case study in internet

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• 07 Nov 2023
• Cold Call Podcast

How Should Meta Be Governed for the Good of Society?

Julie Owono is executive director of Internet Sans Frontières and a member of the Oversight Board, an outside entity with the authority to make binding decisions on tricky moderation questions for Meta’s companies, including Facebook and Instagram. Harvard Business School visiting professor Jesse Shapiro and Owono break down how the Board governs Meta’s social and political power to ensure that it’s used responsibly, and discuss the Board’s impact, as an alternative to government regulation, in the case, “Independent Governance of Meta’s Social Spaces: The Oversight Board.”

• 29 Aug 2023

As Social Networks Get More Competitive, Which Ones Will Survive?

In early 2023, TikTok reached close to 1 billion users globally, placing it fourth behind the leading social networks: Facebook, YouTube, and Instagram. Meanwhile, competition in the market for videos had intensified. Can all four networks continue to attract audiences and creators? Felix Oberholzer-Gee discusses competition and imitation among social networks in his case “Hey, Insta & YouTube, Are You Watching TikTok?”

• 15 Aug 2023

(Virtual) Reality Check: How Long Before We Live in the 'Metaverse'?

Generative AI has captured the collective imagination for the moment, eclipsing the once-hyped metaverse. However, it's not the end of virtual reality. A case study by Andy Wu and David Yoffie lays out the key challenges immersive 3D technology must overcome to be truly transformative.

• 15 Nov 2022

Why TikTok Is Beating YouTube for Eyeball Time (It’s Not Just the Dance Videos)

Quirky amateur video clips might draw people to TikTok, but its algorithm keeps them watching. John Deighton and Leora Kornfeld explore the factors that helped propel TikTok ahead of established social platforms, and where it might go next.

• 22 Aug 2022
• Research & Ideas

Can Amazon Remake Health Care?

Amazon has disrupted everything from grocery shopping to cloud computing, but can it transform health care with its One Medical acquisition? Amitabh Chandra discusses company's track record in health care and the challenges it might face.

• 06 Jan 2021
• Working Paper Summaries

Aggregate Advertising Expenditure in the US Economy: What's Up? Is It Real?

We analyze total United States advertising spending from 1960 to 2018. In nominal terms, the elasticity of annual advertising outlays with respect to gross domestic product appears to have increased substantially beginning in the late 1990s, roughly coinciding with the dramatic growth of internet-based advertising.

• 21 Jan 2020

The Impact of the General Data Protection Regulation on Internet Interconnection

While many countries consider implementing their own versions of privacy and data protection regulations, there are concerns about whether such regulations may negatively impact the growth of the internet and reduce technology firms’ incentives in operating and innovating. Results of this study suggest limited effects of such regulations on the internet layer.

• 18 Jul 2019
• Lessons from the Classroom

The Internet of Things Needs a Business Model. Here It Is

Companies have struggled to find the right opportunities for selling the Internet of Things. Rajiv Lal says that’s all about to change. Open for comment; 0 Comments.

• 04 Mar 2019
• What Do You Think?

What’s the Antidote to Surveillance Capitalism?

SUMMING UP: As companies increasingly build business models around our personal data, what can be done to fight back? James Heskett's readers suggest there are no easy answers. Open for comment; 0 Comments.

• 30 May 2018

Should Retailers Match Their Own Prices Online and in Stores?

For multichannel retailers, pricing strategy can be difficult to execute and confusing to shoppers. Research by Elie Ofek and colleagues offers alternative approaches to getting the price right. Open for comment; 0 Comments.

• 24 May 2018

Distance Still Matters in Business, Despite the Internet

The internet makes distance less a problem for conducting business, but geography still matters in the digital age. Shane Greenstein explains why. Open for comment; 0 Comments.

• 12 Mar 2018

Using Online Prices for Measuring Real Consumption Across Countries

The increasing availability of big data can improve measurement of real consumption in closer to real time. This study shows that online prices may enhance data of the International Comparisons Program, dramatically improving the frequency and transparency of purchasing power parities compared with traditional data collection methods.

• 02 Mar 2018

Evidence of Decreasing Internet Entropy: The Lack of Redundancy in DNS Resolution by Major Websites and Services

Stabilizing the domain name resolution (DNS) infrastructure is critical to the operation of the internet. Single points of failure become more consequential as a larger proportion of the internet's biggest sites are managed by a small number of externally hosted DNS providers. Providers could encourage diversification by requiring domain owners to select a secondary DNS provider.

• 16 Nov 2016

Turning One Thousand Customers into One Million

In the second part of a series on growing startups, Thales S. Teixeira explains how Uber, Etsy, and Airbnb climbed from one thousand customers to one million. Open for comment; 0 Comments.

• 19 Oct 2016

Three Critical Mistakes Digital Businesses Make With Content

Do companies really understand the nature of today's digital transformation? Bharat Anand's book The Content Trap offers a new view of digital strategy that shifts the focus from "produce the best content" to "create the best connections." Open for comment; 0 Comments.

• 14 Sep 2016

Web Surfers Have a Schedule and Stick to It

Note to web marketers: Consumers won't carve out more time to visit your site. So how do you attract them? Start by understanding their online habits, reports new research by Shane Greenstein and colleagues. Open for comment; 0 Comments.

• 17 Aug 2016

The Empirical Economics of Online Attention

This study uses extensive data on user online activity between 2008 and 2013 to examine the links between user allocation of attention and characteristics of user. Findings show remarkable stability in how households allocated their scarce attention over the five years. Results imply that suppliers are competing for a finite supply of user time while generally lacking the ability to use price discounts to attract user attention.

• 15 Aug 2016

Black Swans and Big Trends Can Ruin Anyone's Internet Prediction

Coming off the dot-com bust, Thomas R. Eisenmann was confident enough in his internet vision that he wrote a book about what would happen next. For the most part, he was wrong. He offers lessons learned for navigating the boom-bust cycle. Open for comment; 0 Comments.

• 04 May 2016

What Does Boaty McBoatface Tell Us About Brand Control on the Internet?

SUMMING UP. Boaty McBoatface may have been shot down as the social-media sourced name of a research vessel, but James Heskett's readers are up to their hip-boots in opinions on the matter. Open for comment; 0 Comments.

• 07 Mar 2016

Net Neutrality: A Fast Lane to Understanding the Trade-offs

Shane Greenstein and colleagues identify the economic dimensions involved with net neutrality and show that many questions can be informed by simple economic models of the market for internet services.

Website Builders.com

5 Interesting Internet Case Studies You’d Want To Read Today

While statistics and data are considered important when learning, they aren’t paid enough attention to. Educating each other on real-life case studies in relation to the internet is a milestone in understanding the true impact of the world wide web on our recent generations.

During this era of connectedness, new shapes and forms of awareness made it possible for the unheard to be heard, the unconnected to be connected and for great ideas to take material form in a digital sense.

It is most definitely worth sparing 10 minutes of your time to read a case study you find interesting – increasing your overall awareness of the internet’s impact will gradually ease your learning ability.

Some of our case studies and analyses include:

• A Foreign Affair
• Ecommerce Pioneer: Hot Hot Hot
• Internet Activism
• The Wired Classroom – How The Internet Is Transforming Classrooms
• Website Flipping: What Is It And Can Anyone Do It? The 2023 Guide

Have a read – feel free to send us any suggestions for future case studies at [email protected] .

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Internet of things

• Technology and analytics
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The Sectors Where the Internet of Things Really Matters

• Simona Jankowski
• October 22, 2014

How to Address the Supply-Chain Staffing Crisis

• Joe McKendrick
• September 18, 2023

The Internet of Things Will Change Your Company, Not Just Your Products

• October 24, 2014

Heartbleed, the Branding of a Bug, and the Internet of Things

• Scott Berinato
• April 14, 2014

6 Ways AI Could Disrupt Your Business

• David Edelman
• Vivek Sharma
• January 25, 2024

Is Your Company Squandering Digital Opportunities?

• Mohan Subramaniam
• August 08, 2022

Lessons on Customer Engagement from Fan Controlled Football

• Sascha L. Schmidt
• Sebastian Flegr
• March 09, 2023

How Tech Is Transforming Entry-Level, Customer-Facing Jobs

• Emily Potosky
• Melissa Fletcher
• Christopher Sladdin
• May 01, 2023

Alexa, Should My Company Invest in Voice Technology?

• Navid Bahmani
• Amit Bhatnagar
• Dinesh Gauri
• September 08, 2022

Leveraging New Tech to Boost Supply Chain Resilience

• Suketu Gandhi
• October 26, 2022

The Cognitive Usefulness of the Internet of Things

• H James Wilson
• November 17, 2014

How the Internet of Things Can Prepare Cities for Natural Disasters

• Kris Tremaine
• Kyle Tuberson
• December 01, 2017

5 Ways Product Design Needs to Evolve for the Internet of Things

• Paul Daugherty
• Paul R Daugherty
• Prith Banerjee
• Allan Alter
• November 14, 2014

8 Best Practices for Creating a Compelling Customer Experience

• G M Tomas Hult
• March 14, 2023

How Biometrics Are Transforming the Customer Experience

• Therese Stowell
• March 29, 2023

How People Are Actually Using the Internet of Things

• Brian Whipple
• October 28, 2015

The Internet of Things Is Changing How We Manage Customer Relationships

• Ric Merrifield
• June 05, 2015

The Internet of Things Is More than Just a Bunch of Refrigerators

• October 14, 2014

The Internet of Things Changes the Company-Customer Relationship

• Paul Weichselbaum
• June 29, 2015

Should You Start a Generative AI Company?

• Julian De Freitas
• June 19, 2023

The Year in Tech, 2023: The Insights You Need from Harvard Business Review

• Harvard Business Review
• Beena Ammanath
• Michael Luca
• Bhaskar Ghosh
• October 25, 2022

The Year in Tech, 2025: The Insights You Need from Harvard Business Review

• October 08, 2024

Schindler Elevator Corporation

• Elliott N. Weiss
• Rebecca Goldberg
• March 25, 2018

Fusion Strategy: How Real-Time Data and AI Will Power the Industrial Future

• Vijay Govindarajan
• N Venkat Venkatraman
• March 12, 2024

HBR Insights Web3, Crypto, and Blockchain Collection (3 Books)

• December 05, 2023

Veniam: Pioneering the Internet of Moving Things

• Claudia Costa
• Nuno Camacho
• Goncalo Amorim
• December 31, 2021

Welcome to AI: A Human Guide to Artificial Intelligence

• David L. Shrier
• March 05, 2024

The Internet of Things

• Dimitrios Spiliopoulos
• May 25, 2021

Radius Synergies International Pvt. Ltd: Prepaid Smart Metering in India

• Susmi Routray
• Reema Khurana
• Bharat Bhushan
• March 19, 2023

GE and the Industrial Internet

• Karim R. Lakhani
• Marco Iansiti
• Kerry Herman
• April 16, 2014

The Internet of Things (IoT): Shaping the Future of e-Commerce

• Benjamin Yen
• September 01, 2015

ProGlove Smart Gloves: Let's Save Four Million Dollars A Day!

• Kwan Eng Wee
• Sin Mei Cheah
• April 18, 2022
• Timothy M. Laseter
• Anne Frazer
• Benjamin Boatright
• July 13, 2023

XCMG: DIGITAL BUSINESS TRANSFORMATION OF A MANUFACTURING GIANT

• Mark J. Greeven
• Yunfei Feng
• January 13, 2020

Samsung: The Internet of Things

• Paul Okundaye
• Nicole R.D. Haggerty
• September 13, 2019

IBM: Watson and the Internet of Things

• Scott Johnson
• March 06, 2018

ShotSpotter: AI and the Future of Law Enforcement Technology

• Tom Davenport
• G. Shankaranarayanan
• Donna Stoddard
• July 21, 2022

Cash vs. Accruals: The Case of Revenue Recognition at Cantaloupe Systems

• Robert Siegel
• June 23, 2021

ARM Holdings: IP Licensing to Internet of Things

• Howard Thomas
• Lipika Bhattacharya
• July 18, 2019

The Year in Tech, 2024: The Insights You Need from Harvard Business Review

• David De Cremer
• Richard Florida
• Ethan Mollick
• Nita A. Farahany
• October 24, 2023

The Internet of Things and New Business Opportunities

• Vlad Krotov
• November 01, 2017

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Internet and Democracy

The Internet and Democracy Project is an initiative that will examine how the Internet influences democratic norms and modes, including its impact on civil society, citizen media, government transparency, and the rule of law, with a focus on the Middle East. Through a grant of $1.5 million from the US Department of State’s Middle East Partnership Initiative, the Berkman Center will undertake the study over the next two years in collaboration with its extended community and institutional partners.  As with all its projects, the Berkman Center retains complete independence in its research and other efforts under this grant. 

The goal of this work is to support the rights of citizens to access, develop and share independent sources of information, to advocate responsibly, to strengthen online networks, and to debate ideas freely with both civil society and government. These subjects will be examined through a series of case studies in which new technologies and online resources have influenced democracy and civic engagement.  The project will include original research and the identification and development of innovative web-based tools that support the goals of the project.  The team, led by Project Director Bruce Etling, will draw on communities from around the world, with a focus on the Middle East. Follow the research or join in the conversation through a number of different project tools, including our blog, and RSS feed.

OPML Library Resources

The Internet & Democracy Project maintains an ongoing database of notable tools that we encounter in our research.

Internet & Democracy Tools Database

A collection of cutting edge tech tools that support activists and community organizing. These tools were identified at the Tech Tools External Research Meeting for the Internet and Democracy Project.

Internet & Democracy H2O Playlist (Tech Tools External Research Meeting)

A collection of resources to aid in promoting dialogue around issues in democracy. This includes theoretical texts as well as media and internet and democracy readings.

Internet & Democracy H20 Playlist (Theoretical Democracy Sources)

A collection of resources that consider the Internet and democracy, including case studies.

Internet & Democracy H20 Playlist (Internet and Democracy Sources)

This project is sponsored in part by the U.S. Department of State. 

Our Work 52

Political change in the digital age: the fragility and promise of online organizing.

In this paper, we discuss the possible impact of digital technologies in authoritarian and semi-authoritarian regimes.

A Tale of Two Blogospheres

Discursive Practices on the Left and the Right

The Berkman Center is pleased to announce the release of a new paper exploring U.S. political blogs. This paper compares the practices of discursive production and participation…

The OpenNet Initiative reports on Internet filtering in Sub-Saharan Africa

ONI has released new research on Sub-Saharan Africa, including reports on Uganda and Nigeria, where ONI tested for the first time in 2008 and 2009...

OpenNet Initiative releases 2009 Middle East & North Africa research

The Berkman Center is pleased to share an announcement from the ONI: the partnership has released new studies of Internet filtering in the Middle East and North Africa. Government…

Online Discourse in the Arab World: Dispelling the Myths

at the United States Institute of Peace

The Internet & Democracy presents the Berkman Center's new research on the Arabic blogosphere, which analyzes over 10,000 blogs from 18 countries and which follows last year's …

Keeping an Eye on Iran's Post-Election Protests

Berkman Center people and projects have been paying close attention to the role of the Internet and cell phones in the post-election protests in Iran.

Berkman Center Internet & Democracy Project Releases Study Mapping the Arabic Language Blogosphere

The Berkman Center for Internet & Society’s Internet & Democracy project has released a major study on “Mapping the Arabic Blogosphere: Politics, Culture and Dissent.” Utilizing a…

Internet & Democracy project releases study of the Arabic blogosphere

It is with great pleasure that the Berkman Center announces a major research release from the Internet & Democracy project: “Mapping the Arabic Blogosphere: Politics, Culture and…

Mapping the Arabic Blogosphere: Politics, Culture and Dissent

This case study is part of a series produced by the Internet and Democracy project. It analyzes the composition of the Arabic blogosphere and its possible impact on political and…

Mapping the Persian and Arabic blogospheres

The Berkman Center is pleased to announce updated and forthcoming, new research from the Internet & Democracy project on blogging in Iran and on Arabic language blogs,…

Herdict Chinese is live

(updated June 2)

Herdict Web -- Berkman's tool for tracking global web (in)accessibility -- is now available in Mandarin! And, as of June 2, Herdict is seeing a surge in reporting from China...

The Chinese Internet and Civil Society

Civic Engagement, Deliberation and Culture

The 7th Chinese Internet Research Conference starts today, at the Annenberg School for Communication of the University of Pennsylvania, and a raft of Berkman researchers and…

Herdict Web gets bigger and smarter...

Herdict Web -- Berkman's tool for tracking global web (in)accessibility -- has now been in the wild for six weeks! and what wild and woolly weeks they have been (YouTube blocked…

Conjuring Conficker and GhostNet

malware in the news

Stories about the Conficker worm have been spreading, worm-like, through both online and offline media, while the Citizen Lab at the University of Toronto has documented an…

New case studies from the Internet & Democracy project

The Berkman Center is pleased to announce that the Internet & Democracy project, in association with the Research Center for Information Law at the University of St. Gallen in…

Three Case Studies from Switzerland: Smartvote, Electronic Voting, and Political Communication

With the globalization of Internet use, the deployment of technology to improve democracy has rapidly gained worldwide attention. These case studies are organized around three…

Report release: 2007 Circumvention Landscape Report: Methods, Uses, and Tools

The Berkman Center is pleased to make available its report on techniques and tools for circumventing Internet filtering...

The Internet and Democracy: Lessons Learnt and Future Directions

This event, organized in collaboration with the OII and the Reuters Institute for the Study of Journalism brought together leading researchers to assess the current state of…

2007 Circumvention Landscape Report: Methods, Uses, and Tools

A large variety of different projects have developed tools that can be used to circumvent Internet filtering, allowing people in filtered countries access to otherwise filtered…

The More Things Change, the More They Stay the Same: Online Audiences and the Paradox of Web Traffic

Dr. Matthew Hindman, Assistant Professor of Political Science at Arizona State University

Many areas of Internet scholarship make strong--and often erroneous--assumptions about patterns of Web traffic. Still, there has been little comprehensive research on how online…

Herdict Web

the verdict of the herd

The Berkman Center is pleased to announce the official launch of Herdict Web -- a tool that employs the distributed power of the Internet community to provide insight into what…

Mapping Change in the Iranian Blogosphere

The Internet & Democracy project has begun analyzing developments over the last year in the Iranian blogosphere and has a pair of intriguing hypotheses to explain changes to its…

The Blogging Revolution: Going online in repressive regimes

Antony Loewenstein

In 2007, Australian journalist, author and blogger Antony Loewenstein traveled to Egypt, Iran, Syria, Saudi Arabia, Cuba and China to investigate how the net was challenging…

US presidential campaign & election '08

We've assembled a sampling of recent Internet and politics-related activities and writings from the Berkman community...

Global Network Initiative launches

Berkman is pleased to announce the launch of the Global Network Initiative, a dynamic effort developed in partnership with leading human rights groups, academics, socially…

Political videos online, the spread

From the Internet & Democracy project blog... John Kelly and...Morningside Analytics have created a great new political video barometer at Shifting the Debate. Using link and…

Voter deception 2.0

With less than two weeks remaining before the US presidential election, the Publius project has released a timely essay on the danger of vote suppression tactics potentially…

Russia Online: the Russian-Language Blogosphere and Participatory Internet

An all-day conference in New York City made possible by the collaboration of the Harriman Institute and the School of Journalism at Columbia University, and the Berkman Center for Internet & Society at Harvard University.

Conference Wiki: http://cyber.harvard.edu/russiaonline/Main_Page User: russiaonline PW: columbia This conference is open to the public. Seating may be limited. To reserve…

Video your vote

November 4 at ground level

YouTube and PBS have teamed up to ask US voters to document their voting experiences. You're invited to upload your election day video to the Video Your Vote channel. The Citizen…

Internet & Democracy project releases case study on Kenya's post-election crisis

From the Internet & Democracy blog... We’re following up yesterday’s release of our Burma case study with a look at Africa and the role of technology in Kenya’s post-election…

Harvard Graduate Student Awards - Applications Now Available

We're pleased to announce the BCIS Harvard Graduate Student Awards, intended to help Harvard University graduate students take interdisciplinary approaches to exploring Internet…

Internet & Democracy project releases case study on the "Saffron Revolution"

From the Internet & Democracy blog... Over the past few months, the Internet and Democracy team has been hard at work producing a new set of case studies that take a closer look…

Digitally Networked Technology in Kenya's 2007-2008 Post-Election Crisis

Using the lens of the 2007-2008 Kenyan Presidential Election Crisis, this case study illustrates how digitally networked technologies, specifically mobile phones and the Internet,…

The Role of the Internet in Burma’s Saffron Revolution

This case study is part of a series produced by the Internet and Democracy project. It analyzes the role of the Internet and technology in the 2007 civic crises of Burma’s Saffron…

New: Persian translation of Iran blog study

From the Internet & Democracy blog... We are pleased to release the full Persian translation of our case study: Mapping Iran’s Online Public: Politics and Culture in the Persian…

China, Internet filtering, and the Olympics

The 2008 Olympics open in Beijing in about a week, and Internet filtering practices in China have again made international headlines as journalists and others experience the so…

Thinking through section 201 of the Global Online Freedom Act

Over on the Future of the Internet blog, Berkman summer intern Brendan Ballou takes a look at the Global Online Freedom Act being considered by Congress...

Internet & Democracy in Budapest: Building the Framework

Via the Internet & Democracy blog, Patrick Philippe Meier - I&D conference participant and panel moderator - liveblogged his way through the conference over the past two days at…

2008 Presidential E-lection

This week, the Digital Natives and Internet and Democracy projects both dove into the 2008 campaign, offering their thoughts on the role of the Internet in the current U.S…

Berkman Center Internet & Democracy Project Releases Study Mapping Iran’s Blogosphere

The Berkman Center for Internet & Society’s Internet & Democracy project has released a major study on “Mapping Iran’s Online Public: Politics and Culture in the Persian…

Internet & Democracy project releases study of "Iran's online public"

We are pleased to announce a major research release from the Internet & Democracy project: "Mapping Iran’s Online Public: Politics and Culture in the Persian Blogosphere."

Mapping Iran’s Online Public: Politics and Culture in the Persian Blogosphere

(English and Persian translation)

This case study is part of a series produced by the Internet and Democracy project. It analyzes the composition of the Iranian blogosphere and its possible impact on political and…

Q+ A with Tomorrow's Luncheon Guest, Allison Fine

Allison Fine will join us tomorrow as part of our Tuesday Luncheon Series, and as a primer to her talk, Berkman intern Yvette Wohn sat down with Allison for a Q+ A, where they…

Protests in Tibet - and the Chinese crackdown and troop build-up in Lhasa and elsewhere - have dominated headlines this week. China's blocking of YouTube and other measures…

Is the Internet an Effective Tool for Political Engagement During Elections?

From the Internet & Democracy Project... One major challenge of mature democracies such as the US is political engagement of its citizens. America has one of the lowest voter…

Berkman Buzz: Week of March 3, 2008

A look at the past week's online Berkman conversations.

Berkman in Turkey: Internet & Democracy Digital Activism Event

From the Internet & Democracy Project...On February 7th and 8th, the Berkman Center hosted a three day conference entitled “Digitally-Empowered Activists: Getting the Tools to the…

Digitally-Empowered Activists: Getting the Tools to the People Who Need Them

Hosted by the Internet & Democracy Project

The Berkman Center's Internet & Democracy Projected hosted an event on "Digitally-Empowered Activists: Getting the Tools to the People Who Need Them," in Istanbul, Turkey.

Internet & Democracy

Victoria Stodden, Harvard Law School

Victoria Stodden By discussing the potentials and pitfalls of the internet in a democratic society, Victoria Stodden examined "Internet & Democracy."

The Citizen Journalism Web Site 'OhmyNews' and the 2002 South Korean Presidential Election

This paper is one of the first in a series of case studies that examines the impact of the Internet and technology on democracy. This specific case investigates the influence of…

The Role of Digital Networked Technologies in the Ukrainian Orange Revolution

This working paper is part of a series examining how the Internet influences democracy. This report is a narrative case study that examines the role of the Internet and mobile…

Berkman Center Investigates Internet & Democracy

Project to Focus on Middle East and Other Global Communities

Berkman announces the Internet and Democracy Project, an initiative that will examine how the Internet influences democratic norms and modes, including its impact on civil society…

Jonathan Zittrain

Jason callina.

Bruce Etling

John Palfrey

Caroline Nolan

Corinna di Gennaro

Josh goldstein.

Anita Patel

Related projects & tools 01, impact of the internet on russian politics, media, and society.

With funding from the MacArthur Foundation, the Berkman Center is undertaking a two-year research project to investigate the role of the Internet in Russian society.

• Internet Ethics Cases
• Markkula Center for Applied Ethics
• Focus Areas
• Internet Ethics

Find ethics case studies on topics in Internet ethics including privacy, hacking, social media, the right to be forgotten, and hashtag activism. (For permission to reprint articles, submit requests to [email protected] .)

Ethical questions arise in interactions among students, instructors, administrators, and providers of AI tools.

What can we learn from the Tay experience, about AI and social media ethics more broadly?

Who should be consulted before using emotion-recognition AI to report on constituents’ sentiments?

When 'algorithm alchemy' wrongly accuses people of fraud, who is accountable?

Which stakeholders might benefit from a new age of VR “travel”? Which stakeholders might be harmed?

Ethical questions about data collection, data-sharing, access, use, and privacy.

As PunkSpider is pending re-release, ethical issues are considered about a tool that is able to spot and share vulnerabilities on the web, opening those results to the public.

With URVR recipients can capture and share 360 3D moments and live them out together.

VR rage rooms may provide therapeutic and inexpensive benefits while also raising ethical questions.

A VR dating app intended to help ease the stress and awkwardness of early dating in a safe and comfortable way.

• More pages:

Cases and case studies

• Finding cases and case studies
• Case studies in books & ebooks

Open Access Case Studies

 open access business case studies.

Acadia Institute of Case Studies (Acadia University)  The Institute’s focus is on entrepreneurship and small business operations.

Business Roundtable: Institute for Corporate Ethics: Case Studies

The Institute case studies ground business ethics education in real-world examples. Case materials are available free-of-charge for educational use by faculty, ethics officers, students, and individuals. Teaching notes and other teaching documents will be made available upon request to faculty or corporate trainers only upon verification. Please include your name, title, organization, email and phone information in your request (organizational Web pages where you are listed are recommended, but not required).

BusinessEthics.ca : Case studies dealing with business ethics in Canada selected by  Chris MacDonald a Toronto-based ethics consultant, speaker, and educator.   See also his blog  https://businessethicsblog.com/

Canadian Business Ethics Research Network : Case studies dealing with business ethics in Canada

BCIC Case Study Library : (British Columbia Innovation Council)

Workplace Health Case Studies :  from the Canadian Government

Export Development Canada also collaborates with Canadian universities to develop international business case studies that focus on Canadian exporters. These cases may be used  for teaching in business faculties, to build recognition for university program specializations, or for entry into business-case competitions.

Access is limited to professors, students should discuss availability with their professor. Professors are asked to email [email protected] indicating which  cases  you are requesting, as well as a brief description of the course and level in which you intend on using these teaching materials.

MIT Sloan Cases

MIT Sloan Teaching Innovation Resources (MSTIR) is a collection of teaching materials, including case studies, industry notes, and management simulations, that MIT Sloan provides as a free teaching resource open and available to the world. Similar to the course syllabi and materials found on MIT’s OpenCourseWare site, these materials carry a creative commons license allowing them to be downloaded, copied, and distributed.

Some of the cases from the Oikos online case collection are also available as free cases protected under the Creative Commons license. If you are a faculty member and you are interested in teaching these cases, you can request a free teaching note by sending us an email to  [email protected] .

The Times 100 Case Studies  (from the United Kingdom)  Case studies on real companies.

World Resource Institute   WRI’s mission is to move human society to live in ways that protect Earth’s environment and its capacity to provide for the needs and aspirations of current and future generations.   Search for  "case studies" to obtain a list.

WBCSD   Case studies from World Business Council for a Sustainable World.

Company-Specific Case Studies

IBM  : Showcasing IBM client stories

LANSA : Read how companies across many different industries have developed and implemented innovative solutions using LANSA development tools and solutions.

Primus : customized Primus solution cases.

Schroeder & Schroeder, Inc. : View their  case studies for examples of the areas in which their  consultants have been able to help organizations.

Free Case Studies from Case Study Publishers:

The Case Centre :  The Case Centre is a not-for-profit company that makes available  a few cases for free.

Stanford Graduate School of Business : Need to register first. Seventy-seven free electronically available cases from the Stanford Graduate School of Business from 1998-2012,  categorized by topic.

Open Access Case Study Journals:

Journal of Case Research in Business and Economics of Academic and Business Research Institute.   Available online from 2008 onwards.

Journal of Case Studies in Accreditation and Assessment of Academic and Business Research Institute. Available 2010-2015.

Journal of Business Cases and Applications  published by Academic and Business Research Institute. These articles can be handed out, posted to blackboard, linked to courses without copyright fees.  Teaching Notes are available for most cases and are not password protected, except for Volume I (2007-2008) .  Since 2010 Teaching notes are included with cases

International Journal of Case Studies in Management     From HEC Montreal. Free access to business cases in French or English.  You must sign in to use this service. Faculty may use this material for their  students and teaching copies are  sometimes supplied.

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A study of internet addiction and its effects on mental health: A study based on Iranian University Students

Javad yoosefi lebni.

1 Health Education and Health Promotion, Health Institute, Kermanshah University of Medical Sciences, Kermanshah, Iran

Razie Toghroli

2 Social Determinants in Health Promotion Research Center, Hormozgan Health Institute, Hormozgan University of Medical Sciences, Bandar Abbas, Iran

Jaffar Abbas

3 Antai College of Economics and Management/School of Media and Communication, Shanghai Jiao Tong University, Shanghai-China

Nazila NeJhaddadgar

4 Department of Health Care Services and Health Education, School of Health, Ardabil University of Medical Science, Ardabil, Iran

Mohammad Reza Salahshoor

5 Department of Anatomical Sciences, Medical School, Kermanshah University of Medical Sciences, Kermanshah, Iran

Morteza Mansourian

6 Health Management and Economics Research Center, Iran University of Medical Sciences, Tehran, Iran

Hadi Darvishi Gilan

Neda kianipour.

7 Students Research Committee, Kermanshah University of Medical Sciences, Kermanshah, Iran

Fakhreddin Chaboksavar

Seyyed amar azizi, arash ziapour, introduction:.

The Internet has drastically affected human behavior, and it has positive and negative effects; however, its excessive usage exposes users to internet addiction. The diagnosis of students' mental dysfunction is vital to monitor their academic progress and success by preventing this technology through proper handling of the usage addiction.

MATERIALS AND METHODS:

This descriptive-analytical study selected 447 students (232 females and 215 males) of the first and second semesters enrolled at Kermanshah University of Medical Sciences, Iran, in 2018 by using Cochrane's sample size formula and stratified random sampling. The study applied Young's Internet Addiction Test and Goldberg General Health Questionnaire 28 for data collection. The study screened the data received and analyzed valid data set through the t -test and Pearson's correlation coefficient by incorporating SPSS Statistics software version 23.0.

The results of the current study specified that the total mean score of the students for internet addiction and mental health was 3.81 ± 0.88 and 2.56 ± 0.33, correspondingly. The results revealed that internet addiction positively correlated with depression and mental health, which indicated a negative relationship ( P > 0.001). The multiple regression analysis results showed students' five significant vulnerability predictors toward internet addiction, such as the critical reason for using the Internet, faculty, depression, the central place for using the Internet, and somatic symptoms.

CONCLUSIONS:

The study findings specified that students' excessive internet usage leads to anxiety, depression, and adverse mental health, which affect their academic performance. Monitoring and controlling students' internet addiction through informative sessions on how to use the Internet adequately is useful.

Introduction

In recent years, technological advancements have taken place in the modern world. In the complexity of today's world, internet use is playing a vital role in educational institutions to attain different learning skills, which have become a necessity for university students. However, scholars have shown concerns about the excessive use of this technology and the hidden risk factors of internet users, such as physical and mental health.[ 1 , 2 ] The Internet is an easy and quick medium of interaction to gain the required information for communication with others around the world. However, a lack of control over excessive internet use can disturb individuals' living standards and relationships between family members, and it can bring instability of feelings.[ 3 , 4 ] The users of the Internet have increased incredibly worldwide, with the peak of a digital industrial revolution in progress, and new technological revolution will undoubtedly create new problems and predicaments.[ 4 , 5 ] The history of internet users goes back some decades at present. The Internet has become one of the most fast-growing and transformative technologies. Globally, the users of the Internet have increased from 414 million in 2000, 665 million in 2002, and over 4.574 billion by December 31, 2019. The US National Science Foundation specified that the internet users enabled by smartphones access would increase to 5 billion in 2020.[ 6 , 7 ] In recent years, internet users in Iran have grown dramatically. According to the reported statistics, the Iranian users of the internet have risen from 11.0 million in 2006, 33.0 million in 2002, and over 62 million by July 1, 2019. Hence, the users of the Internet in Iran have increased drastically over 25 times, and recent research conducted in Iran indicated that the young population makes up the majority of internet users.[ 8 ] Previous research specified that the Iranian users devote 35% of their time to chat rooms, 28% to online games, 30% to checking E-mails, and 25% to surfing the net on averages, while connected to the Internet. Besides, another study reported that Iranian users spend 52 min/week as an average time, while linked to the Internet.[ 9 ]

Internet addiction disorder, pathological internet use, or problematic internet use typically refers to the questionable or compulsive use of the Internet, which results in substantial impairment in the function of individuals in their different life domains over prolonged time. Internet addiction and other relationships based on the usage of digital media and mental health are vital considerable research fields, arguments, and discussions among numerous experts and researchers in various disciplines. This addictive behavior has made controversy from the areas of scientific, medical, and technological communities. Internet addiction is an interdisciplinary phenomenon, and different researchers have investigated it from different perspectives from various disciplines, such as medicine, computer science, sociology, law, and psychology.[ 10 ] Some scholars have considered internet addiction as a social crisis, and it has attracted the attention of different researchers and experts. This phenomenon is a biological, psychological, social, economic, and cultural problem, which is impossible to be taken into account as a simple matter because different factors influence it.[ 11 ] The excessive and pathological use of the Internet refers to internet addiction.[ 6 ] Therefore, with the growing number of internet users and its widespread psychological and sociological implications, it is necessary to determine and recognize the contribution of predictive factors in internet addiction. By conducting pathological studies about internet addiction to judge the addictive behaviors, it would enable us to utilize this technology with a balanced approach better and more usefully.[ 12 ] Internet addiction generally refers to a type of applying the Internet, which leads to psychological, social, educational, or occupational problems in a person's life.[ 13 , 14 ] Scholars have described this phenomenon as internet addiction dysfunction[ 15 ] and the problematic application of the Internet,[ 16 ] or habitual use of the Internet,[ 17 ] which determines it as one of the forms of behavioral addiction.[ 18 ] Researchers have also described internet addiction as “the modern addiction.” In practice, this type of addiction is true dependency, like drug addiction and other kinds of dependency. Although this kind of dependency does not have the somatic problems of chemical addiction, its resultant social problems are like other types of addiction.[ 1 ] In the 2015 World Statistics report, the number of internet users and the population of countries were specified; it was reported that the total world population was 7,264,623,793, of which 3,079,339,857 were using the Internet, and the young made up the majority of users.[ 8 ] While taking into account many points of proper and practical use of the Internet and prevention of mental illness, these reported statistics underscore the importance of the Internet and social networks. Internet addiction is an etymological process of using the Internet that creates a psychological state in which the user's behavior is disturbed, thereby leading to a dysfunction in his/her cognitive status.[ 19 ] Mental health is one of the main pillars of healthy human societies, which plays a vital role in ensuring the dynamism and efficiency of any society. As university students are among the most prestigious layers of societies, they present future builders in any country, and newly arrived students in universities from far-away cities are the first who fall victim to internet addiction. The mental health of the students is essential for raising their learning and scientific awareness.[ 19 ] Mental health is a concept that reflects our thinking, feelings, and functioning in dealing with various life situations.[ 20 ] In this modern world, the disease patterns are shifting toward no communicable diseases, and the rising rate of mental dysfunction and the resultant costs imposed on societies have attracted the attention of health promotion specialists.[ 8 ] In this regard, the Global Burden of Disease statistics has introduced mental illnesses as one of the three primary causes of lost years of life due to disability.[ 21 ] According to the WHO, mental health is defined as one's ability to communicate with others harmoniously; modify the personal and social environment; and resolve conflicts and personal preferences logically, fairly, and appropriately.[ 22 ] Besides, the statistics announced by the WHO reported that 52 million people of different age groups suffer from severe illnesses worldwide and 250 million have mild mental dysfunction. In Iran, these statistics are not lower than those in other countries.[ 23 ] The results of the epidemiological studies conducted to examine psychiatric dysfunction in Iran are indicative of the variability of the prevalence of dysfunction between 11.9% and 30.2%.[ 24 , 25 ]

Concerning internet addiction, addressing the problems of individuals' mental health is of great importance. An earlier study conducted by Fallah reported that depression was more prevailing among internet users with addictive behavior as compared with average internet users. The finding specified that individuals having internet addiction showed anxious behavior and their mental health was more exposed to higher risks.[ 23 ] Lashgarara et al . described that 34% of university students had addictive behavior to the Internet based on the Young's categorization.[ 26 ]

In a previous study, Fonia et al . reported that students' mental health and internet addiction showed a negative relationship, and their internet addictive behavior was not significant. It was different from the students' gender and marital status variables.[ 27 ] Another study of Nastizai claimed that students' internet addiction developed a higher risk of mental health than ordinary users of the Internet.[ 28 ] Fonia et al . reported that there was a significant difference between internet addiction among male and female students.[ 27 ] Similarly, the relationship between internet addiction and users' mental health received more considerable attention, and previous studies have emphasized this matter, such as the investigations of Fallah Mehneh,[ 29 ] Alavi et al .,[ 30 ] Mirzaian et al .,[ 31 ] and Taheri Mobarakeh et al .[ 32 ] The tendency of using the Internet among students is higher, and they are more vulnerable to the risk of internet addiction. Thus, more attention to students' mental health needs should be considerable paid for their future as well as the development of the nation.[ 22 , 25 ] Universities need to pay attention to boosting students' mental health, personal growth, and well-being. Because internet addiction prevails worldwide, it also exists in Iran for several years, and young individuals have shown greater engagement toward internet use, while students make up the majority of internet users. The excessive use of the Internet leads to psychological injury, mental health damage, and other health problems. Experts have suggested necessary measures to prevent internet addiction among students and treat disorders and health problems where appropriate.[ 33 ] The present research emphasized investigating internet addiction and its effects on the mental health of medical students at Kermanshah University of Medical Sciences, and its findings provide valuable insights.

Materials and Methods

This descriptive-analytical study selected 447 students (232 females and 215 males) of the first and second semesters enrolled at Kermanshah University of Medical Sciences, in 2018 (May 2017–October 2018) by applying Cochrane's sample size formula and stratified random sampling methods. This method draws the statistical population according to the hierarchy of the types of population units. The study applied Young's Internet Addiction Test (IAT) and Goldberg General Health Questionnaire (GHQ-28) for data collection. The study screened the data received and analyzed valid data set through the t -test and Pearson's correlation coefficient by incorporating SPSS Statistics software version 24.0. Hence, the authors randomly selected nine faculties (medicine, dentistry, pharmaceutical medicine, nursing and midwifery, paramedics, public health, nutrition sciences, and food industries, and self-governing college). In the next step, we selected majors and classes from each faculty (as many as the number of research samples) and evaluated the data. The inclusion criterion was the right to choose the courses freely, and the investigators have excluded incomplete questionnaires from the study. Besides, we assured participants about the confidentiality of the collected information and lack of disclosure of their personal information. Besides, the ethical principles employed in the present study included critical steps, such as obtaining the necessary permits, retaining the right for the schools under investigation to either accept or reject to participate in the research study, and ensuring confidentiality and nondisclosure of agreement. The investigators distributed the questionnaires among the target respondents. The authors explained the objectives of the present study to the target individuals and obtained informed consent from all participants before to execute the research. Not to mention, the exclusion criteria were the sample's disinterest in participating in the study and handing over incomplete questionnaires.

Demographic questionnaire

The first section of the self-administered instrument contained the demographics and comprised questions on gender, age, marital status, place of residence, faculty, education, having a personal computer, central location, and time of using the Internet, and the primary reason for using the Internet.

Internet Addiction Test

Young developed this 20-item scale for measuring the internet addiction, which affects a variety of aspects in users' lives.[ 17 ] The study applied the Persian translation of Young's IAT developed by Alavi et al .[ 30 ] The questions showed the scores on a selected 5-point Likert scale (5 = always, 4 = usually, 3 = most of the time, 2 = sometimes, and 1 = seldom). The ranges of minimum and maximum scores showed 20–100. The scores divided internet users into the following three groups: typical users indicating a score of 20–49; at-risk users, specifying a score of 50–79; and the internet users having an addiction with a score of 80–100. The highest scores represent the highest levels of students' dependency on the Internet, which leads to addictive behavior. Recent studies evidenced that a score of 50 or above shows internet addiction. Besides, this study confirmed the questionnaire's validity from three experts by applying the content validity index (0.84), while the survey confirmed reliability through the t -test (0.88). The Cronbach's alpha provided a satisfactory value (0.87) with a sample of twenty medical students within 2-week process of data collection. The findings of the reliability and validity of this instrument/tool are consistent with the results of previous studies, which indicated over 90%.[ 34 , 35 , 36 , 37 , 38 ]

The General Health Questionnaire

This prospective study used GHQ-28 for gathering data.[ 39 ] The study screened the data received and analyzed valid data set through the t -test and Pearson's correlation coefficient by using the SPSS Statistics software version 24.0. The self-reported Goldberg's 28-item questionnaire examines the individual's mental health in the recent month and includes symptoms such as abnormal thoughts and feelings and aspects of visible behavior. This questionnaire consists of the following four subscales: somatic symptoms (questions 1–7), anxiety (questions 8–14), social dysfunction (questions 15–21), and depression (questions 22–28). Each subscale contains seven questions that measure the various aspects of mental health, ranging from somatic to psychological dysfunction.[ 39 ] The questions presented scores with a 4-point Likert scale (0 = not at all, 1 = average, 2 = more than average, and 3 = far more than average). The minimum and maximum ranges illustrated 0–84, which showed categories into four levels of mental health, for instance, normal (0–22), weak (21–40), balanced (41–60), and severe (61–84). The highest ratings/scores represented the lowest level of students' mental health status. The study examined and confirmed the questionnaire's reliability for each section by using content validity (0.80). The sought the opinion from three experts by using the content validity index (0.80) and confirmed reliability through several tests, such as test-retest (0.87). The study calculated the Cronbach's alpha (0.93) value from the sample of twenty medical students. The results derived from the tests of reliability and validity of this instrument are in line with the findings of previous global studies, which specified the same results.[ 9 , 40 , 41 , 42 ]

The study applied descriptive statistics (percentage, mean, and standard deviation) and inferential statistics ( t -test and Pearson's correlation coefficient) to analyze the data received by using the SPSS Statistics software (version 23.0, SPSS Inc., Chicago, IL, USA), and applied required analysis at the statistical significance level of 0.05 ( P < 0.01).

Ethical consideration

This study is the part of the research project (IR.KUMS.REC.1397.108, No. 97056) sponsored by the Deputy of Research and Technology from Kermanshah University of Medical Sciences, Iran. The authors maintained all the protocols before performing all the procedures engaged in this study involving human participants in accordance with the ethical standards of the institutional research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

The total population comprised of 447 participants in the present study, including 215 male (48.1%) and 232 female (51.9%) students. The average age of the respondents under investigation was 23.47 ± 4.58 years, and the majority of respondents' age ranged between 19 and 24 years (69.6%). Concerning the marital status, there were 360 single participants (80.50%) in this population. The second majority of the study indicated bachelor's degree students (202 students or 45.20%), and the majority of the discipline was a school of medicine (71 students or 15.90%). The majority of the dormitory students comprised 48.30% (216/447). The study findings specified that 356 students possessed their computers (356/447 = 79.60%), and the number of students using the Internet at their dormitories comprised 205 respondents (205/447 = 45.90%). The results indicated that the majority of the students used the Internet either in the morning or in the evening (367/447 = 82.10%).

The main reason for using the internet application was chatting with friends and family members. The mean and standard deviation of students with internet addiction was 3.81 ± 0.88. Besides, the mean and standard deviation of students' mental health was 2.56 ± 0.33, which stated that the general mental health of students was not in good condition. Regarding the mental health of the students' sample, the study results indicated that the highest and lowest rates showed linkage to depression with a mean and standard deviation of 2.84 ± 0.21 and somatic dysfunction with a mean and standard deviation of 2.16 ± 0.79, respectively, as indicated in Table 1 . This specific study applied the Pearson's correlation coefficient to determine the relationship between the students' internet addiction and mental health. The results of the correlation matrix demonstrated that they did not statistically significantly correlate with each other ( P < 0.001, r = 0.052). The study results specified that students' depression and somatic symptoms had the highest ( P = 0.001, r = 0.166) and lowest ( P > 0.001, r = 0.006) relationships with internet addiction, as indicated in Table 2 .

Internet addiction and mental health scores for different genders

The results of Pearson’s correlation coefficient between internet addiction and mental health among students

**Correlation was significant at the 0.01 level (two tailed)

The present study aimed to investigate internet addiction and its effects on the mental health of medical students at Kermanshah University of Medical Sciences. The results of the present study demonstrated that 45.5% of students at Kermanshah University of Medical Sciences were addicted to the Internet. This finding was concurrent with the results of studies conducted by Farhadinia et al .,[ 43 ] Sepehrian and Jokar,[ 44 ] Fonia et al .,[ 27 ] and Dargahi and Razavi.[ 45 ] Those who use the Internet more than others can replace stronger relationships in real life with low-quality social relationships, thereby resulting in more loneliness and depression. To further explicate the matter, the Internet may serve as a substitute for lives without vitality. Loneliness and isolation may cause people to spend more time on the Internet, thereby decreasing the quality of their social relationships.

As for the demographic characteristics, the results demonstrated that there was a significant difference between male and female students in terms of internet addiction. In addition, 23% of male students were internet addicts, which exceeded that of female students by 22.4%. In this study, male students should be given priority in prevention programs for internet addiction. These results were consistent with the results of studies conducted by Alavi et al .,[ 30 ] Orsal et al .,[ 46 ] and Fonia et al .,[ 27 ] whereas inconsistent with the results of studies performed by Atashpour et al .[ 47 ] and Shahbazirad and Mirderikvand.[ 48 ] Male students seem to have more internet addiction than girls. In fact, the present research, in line with the findings of previous studies, shows that men are more exposed to internet addiction, not because of biological differences between the two genders, but due to different social and environmental factors to which each gender is exposed. According to the results, it seems that this finding can be an alarm at the increase in this disorder among students, and it is better that proper planning be done in this area in cooperation with university officials.

Based on the results of the present study, the mean score of male students' mental health was higher than that of female students, and no significant difference was seen between gender and mental health. However, the finding of the present study was consistent with the results of studies conducted by Taji and Verdinejad,[ 49 ] Namdar et al .,[ 50 ] and Imani et al .[ 51 ] In studies done by Asadi et al .,[ 52 ] Gorgich et al .,[ 9 ] Fonia et al .,[ 27 ] and Xu and Liu,[ 23 ] it was expressed that female students had more mental disorders than male students, which was inconsistent with the results of the present study. It should be noted that the mean score of male students' mental health was higher than that of female students, possibly due to men's ability to communicate with others in the society and university, the ability to deal with problems and difficulties, and the ability to earn money, as well as women's excessive emotional dependency on their families and lack of social security in the society.

The results of this study revealed that half of the students had poor mental health, and there was a significant difference between the mean scores of depression and internet addiction. These results were consistent with the results of studies done by Nastizai,[ 28 ] Anderson et al .,[ 12 ] and Chung and Wong.[ 53 ] In a study done by Abdollahi on nursing students at Tehran University of Medical Sciences, it was shown that 32.1% of students had suspected mental disorders, which was 29.7% in women and 34.3% in men.[ 54 ] In addition, Rafiei and Mosavipour showed that 67.9% of students at Arak University of Medical Sciences had symptoms of mental disorders, and only 32.1% of them had normal mental health.[ 55 ] Similarly, Masoudi et al . concluded that 52.4% of students at Tehran University of Medical Sciences were suffering from mental health disorders.[ 56 ] Similarly, in a study done by Yavarian et al . on students at Uromia University of Medical Sciences, it was demonstrated that 45.8% of students had different degrees of mental health disorders. In their study, it was also revealed that 10%, 0.5%, and 3.2% of students had severe disorders in terms of somatic symptoms, anxiety and insomnia, and depression, respectively. This finding was concurrent with the results of the present study.[ 57 ] It seems that the different prevalence of psychiatric disorders in various studies can be attributed to several factors, including the differences in groups under study.

The results revealed that internet addiction and mental health were negatively related, which was consistent with the results of studies conducted by Shahbazirad and Mirderikvand,[ 48 ] Fallah Mehneh,[ 58 ] and Mousavomoghadam et al .[ 59 ] Hosseini et al . showed that 4.2% of students at Payam Noor University of Charm had severe addiction to the Internet. In addition, a significant relationship was observed between internet addiction and mental health.[ 60 ] Similarly, in a study performed by Farhadinia et al ., it was demonstrated that internet addiction and mental health significantly correlated among the students of Lorestan University of Medical Sciences,[ 43 ] which seems to lay the groundwork for the internet addicts. Some people resort to the Internet to reduce their depression. In this case, the Internet may provide a substitute for the joyless lives of depressed people, or they may get depressed as a result of internet addiction. In other words, the internet addicts will experience the negative consequences, such as depression.

In justifying the relationship between depression and internet addiction, it can be expressed that the excessive use of the Internet can lead to social isolation and depression through reducing familial, social, and local connection. Therefore, depression may occur as a result of internet addiction, and in this case, the internet addicts experience the resultant negative consequences, such as depression.[ 28 ]

The results revealed that the five major predictors of vulnerability to internet addiction in university students were as follows: the key reason for using the Internet, faculty, depression, the main place for using the Internet, and somatic symptoms.

Limitations of the study

Concerning the limitations, this study evaluated medical students in the classrooms based on different groups. The discussions among students could present bias in their feedback. There was no face-to-face interview session, and the data set reported on a self-reported questionnaire, which increases the risk of social desirability biases among medical students of medicine, dentistry, and pharmaceutical departments at self-governing Education Incubator of Kermanshah, Iran. The limitations of the current study specify that researchers can consider a large sample size based on medical students as well as other departments to execute their investigations in western part of Iran. Scholars can find experimental and longitudinal methods with larger samples to examine different results.

Conclusions

According to the findings of the present study, it can be concluded that students' excessive use of the Internet leads to depression, anxiety, and reduced mental health, thereby affecting their academic performance. Hence, it is suggested that further monitoring and control be exercised on how the Internet is used by university students, and they should be informed of the detrimental effects of this technology in the case of misuse or overuse. The findings of the present study are also indicative of the significance of preventative measures in the form of educational and counseling programs for students regarding the proper and practical use of the Internet. In addition, addressing the issues and problems relating to communication technologies, such as the Internet, can lay the groundwork for proper education and instigate parents' and families' further attention to proper and effective use of the Internet.

Financial support and sponsorship

Conflicts of interest.

There are no conflicts of interest.

Acknowledgments

The authors hereby bestow their gratitude to the students in the for-profit Schools of Medicine, Dentistry, Paramedics, Nursing and Midwifery, Paramedicine, Nutrition Sciences and Food Industries, Public Health and Self-Governing College in Kermanshah University of Medical Sciences for their participation in the present study.

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Haiti Earthquake 2010

Haiti earthquake case study.

A 7.0 magnitude earthquake .

The earthquake occurred on January 12th, 2010, at 16.53 local time (21.53 GMT).

The earthquake occurred at 18.457°N, 72.533°W. The epicentre was near the town of Léogâne, Ouest department, approximately 25 kilometres (16 mi) west of Port-au-Prince, Haiti’s capital. The earthquake’s focus was 13km (8.1 miles) below the Earth’s surface.

Haiti is situated at the northern end of the Caribbean Plate, on a transform (slip/conservative) plate boundary with the North American Plate. The North American plate is moving west. This movement is not smooth, and there is friction between the North American Plate and the Caribbean Plate. Pressure builds between the two plates until released as an earthquake.

A map to show the location of Haiti in relation to tectonic plates. Source BBC.

The epicentre of the earthquake was 16km southwest of Port-Au-Prince. The earthquake was caused by a slip along an existing fault (Enriquillo-Plaintain Garden fault).

A map to show the location of the epicentre of the earthquake

Primary Effects

As of February 12th 2010, an estimated three million people were affected by the quake; the Haitian Government reports that between 217,000 and 230,000 people died, an estimated 300,000 were injured, and an estimated 1,000,000 were made homeless. They also estimated that 250,000 residences and 30,000 commercial buildings had collapsed or were severely damaged.

Secondary Effects

• Two million people were left without water and food.
• Regular power cuts occurred.
• Crime increased – looting became a problem and sexual violence escalated.
• People moved into temporary shelters.
• By November 2010 there were outbreaks of cholera.

Immediate Responses

• Due to the port being damaged, aid was slow to arrive.
• The USA sent rescue teams and 10,000 troops.
• Bottled water and purification tablets were provided.
• 235,000 people were moved away from Port-au-Prince to less-damaged cities.
• £20 million was donated by The UK government.

Long-term Responses

• As one of the poorest countries on Earth, Haiti relied on overseas aid.
• Although the response was slow, new homes were built to a higher standard. Over one million people still lived in temporary shelters one year after the earthquake.
• The port needed rebuilding, which required a large amount of investment.

So, why did so many people die in the Haiti earthquake? There are several reasons for this:

• The earthquake occurred at shallow depth – this means that the seismic waves must travel a smaller distance through the Earth to reach the surface to maintain more energy.
• The earthquake struck the most densely populated area of the country.
• Haiti is the poorest country in the Western Hemisphere
• The buildings in Port-Au-Prince and other areas of Haiti were generally in poor condition and were not designed or constructed to be earthquake-resistant.
• Three million people live in Port au Prince; most live in slum conditions after rapid urbanisation.
• Haiti only has one airport with one runway. The control tower was severely damaged in the earthquake. The port is also unusable due to damage.
• Initially, aid had been piling up at the airport due to a lack of trucks and people to distribute it. Water and food have taken days to arrive, and there is not enough to go around.
• Rescue teams from around the world took up to 48 hours to arrive in Haiti due to the problems at the airport. As a result, local people have had to use their bare hands to try and dig people out of the rubble.
• There has been a severe shortage of doctors, and many people have died of injuries like broken limbs.

 The BBC News website has a comprehensive overview of the earthquake here . In addition, the BBC has produced an excellent article titled Why so many people died in the Haiti earthquake? and provides comparative data with similar earthquakes.

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Internet of Things for Sustainability: A Case Study of University Campus

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Integration of Lean Six Sigma with Internet of Things (IoT) for productivity improvement: a case study of contactor manufacturing industry

• CASE STUDIES
• Published: 04 July 2023
• Volume 14 , pages 1990–2018, ( 2023 )

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• Santosh B. Rane 1 ,
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In today's era of digitalization and competitive market environment, organizations are more focused on manufacturing quality products at optimum cost to capture maximum business as a variety of options are available to customers for purchasing goods and services. In this scenario, the latest technologies-based productivity improvement can help organizations to achieve set targets of production and ensure the quality of products. In this study, the contactor manufacturing industry has been considered to demonstrate integrated Lean Six Sigma with the Internet of Things (IoT) approach for productivity improvement. A systematic literature survey was performed to understand the concept of Lean Six Sigma (LSS), Define Measure Analysis Improve Control approach and IoT technology. The implementation of the LSS approach reduced the rejection rate of contactors and saved the total production cost (Rs. 51,88,260/-) annually. The annual consumption of grinding wheels has been reduced by 8 quantities to produce the same quantity of contactors. The surface quality of magnets has been identified as a root cause for contactor rejections as it contributes 53.4% of total rejections. The improvement measures are recommended based on the expert's suggestions as grinding wheel dressing must be performed after the completion of a batch of 20,000 parts. The condition monitoring and IoT approach implementation are done by monitoring grinding speed (650–950 RPM), grinding wheel thickness reduction by 0.4–0.6 mm after dressing and dressing of grinding wheel after completion of 20,000 for reducing rejections. This study concluded that industries should implement the Lean Six Sigma approach with the latest technologies and appropriate tools at each stage to set processes to world-class standards and industries should identify opportunities for process and product improvement.

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Rane, S.B., Wavhal, S. & Potdar, P.R. Integration of Lean Six Sigma with Internet of Things (IoT) for productivity improvement: a case study of contactor manufacturing industry. Int J Syst Assur Eng Manag 14 , 1990–2018 (2023). https://doi.org/10.1007/s13198-023-01980-7

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Published on 22.4.2024 in Vol 26 (2024)

Using ChatGPT-4 to Create Structured Medical Notes From Audio Recordings of Physician-Patient Encounters: Comparative Study

Authors of this article:

Original Paper

• Annessa Kernberg, MD   ; 
• Jeffrey A Gold, MD   ; 
• Vishnu Mohan, MD  

Department of Medical Informatics and Clinical Epidemiology, Oregon Health and Sciences University, Portland, OR, United States

Corresponding Author:

Vishnu Mohan, MD

Department of Medical Informatics and Clinical Epidemiology

Oregon Health and Sciences University

3181 SW Sam Jackson Park Road

Portland, OR, 97239

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Background: Medical documentation plays a crucial role in clinical practice, facilitating accurate patient management and communication among health care professionals. However, inaccuracies in medical notes can lead to miscommunication and diagnostic errors. Additionally, the demands of documentation contribute to physician burnout. Although intermediaries like medical scribes and speech recognition software have been used to ease this burden, they have limitations in terms of accuracy and addressing provider-specific metrics. The integration of ambient artificial intelligence (AI)–powered solutions offers a promising way to improve documentation while fitting seamlessly into existing workflows.

Objective: This study aims to assess the accuracy and quality of Subjective, Objective, Assessment, and Plan (SOAP) notes generated by ChatGPT-4, an AI model, using established transcripts of History and Physical Examination as the gold standard. We seek to identify potential errors and evaluate the model’s performance across different categories.

Methods: We conducted simulated patient-provider encounters representing various ambulatory specialties and transcribed the audio files. Key reportable elements were identified, and ChatGPT-4 was used to generate SOAP notes based on these transcripts. Three versions of each note were created and compared to the gold standard via chart review; errors generated from the comparison were categorized as omissions, incorrect information, or additions. We compared the accuracy of data elements across versions, transcript length, and data categories. Additionally, we assessed note quality using the Physician Documentation Quality Instrument (PDQI) scoring system.

Results: Although ChatGPT-4 consistently generated SOAP-style notes, there were, on average, 23.6 errors per clinical case, with errors of omission (86%) being the most common, followed by addition errors (10.5%) and inclusion of incorrect facts (3.2%). There was significant variance between replicates of the same case, with only 52.9% of data elements reported correctly across all 3 replicates. The accuracy of data elements varied across cases, with the highest accuracy observed in the “Objective” section. Consequently, the measure of note quality, assessed by PDQI, demonstrated intra- and intercase variance. Finally, the accuracy of ChatGPT-4 was inversely correlated to both the transcript length ( P =.05) and the number of scorable data elements ( P =.05).

Conclusions: Our study reveals substantial variability in errors, accuracy, and note quality generated by ChatGPT-4. Errors were not limited to specific sections, and the inconsistency in error types across replicates complicated predictability. Transcript length and data complexity were inversely correlated with note accuracy, raising concerns about the model’s effectiveness in handling complex medical cases. The quality and reliability of clinical notes produced by ChatGPT-4 do not meet the standards required for clinical use. Although AI holds promise in health care, caution should be exercised before widespread adoption. Further research is needed to address accuracy, variability, and potential errors. ChatGPT-4, while valuable in various applications, should not be considered a safe alternative to human-generated clinical documentation at this time.

Introduction

Medical documentation is an integral aspect of clinical practice, ensuring accuracy and comprehensive patient management and serving as a communication tool among health care professionals. In recent years, it has become increasingly evident that inaccuracies in medical notes lead to miscommunication, diagnostic discrepancies, and patients’ perceptions of subpar medical care [ 1 ]. Beyond the immediate implications of documentation errors, documentation demands have been identified as a significant contributor to physician burnout [ 2 ]. With health care professionals spending an increasing amount of their working hours on paperwork, there is less time and energy left for direct patient care.

To counter this, many institutions have adopted the use of intermediaries, such as medical scribes or speech recognition software, to shoulder the documentation load and allow clinicians to focus on patient interactions. However, both of these solutions have significant limitations and concerns regarding documentation accuracy and lack of impact on many provider-specific metrics surrounding after-hours charting and burnout [ 3 , 4 ]. In addition, the financial implications of employing medical scribes render them inaccessible to numerous health care practices [ 5 ]. Consequently, there is a continued search for innovative solutions to create effective and accurate documentation while seamlessly integrating into existing workflows.

With the rapid and exponential growth in computing capacity, artificial intelligence (AI) is being increasingly used in health care, holding the promise of revolutionizing medical documentation, thus potentially alleviating the burden on physicians [ 6 ]. AI-powered systems can analyze vast amounts of data quickly, identify patterns, and suggest diagnostic options. Although the allure of AI is undeniable, questions regarding its accuracy, reliability, and suitability in the clinical setting remain. The maturation of speech recognition technology has led to large-scale adoption by health care organizations, allowing for real-time transcription services. This, combined with software using large language models (LLMs), now enables the creation of structured medical notes in close temporal relation to the clinical encounter, thereby decreasing the clinician documentation burden [ 7 , 8 ]. Multiple software vendors are developing and deploying documentation assistance software powered by ambient AI, referred to as ambient digital scribes. There is already significant interest on the part of clinicians and health care organizations to adopt them. However, little data exist on the safety and quality of the documentation, with analysis made more difficult by the proprietary AI engine used by each vendor.

One such AI system is OpenAI’s ChatGPT-4, a state-of-the-art LLM known for its ability to engage in text-based communication with users (as a chatbot), which is used in some commercial ambient digital scribe solutions. Released in November 2022, ChatGPT-4 is trained on a vast amount of text data from the internet and uses an LLM to answer the users’ prompts. Health care providers envision numerous applications for ChatGPT-4, such as answering patient questions, automated insurance prior authorizations, and creating differential diagnoses [ 9 , 10 ]. It is important to note that open AI platforms, such as ChatGPT-4, are not recommended for clinical use due to the many regulatory and privacy issues. Despite this, there is a continued interest in whether ChatGPT-4 could serve as a freely available tool to assist as a documentation intermediary, bridging the gap between health care professionals and the tedious task of recordkeeping.

However, it is imperative that prior to the widespread adoption of these tools, their safety and efficacy need to be evaluated in a structured and clinically contextually relevant manner. Therefore, the goal of this study was to use transcripts from simulated patient-provider encounters to determine the accuracy, readability, and reproducibility of ChatGPT-4–generated Subjective, Objective, Assessment, and Plan (SOAP) notes.

As part of a project designed to evaluate the accuracy and efficacy of human scribe–generated notes, we created 14 simulated patient-provider encounters. All encounters used professional standardized patients and represented a wide range of ambulatory specialties. A standardized patient is an individual trained to simulate a medical scenario for health care education, assessment, and research. Briefly, for each case, a storyboard was created by subject matter experts and used for training the standardized patient to ensure standard content delivery according to best practices [ 11 ]. After an initial dry-run, each scenario was conducted in a simulated ambulatory patient exam room equipped with audio-video capture. At the end of the scenario, audio-video files were exported for use. These cases represented a variety of diagnoses ( Table 1 ).

Audio files for each case were professionally transcribed. For each encounter, a list of key reportable elements was created for each case using the transcripts and informed by the initial storyboard, by 2 clinical experts of the study team. This is being used as the scoring rubric for subsequent analysis. These encounter transcripts were then fed into ChatGPT-4 using a standard prompt (“generate a clinical note in SOAP format for the following”). The SOAP format is a widely used clinical documentation format that concatenates data elements of the clinical interview into headers representing SOAP-related components. The SOAP format is a standard model for medical documentation, providing a clear, concise framework for health care professionals to record and share patient information. Each transcript was run through the model three times to assess output fidelity associated with replicability, thus generating three documentation versions for each case for a total of 42 ChatGPT-4 generated SOAP notes (the prompt and full output are present in Multimedia Appendix 1 ). A new discussion space was created for each case to prevent the various transcripts from conflating each other. Each prompt request was conducted consecutively within the same discussion space.

After acquiring the generated notes, various comparisons were made to assess the output’s accuracy and quality. Within a single case, the 3 versions were analyzed based on errors generated. A list of errors was defined as follows: (1) omissions—where expected documentation elements or data were missing; (2) incorrect—where the data element was referred to but incorrect; and (3) additions—information added that was not in the transcript. The framework for defining quality in clinical documentation based on omissions, incorrect information, and additions is a structured approach to evaluate the accuracy and completeness of medical records. These characteristics (omissions, incorrect information, and additions), if present, help define the quality of documentation given their implications. For example, omissions can lead to gaps in patient care, misdiagnosis, or delays in treatment. Incorrect information can compromise patient safety and lead to negative health consequences. Additions, while not always harmful, can be inaccurate and reduce the efficiency of care delivery. This framework is particularly useful in assessing the performance of health care documentation processes, such as those generated by medical scribes, and in quantifying appropriate information retrieval [ 4 , 12 ]. A correct data element was defined as one without the previously outlined errors.

To ensure and assess note quality, we outlined critical data elements for each clinical case. Members of the study team independently selected these crucial data elements and subsequently compiled them to guarantee comprehensiveness. They used these elements to generate a gold standard checklist and an associated gold standard History and Physical Examination note. Then, 2 raters graded the 3 ChatGPT-4 versions of each encounter based on whether they correctly included, missed, or wrongly presented the corresponding data element. We enumerated the number of errors and correct data elements for each version. Afterward, we compared the correct data elements across the 3 ChatGPT-4 versions for presence and consistency, as follows: (1) across all three versions, (2) across two versions, (3) only in a single version, or (4) not present at all. Finally, we compared the percentages of appropriate data elements across the versions to the transcript’s length and the number of data elements.

The data elements were divided into three documentation-related sections: (1) Subjective , further subdivided into the history of present illness and other patient-reported information, including medications, allergies, family history, social history, and past medical history; (2) Objective , which includes vital signs, physical exam, and any reported test results; and (3) Assessment and Plan , which includes the provider reported differential, plan, and follow-up instructions. The percentages of correct data elements were then compared based on these categories.

Lastly, the Physician Documentation Quality Instrument (PDQI) scoring system, which is a validated tool to assess note quality, was used to evaluate the quality of the generated notes [ 13 ]. Using a set of predefined criteria, the PDQI facilitates the objective analysis of documentation practices. Within the PDQI, 9 criteria assess if the document is (1) up to date, (2) accurate, (3) thorough, (4) useful, (5) organized, (6) comprehensible, (7) succinct, (8) synthesized, and (9) consistent. The items are then scored based on a 5-point Likert scale, with the highest value representing the ideal characteristic. A maximum score of 45 represents the document that extremely shows the associated attribute, and a minimum score of 9 points indicates that the attribute is not at all present. The PDQI score was calculated for the 3 versions of the generated note, averaged, and compared across the 14 cases by a member of the study team (AK).

Statistical Analysis

All statistical analyses were performed using GraphPad Prism (version 10; GraphPad Software Inc). For between-group comparisons, we used the Friedman test for overall and between-group comparisons given the nonnormal distribution of the data as determined by the Kolmogorov-Smirnov test. Pearson r test was used for univariate correlations. A P value <.05 was considered statistically significant.

Ethical Considerations

The study was deemed exempt from an institutional review board approval as it did not include human subjects and therefore did not pose any risks.

We first looked at the overall structure of the notes. Consistently, ChatGPT-4 was able to generate a SOAP-style note. Overall, there was a significant variance in note length between the 3 replicates, with the transcripts of some cases being very similar in length, while others showed nearly a 50% variance between replicates ( Figure 1 ).

We classified errors into 3 types: errors of omission, those related to incorrect facts, and errors associated with information addition. Overall, the total number of errors ranged from 5.7 to 64.7 errors per case, with significant differences between the replicates ( Figure 2 A). When we subdivided errors into the 3 basic types, errors of omission were by far the most common, comprising, on average, 86.3% of all errors, followed by addition errors (10.5%) and incorrect facts (3.2%). Examples of these types of errors are illustrated in Table 2 . There was significant variance both in the total number and distribution of errors between cases and between replicates of the same case ( Figure 2 B).

For accuracy, we assessed the overall congruence between replicates. The frequency of correct reporting across the 3 replicates was compared against the gold standard History and Physical Examination. Overall, the mean percentage of elements reported correctly across all 3 replicates for the 14 cases was 53% (range 22%-79%). Interestingly, nearly 30% of data elements were reported correctly in only 1 or 2 of the replicates, suggesting issues with both accuracy and congruency ( Figure 3 ).

Breaking down ChatGPT-4’s performance based on individual categories, there was a significant variance in the accuracy in each section of the note. Specifically, the highest accuracy was observed in the Objective section of the note (median 86.9, IQR 75.4%-96.9%) and was significantly higher compared to the History and Physical examination (median 63.8%, IQR 54.2%-76.8%; P =–.02), Other (median 75.2%, IQR 68.5%-82.4%), and Assessment and Plan (median 66.9%, IQR 36.4%-83.5%; Figure 4 ).

The combination of variance in note structure as well as the number and type of errors resulted in similar variance in overall note quality as determined by PDQI-9. Overall, the mean PDQI-9 score was 29.7 (range 23.7-39.7), with significant variance between replicates within a case ( Figure 5 ).

Finally, we wished to determine whether characteristics in the parent transcript were associated with note quality. Overall, transcript length and the total number of scorable elements (as a measure of information density or complexity) both correlated inversely with the total percentage of elements reported correctly across the 3 replicates for each case ( Figure 6 ). We observed similar findings for PDQI-9 (details are not shown).

Principal Results

Our study highlights the significant variations in errors, accuracy, and quality of SOAP notes generated by ChatGPT-4. With regard to errors, they are not limited to specific sections of the note and include errors of omission as well as commission. Although the number of errors is consistent with regard to the number of data elements, another important finding is that the error rate is not consistent across replicates of the same case. This means that the model is not making the same errors repeatedly, making it difficult for health care providers to predict where errors may occur. This variability introduces a level of unpredictability, which can impact clinical oversight.

Comparison With Prior Work

In the context of medical research, our investigation has shed light on the critical issue of documentation accuracy, which has been a recurring concern in prior studies. Our findings align with the existing body of research on digital scribes, revealing noteworthy variations in accuracy, particularly in the context of nonobjective data [ 4 , 14 ]. In the realm of ChatGPT-4, the study conducted by Johnson et al [ 15 ] delved into its performance in giving precise and comprehensive medical information. This inquiry enlisted the expertise of 33 physicians, spanning 17 different specialties, who formulated questions that were subsequently posed to ChatGPT. Approximately 57.8% of the generated responses were assessed as accurate or nearly correct. This outcome underscores the imperative for exercising caution when solely relying on AI-generated medical information and the need for continuous evaluation, as others have noted [ 16 ]. However, in another study by Walker et al [ 17 ] aimed at evaluating the reliability of medical information provided by ChatGPT-4, multiple iterations of their queries executed through the model yielded a remarkable 100% internal consistency among the generated outputs [ 17 ]. Although promising, it should be noted that the queries used in their experiment consisted of direct single-sentence questions pertaining to specific hepatobiliary diagnoses. This mode of input differs significantly from the transcription of patient encounters. Our research, in contrast, stands out by probing the reproducibility of note generation—a relatively less explored topic in existing literature.

The PDQI-9 scores also highlight the overall variance in quality. In previous research, the PDQI-9 score of 26.2 was rated “terrible or bad,” versus a PDQI-9 score of 36.6, which was rated “good or excellent” [ 13 ]. In our study, the mean PDQI-9 score of 29.7 is closer to the “terrible or bad” range. These observations suggest that although ChatGPT-4 can consistently generate a SOAP-style note, it introduces errors and struggles with maintaining uniformity and accuracy. These issues could pose potential challenges if implemented in a clinical setting.

An essential aspect of our research was to identify the factors contributing to inaccuracies in AI-generated notes. Notably, we found an inverse correlation between note accuracy and transcript length as well as the amount of reportable data. This observation has profound implications for large language models like ChatGPT-4, indicating their challenges with longer and denser information. This raises questions about their effectiveness in handling complex medical cases.

These findings have significant clinical implications. The high variability in PDQI-9 scores, coupled with a high error rate, indicates low-quality notes. Recently, there have been concerns regarding ChatGPT-4’s capacity to generate what can be classified as “hallucinations”—synthesized data that may be misinterpreted as factual information. These data are often incomplete and sometimes misleading [ 18 ]. This has implications for the quality of patient care, potentially leading to diagnostic errors and eroding trust in AI, both among health care providers and patients. Acknowledging the increasing documentation burden contributing to physician burnout, generative AI technology for clinical note documentation may save time [ 2 , 19 ]. However, if our data are representative of similar accuracy rates with other AI-powered systems, any time savings could be negated by the need for corrections. This mirrors previous studies with human scribes, where widespread adoption had little impact on after-hours charting or chart completion time [ 20 - 22 ].

Limitations

Our research is not without limitations. Primarily, the generated SOAP notes underwent processing through an open AI model, in contrast to the proprietary closed models commonly used in the generative AI domain of health care. It is pertinent to note that proprietary technologies, such as DAX Copilot (a collaborative venture of Microsoft and Nuance), have restricted accessibility, available only to entities holding contractual agreements with the parent company. Furthermore, these models evolve iteratively. Consequently, the errors as well as the correct elements in our current data set might not manifest in subsequent versions. However, it is important to note that the methodology reported here establishes a means by which these systems can be evaluated systematically. It should be acknowledged that this study only used transcripts, eliminating the confounder of any potential errors introduced by the speech recognition aspect [ 23 , 24 ]. Integrating this aspect will be critical for a more complete evaluation of fully integrated generative AI–powered documentation assistants. Another limitation is the inability to draw conclusions regarding the correlation between types of cases and associated errors. A substantially larger volume of encounters would be required to delineate this relationship. Additionally, despite its standardized criteria, using the PDQI can still be influenced by the subjective judgment of the reviewer and can be a time-consuming process, particularly for longer documents. Conversely, the instrument does cover a broad range of quality dimensions, facilitating a more holistic evaluation. Furthermore, it can be used as a diagnostic tool to identify strengths and weaknesses, guiding targeted quality improvement initiatives. Finally, in large language models, such as ChatGPT-4, the temperature of the model is a parameter that controls the randomness or predictability of the model’s output. It is a component that tunes the model to generate responses that are either more varied and creative or more deterministic and conservative. With this in mind, ChatGPT-4’s temperature allows for variability, but this setting is not accessible to the end user [ 25 , 26 ]. Further, even setting the temperature to zero does not appear to ensure uniformity of response [ 27 ]. Along these lines, the absence of real-time feedback within the application also limits the model’s ability to adjust its responses based on user input, and therefore, hinders the model’s opportunity to learn from real-world interactions and refine its output.

Conclusions

In conclusion, our study used standardized simulated patient-provider interactions to evaluate the quality and reliability of AI-generated clinical notes. The generated notes do not meet the acceptable quality standards for clinical use. Our methodology provides a foundation for future assessments of AI technology in terms of quality and safety. At this time, AI should not be considered a safe alternative to digital scribes.

Data Availability

The data sets generated and analyzed during this study are available from the corresponding author on reasonable request.

Conflicts of Interest

None declared.

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Abbreviations

Edited by T de Azevedo Cardoso, G Eysenbach; submitted 09.11.23; peer-reviewed by A Almansour, C Chuang; comments to author 31.01.24; revised version received 20.02.24; accepted 10.03.24; published 22.04.24.

©Annessa Kernberg, Jeffrey A Gold, Vishnu Mohan. Originally published in the Journal of Medical Internet Research (https://www.jmir.org), 22.04.2024.

This is an open-access article distributed under the terms of the Creative Commons Attribution License (https://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work, first published in the Journal of Medical Internet Research, is properly cited. The complete bibliographic information, a link to the original publication on https://www.jmir.org/, as well as this copyright and license information must be included.

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