Strategic implications of asynchronous healthcare communication E ...

Int. J. Healthcare Technology and Management, Vol. 5, Nos. 3/4/5, 2003

Strategic implications of asynchronous healthcare communication E. Vance Wilson* School of Business, University of Wisconsin-Milwaukee, P.O. Box 742, Milwaukee, WI 53201, USA E-mail: [email protected] *Corresponding author

Nancy K. Lankton Eli Broad College of Business, Michigan State University, N203 Business Complex, East Lansing, MI 48879, USA E-mail: [email protected] Abstract: Asynchronous online communication technologies are likely to cause major changes in the way patients and their healthcare providers communicate. Initially, these technologies will be applied to undemanding communication uses, such as requesting prescription refills. In the longer term, however, the technologies may provide strategic benefits to healthcare innovators. In this paper we project changes that we expect to accompany the advent of asynchronous healthcare communication and propose several strategic opportunities that these changes will create. Keywords: disruptive innovation; provider±patient communication; technological change; technology trajectories. Reference to this paper should be made as follows: Wilson, E.V. and Lankton, N.K. (2003), `Strategic implications of asynchronous healthcare communication', Int. J. Healthcare Technology and Management, Vol. 5, Nos. 3/4/5, pp.213±231. Biographical notes: Vance Wilson is an Assistant Professor of MIS in the School of Business Administration at the University of Wisconsin-Milwaukee. He has written extensively on the subject of computer-mediated communication and has recently begun a healthcare research programme focusing on new forms of patient-connected information technologies. Biographical notes: Nancy K. Lankton is an Assistant Professor in the Department of Accounting and Information Systems at Michigan State University. She received her PhD from Arizona State University in 2000. Nancy is interested in research involving technology investments, use, and acceptance, especially in healthcare. She currently is teaching accounting information systems and data modelling.

Copyright # 2003 Inderscience Enterprises Ltd.

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E.V. Wilson and N.K. Lankton

Introduction

By applying the strategy of disruptive innovation [1], technological innovations that enter the low end of the healthcare market and subsequently move upmarket may provide a way to reduce healthcare costs, or at least slow cost increases. Christensen, Bohmer, and Kenagy [2] suggest that most vendors of healthcare technologies have overshot patients' current needs by focusing exclusively on sustaining innovations that improve existing technologies in areas that have been valued historically. They argue that most patients would be served better by new technologies that are simpler, more convenient, and more cost±effective than the status quo. These are primary characteristics of a disruptive innovation, which `[i]n any industry sneaks in from below . . . [w]hile the dominant players are focused on improving their products or services' ([2] p.104). Although these simpler disruptive technological innovations may initially fulfil only the least-demanding requirements of a marketplace, they can improve over time through their own sustaining innovations to meet more-demanding needs while maintaining their initial cost advantages (see Figure 1). Figure 1

The impact of sustaining and disruptive technological change [1]

Healthcare industries as a whole are relatively resistant to disruptive change, but some disruptive innovations, such as personal blood glucose metres for diabetes and angioplasty for coronary artery disease, have taken hold and largely replaced prior treatments [2]. These innovations initially resulted in greater convenience and lower costs, and over time they improved to give patients higher quality of care. In each case, effects of disruption led to important strategic implications, both for vendors of the supplanted treatments and portions of the larger healthcare market.

Strategic implications of asynchronous healthcare communication

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In this paper, we examine a technological innovation that has the potential to broadly transform healthcare [3], with strategic implications that spread throughout the healthcare industry. The innovation is asynchronous healthcare communication (AHC). AHC technologies are used to support interpersonal communication between patients and healthcare providers (hereafter referenced simply as providers) in a manner that does not require participants to meet in person, as in an office visit, or to communicate synchronously, as in a phone call. Although limited asynchronous communication has been available in healthcare settings for many years ± taking such forms as postal mail, voicemail, and even homing pigeons [4] ± AHC technologies are based upon relatively recent innovations in the area of computer-mediated communication. AHC is supported by the same technological infrastructure as e-Health applications, which underwent explosive growth in the late 1990s. However, the two technologies serve different needs. E-Health is primarily a mass-communication technology that provides patients access to health information but typically does not support interpersonal communication with healthcare providers, which is the principal goal of AHC. In the following sections, we first review communication between providers and patients from an historical perspective, paying special attention to the paths various technologies have taken in supporting this form of communication. We then define the structure and primary characteristics of AHC technologies that allow AHC to support least-demanding interactions between providers and patients and to act as a disruptive innovation by entering the low end of the healthcare communication marketplace. We subsequently propose several strategic opportunities to enhance AHC abilities to handle more demanding communications. These enhancements require substantial modifications to basic online messaging, e.g. e-mail, that include developing specialised systems that guide patients and reduce time demands on provider staff, supporting real-time message tracking, and integrating automated telephony into AHC technologies. We demonstrate how several of these propositions might be implemented with a system prototype named G-Mail, which is designed to improve the provider±patient messaging component of AHC by guiding patient inputs and tracking the messaging process. Finally, our conclusions summarise the paper and present several directions for future research.

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Healthcare communication

Provider±patient communication has fundamental purposes of exchanging information, making treatment-related decisions, and creating good interpersonal relationships [5]. Communication plays an integral role in virtually all provider±patient interactions, however, not all interactions place similar demands upon the communication. Consider a patient who is requesting an appointment for an annual physical versus another who is describing sharp abdominal pains. Both interactions require some information exchange, however the patient in the latter case would certainly have greater demands for the communication to provide immediate exchange than the patient in the former case. In addition, the patient with the abdominal pains would expect the communication to support a more demanding variety of diagnostic tests (treatment-related decisions) and more reassurance and relational support (creating good interpersonal relationships).

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For each healthcare communication purpose, we can project that certain interactions will consistently place higher demands than others on the communication. The aggregated communication demands across all interactions may be expected to produce a normative hierarchy of interactions ranging from least-demanding, e.g. requesting a routine prescription refill, to most-demanding, e.g. diagnosing a life-threatening disease. We describe this hierarchy as normative because it represents the normal pattern among interactions (see Table 1). We acknowledge that exceptions to the normative pattern will occur. For example, the label of `most-demanding' will not be particularly relevant to preparing for emergency surgery in the situation where the patient is unconscious and incapable of interaction. Table 1

Examples of interaction demands hierarchy

Provider±patient Interactions

Examples

Least-demanding interactions

Refilling a routine prescription Scheduling/rescheduling an appointment Receiving lab tests

More-demanding interactions

Changing a medication Having an annual physical Diagnosing a simple acute illness

Most-demanding interactions

Diagnosing a life-threatening disease Evaluating a transplant surgery Preparing for critical emergency surgery

The performance of communication in meeting interaction demands is interesting to researchers who study effective techniques for provider±patient communication at the individual level, for example, in developing a personable bedside manner [6]. However, this approach is also relevant to the disruptive innovation viewpoint we present in this paper, as it supplies a framework in which to compare the relative status of communication technologies in meeting demands of the healthcare marketplace by assessing their technology trajectories, i.e. the paths of technological progress charted over time [1]. The communication technologies we will discuss fall into three basic categories based on where and when the communication occurs, criteria that are particularly relevant to studies of communication technology [7]. These categories are in-person communication, at-distance communication, and asynchronous communication.


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2.1 In-person communication Until the late 1800s, communication between providers and patients was conducted almost entirely in-person using the native technologies of speech and nonverbal cues. In-person communication, viewed as a technology rather than an individual attribute, provides a level of performance that is capable of handling the most-demanding interactions between providers and patients. This exact capability is definitional, in that we do not consider in our discussion those types of interactions that cannot be performed, whether this is due to limits of medical technology or communication technology. Thus Figure 2 shows in-person communication as having a technology trajectory that exactly matches the increase in most-demanding interactions. This gradual increase occurs as new healthcare knowledge, treatments, and procedures enter the marketplace. Although in-person communication is very capable technology, it does require the patient and provider to meet physically, typically at a hospital, the healthcare office, or the patient's home. This makes in-person communication expensive and inconvenient, especially for patients who must travel to the provider's offices. Figure 2

Comparison of three technology trajectories in healthcare communication

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2.2 At-distance communication At-distance technologies enable synchronous communication between people who are located at sufficient distance to obstruct in-person communication, whether across town or on the other side of the country. The overwhelming majority of at-distance communication uses the telephone, which became available commercially in the late 1870s and was fully integrated into physician practice by the 1920s [8]. At-distance healthcare communication is available now to the large portion of patients with access to a telephone, assuming their provider is available to take the call. The relative convenience and low costs associated with the telephone quickly resulted in phone calls replacing the bulk of least-demanding interactions that previously were conducted in person, such as requesting a routine prescription refill. Following initial entry into healthcare markets, the telephone industry went on to improve the speed and reliability of connections and reduce costs for most services. At-distance communication now handles more-demanding provider±patient interactions, such as telemedicine consultations that make use of telephone-based videoconferencing [9], and it is estimated that 70% of the health problems about which patients call their providers can be managed over the telephone without requiring in-person communication [10]. In hindsight, it is clear that at-distance technology was a disruptive innovation for the healthcare industry, although the disruption has not extended to most-demanding interactions. At-distance technology entered the marketplace by providing an inexpensive, convenient, and simple solution that met least-demanding needs, and it then improved through a series of sustaining innovations to take over more of the marketplace (see Figure 2). In this case, no commercial vendors were displaced by the transformation that occurred because the in-person communication technology it disrupted was a native technology.

2.3 Asynchronous communication AHC applications incorporating basic e-mail functions are now being introduced to healthcare. Many providers have initially resisted asynchronous communication (e.g. see [11]). However, a recent survey reports 26% of US physicians are now using AHC applications for communication with patients, and 90% of this group report improvements in patient satisfaction resulting from AHC [12]. In its initial form, AHC exhibits the key characteristics of a disruptive innovation. First, disruptive innovations are accepted initially by the least-demanding parts of a market. Healthcare consumer surveys show that patients' interest in asynchronous communication is highest for least-demanding uses, such as viewing lab test results and receiving generic health information subsequent to an office visit [13]. Second, acceptance of a disruptive innovation typically is based upon low cost, convenience, and simplicity compared to alternative technologies. Two-thirds of all adults in the US currently have internet access [14], and high access levels exist throughout the developed world. It is likely that individuals who have internet access and prior experience using internet applications will view AHC as inexpensive, convenient, and simple to use. Indeed, surveys find most internet-connected healthcare consumers plan to adopt AHC as soon as their providers begin to offer this service [13].


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The healthcare marketplace presents few structural barriers to disruption by AHC. The primary technology that AHC will disrupt is at-distance communication via telephone. The telephone industry is extremely competitive, and vendors work constantly to improve their products through sustaining innovations, producing such innovations as wireless telephones with the ability to send and receive photo snapshots [15]. However, these innovations are unlikely to provide an incentive for patients to keep using the telephone for least-demanding interactions rather than switch to AHC. At present, AHC has been able to enter the very low end of the healthcare communication marketplace and begin to disrupt at-distance technologies (see Figure 2). The future technology trajectory of AHC will depend on the ways that basic AHC technologies are improved to meet the joint needs of providers and patients.

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AHC technologies

It is important to note that AHC is not a single technology. Instead, AHC encompasses an interrelated set of technologies that have been adopted and, in some cases, lightly adapted from the general computing marketplace. These include: * *

*

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hardware, typically a network-enabled computer software applications, initially in the form of electronic mail, web browsers, internet chat, and internet (Usenet) bulletin board applications that may be modified somewhat from those used by the general marketplace networks, primarily local area networks (LANs) that are connected to the internet protocols, relating to applications, such as MIME (multipurpose internet mail extensions), networks, such as TCP/IP (transmission control protocol/internet protocol), and security, including SSL (secure sockets layer) and SET (secure electronic transactions) protocols.

None of these technologies were designed with the intent of meeting healthcare requirements or creating disruptive innovation in the healthcare industry. Yet several of their features have proved to be essential in lowering costs, increasing convenience, and simplifying AHC. The first feature is the standardisation of application and network protocols that emerged in development of the internet. These protocols promote creation, delivery, and reception of e-mail and web-based messages among disparate computing platforms, making it possible for most types of information to be exchanged between providers and patients. The second feature is that most software client applications are widely available and may be obtained with little or no expense. Such client ubiquity makes it possible to access and send messages from virtually any internet-connected computer. The third feature is the development of simplified user interfaces in client applications. These typically require little start-up training and only minimal ongoing guidance for successful use, even by novices. Three other features help to overcome objections to AHC that have been made by

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providers and, to a lesser extent, patients. The first feature overcomes the problem of keeping communication secure. Encryption is a feature that is available for virtually all internet messaging and provides a solution to communication security and privacy concerns that frequently are raised regarding AHC (e.g. [16]). Encryption technologies can be very effective, as shown by online sales organisations that apply common communication security measures to handle billions of dollars of electronic transactions annually. In addition, two message-tracking features commonly found in e-mail applications can help overcome objections related to immediacy of message feedback and the ability to handle urgent messages in AHC applications. These features are notification, in which an individual is notified in some manner that a new message has arrived, and confirmation, in which a reply is returned to the sender confirming that the message has been opened. Both notification and confirmation capabilities have drawbacks in current e-mail applications. Notification does not occur when the receiving computer is turned off, and the confirmation process is not able to certify that it is the intended receiver who has opened a message or that the message was fully read and understood. However, the limited capabilities of confirmation and notification are proving sufficient for least-demanding provider±patient interactions, and there is potential to improve both capabilities to support up-market movement of AHC. The AHC applications that are now being used in healthcare offer basic capabilities to support patients in sending messages and completing some least-demanding interactions with the provider. AHC messaging typically provides e-mail-like functions supplemented with login authentication and network security features. An example of a basic AHC system is in use at Aurora Health Care, a large provider in the Midwest US (see Figure 3). The My Aurora web application uses authenticated login and secure message transmission. Patients use it to transmit unstructured, open-ended messages to a central receiving point at the healthcare clinic. They also indicate the method they prefer for replies, which currently is limited to being phoned back at home or work. The application has no confirmation or notification capabilities. Patients are instructed that the application is for nonurgent communication and are provided with basic parameters for estimating when they will be contacted. Separate web pages are used for other interactions, including requests for prescription refills, requests for office appointments, and links to e-Health information.

Strategic implications of asynchronous healthcare communication Figure 3

Basic AHC messaging with the My Aurora web application

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Strategic opportunities in AHC

Basic features adopted from the general computing marketplace have gained AHC a foothold in healthcare, but history of prior disruptive innovations in healthcare [2] suggests that feature enhancements can move AHC substantially up-market and this movement can provide substantial benefits for both providers and patients over prior technologies, primarily at-distance communication via telephone. To us this suggests two key implications. First, strategic opportunities currently exist in development of AHC. Second, as Christensen reports, `there is strong evidence that leadership in disruptive technology has been very important' to organisations' future successes ([1] p.124). In other words, it is time right now for healthcare organisations that want to benefit from disruptive innovations to begin designing and testing enhancements to basic AHC. In the remainder of this section, we propose several general areas in which enhancements can be made to overcome specific barriers to use or take advantage of capabilities that are unique to AHC. In the subsequent section we present a prototype AHC application that demonstrates how several of these enhancements might be implemented.

4.1 Increase attractiveness of AHC through design alternatives A key reason providers object to using e-mail for communication with patients is the time and effort they expect it will take to read and reply to unstructured, open-ended messages, as compared to telephone messages [8]. One way of overcoming these concerns is to charge patients for ònline consultations' [17]. However, most healthcare consumers indicate they are not willing to pay charges for this service [12]. We propose another route to overcoming providers' objections, one that focuses on developing design alternatives in AHC that transcend limitations of e-mail applications. The first alternative places restrictions on message input options as a method for guiding patients to produce better messages. The second gives providers reply templates that reduce the time it takes to respond effectively to common types of messages.

4.2 Guide patients by restricting input options This design limits patients' messaging options to a specific set of input fields that are designed to elicit information that is complete, concise, and relevant to the topic at hand. Users of general-purpose e-mail applications have historically rejected applications that are overly restrictive, one prominent example being the Coordinator e-mail system developed in the 1980s [18]. Consequently, the idea of restricting user input in e-mail has become anathematic [19]. In AHC, however, patients may view restricted input options as an acceptable trade-off for the benefits of asynchronous communication with providers. This is especially likely, first, if the input restrictions are relevant to the type of message that patients want to send and, second, if the restrictions are framed as guidance by the provider rather than simply a one-sided constraint of patients' volition [20].


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4.3 Develop provider reply templates AHC could increase costs associated with the time it takes providers to reply to messages. Unlike the telephone, AHC gives the provider the opportunity to completely describe treatments and include supplemental materials, including graphics and images, that patients can view at their leisure and store for subsequent review. Although time-consuming to produce, such messages would benefit patients and one solution would be to charge patients for this added value. We propose the alternative of supplying providers with preformatted message reply templates that are developed for common conditions that are encountered in the particular clinical specialisation. These templates should include options for customising replies and adding supplemental materials and links to appropriate e-Health content. Once the fixed costs of set-up are covered, use of organised templates would add little to the provider's variable costs of operations. Thus, message reply templates could increase patient satisfaction with AHC while decreasing or maintaining associated costs as compared to telephone messaging.

4.4 Support real-time message tracking E-mail applications provide services for notifying recipients that messages have arrived and confirming to senders that messages were received. However, there is no capability for tracking the real-time passage of a message through a provider organisation, for example, showing that it has been received by office staff and subsequently forwarded to the patient's primary-care physician. Thus, there is greater uncertainty for patients in sending e-mail to a provider than in making a telephone call where the status (or future status) of the message can be easily communicated. We suggest emulating shippers, such as UPS, who have deployed web-based package-tracking applications that reduce costs and increase customer satisfaction [21]. At any given time, these applications allow customers to find out approximately where the package is in its overall route. It is technically possible to track and monitor AHC messages with even greater ease than physical packages, and this capability could virtually eliminate uncertainty as a barrier to using AHC versus the telephone. Regardless of whether the communication is in-person, at-distance, or asynchronous, patients and providers both have concerns as to whether their messages have been received, understood, and acted upon. With in-person and at-distance communication, immediate feedback can be sought, but asynchronous communication generally has been treated as somewhat of a black box ± typically, it is only when a reply is returned that you know the message was received. Automated message tracking and monitoring functions could provide real-time feedback that has been missing from most asynchronous communication applications.

4.5 Integrate automated telephony into AHC Up to this point, we have discussed telephones and AHC as two distinct communication types, but there are good reasons to integrate automated telephony into AHC. Two of the drawbacks of computer-mediated communication applications, including AHC, are the inabilities to notify recipients of a message when they are not at the computer or other receiving device and to confirm that a

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message has been received and read by the intended recipient. These drawbacks can be overcome to a large extent by supplementing AHC with automated telephony, applying Voice XML or similar technologies that use computer-generated voice messages to make contacts and request responses. Applications of voice telephony are quite inexpensive to maintain, and although some are controversial, e.g. telemarketing, simple versions of this technology are used effectively in school attendance and community notification applications. Where patients have a pre-existing relationship with the provider, it should be possible to frame patient-selectable automated telephony services, including support for login and message retrieval via telephone, as an overall benefit of AHC.

4.6 Add annotation capability to messaging One aspect of pen-and-paper writing that is virtually missing from user interfaces for computer-mediated communication is the ability to easily annotate an existing document. Annotation by drawing circles around key points, noting questions, or clarifying content with a brief note in the margins provides an easy route to customise existing e-Health information and increase the range of expression that can be conveyed with AHC beyond what is possible with at-distance communication technologies, such as the telephone. We present annotation as an example of an obvious, but overlooked, user interface enhancement that would be particularly relevant to AHC. However, numerous other user interface capabilities might prove to be even more valuable, for example, incorporating easy-to-use web tools for patients to view three-dimensional medical imagery.

4.7 Summary of strategic opportunities We have presented several opportunities for enhancing basic AHC. We chose each area based on the potential of enhancements in the area to allow AHC technologies to handle more-demanding interactions and thereby move up-market. It is important to reiterate that the rationale for improving AHC is not based upon the desire to take `market share' away from in-person or at-distance communication. Christensen et al. emphasise this point in discussing solutions to the crisis in healthcare. They write, ``We believe that a whole host of disruptive innovations, small and large, could end the crisis ± but only if the entrenched powers get out of the way and let market forces play out. If the natural process of disruption is allowed to proceed, we'll be able to build a new system that's characterized by lower costs, higher quality, and greater convenience than could ever be achieved under the old system.'' [2, p.104]

Our view is that both patients and providers can benefit by efforts to improve AHC. In the next section, we describe a prototype system that demonstrates how some of our propositions might be implemented.


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G-Mail: a prototype AHC application

We are currently developing a prototype AHC application that implements guided messaging and message tracking features. The G-Mail application guides patients in producing messages that are concise, complete, and relevant. It also allows patients to monitor the status of messages and lets providers monitor the status of replies. G-Mail is designed for use by patients who have an existing relationship with the provider. The typical provider that uses G-Mail is anticipated to be a medical clinic with multiple practitioners and full-time office and support staff. Patients access G-Mail by using any internet-connected web browser to link to the clinic website. G-Mail implements guidance in two stages. The guided triage stage is part of the login ID and password authorisation process. In guided triage, patients self-select the category of message they want to send (see Figure 4). These message categories are used by the system to automatically route the messages to the appropriate provider personnel. For example, appointment requests could be routed to receptionist staff, prescription refills to clinic nursing staff, and follow-up questions to the primary-care physician. Although we anticipate that some message categories will be common to all providers, the list that is presented in the triage stage should be customisable to meet needs that are particular to individual providers, such as categories related to clinical specialisation. Figure 4

Login access to G-Mail application, implementing the triage stage of guidance

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The guided elicitation stage begins once the patient's access is authorised. The patient's web browser client subsequently receives a screen that elicits information relevant to the chosen message category. Figure 5 illustrates a screen that might be generated in response to the message category of Ask a question following my office visit. The patient is initially guided to designate which office visit the question relates to and select the topic of the question. A text area is provided for entering the question, and the patient is then guided to indicate the urgency of the question and how he/she wishes to be notified. Information that is known about the patient from his/her login account, such as patient's e-mail address and phone numbers, is automatically entered on this screen. Additional guidance is available from dialogs that verify the patient has completed all items prior to transmission and make suggestions in response to the patient's input, such as providing the provider's emergency contact number as an alternative when the user denotes that a question is urgent. Although the current G-Mail prototype does not use information that back-office healthcare systems might provide, such as billing and diagnosis records, it is desirable for these systems to be integrated into the guided elicitation component of G-Mail at some future date. Having guided access to their own records will reduce patients' uncertainty concerning their own medical histories and, as a consequence, this should help increase the clarity of their messages. Figure 5

G-Mail entry form, implementing the elicitation stage of guidance


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Provider personnel will routinely respond to incoming messages from patients, and these responses are monitored in real-time by G-Mail (see Figure 6). Once the patient has completed guided elicitation, the message is sent and routed to the appropriate provider personnel (step 1). Confirmation of message receipt is then sent to the patient's e-mail account (step 2). This confirmation message contains a link to a monitoring facility on the web server, which lets the patient check the status of the message (step 3). Once a reply has been prepared, patients are notified via e-mail (step 4) and follow a link to retrieve the reply from the web server (step 5). The web server also provides a facility for the provider to monitor replies (step 6), allowing alternative measures, such as a phone call from the provider, to be taken in case a reply is not retrieved within the appropriate time period. This is an area where automated telephony might add value to a future version of G-Mail. Figure 6

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Steps in transmission and monitoring of a typical G-Mail message

The role of guidance and monitoring

The guided triage and elicitation stages of G-Mail provide several benefits to participants over both at-distance communication and basic AHC. First, patients' messages are automatically routed to the personnel who are best equipped to handle them. These personnel benefit in turn by replacing contacts previously made by telephone and walk-in traffic with electronic messages, in which responses can be shifted across time and handled in a planned fashion rather than requiring an immediate reaction. Second, compared to the unstructured, open-ended messaging provided by basic AHC and telephone, guided elicitation will increase the accuracy

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and completeness of information that patients provide and will reduce the number of follow-up contacts provider personnel must make to obtain missing information. Finally, guided elicitation will alleviate provider's concerns that they will be òverwhelmed by long, numerous e-mail messages from their patients' [8]. The G-Mail prototype implements relatively simple guidance, primarily reminding patients to provide all the necessary information. However, it is technically possible to build extremely complex and sophisticated computer guidance systems if the need warrants this effort. One well-known healthcare example is the Mycin system for diagnosis and recommend treatment of certain blood infections, which was initially developed in the 1970s and has grown to incorporate hundreds of rules [22]. The fact that G-Mail is simple at present should not be taken to imply that healthcare guidance must be simple. Further, even simple forms of guidance have been shown to significantly improve performance in use of computer applications [20]. Monitoring provides several additional benefits. The monitoring facilities built into G-Mail overcome limitations in the way confirmation is implemented in general-purpose e-mail applications. In G-Mail, both patients and provider personnel can follow the real-time progress of a message or reply. This will increase the patient's trust that his/her message has not been lost or forgotten and is being handled in a timely manner. In addition, providers can be assured that patients have received their replies. We propose that the benefits offered by guidance and monitoring are substantial enough to overcome many patients' resistance to having their options restricted and many providers' resistance to using AHC. We anticipate that further benefits may be gained in a future version of G-Mail by incorporating other suggestions from the Strategic Opportunities section, such as message reply templates and automated telephony.

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Conclusion

Several issues remain regarding the future of AHC technologies that can only be answered by further research. First, research should examine whether there is real market demand for AHC, especially for more-demanding communication uses. Survey results indicate that consumers strongly desire AHC for least-demanding uses, such as requesting a prescription [13], but advanced features in healthcare systems sometimes go virtually unused [23]. This means that significant risks will be associated with choosing which features to implement in AHC and that a strategic business plan for disruptive innovation must allow for changes in the environment. It will be helpful in the short term to conduct ongoing descriptive research to identify successful features as they emerge in practice. In the long term it should be the goal of research to develop theories that can predict and explain feature fit and utility in AHC. Second, research should evaluate whether the quality of communication in AHC is sufficient to support the unique relationship between patients and providers. This is a troubling issue. In research outside healthcare, asynchronous online communication has been linked to reductions in message comprehension [24,25], affect toward the


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communication partner [26], and satisfaction with the communication process [27] compared with in-person communication. Thus, there is potential for AHC to be detrimental in individual cases even as enhanced features allow these technologies to handle more-demanding uses. It will be important for future research to identify best practices in AHC use that can be applied to mitigate these types of negative consequences. Finally, research should aim to improve the ability to forecast the long-term effects of AHC and other disruptive innovations in healthcare. Unlike sustaining innovations, disruptive innovations cannot be predicted effectively by standard management techniques. Christensen addresses this issue in the context of electric autos: `Ì can hire consultants, but the only thing I can know for sure is that their ®ndings will be wrong. Nor can customers tell me whether or how they might use electric vehicles, because they will discover how they might use the products at the same time as we discover it . . .. The only useful information about the market will be what I create through expeditions into the market, through testing and probing, trial and error.'' [3, p.210, italics in original]

This appraisal may not be reassuring to experienced healthcare managers, but it is the best advice currently available. Future researchers can assist in developing tools and streamlined methods for managers to apply in analysing real-time data and increasing immediacy of forecasting techniques. In our assessment, AHC is acting as a disruptive innovation in healthcare communication. The changes we anticipate from disruption will affect millions of patients and provider personnel and will present strategic implications to a wide range of healthcare organisations. For example, next-generation AHC could very well lead to what may be called `virtual' office visits, with much lower costs than the traditional office visit as we know it today. We believe that this disruption presents enormous opportunities to healthcare organisations who take the initiative to explore ways of improving AHC to overcome barriers and take advantage of the unique strengths of these technologies.

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