The Future of Health Care: Using the Internet to Deliver Health Interventions

Imagine you have trouble sleeping. Perhaps you can't fall asleep at night or you wake up in the middle of the night and you're unable to get back to sleep. Maybe this has been going on for a few months -- or maybe years.
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Imagine you have trouble sleeping. Perhaps you can't fall asleep at night or you wake up in the middle of the night and you're unable to get back to sleep. Maybe this has been going on for a few months -- or maybe years. It's exhausting, frustrating, and demoralizing. You find yourself making mistakes at work, having difficulty concentrating at school, or snapping at your kids, and you blame most of it on your sleepless nights. After a while, you realize you could use some help. You talk to a few friends, search online, and get some "advice": Drink warm milk. Take a bath. Count sheep. None of it helps.

Maybe you start taking over-the-counter sleeping pills -- maybe you take them a lot. If you're really desperate, you talk to your doctor, and get a prescription for real drugs. Relief! Dancing butterflies visit as you drift off to strange dreams of Abraham Lincoln and talking rodents. But then you realize even the pills aren't really helping much anymore. Or they are helping, but you're afraid you'll never be able to sleep without them.

You've now spent a lot on all of this -- cash on pills, time for doctor visits, maybe sick days just to "get some sleep" -- and you're still not satisfied. Now, for a large percentage of you, this isn't hard to imagine. It's happening to millions of us. In fact, roughly 75 million Americans (or about one-third of the adult population) have trouble sleeping, and approximately 23 million of us (10 percent) suffer from diagnosable chronic insomnia. This is not a small problem -- and the consequences, from both individual and public health perspectives, are huge.

If only there were a non-medicinal treatment for insomnia that works... Wait! There is one: cognitive-behavioral therapy (CBT). CBT is a treatment approach that focuses on the way a person's thoughts, feelings, and behaviors are connected. This is not, however, the same thing as saying your sleep problems are all in your head. CBT works to replace negative cognitions and behavior patterns with more adaptive and positive ways of thinking and acting. For treating insomnia, the focus is on the dysfunctional thoughts and maladaptive behaviors that perpetuate sleep problems, such as assuming catastrophic consequences from a poor night's sleep or using the bed for anything other than sleep or sex (yes, you can use it for that -- but no texting, typing or TV in bed).

CBT is such a good option for treating insomnia that it was deemed by the National Institutes of Health in 2005 as effective as medication in the short-term, but with the potential for longer-lasting benefits. Sounds dreamy, right? But there's a catch. At last count (2012), there were only 181 practitioners certified in behavioral sleep medicine in the United States -- that is, clinicians specially trained in providing CBT treatment for insomnia. This isn't to say there aren't other clinicians who can provide help, but it's easy to see how the chances of your obtaining this effective specialty care in, say, rural Indiana might be slim.

Believe it or not, the Internet may well hold the cure. Essential interventions for insomnia, as well as for all kinds of behavioral and mental health issues, are being created and evaluated, and are already populating websites near you. Internet interventions, as researchers and scientists in the field of eHealth call them, are not the innumerable "medical" websites pushing the latest vitamin remedy for whatever ails you. You won't be interacting with an avatar who nods in understanding as you type in specifics about growing up with your schizophrenogenic mother. Nor do they number among the countless sites with static patient education information that may, in fact, be more harmful than helpful to the innocent browser. This new breed of health sites is more than self-help books PDF'd and uploaded online (although you can find those, too).

The best Internet interventions are sophisticated, structured, tailored, behavior treatment programs that you can log onto and get the same kind of personalized expert care very few people around the country are currently able to receive. These systems employ all the advantages of the Internet -- graphics, animations, audio, video -- and custom-tailor your intervention based on algorithms created and empirically validated in randomized clinical trials. Many are fully automated, requiring no human support, dramatically reducing costs. Some are supported with minimal clinician contact (maybe a personalized email or phone call). It's obviously not face-to-face care, but it's been shown to be almost, if not as good as, face-to-face treatment for many kinds of problems. And, it's available to you, in the comfort of your own home, on your own time. You sign up. You work hard. You get help.

This is the future of health care. Available, inexpensive, customized, proven Internet interventions for many of the problems we have. Treatment we might never have been able to receive before. Treatment for issues we didn't even know had solutions.

But, while many of us would like to believe that the Internet can solve all our woes, it is not a panacea. There are legal issues, including privacy protection and security of personal information; liability concerns, such as those related to misuse or misunderstanding of program content; problems of access, including the ongoing debate of the "digital divide" and the need for further broadband adoption; and issues of intervention utilization, including user adherence and treatment completion. Good Internet interventions can take years to develop and can be complex and costly pieces of software. They are not for everyone or for all problems, but they undoubtedly have the potential to help countless people.

So if Internet interventions sound good, get ready. Researchers around the U.S. and throughout the world have been working on online programs for over a decade. Such programs have already been developed for depression, anxiety, panic, phobias, obesity, alcohol/nicotine addiction, diabetes, asthma, pain, and encopresis (a soiling disorder -- yeah, even that).[1] The National Institutes of Health have already put millions of dollars into it.[2] Some of the most respected science and medical journals in the world, such as the Journal of the American Medical Association, New England Journal of Medicine, and Archives of General Psychiatry are now publishing studies that show that these programs work and that people are getting better.

There are now highly respected journals devoted to this type of work. For example, check out the open access online journal, Journal of Medical Internet Research. It's now considered the top medical informatics journal in the world. Sift through an issue, and you'll see the groundbreaking work being done in this area. Businesses are starting to crop up, making these programs available to employers, insurance companies, and yes, even individuals. But we are at the dawn of this phenomenon.

There has been a call for change, and experts are being urged to use technology to make health care more accessible and affordable. Internet interventions can do just that. eHealth research is our present -- and the resulting programs are our future. Stay tuned. Log on. Get better.

For more by Dr. Lee Ritterband, click here.

For more by Dr. Frances Thorndike, click here.

For more on sleep, click here.

For more healthy living health news, click here.


[1] Marks IM, Cavanagh K, Gega L. Hands-on help: computer-aided psychotherapy. Hove, England, and New York: Psychology; 2007.

[2] Ritterband LM, Andersson G, Christensen HM, Carlbring P, Cuijpers P. Directions for the International Society for Research on Internet Interventions (ISRII). J Med Internet Res 2006;8(3):e23.

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