Economic Evaluation of an Investment in Medical Websites and Medical Web-Based Services

Question 1: Have you ever used medical websites to seek medical advice?

Regarding the first question of the survey’s questionnaire, Table 39 presents the cross-tabulated results/responses of the participants, providing information if the patients have ever used any online site with medical content to seek medical advice, check their symptoms, read articles about specific healthcare issues or even seek support from forum and online communities supported by these websites.

Examining the participant’s responses it is observed that a bit more than 55% of the total participants answered that they have used at least once a medical website to seek medical guidance. Moreover the percentage of the female participants who answered that have seek medical advice through online roots was almost double than the same percentage of male participants, suggesting that women are more eager to follow that route and maybe show more trust in medical websites than men participants.

Regarding the level of education the results do not present any major difference between the various educational levels. The responses seem to follow the same line with little more than the half of the participants in each level to report that they have used online sites and/or services in order to seek medical advice. Exception is the participants without any educational qualification who all of them answered that they have used online routes to seek medical guidance. However, their total number is small since they were only 4 participants without any educational qualification and thus it is not possible to support valid, strong and general concluding remarks and suggestions about this group.

Moreover, regarding the country/continent of origin of the participants, the participants from Asia and Americas were reported to have used medical websites in greater percentage than the rest of the participants. Observing the results of the countries with the most participants, it is observed that the results are mixed with slightly more participant responding “Yes” to that question with Germany, Greece and Italy to have greater percentage of “NO” responses rather than “Yes” ones (Figure 35).

Furthermore, regarding the occupation and level of income of the respondents it is observed that full time employees, part tie employs and retired participants have answered “Yes” implying that they are more eager to use medical websites to seek medical advice than the students, the self-employed and the unemployed participants. It was the students to have use the online route to seek medical advice due to the widespread use of Internet and devices that are automatically connected to any available network as well as the anonymity that the Internet offers to the students. In contract the responses were almost evenly distributed between the “yes” and “no” choices with a bit more response in the later. This can be explained taking into account that university students are in a post-adolescence stage where they have more freedom and they are not so afraid or embarrassed to discuss about their health. They care about their health and they make more thoughtful attempts to seek medical advice than adolescents something that can make them not to trust widespread and mainstream medical websites. Self-employed might not have the time to spent on the Internet and prefer face to face consultation that might save them more time in the long run and also might have trust issues also while long-term unemployed might not be able to afford services that are not offered for free on the World Wide Web or even not be able to afford even the required hardware to access the online medical websites.

What is noteworthy is the observation that as the level of the annual income rises the percentage of the participants who responded to have used medical websites to seek medical advices rises as well, although most of the medical website offer access to advice and basic online services for free. This indicates a positive correlation between the level of the annual income and the use of medical websites.


The NHS Direct provides a range of other services to complement NHS 111. Ore specific provides a digital health and advice service, including web and mobile based ‘Health and Symptom Checkers’ which include the ability for patients to speak to an advisor. These services are accessed through NHS Choices. Moreover provides also a complex health and medicines information service as well as a dental nurse assessment service. In addition to these offers also the Choose and Book appointments service for patients newly referred to hospital consultant out-patient clinics to choose and book their clinic appointments (From the NHS Direct website, accessed on 20/5/2013).

The WebMD offers current news and articles related to healthcare issues by creating and maintaining up-to-date medical reference content databases, online communities, hosting of live web events concerning the healthcare, user interaction for experience sharing and a variety of interactive tools and medical applications (http://www.webmd.com/about-webmd-policies/, accessed on 20/5/2013). WebMD has accredited by URAC as health website. URAC is a non-for-profit organization, which main aim is to promote healthcare quality through its accreditation, education and measurement programs (https://www.urac.org/about/, accessed on 20/5/2013). Moreover WebMD has a Trust-e and a Hon-code certification making it one of the top medical websites.

The BootsWebMD it is a cooperation between Boots and WebMD website that provides the users/patients with UK specific, GP reviewed, credible health information covering health issues for the general public in England, Scotland, Wales and Northern Ireland (http://webmd.boots.com/about-webmd-policies/, accessed on 25/5/2013). Boots is a member of Alliance Boots which is an international pharmacy-led health and beauty group (http://boots-uk.com, accessed on 25/5/2013).

The Patient.co.uk is the UK’s leading independent health site, established for over 15 years and it is a trusted source of information for both patients and health professionals nationwide. The website’s content consists of more than 4000 health information leaflets, a wellbeing centre, a free health check and a very active through blogs and forums online community. It is accredited by The Information Standard, the Department of Health’s quality mark and was listed as ‘The top health website you can’t live without’ by The Times newspaper (Jan 2013). Finally it is certifies by the British Medical Association (BMA) and holds also a Hon-code certification making it one of the top medical websites worldwide.

The NetDoctor.co.uk website is a collaboration between doctors, healthcare professionals, information specialists and patients. More than 250 leading doctors and health professionals write, edit and update the contents of NetDoctor.co.uk database. These same health professionals respond to users questions and concerns through an “Ask a doctor online” application (http://www.netdoctor.co.uk/whoisnd.htm, accessed on 25/5/2013).

Mayo Clinic is a non-profit worldwide leader in medical care, offering updated material on healthcare conditions, interactive tools/applications and online communities. (http:// mayoclinic.com/, accessed on 25/5/2013).

Finally in the follow-up sub-question to Question 1 that was asking the respondent to name the medical website that they had used lately, the top answers included NHS websites (NHS Direct, NHS Choice, NHS live-well), WebMD and Boots WebMD (http://www.webmd.com/ and http://www.webmd.
boots.com), Patients.co.uk, NetDoctor.co.uk and Mayo Clinic website (http://www.mayoclinic.com/). These websites appeared also in the top lists of the previous analysis contacted regarding the factors of success or failure of the medical websites

Question 2: Have you ever subscribed or used a medical web application?

During the analysis of the factors that have an impact on the survivability and success of the medical websites, many types of different medical web-based services offered to the public for free or with a monetary cost had been identified. The most popularly offered were:

• 
  The “Ask a Doctor” online application/service which is offering to the users an online platform with interactive chat options to conduct a medical expert in order to seek advice. The users usually not only can describe their symptoms in a text form but also to attach photos, videos or other kind of files that consider that can help doctor to provide them with an accurate first diagnose to the healthcare issues they might suffering from.
  
• 
  The “Find a Doctor Nearby” medical online application that using the geo-coordinates of the users’ location to enable them locate doctors, medical practices or even pharmacists in close proximity to their location.
  
• 
  The “Symptom checker” and “Drug Identifier” online applications that in the first case can provide an automatic diagnose taking into consideration the symptoms that the user puts as inputs into their algorithm. I the case of the “Drug Identifier” applications the user is able to identify any pill by providing details about their shape, colour or inscribed writing on it. Moreover the users can also search for the potential side effects and/or the recommended maximum dosage they can take of known medicines.
  
• 
  Finally, the “Disease Diaries”, “Weight Watchers”, “Body Mass Impact (BMI) Calculators” enable the users/patients to keep online records of their symptoms, their drug intakes, their glucose, weight and blood pressure or BMI index.
  

From the participants that answered that they have never subscribed or used services/applications like these 67% of them responded that they would be willing to use them after they prompted to take into consideration:

• 
  the time you save by using them from not needing to wait in consultancy rooms, 
  
• 
  the time and the cost to go to the GP, 
  
• 
  the better results that you may obtain comparing this to the traditional telephone communication with the doctor 
  
• 
  the anonymity that the Internet offers 
  
• 
  the ability to have many alternative diagnosis with just a click
  

This provides a first impression of how strong are the Aforementioned“benefits” of these medical online applications for the participants.

Question regarding the Willingness to Pay (Intention) of the participants

Question regarding Willingness to Pay of the participants

Would you be willing to pay in order to use these services in case they were not offered free and after taking into consideration?

• 
  the time you save by using them from not needing to wait in consultancy rooms, 
  
• 
  the time and the cost to go to the GP, 
  
• 
  the better results that you may obtain comparing this to the traditional telephone communication with the doctor 
  
• 
  the anonymity that the Internet offers 
  
• 
  and the ability to have many alternative diagnosis with just a click?
  

Through this questions participants were prompted to answer if they would be willing to pay in order to use these medical online applications.
Most of the participants (74.7%), who had used a medical website and had subscribed or were willing to subscribe to a medical web application, responded that they are willing to pay if these services were not offered for free and after taking into consideration:

• 
  the time you save by using them from not needing to wait in consultancy rooms, 
  
• 
  the time and the cost to go to the GP, 
  
• 
  the better results that you may obtain comparing this to the traditional telephone communication with the doctor 
  
• 
  the anonymity that the Internet offers 
  
• 
  the ability to have many alternative diagnosis with just a click
  

Impressive is the percentage of the male participant who were willing pay that touched 86% of positive respond while the female participants’ responses were presenting a smaller difference between the positive and negative responses with 57.1% of them answering “Yes”. Moreover the analysis of the responses has shown that the level of education affects this decision of the participants since the participants who had used a medical website and had subscribed or were willing to subscribe to a medical web application but they hadn’t any educational qualification or their qualification was less than a high school degree were totally negative and unwilling to pay. On the other hand for the other educational qualification holders (High school Degree, Undergraduate Degree and Postgraduate Degree) the results were almost equal with an average percentage of more than 74% to be willing to pay.

Regarding the level of annual income and the WTP of the participants towards medical web-based services we observed that the participants that had experience of using or were willing to use medical websites and web applications and they were belonging in the £15,000-£25,000 were more willing to pay in a percentage that is touching 83.3%. What is interesting is that although in the other levels of annual income (<£15,000, £25,000-£35,000 and £35,000-£45,000) the results are similar with more than 75% responded a positive WTP in the highest level (£50,000+) the participants seem more conservative with only slightly more than the half of them (52.4%) to express a positive WTP towards the medical web-based services.

Moreover, the self-employed and retired participants express also a strong positive WTP towards the medical web-based services with percentages that are touching 100% and 85.7% respectively. Furthermore, Figure 36 presents a graphic representation of the responses in this question by the most countries of origin of the participants. As it is observed in most of these case the percentage of the participants is well above 70% of the participants from these countries of origin who had experience of using or were willing to use medical websites and web applications.


Figure : Responses of the countries with the more participants in Question regarding their WTP

Finally, as far as it concerns the rest of the participants, who reported that they are not willing to pay any monetary units in order get medical advice and use medical specific services from medical websites, provided as main reasons their belief that these services should be offered for free by the national healthcare organization/ministry (NHS is case of UK) or be covered by their public/private health insurance contract. Trust issues are also stated from almost 48% of the participants as reason that makes them unwilling to pay to use such services and prefer face to face contact with their personal doctor.

Question regarding the Maximum Willingness to Pay (Monetised Intention) of the participants

This question is the core question of the survey, aiming to investigate the maximum amount of monetary units expressed in £ that the participants are willing to pay for using the aforementioned medical web-based services. This WTP of the participants, expressed in easily comparable monetary units, towards the medical web-based services will the “benefit” value in the following Cost-Benefit analysis. This value is considered as “benefit” because the participants respond after taking in to account the³:

• 
  the time you save by using them from not needing to wait in consultancy rooms, 
  
• 
  the time and the cost to go to the GP, 
  
• 
  the better results that you may obtain comparing this to the traditional telephone communication with the doctor 
  
• 
  the anonymity that the Internet offers 
  

the ability to have many alternative diagnosis with just a click

This question was offered in a combination of (closed form) discrete-choice and open-end form of question since the participants was asked to choose one of a set of predefined monetary values but also there was also an option if they want to state another value. More specific, the participants were asked to choose from a range of prices (£1, £5, £10, £15and £20) which one presents better their own preference with the actual amount to be between their choice and the next bigger bid (Ryan M. et al., 1997; Mitchell et al. 1981). They were also given the opportunity to add their own specific maximum amount of money that they will be willing to pay.

By using this structure of the question, it was possible to overcome the difficulty of the participants to answer open-ended questions regarding their willingness to pay and also eliminate the bound bias of discrete-choice form (Frew et al., 2004, Ryan et al., 2004).

This question was offered in a combination of (closed form) discrete-choice and open-end form of question since the participants was asked to choose one of a set of predefined monetary values but also there was also an option if they want to state another value. More specific, the participants were asked to choose from a range of prices (£1, £5, £10, £15and £20) which one presents better their own preference with the actual amount to be between their choice and the next bigger bid (Ryan M. et al., 1997; Mitchell et al. 1981). They were also given the opportunity to add their own specific maximum amount of money that they will be willing to pay.

By using this structure of the question, it was possible to overcome the difficulty of the participants to answer open-ended questions regarding their willingness to pay and also eliminate the bound bias of discrete-choice form (Frew et al., 2004, Ryan et al., 2004).

Table 4 presents comprehensively the responses of the participants in its distinctive answer option cross-tabulated with the gender, the age, the educational level, the occupation and the level of the annual income of the participants. Even at the first glance, it is obvious that the greater percentage of the participants, no matter their age, gender, occupation, level of education and annual income, it is concentrated around two monetary options the £5 and £10. The higher bound of this selection (£10) is a more preferable option for the participants that belong in the 35-55 age range, self-employed and having a level of annual income either among £25,000-£35,000 or greater than £50,000.

Examining more thoroughly the responses of the participants in this core-question of the survey the results showed that 74.7% of the respondent who had used a medical website and had subscribed or were willing to subscribe to a medical web application, produced an average WTP value expressed in monetary units of £6.44. Moreover, a second weighted average price, following the Ryan et al. (1997) suggestion that the amount of money that presents better their real maximum Willingness to Pay is between their choice and the next bigger bid, was calculated to be used as a less conservative and more optimistic estimation of the value/ “benefit” of the medical web-based services . This price was found equal to £9.

A follow-up question regarding the level of certainty of the respondents that they would pay in real life the stated amount of money for the medical web-based services were used in order to avoid the avoid the hypothetical bias and to mirror better the real behaviour of the participants/users by distinguishing this way the “true yes” answers (Johannesson et al., 1998; Bluumeschein, 1998). Most of the respondents (66.3%) responded a high level certainty (Sure/Very Sure responses). Finally, as Table 40 presents, as the price boundary options is increased the percentage of the participants that are sure that they would pay this amount of monetary units in real life increases as well, showing that the participant were aware of the significance and all the real-world implications of their decision.

Table : Level of Certainty of the respondents

	Actual number	Percentage	Not sure	Sure	Very Sure
Other	18	8.50%	47.61%	28.50%	23.80%
£1	41	16.60%	43.90%	34.10%	21.90%
£5	104	42.20%	30.80%	52.00%	17.20%
£10	57	23.40%	29.80%	41.90%	21.10%
£15	7	2.80%	28.50%	57.10%	17.20%
£20	15	6.10%	13.33%	60.00%	26.67%

Table : Cross-tabulated responses to the Maximum WTP Question

	£0		£1		£5		£10		£15		£20		£30		Other
Gender	Number	Percentage	Number	Percentage	Number	Percentage	Number	Percentage	Number	Percentage	Number	Percentage	Number	Percentage	Number	Percentage
Female	3	2.70%	22	19.10%	45	39.10%	15	13.00%	3	2.70%	6	5.20%	1	0.90%	4	3.40%
Male	7	5.10%	21	15.30%	61	44.50%	29	21.20%	4	3.00%	9	6.50%	0	0.00%	5	3.60%
Age	Number	Percentage	Number	Percentage	Number	Percentage	Number	Percentage	Number	Percentage	Number	Percentage	Number	Percentage	Number	Percentage
18-25	3	4.20%	16	22.50%	34	48.00%	13	18.30%	2	2.80%	3	4.20%	0	0.00%	0	0.00%
25-35	2	1.70%	21	18.20%	52	45.20%	28	24.30%	3	2.60%	7	6.10%	0	0.00%	5	4.30%
35-45	3	8.50%	7	20.00%	10	28.60%	11	31.40%	0	0.00%	2	5.70%	0	0.00%	0	0.00%
45-55	1	7.70%	0	0.00%	4	30.80%	5	38.50%	0	0.00%	0	0.00%	1	7.70%	1	7.70%
55-65	0	0.00%	0	0.00%	5	41.70%	2	16.70%	1	8.30%	2	16.70%	0	0.00%	2	16.70%
65+	1	33.30%	0	0.00%	0	0.00%	1	33.30%	0	0.00%	1	33.30%	0	0.00%	0	0.00%
Education	Number	Percentage	Number	Percentage	Number	Percentage	Number	Percentage	Number	Percentage	Number	Percentage	Number	Percentage	Number	Percentage
High school	0	0.00%	1	5.60%	9	50.00%	4	22.20%	0	0.00%	0	0.00%	0	0.00%	2	11.10%
Less than High school	0	0.00%	0	0.00%	1	100.00%	0	0.00%	0	0.00%	0	0.00%	0	0.00%	0	0.00%
No Qualification	0	0.00%	0	0.00%	0	0.00%	0	0.00%	0	0.00%	0	0.00%	0	0.00%	0	0.00%
Postgraduate	7	4.90%	27	19.00%	56	39.40%	27	19.00%	6	4.20%	11	7.70%	1	0.70%	7	5.00%
Undergraduate	3	3.20%	14	15.30%	40	43.90%	29	31.80%	1	1.00%	4	4.30%	0	0.00%	0	0.00%
Occupation	Number	Percentage	Number	Percentage	Number	Percentage	Number	Percentage	Number	Percentage	Number	Percentage	Number	Percentage	Number	Percentage
student	3	2.10%	32	22.70%	67	47.50%	26	18.40%	3	2.10%	8	5.70%	0	0.00%	2	14.10%
full-time employee	6	9.20%	8	12.30%	21	32.30%	19	29.20%	4	6.20%	3	4.60%	0	0.00%	4	6.20%
part-time employee	0	0.00%	3	21.40%	6	42.90%	4	28.60%	0	0.00%	0	0.00%	0	0.00%	1	7.10%
self-employed	0	0.00%	0	0.00%	3	27.20%	6	54.50%	0	0.00%	1	9.00%	0	0.00%	0	0.00%
unemployed	0	0.00%	1	7.10%	7	50.00%	3	21.40%	0	0.00%	2	14.28%	0	0.00%	1	7.10%
retired	1	14.30%	0	0.00%	2	28.60%	2	28.60%	0	0.00%	1	14.30%	1	14.30%	0	0.00%
Income-Max WTP	Number	Percentage	Number	Percentage	Number	Percentage	Number	Percentage	Number	Percentage	Number	Percentage	Number	Percentage	Number	Percentage
<15000	3	2.00%	31	20.80%	63	42.20%	29	19.40%	3	2.00%	10	6.70%	0	0.00%	4	2.70%
15000-25000	1	2.80%	7	19.40%	16	44.40%	8	22.20%	1	2.80%	1	2.80%	1	2.80%	1	2.80%
25000-35000	1	3.30%	2	6.70%	12	40.00%	14	46.70%	0	0.00%	1	3.30%	0	0.00%	0	0.00%
35000-45000	2	9.10%	1	4.50%	9	40.10%	5	23.80%	1	4.50%	2	9.10%	0	0.00%	2	9.10%
50000 plus	3	20.00%	3	20.00%	1	6.70%	4	26.70%	1	6.70%	1	6.70%	0	0.00%	2	13.30%

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