probe the veracity of the online information that patients bring. 52 the most commonly searched websites were those of the Cancer Council of Victoria, the National Cancer Institute, and the American Society of Oncology. 52 In Cooley et al, 75 the most commonly visited websites were search engines (eg, Google, Yahoo, MSN), health websites (eg, eMedicine, WebMD, iVillage), and news websites (eg, CNN, MSNBC, Fox News). 75 A full tabulation of website domains recorded in articles examined in this study is provided in Table 2 Although patients may not solicit medically accurate information from the Internet, it may still be important to recognize their effort in being more active and involved in their health. It is critical to partner with them in this effort. Clinicians can aid patients by recommending credible sources for online health information sponsored by entities such as the National Institutes of Health, the American Heart Association, and the American Cancer Society. Hospitals and health systems may consider hosting physician-verified health information on their websites or online portals or linking to verified online health information. There were several notable limitations to our systematic review. First, there was significant methodologic heterogeneity across the studies in the quantification of the percentage of patients who conducted online searches. This, in addition to the bimodal distribution of the study sizes and heterogeneity in outcome ascertainment, prevented formal quantitative synthesis. Second, geographic variance in study groups may have introduced cultural biases in our results and may be responsible for some of the seemingly contradictory findings. Third, a disproportionate number of studies focused on oncologic conditions, which may have also colored responses from both patients and providers. Fourth, most of the studies endorsed a certain outcome rather than a null result, raising the question of selective reporting or publication bias. Furthermore, the nature of this study requires that patients have Internet access, so included articles may have only surveyed a particular subset of the population. Last, because elderly populations are less likely to use the Internet, this study may not have adequately captured their experiences. 76 Investigations of the relationship between online health information seeking and health outcomes are relatively new. As more studies are performed, the field may benefit from greater consideration of the accuracy of online health information, harmonization of outcomes, and study designs that use randomization. About the latter point, RCTs might be performed that randomize patients to online searching vs no searching or to different types of searching, and then evaluate outcomes such as relevance of search results, patient understanding, patient engagement, patient anxiety, or quality of the patient-clinician relationship. Such RCTs may be performed at different time points in the workflow of patient care and may consider potential effect modification on the basis of age, sex, socioeconomic income, medical condition, and geographic location. One example is an RCT of online health searching in the emergency department waiting room of patients presenting with new symptoms (NCT03073746). The trial randomized patients 1:1:1 to no searching vs usual Google search vs Google Health search, the latter being a dedicated symptom search tool that provides curated information, with accuracy verified by medical doctors, and presented based on probability. The trial's primary outcome is accuracy of the patient's previsit differential diagnosis compared with the clinician's postvisit differential diagnosis, and secondary outcomes include patient anxiety and quality of the patient-clinician relationship. Publisher Copyright: © 2018

PY - 2018/10

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AB - Online health searches are common and may be impacting patients and their relationships with their clinicians in ways that are not fully understood. We searched PubMed, Embase, Cochrane Reviews, Cochrane Trials, Scopus, and CINAHL from January 1, 1990 to January 29, 2016 for studies in which patients searched online for any aspect of health care and then visited their clinician. We extracted data pertaining to either patients’ or clinicians’ perceptions of the effects of these online searches on patients and the patient-clinician relationship. Searches seemed to induce patient anxiety but more often led to patient reassurance, clinical understanding, and empowerment. Patients tended to perceive that online health searches had a positive effect on the patient-clinician relationship, although the nature of the effect could depend on the clinician's response to patient queries about the information. Clinicians generally perceived neutral effects on patients and the patient-clinician relationship and commonly raised concerns about the accuracy of online content. Significant methodologic heterogeneity prevented quantitative synthesis. Accuracy of online health search content was not assessed, and randomized controlled trials were notably lacking.

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KW - Internet accuracy

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KW - Online health search

KW - Patient-clinician relationship

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Online Health Searches and Their Perceived Effects on Patients and Patient-Clinician Relationships: A Systematic Review

Abstract

Keywords

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