Tomorrow's leaders in health promotion are being educated at American University today.

 
SUMMARY AND CONCLUSIONS

Introduction

This study has been focused on the development of a conceptual framework and a design for the next generation of advanced information technology systems for the improvement of the health status and quality of life of Americans. The system was designed to accomplish a two-fold mission: first, to combine the powerful features of advanced technology systems with the best evidence and practices of the health and behavioral sciences for the purpose of influencing the health-related lifestyle choices of individuals and populations in a highly effective way; and; second, to provide a conceptual framework for streamlining, reengineering, or reconceptualizing a healthcare system that has technology integrated or embedded into all processes and aspects of care.

The vision and design for the system that was presented in Chapter IV is substantially different from other systems that are on the market today in three ways. First, the design is grounded on a health promotion philosophy that views health from an optimal and systemic worldview and behavior change as an iterative, lifelong, long-term, and multidimensional process. Second, the conceptual framework and system is designed for full collaboration and integration among all of the agents of care and the multitude of stakeholders in the healthcare process. Third, the system design is based on user-centric and open-systems concepts that enable the system to be data-driven and tailored to the user at the service and interface level, interoperable with a full range of technologies and options; and intelligent, dynamic, and relatively free from substantial upgrade path limitations.

The Major Findings

In the opinion of the researcher, the single most important finding of this research project is that it is possible to develop a conceptual framework and design for a comprehensive, fully integrated, intelligent, dynamic, and advanced health-promoting informatic system. It fills an important void that currently exists. The design fulfills or exceeds all of the major requirements and criteria that were identified in the analysis portion of this study. This framework and design can serve as an effective structure and model for those will be designing, doing research on, or implementing the next generation of systems that support technology-facilitated behavior change.

There is ample evidence in the literature and from practitioners within the healthcare environment about the need and the forces that are driving decision makers, practitioners, policy makers, and entrepreneurs to look for better ways to address many of the most intractable health-related problems of society. Clearly improvements need to be made in many areas. Technology-based system designs, such as the one featured in this study, are superior in many ways to the conventional designs, and they offer much promise for the future (Intel Corporation, 2000; Berners-Lee, 1999; Gates, 1999; Forrester Research Group, 1999; Ratzan, 1998; Koop, 1995). However, highly complex and sophisticated system designs such as the one presented in Chapter IV have major limitations in the real world (Future of Health Technology Institute Summit 1999; Hocking, 1998; Street et al., 1997). Some of the most important implications and limitations of this conceptual framework and design will be discussed below.

Conclusions

Implications for Theory and Practice

There are several important implications from this research for each of the constituencies and audiences mentioned in this report. A few of the key implications for theory and practice will be highlighted in this discussion.

First, from a theoretical standpoint, the conceptual framework and model system design that evolved out of the system design and analysis process is valuable for researchers, systems designers, and policy makers who will be involved with the next generation of health-enhancing information systems. They can use the framework as a structure or benchmark to compare, contrast, and evaluate the objectives, attributes, and features of the systems that are already available against this model design. Further, this framework will be useful those individuals and entities who want to move beyond the traditional medical model and disease management approaches and push the concepts of more efficient and effective care or "treatment" farther upstream and into the realm of fully integrated "womb-to-tomb" healthcare.

Second, for practitioners, designers, and researchers, this framework has important implications for all aspects of technology-facilitated behavior change. A highly effective system must be founded on strong scientific principles. In this system design the problem is identified in terms of the health-compromising lifestyle choices of individuals and the lack of systems that are well designed and advanced enough to be able to produce positive health changes in a highly efficient manner. The Transtheoretical model and psycho-socio-bio-ecological concepts that are featured in this design provide the theoretical underpinnings, a mechanism and process for behavior change, and an environment that is likely to support and sustain those changes for the long term (Smedley et al., 2000; Prochaska et al, 1994). The theoretical base for this system that has been described throughout this document is one of the most important reasons why this design stands out among all of the other systems that rely on information dissemination, mass production, or shotgun tactics and system-centric designs. This conceptual framework will help consumers, practitioners, designers, and policy and decision makers to understand the nuances and implications of the different types of systems, why they have performed so poorly in terms of promoting long-term change among the general population in the past, and why this design holds so much promise for the future.

Third, for decision and policy makers, designers, entrepreneurs, and organizations who might invest in, provide resources for, or sponsor the development and implementation of this design, there several important implications that are related to the scope and complexity of the system design. The system design helps to clarify and illustrate the fundamental principles of the system, the interrelationships among the elements, the types and characteristics of technologies that are featured or anticipated to be part of the design, and the array of data and affiliated systems that would be part of it. The system design and framework will be useful for those involved in the decision-making process. The alternative paths to adoption presented in Chapter IV and in Appendix IV are helpful for evaluating the relative risk, benefits, and implications of going forward with this design as is, choosing one of the alternative development methodologies that would move them in the direction of the model design, doing nothing, or electing to adopt another type of system. When these stakeholders are clearly informed about the system and model, they can make informed judgements about the value of this approach, weigh the alternatives, and choose the option that best suits their organization and constituency.

Fourth, the framework and design has implications for each of the stakeholders mentioned in the report. For example, consumers should be more informed about what to look for and demand from the best-of-the-breed systems. This will allow them to invest more wisely and advocate for better products. Organizations and those who support the healthcare system should have a clearer understanding of what to expect from the different types of systems, how they can improve on what they currently use, and what to plan for in the future.

Finally, there are extremely important implications for the two primary audiences for this report; one, the developers and, two the practitioners and agents of change. After reading the full discussion of all of the issues related to this design, developers should be able to distinguish between the strategies of health promotion, the medical model, and disease management; to understand the factors necessary for effective and long-term behavior change; and to realize the interrelationships among the healthcare entities and how they go about ministering to those under their care. Ideally, that insight will allow developers to design systems that are more in tune with the needs of all of the players in the healthcare system. As a byproduct of reading this report, health practitioners should be more informed about the technology domain, and the systems design process, as well as realize the importance of and be inspired to take a more proactive role in the design, implementation, and evaluation process.

Limitations

There are several important limitations that are related to the conceptual framework, the system design, and the design process. First, even though a great deal of effort was made to avoid the constraints and limitations of many of the other system designs, there is no absolute ideal model for all situations, and this framework and design should not be considered as a panacea. It is very important for the reader remember that this framework and model were conceptualized and designed from a single idealized vision in a constraint-free environment. Although there is a very strong rationale behind this design, the approach to care, methodology of adoption, and system of choice should be tailored or matched to each situation. This research project should not be the end of the process. It should be used as a starting point, benchmark, or framework for beadboarding (Rosenau, 1990).

Second, this framework and the design of this model system can not be fully evaluated until it is tested. Moreover, it is clear that even if this system or one of the alternative approaches were built and deployed, a significant amount of work would be needed to improve on the design, and a continual effort would be needed to keep it current with the latest advances in the sciences and technology.

Third, there are many unresolved questions about whether this design could make a successful transition from the conceptual design phase into a real-world implementation environment. Many risks, issues, limitations, advantages, and disadvantages were highlighted in Tables 17 - 18 in the alternative scenario development process in Appendices or Appendices as a pdf file. That data underscores the worth of a careful analysis of the needs of the user population; the value, resources, and acceptable level of risk and errors; and the anticipated benefit or return that an entity expects to realize by investing in such a system development venture. Again, the most prudent approach is to be sure that the needs are balanced with the required return for the short and long term, and that the development path is tailored to each entity and the constituency under their care.

A fourth limitation of this type of approach to system design relates to the improper disclosure and understandable reluctance of some private as well as public entities to share their intellectual property with others. Even though enormous benefits for the common good could be derived from more rapid and more open sharing of ideas and some of the more advanced technologies, doing so is often contrary contemporary business and research practices. Thus, access to some of the key ingredients and best secrets for the advanced technology systems remain beyond the reach or resources of most organizations. In many instances this mentality would doom projects such as this to failure.

The fifth limitation of this research relates to the diffusion of the results and conclusions of this study. Unless these concepts, framework, and design begin to diffuse through the networks of professionals, practitioners, informaticists, and designers, little progress in this thoughtful approach can be anticipated. Therefore, the researcher and other like-minded parties should make dissemination of the findings a priority and engage in efforts such as those that are listed in Appendices or Appendices as a pdf file. Moreover, substantial changes are needed in the academic, training, and continuing education centers in order to develop the professionals who have the transdisciplinary skills and expertise to lead or participate effectively on these development teams.

Finally, there are several general observations and limitations that are related to this study and the model design. First, this design has never been tested as a whole framework or system. Second, the framework and design has not been fully scrutinized and validated by a broad range of experts. Third, there are major questions about whether an agency with enough resources to build the system properly would be willing to be the first to take on the risk of engaging in such an enormous undertaking. Fourth, this design and framework is built on a humanistic and philosophical model and not a business or an economic model. Bottom-line considerations must be weighed heavily in the real world. Fifth, in order to design such a system, the strongest political or organizational commitment will be necessary to develop the system and continue with it long enough to realize its full capabilities, potential, and effect (Ball, 2000; Dewan et al., 1999). Sixth, since so much of the technology and this approach are new, many of the assumptions, particularly with respect to the business models and some of the unsupported projections, may be on the wrong tangent or incorrect (Shortliffe, 1998). For example, many health-related "dot.com" companies were founded on business models that relied on making profit and recovering a significant percentage of their investment by providing content to users. Recently, a study by Deloitte and Touche and Cyberdialogue found that consumers are willing to pay for interactive service and convenience tools but not content (Hagland, 2000).

Recommendations for Future Research

In light of the conclusions from this study, as well as the enormous potential and promise for health-promoting informatic systems in the future, several promising areas for exploration by future research projects are worth highlighting. The first and the most obvious recommendation is moving beyond the design/proof of concept stage and into developing and testing modules or prototypes from this model system design. This type of project is most appropriate for a research institution, a research and development department of a large healthcare entity, a consortium of organizations, or as a small business innovation (SBIR) or small business technology transfer (STTR) grant.

Second, governmental policy makers, decision makers of organizations, and advocacy groups should demand rigorous examination of the efficacy and impact of the systems, the worth of the framework, and the relative effectiveness of the alternative approaches on organizations of all types for the short and long term. Moreover, the cost of the evaluations needs to be built directly into the project budgets.

Third, the effectiveness and impact of the system should be subjected to empirical testing on multiple populations. Some of the criteria that should be tested are: changes in lifestyle choices and behaviors, user acceptance and use patterns, usability issues, the impact of the system on populations in meeting the Healthy People 2000 objectives, the positive and negative impacts of the system on individual users and healthcare professions in a virtual community, the impact on the entities of the healthcare system, and economic impact of the system. The evaluation of the impact of the system should be based on individual as well as population-wide parameters.

Fourth, the framework and design should be subjected to careful and full scrutiny by a panel of experts from multiple domains. The panel could validate the worth and fundamental principles of the framework and design or make suggestions about possible modifications, improvements, and alternatives to the model or system.

Fifth, since so much of the acceptance and success of systems in organizations is determined by the organizational culture and managerial support, studies that look at factors that influence the acceptance and use of systems would be an important contribution to the field. Case studies and qualitative research that investigate the implications for leadership and organizational policy would be particularly useful in this area.

Sixth, the health of Americans is vitally important to all aspects of the economy and society. Therefore, studies that explore the health-related, political, economic and fiscal implications, and issues of supporting, developing and deploying these systems are worthy of research in the policy arena. A particularly fruitful area of research would involve studies comparing the differences between the alternative methodologies that were featured in Table 18 for a variety of organizations of all sizes and from every sector of the economy.

In Closing

This study has explored a vitally important area that has many implications for the healthcare professions and society for today and on into the 21st century. Clearly, there are now enough well-informed champions in the field and a critical mass of users of the new technologies to believe that the time is right for moving forward with these projects in an intelligent way. More important, from a business perspective, business and governments are beginning to develop and test viable short- and long-term business models, to see how these systems can be used to help realize many important organizational and national goals for the benefit of multiple constituencies. The suggestion that a system be built that is based on this design is clearly a lot to ask, and it would be a bold step forward, however, this researcher is convinced that this, or one of the alternative approaches, is the direction many organizations should be moving.

Finally, this study has been built on the wisdom of the pioneers in several fields. The researcher has sought to stand on the shoulders of visionaries in these fields to get a glimpse of the future. But as Michael Ackerman said, "The only successful way to predict the future is to invent it" (Ackerman, 1997). That is what this design study was meant to be, a start down that path.

Link to Appendices.

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