Reluctant and Selective Users of the Internet

Much examination has been done of the population segments who have taken to the Internet, but little is said about those who have not. Individuals that are reluctant to come online are dismissed as primitive luddites.

The author has identified three segments that have been very reluctant to get with the program, and will take a close look at each: healthcare, education, and "indispensable intermediaries."

Medicine and the Web

The healthcare industry is awash in various forms of information and a wide range of stakeholders: physicians, patients, researches, administrators, public health officials, government agencies, pharmaceutical companies, etc. So it would seem that a central medium for information exchange would be of great use to this industry.

By the turn of the century, it was largely believed that an internet-based transformation of the industry was desirable, imminent, and inevitable, even from sources within the industry (such as the New England Journal of Medicine). In spite of massive investment in technology by companies, government agencies, and professional organizations, little progress has been made.

The portal WebMD has received high levels of traffic (over 11 million unique visitors per month in 2006), the majority of individuals have used the Internet to seek medical information, and 97% of physicians use the Internet for clinical research and communication. And yet, the overall influence of communication technology on the profession has been very limited.

The short answer: physicians have been reluctant to adopted internet technology as a tool for interacting with, diagnosing, and monitoring patients. Some facts:

One explanation is lack of economic incentive: since fees are paid through a third-party system (insurance), physicians have no way of being compensated for internet-based activities. At the same time, they have concerns about privacy, liability, and patient safety and well-being.

Ironically, doctors have generally been quick to embrace technology, especially in the diagnosis and treatment of their patients. From the 19th century to the modern age, there has been constant technological progress, and physicians have adopted and adapted at a rapid pace.

A precedent is cited - telemedicine - which was an experiment in the later 1950's in which doctors used telephones and closed-circuit television to provide care to patients in remote areas. Simply stated, it never caught on. Even though grants covered the (considerable) cost of equipment and transmissions, physicians were extremely reluctant to embrace the practice, even in fields such as psychiatry, where physical proximity would seem to be irrelevant.

Going further back, to the late 1800's, the invention and spread of the telephone turned out to be a burden to doctors, who were suddenly more accessible to "anxious patients" whose demands became a burden. In the present age, it is not unusual for a physician to place intermediaries between himself and his patients - such that even via telephone, a patient must speak to a receptionist or answering service, who would pass the message along to the doctor, who would then decide if the matter requires immediate attention.

At the same time, physicians also expressed concerns about privacy (over party lines), felt they were not being reimbursed for services delivered via telephone, sensed that patients may be attempting to substitute phone consultations for physical examinations (hence diagnoses would be missed), could more easily misinterpret instructions given them, etc. The same concerns remain for electronic communications.

And so, there are a bevy of reasons that physicians are reluctant to make use of e-mail as a means of corresponding with patients.

Regarding the WWW, demand for medical information is high: 80% of users indicate they use the Internet to research health-related topics. Unfortunately, it's in the nature of the Internet that users expect information to be freely available - they are not willing to pay fees for subscription-based sites. As a result, many high-profile startups collapsed in the dot-com crash, and only one (WebMD) remains, generating modest revenue from advertising sales.

And in this sense, the Web has become yet another nuisance: the vast amount of outdated information, bad information, and commercial information about healthcare and related products have placed many physicians in the position of having to straighten out a misinformed or misled patient.

Meanwhile, the potential liability exposure to licensed practitioners for placing any instructional information online is high. If the information is outdated, or if it is misinterpreted and misused, the practitioner may be held liable - which may precipitate a malpractice suite and cause them to lose their license. There is simply no reward for taking such a risk.


The Internet itself was created in the academic and research communities as a means for sharing information and research, and universities have been aggressive in the use of technology as a means of storing and accessing information and communicating within their communities. In spite of this fact, Universities have largely rejected the use of the Internet for their core business: delivering an education to students.

Also, education is highly politicized: the "right" to an education is a political good, and the majority of universities are state-funded institutions, whose charters often expressly charge them with contributing to the knowledge and intellectual development of the public. It is even more ironic that the only online university to enjoy much success, the University of Phoenix, was created entirely as a commercial enterprise - it is not, and never was, associated with a physical university.

Professors have stated concerns with students becoming over-reliant on digital sources of information, the reliability of the technology itself to operate when needed, the social inequalities leading the medium to exclude low-income individuals from participating, and other such concerns. Much of this has been dismissed as pretension.

From a practical perspective, there are a lack of professional or financial incentives for professors to take on the additional workload of teaching internet courses to the general public. Publishing and teaching on the Internet does not "count" in academic circles - and much like the worst of their students, professors are reluctant to do any extra work unless they expect to receive extra credit.

Indispensable Intermediaries

The Internet has been a medium that has created a great deal of efficiency through disintermediation - cutting out the middleman to reduce costs to the consumer. Unfortunately, disintermediation is seen as a threat to the livelihood of the middlemen it would render useless.

In some instances, real-world intermediaries took action against the vendors who sought to do business directly with the customers. For example, you cannot purchase an automobile directly from a manufacturer - but must purchase from a local dealership - due to contractual obligations to franchises. Neither is it possible to purchase certain electronic goods online, because certain powerful retailers made it clear to manufacturers that they would consider this to be competition, and would no longer stock their merchandise in their retail stores.

In such instances, there are individuals who purposefully oppose progress, even at additional cost and inconvenience to the consumer, for the sake of their own livelihood - and when they have the legal right, contractual agreement, or channel power to do so, they often will.


A rehash of what's been said, underscoring the fact that when a certain type of business or industry segment seems reluctant to go online, there are often reasons for their doing so, other than a senseless resistance to change.