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      Knowledge-for-data trade at the interface between precision medicine and person-centered care

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      Croatian Medical Journal
      Croatian Medical Schools

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          Abstract

          The interaction between the individual citizen and the health care system is a key element of the person-centered care. The two sides, the citizens and the system, the users and the provider, have a common interest in achieving health, but are in conflict over the control issues. In this article, I suggest that the equilibrium between the individuals and the health care system could be achieved through the exchange of patient’s personal data for the knowledge on how to be treated. This exchange has already been present occasionally, but has provided only additional benefits for the patients. With the onset of digital technologies and the introduction of the precision medicine, it could be a mode satisfying both sides. Such a trade presents high risks for the individual citizens, although promising them the benefits of up-to-date medical care through precision medicine. The challenge of person-centered care Person-centered care is a health care concept in which individuals control their health. Consequently, citizens should be in the position to individually choose, monitor, and influence any activity related to their health and the health of their communities. It stands in contrast to medical paternalism, where medical professionals decide on medical interventions needed (1). Person-centered care is a result of two mutually dependent processes. The first is the increasing recognition of human rights and respect of individual autonomy and privacy. This is codified by the Universal Declaration of Human Rights and the Declaration of Helsinki, and further developed through the principles of bioethics and medical ethics. In short, every individual should have the right to decide about his or her own body and mind, in particular in relation to health issues (2). The second process is the technological advancement of medicine. The extensive and complex medical records contain many different types of data (text, numbers, graphs, or images) for almost every individual. At the same time, different medical specialties produce separate sets of medical records, all of which are legally owned by the patient, who has the right and duty to take care of them. The two processes already exist, but person-centered care still needs to be justified and discussed (3). The reason for this is an extremely complex health care system. To imagine a user-centered system is easy, just let us look at the libraries. One can enter the library, register, and choose the book according to his or her own preferences. Librarians are there to provide support and advice. If the book is boring or inadequate, it can be easily replaced. The interested individual could also move to another library offering different book collections. The most obvious difference between libraries and the health care system is that a wrong therapy could be detrimental to the person and is connected with legal liabilities. Next, choosing the right medical procedure is knowledge- and technology-intensive process. This includes coordinated education of all medical professionals; planning, acquiring, and maintaining the necessary infrastructure; plus managing the system to provide care efficiently and openly to all in need. In addition, the health care system is very costly, and it represents an important part of the societal economic activities. A complex billing system is installed to charge individuals, insurers, public bodies, and taxpayers for the costs of the health service. Health economy accounts for more than 10% of gross domestic product of the most developed nations, predicted to increase in the near future to as much as 20%. In conclusion, although the person-based care assumes that individuals should control their own body, mind, and health, the health care system's complexity, financial value, and societal importance are so high that the system remains in charge. The conflict between users and providers is tamed by the notions that their common goal is health and that the current health care system is organized around and for the patients. There is no doubt that citizens and health care system are partners in the process. Still, recognizing the conflict and dealing with it is essential for person-centered care implementation. To understand and solve this conflict we need to get insight into the distinctive perspectives of the two parties, and pinpoint the differences between them. The health care system perspective The health care system perspective is oriented to get the system efficiently running, providing high-quality care for “reasonable” cost. The efficiency of the health care system depends on a complex list of demands, including the availability of care, new technologies, multiparty workflows, dynamic legal requirements, and reliable cost accounting (4). To meet some of these demands, digital technologies such as eHealth are increasingly used (5). eHealth provides managing solutions by advanced analytics of the integrated data. I believe that this description “providing managing solutions by advanced analytics of the integrated data” could characterize the core business of the digitally enhanced health care system. Integrated eHealth medical records help physicians to more easily access accumulated patients’ data and make these data available for the “advanced analytics,” which can provide reference values and process or even interpret data. On the basis of integrated and analyzed individual data, the informed medical teams are expected to provide exact individualized treatments, the notion represented in the concept of the precision medicine (6). The precision medicine enables the patients to get precisely the exact medical treatments they need, representing a key technology of eHealth. Together with providing individualized solutions to the patients, the digital technologies are also crucial for the system itself. This includes managing the workflow by eAppointments, providing drugs through eRecepies, and keeping eRecords of the procedures. eHealth makes health care more efficient and less costly than it used to be. eHealth functioning is data-dependent. To live up to its societal expectations, digitalized health care system is thirsty for data. Still, the data do not belong to the system but to the patients (7). This dependency on a large quantity of data owned outside the system creates a very weak spot from the health care perspective. Therefore, the health care system perspective in the context of person-centered care is characterized by a lack of the very foundation of its functioning – the patients’ data. The individual citizen’s perspective The individual citizen’s perspective is rather different. There is no subset of citizens who are primarily patients. All individuals are concerned about health, be it their own health, their loved ones' health, or local and global community's health. This in particular includes healthy people, including “top performers,” as their continuous and successful activities depend on their health status (8). The individual perspective in a search for health is opposite to the search for data. The individual citizens need the knowledge on how to interpret their personal data, combat the illness, and reach health. In contrast to health care system, which is thirsty for data, the persons seeking health are thirsty for knowledge. The exchange of knowledge for data comes natural. This exchange is not a new feature of digital society or a peculiarity of person-centered medicine. The same exchange occurred in the system based on medical paternalism. The patient would present their symptoms and get the knowledge on how to be cured. The data had little value (the anonymity needed to be preserved indeed), and the knowledge was a key asset of the physicians, giving them the dominant role. Although the exchange of knowledge-for-data occurred during medical intervention, this did not have the wide implications present today, when enormous quantities of personal medical data are generated on a continuous basis. The interaction of health, knowledge, and data By the onset of the digital society, the value of health, knowledge, and data had increased immensely. The recently created Navigating Knowledge Landscapes Network has acknowledged the importance of knowledge in the digital society (9). Describing the individual search for health as navigation through the knowledge landscapes, they have recognized and highlighted the key target of the search – knowledge. The individual quest for health represents a search for health-related knowledge (10). This search for knowledge extends greatly in the digital society. The health advice is not asked for only in the physician’s practice, or by talking to the family, relatives, or friends. The search for knowledge in the digital environment includes browsing through web pages, digital repositories, and social networks. Knowledge is global and always available. Digital environment empowers the patient by providing at least partial independence from the health care system and offering alternative knowledge resources. This improves the position of individuals as health care users, but it also exposes them to previously unknown risks (11). The digital society also improves the health care system, which is positioned at the intersection of health, knowledge, and data, all three being the candidates for the key currencies of the digital economy. Being healthy represents the ultimate wealth, as it cannot be acquired through instant shopping and as it requires a long-term careful investment strategy. The knowledge represents a key resource of innovations for the current knowledge-based economy, while the data are the basis of the new system of “dataism,” giving more power to data ownership than to capital ownership, hence replacing “capitalism” (12). The described exchange of knowledge for data gets a new dimension in the current digital setting. The available technologies enable combining of information obtained by genetic and other -omics technologies with body sensors, adding the real-time monitoring aspect to data collection (13). This is augmented by increasing data processing power and emergence of artificial intelligence expected to interpret the collected data (14). The purpose of data processing would be not only to precisely cure the individual, but to prevent illness and maintain the health of every citizen. Having every (or at least many) citizens involved would provide the desired benefit through big data analysis (15). Hence, many citizens would be willing to tick the box “I accept,” if the core of the promise was health. This makes the knowledge-for-data trade so important and likely to be the base of the future health care. As the data value would inevitably rise, the knowledge-for-data trade can evolve as a key site where societal forces can “buy” or “steal” personal data. Citizens might be instructed to voluntarily give up all their personal data to be included into “big data” analysis improving the health of community, nation, or society. Giving up personal data to the benefit of society could be considered as a rather positive notion (16). Therefore, the knowledge-for-data trade in the health arena could be a key element for the overall loss of individual private data ownership. The depreciation of data ownership and appreciation of the knowledge provided (in particular through precision medicine) could provide the key entry site for private data to be imported to the system. This would not only be a demise of person-centered care, but a creation of new “digital paternalism” (eg, advanced analytics of integrated data would indicate “precisely” what this individual should be – history teacher, policeman in a particular suburb, or cab driver…). The insight in the personal data could provide the decision power to the governing bodies, which if concentrated in the hands of the few, could undermine democracies and lead to digital dictatorships. On the other hand, keeping individuals aware of their personal data value and protecting the individual data ownership legally (eg, through General Data Protection Regulation recently introduced in the European Union) would empower individuals (17). Subsequently, the knowledge-for-data trade could favor the individual citizens. In this way, the knowledge-for-data trade could be a major asset in establishing the person-centered care, centered around data owners. Appreciating the value of private data could be a major tool to protect individual rights and allow for the survival of democracy in the digital society. In conclusion, the knowledge-for-data trade represents a critical feature of the interaction between individual citizens and health care system. This trade is crucial for the establishment of both precision medicine and person-centered care. The result of the trade could lead in two opposite directions: loss of private data ownership, medical paternalism, and digital dictatorships or empowering the private data ownership, person-centered care, and digital democracies.

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          The effectiveness of research implementation strategies for promoting evidence-informed policy and management decisions in healthcare: a systematic review

          Background It is widely acknowledged that health policy and management decisions rarely reflect research evidence. Therefore, it is important to determine how to improve evidence-informed decision-making. The primary aim of this systematic review was to evaluate the effectiveness of research implementation strategies for promoting evidence-informed policy and management decisions in healthcare. The secondary aim of the review was to describe factors perceived to be associated with effective strategies and the inter-relationship between these factors. Methods An electronic search was developed to identify studies published between January 01, 2000, and February 02, 2016. This was supplemented by checking the reference list of included articles, systematic reviews, and hand-searching publication lists from prominent authors. Two reviewers independently screened studies for inclusion, assessed methodological quality, and extracted data. Results After duplicate removal, the search strategy identified 3830 titles. Following title and abstract screening, 96 full-text articles were reviewed, of which 19 studies (21 articles) met all inclusion criteria. Three studies were included in the narrative synthesis, finding policy briefs including expert opinion might affect intended actions, and intentions persisting to actions for public health policy in developing nations. Workshops, ongoing technical assistance, and distribution of instructional digital materials may improve knowledge and skills around evidence-informed decision-making in US public health departments. Tailored, targeted messages were more effective in increasing public health policies and programs in Canadian public health departments compared to messages and a knowledge broker. Sixteen studies (18 articles) were included in the thematic synthesis, leading to a conceptualisation of inter-relating factors perceived to be associated with effective research implementation strategies. A unidirectional, hierarchal flow was described from (1) establishing an imperative for practice change, (2) building trust between implementation stakeholders and (3) developing a shared vision, to (4) actioning change mechanisms. This was underpinned by the (5) employment of effective communication strategies and (6) provision of resources to support change. Conclusions Evidence is developing to support the use of research implementation strategies for promoting evidence-informed policy and management decisions in healthcare. The design of future implementation strategies should be based on the inter-relating factors perceived to be associated with effective strategies. Trial registration This systematic review was registered with Prospero (record number: 42016032947). Electronic supplementary material The online version of this article (10.1186/s13012-017-0662-0) contains supplementary material, which is available to authorized users.
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            Enhancing Reuse of Data and Biological Material in Medical Research: From FAIR to FAIR-Health

            The known challenge of underutilization of data and biological material from biorepositories as potential resources for medical research has been the focus of discussion for over a decade. Recently developed guidelines for improved data availability and reusability—entitled FAIR Principles (Findability, Accessibility, Interoperability, and Reusability)—are likely to address only parts of the problem. In this article, we argue that biological material and data should be viewed as a unified resource. This approach would facilitate access to complete provenance information, which is a prerequisite for reproducibility and meaningful integration of the data. A unified view also allows for optimization of long-term storage strategies, as demonstrated in the case of biobanks. We propose an extension of the FAIR Principles to include the following additional components: (1) quality aspects related to research reproducibility and meaningful reuse of the data, (2) incentives to stimulate effective enrichment of data sets and biological material collections and its reuse on all levels, and (3) privacy-respecting approaches for working with the human material and data. These FAIR-Health principles should then be applied to both the biological material and data. We also propose the development of common guidelines for cloud architectures, due to the unprecedented growth of volume and breadth of medical data generation, as well as the associated need to process the data efficiently.
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              Concepts and definitions of health and health-related values in the knowledge landscapes of the digital society

              The knowledge landscapes ( http://knowledge-landscapes.hiim.hr/ ) represent multidimensional environments, which individuals encounter when searching for knowledge, particularly, knowledge related to health (1,2). In digital society, knowledge is well distributed virtually and online. A substantial fraction of knowledge landscapes is also located in the digital environment. Both health and knowledge need to be understood today as a part of the digital society. It is important to estimate the impact that digital society has on knowledge landscapes and on health. This is especially relevant in relation to the 90th anniversary of Zagreb Andrija Štampar School of Public Health and the work of its founder, Andrija Štampar, with ongoing ambition of the School to be on the leading edge of public health understanding in the present society (3). Hence, this article deals with the concepts of health in relation to the present digital environment. How knowledge relevant to health and well-being is distributed in the digital society, and how the search for this knowledge, ie, navigating knowledge landscapes, influences everyday life and health needs to be clarified. We present different definitions of health and health-related values. The usual approach to explaining health definitions would be to give a historical and chronological overview showing the development of the ideas over time to better understand the current position. In contrast to this, in the online environment, the overload of information and limitless opportunities of content presentation result in co-existence of different views. We claim that, today, we need a historical overview to identify and understand this multiplicity of views and standpoints co-existing in the digital environment. This co-existence being the product of digital society could be referred to as “digital anachronism”. Historical overview of attitudes and considerations about health – from concepts of balance to ideas about health as economic category The concept of health as a balance between a person and the environment, the unity of soul and body, and the natural origin of disease, was the backbone of the perception of health in ancient Greece. Similar concepts existed in ancient Indian and Chinese medicine (4,5). In the 5th century BC, Pindar defined health as “harmonious functioning of the organs”, emphasizing the physical dimension of health, the physical body and the overall functionality, accompanied by the feeling of comfort and absence of pain. Even today, his definition bears importance as a prerequisite for the overall health and wellness. Plato (429-347 BC) in his “Dialogues” pointed out that a perfect human society could be achieved by harmonizing the interests of the individual and the community, and that the ideal of ancient Greek philosophy “a healthy mind in a healthy body” could be achieved if people established internal harmony and harmony with the physical and the social environment. According to Aristotle’s teaching, man is a social being by his very nature; he tends to live in communities with the duty to respect the moral standards and ethical rules. Aristotle emphasized the necessity for regulating the relations in the society to achieve harmonious functioning and preservation of health of its members. Democritus connected health with behavior, wandering why people prayed to God for health, which was essentially under their own control. Hippocrates explained health in connection with the environmental factors and lifestyle. Hippocrates was the creator of the concept of “positive health”, which depended on the primary human constitution (we consider it today as genetics), diet, and exercise. He thought that proper diet and exercise were essential for health, and that seasons’ changes had a profound effect on the mind and body, resulting in different types of predominant diseases during the winter (respiratory tract diseases) and summer (digestive tract diseases) (4,5). A lot might be said about the long standing philosophical discussion about body and soul, and in present society between body and mind, as an active dichotomy (Plato and Hellenism) or as an integrated unity (usually reference to Aristotle), which is important to know about in the current online environment. In the Middle Ages, health perception was strongly influenced by religion and the church. After Roman Empire fell apart, the church was left as an only important infrastructure providing care for the people and collecting the knowledge on remedies, eg, herbs grown in monastery gardens (6). The “forgotten” knowledge of antiquity was re-discovered during the Renaissance and re-framed up to the present. During the period of Industrial Revolution, health became an economic category, which was to allow good condition and working ability and reduce lost work days due to illness. Accordingly, the value of health was such as enabling economic profit. The health was intertwined with Darwinian understandings of strength and being the fittest, where meaning of life was tied to physical survival. Another health aspect considered the ability of the individual to adapt to the influences from the environment to the extent that the individual could tolerate and resist. When the adjustment is over, the disease occurs as a natural consequence. This approach first reflected only biological mechanisms of adaptation, later adding on influences from the environment, which needed to be governed and modified (4,5). Modern concepts of health – from individual to societal risks and back to the individual All modern concepts of health recognize health as more than the absence of disease, implying a maximum capacity of the individual for self-realization and self-fulfillment. This should equilibrate the human inner forces and possibilities with the feeling of pleasure or dissatisfaction in their relations with the environment (7). Social medicine and public health approach to health advocate that we should not only observe the health of the individuals, but also the health of the groups and the community, as a result of the interaction of the individuals with the social environment. The holistic concept of health is contained in the expression of wholeness. Health is a relative state in which one is able to function well physically, mentally, socially, and spiritually to express the full range of one’s unique potentialities within the environment in which one lives. Both health and illness are dynamic processes and each person is located on a graduated scale or continuous spectrum (continuum) ranging from wellness and optimal functioning in every aspect of one’s life, at one end, to illness culminating in death, at the other (3,8). The theory of salutogenesis takes a different view of what creates health and what factors support health, as opposed to the conventional approach of pathogenesis to study the factors that cause disease (9). To find the “origins of health”, one needs to search for factors that support the human health and welfare (10). Definitions of health by the World Health Organization To establish social welfare and to facilitate, encourage, and secure individual autonomy and dignity are key challenges in the present time and society. The modern understanding of health became official when the World Health Organization (WHO), at the time of its establishment in 1948, included the definition of health in its Constitution. The definition was proposed by Dr Andrija Štampar, a prominent scholar from Croatia in the field of social medicine and public health and one of the founders of the WHO. This generally accepted definition states that “health is a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity” (11). This definition promoted for the first time that, in addition to physical and mental health, social welfare is an integral component of the overall health, because health is closely linked to the social environment and living and working conditions. Respecting this definition as a global concept, many researchers and theorists subsequently advocated for adoption of working, practical, and operational definitions of health. In 1977, with the adoption of the WHO Global Strategy “Health for All by the Year 2000”, a pragmatic concept of health – the ability to conduct a socially and economically productive life – was accepted indirectly, which was an essential goal of this Strategy (12). To define health in operational and working terms was vital for creating policies and programs for maintaining and improving health, and it considerably managed to exceed the widely rooted notion that health simply means the absence of disease. The Ottawa Charter from the 1st International Conference on Health Promotion, held in Ottawa, Canada, in 1986, says that health is created in the context of everyday life and environment, where people live, love, work, and play. Thus, active and interactive understanding of health was introduced. The goal of health promotion is to combine the approach for addressing the social determinants with the resolution and commitment to motivate and encourage the individuals and the community for their active approach toward health and embracing healthy lifestyles (13-16). Within the last few decades, the WHO definition of health has been increasingly amended and supplemented by the fourth dimension – spiritual health. Generally speaking, spiritual health involves a sense of fulfillment and satisfaction with our own lives, system of values, self-confidence and self-esteem, self-awareness and presence, peacefulness and tranquility with dynamic emotional balance, both internal and toward the environment, morality and truthfulness, selflessness, positive emotions, compassion and willingness to help and support others, responsibility and contribution to the common good, and successful management of everyday life problems and demands as well as social stress (17). How the health is perceived in the current digital environment – a lay person’s perspective The digital society, where information technology has led to fundamental societal shifts, is a carrier of particular characteristics. It got new organizing principles (relations and arenas) for public institutions and private agents, and it has also altered the relation between public and private (18). In digital society, information technology has become something more than a tool for communication, storage, and sharing of information. Therefore, it should not be reduced to another story we add to the former stories of society. Instead, the society has altered as such, and it needs to be described on its own terms. To act as a citizen in a digital society presupposes having particular skills on how to get hold on knowledge and how to access, interpret, and use it in the online environment. In the digital society, knowledge is organized in dynamic tentative online infrastructures and made available to users through different search tools and engines and their operative algorithms. This means that digital society frames, alters, and produces knowledge in a complex way, and the individuals today need skills to read these continuously changing landscapes critically and navigate them safely (1,2,19,20). We have conceptualized this multidimensional, technology-enabled environment, open to individual access, as the knowledge landscapes (1). As a citizen, the individual needs to know how to navigate these knowledge landscapes to gain health-related information and be able to decide on strategies and services for one’s own life and the lives of others one cares for. The wide array of producers contribute to the contents to be found online, which enables them to express their own thoughts and visions, in particular in regard to health. An important question is whether societally prescribed values and theoretical positions are also reflected in lay people’s empirical understandings and perceptions of health. Health professionals and politicians also need to know what people themselves perceive as the most important issues regarding health, in particular what health is, and which factors in people’s lives constitute health. This knowledge is needed to meet individuals in various health care settings and to deal with health issues across the digital realm. Research on individual perceptions regarding health and illness has been accumulating for some time, and it is becoming apparent that they have significant consequences on the person’s health behavior (21). It is found that gender and age influence people’s perceptions of health as much as their background and environmental factors. Overall, lay people’s perspective on health and illness should not be viewed as constructs on opposite ends of a single continuum, but rather as two distinct but overlapping constructs (22). Experiences of health are more intangible and elusive than experiences of illness, making the former much more challenging to study (23). Health could be taken for granted and not brought to the persons attention before it’s challenged in situations characterized mainly by the actual or threat of change, disease, or loss. Zahra et al (24) studied lay people’s perceptions of health and factors affecting health across 29 countries. People belonging to different backgrounds had different perceptions regarding determinants of health. The highest percentage of people agreed that environment was the determinant of health, which was consistent with the scientific view of increased burden of diseases caused by environmental factors. Fugelli & Ingstad (25,26) conducted a multi-sited ethnographic study to explore lay people’s perceptions of health in different contexts, environments, and sites. They interviewed people in their own homes, in five different locations in Norway, in rural areas, small and big cities, people from different socioeconomic and cultural background, living on the coast, inland, in fishing-, agriculture- and industrial communities. They identified six essential elements in people’s conceptualization of health in their actual situations: well-being, function, nature, a sense of humor, coping, and having energy. The lay perspective on health appears to be characterized by three qualities: wholeness, pragmatism, and individualism. Wholeness is related to health as a holistic phenomenon. Health is an aspect interwoven with all other aspects of life, everyday life, working life, family life, and community life. Health is viewed a resource and a total, personal, situation-specific phenomenon. Absence of disease is not enough – the life situation as a whole must be taken into consideration. Family functioning and children’s welfare is an important part of experiencing health as wholeness. To be able to live according to one’s personal values is also an important issue. Pragmatism reflects the health as a relative phenomenon. Health is experienced and evaluated according to what people find reasonable to expect, given their age, medical conditions, and social situation. In this way, health is not necessarily freedom from disease or loss of functional abilities. Other positive values in life can compensate for different types of losses. Most people are realistic in their life-expectations. Finally, individualism relates to health as a highly personal phenomenon. The perception of health depends on who you are as a person. To be part of a society and to feel close to some other persons seems to be important to all. Furthermore, values are individual and, as every human being is unique, strategies for improving health must be individualized. Health definitions at the intersection of technology, medicine, and individuals in the digital society The digital society allows different perspectives to co-exist and dynamically evolve in the different forms of online environment. Subsequently, the different views on health are present online in the same time, competing for attention of the visitors, users, and creators of the digital content. Some of these ideas, although seemingly new and appealing, frequently represent refurbished historical concepts. Moreover, every public health-related intervention should consider its online context. To be able to identify and recognize the individual understanding of health is important, in particular when this conception of health contradicts recommendations for diseases that need medical intervention. The plurality of health definitions reflects the variety of contexts in which health is elaborated. A concept ‘home context’ is the context in which the concept originates. It makes sense predominantly inside but not necessarily outside its home context. Conceptualizing is a verbal act that sets out to identify and shape phenomena’s border and content. The conceptualization localizes and attributes identity, content, or meaning. The definitions of health obviously reflect socially and culturally constructed and tentative categories. The relation between an individual and society is implied in most concepts of health. In particular, in the digital environment, critical analysis of health concepts helps us to understand better health policies and politics and their consequences. As they frequently represent societal powers rather than phenomenological differences, they are accordingly accepted, criticized, or even rejected. Today’s society is a complex, high-cost, high-tech society where citizens constantly need to learn and update their knowledge and skills to be able to manage their own lives. As digital society is built on software that is constantly renewed or replaced by new software, navigation has become a new ‘skill of hunting and gathering’. To appreciate concepts and conceptualizations, knowledge has become a key quality in digital society. The health concepts – particularly concepts we use to explain, treat, heal or cope with disease – are words we also use as search tools. A feature of digital society is that past and present categories and understandings are available at the same time, undermining the traditional western schooling system, where accumulation of past knowledge is understood and acknowledged as predecessor to present, updated knowledge. We refer to this syncreticity, co-existence of different views without hierarchy and without precedence, as “digital anachronism”. Subsequently, public information and public interventions in regard to health should consider this variety of approaches online and thus themselves be explicit and also argue for why and how a particular approach to health is chosen. The definitions of health presented here are also understood as navigation-tools to be applied within online environment. Being aware of them can help the navigator to understand and interpret the information, texts, or documents that occur in online encounters of the health related issues.
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                Author and article information

                Journal
                Croat Med J
                Croat. Med. J
                CMJ
                Croatian Medical Journal
                Croatian Medical Schools
                0353-9504
                1332-8166
                June 2018
                : 59
                : 3
                : 132-135
                Affiliations
                [1]Croatian Institute for Brain Research, University of Zagreb School of Medicine, Zagreb, Croatia
 srecko.gajovic@ 123456hiim.hr
                Article
                CroatMedJ_59_0132
                10.3325/cmj.2018.59.132
                6045896
                29972736
                3f8632ff-b0d9-4dd5-a32a-ec097bf8dd3b
                Copyright © 2018 by the Croatian Medical Journal. All rights reserved.

                This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

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