The Internet and the World Wide Web: Implications for Health Care

Few things have captured the imagination of the American Public as much as the Internet. Though it has been in existence for almost 28 years, it wasn't until the creation of Web browsers that it came to the attention of the general population and corporate America. Web browsers gave a new look to the text only interface to the world's resources. All at once these resources became live documents composed of rich text, pictures in realistic color, CD quality sound movie clips. Suddenly the world of the Internet became one's personal multimedia resource library. This article provides an abbreviated introduction to the Internet and some examples of ways in which it will help improve the quality of care we give.

The Internet was created in the 60's at the height of the cold war as an experiment by the defense department. The challenge was to create a network that could withstand nuclear attack. The first users of this network were a handful of defense contractors and academic centers who used it to exchange information and utilize computational resources on remote systems. For the next 14 years, growth of this network was slow. Then in 1983, TCP/IP was established as the communication protocol for the network. Also a "name server" was developed at the University of Wisconsin. Together these freed users from having to know the exact path to the remote destination. Now desktop workstations were able to connect to this network and the growth of what is now officially called the Internet began to take off. From August of 1983 to July of 1997, the network grew from 563 computer hosts to 19,540,000 essentially doubling its size every 11.1 months.

The Internet is composed of several essential services which enable collaboration among remote sites. These include e-mail, mailing lists, Newsgroups, Gopher, and the World Wide Web. A new tool which can be distributed across the Web and which will run on the browsing computer system is called Java. This article will discuss each of these services briefly.

E-mail is the most basic of the Internet features and many will argue the most valuable. Internet e-mail allows for the exchange of electronic mail messages between two or more people. These messages may contain anything from simple text to formatted documents, a multimedia video clip or even an executable file.

Mailing lists, also known as discussion groups, are a on-to-many communication medium. Using electronic mail as the delivery system, a mailing list will take a message that is sent to it and duplicate it so that each of the subscribers to the list receives a copy. Well-focused mailing lists have traditionally been one of the greatest benefits of being connected to the Internet. Topical lists allow one the ability to communicate with a roomful of experts for news, debate or consultation regardless of your location or the time of the day you choose to participate.

Newsgroups are another method of one-to-many communication. Unlike mailing lists where the communication arrives in your e-mail box, newsgroups are more like bulletin boards to which one goes and reads messages that have already been "posted." Newsgroups are good for the occasional reader and are a great way to find information if you don't mind sorting through the chatter. Anyone can create a newsgroup if there is enough interest. There is an official voting procedure for all proposed newsgroups and if it passes, the group is created.

Gopher was the first tool to be created which put Internet navigation within the reach of people without Internet experience. Released by the University of Minnesota in 1991, Gopher created a text-only menu system that allowed one to read text and retrieve files from computer systems around the globe. Simply selecting the item with a mouse or the arrow key retrieved the information. It was common for the first time user to have more fun and spend more time browsing different Gopher sites than they had expected.

The World Wide Web (WWW) was the next great advancement in Internet technology. It was conceived by Tim Berners-Lee of the Center for Particle Physics in Switzerland (CERN) in 1991. Intended as a way to share documents between scientists, his original protocol created a hypertext "hot" link between an item on the screen and another network resource. One example of hypertext format can be found in the "help" systems of the Macintosh and Windows PC. In September of 1993 the National Center for Supercomputing Applications released a Web browser, Mosaic, for all the common computer platforms which assembled these multimedia elements into one document. Now a hypertext document could link words and images with text or other files anywhere on the Internet. This laid the foundation for the Internet to become an enormous multimedia library. Since then several other browsers have been released. Currently the most widely used browser Netscape Navigator and Microsoft Explorer.

Java is another tool that captured the imagination of the Internet community. With Java, it was possible for a Web site to include a small executable file in the document that is retrieved. This enabled pages to have a customized functionality on the user's computer. A simple example of this would be an interactive calculator on your screen that responded to your commands. Rather than merely displaying a page with text, images and maybe even a movie of the experiment, Java allows the publisher to provide a small application (or applet) which can demonstration the behavior of the actual product.

Active-X is another way of creating portable applications that can be delivered on the Internet. This tool is similar to Java but it is not yet as widely accepted.

The newest craze to hit the Internet is "Push Technologies." These are applications which "push" data from the server to the client at regular intervals. The first of these was called PointCast. PointCast will retrieve magazine and newspaper articles, stock quotes and weather reports that you select at defined intervals. It will then display these on your screen when your computer is idle. Since this is seen as a great way to distribute commercial information, several other companies have joined in with their own version of push technology. This is not without cost to the user. Most of these documents are graphics intensive and can take a long time to retrieve with all but the fastest modems.

As the Internet reaches out into more and more people's homes, its promise as a health care tool grows. It has the potential of improving the lives of our patients and the quality of our care in some very significant ways. It also promises to allow us to run the business of medicine more efficiently.

Discussion groups are ideal tools for linking individuals with common needs and who live far apart. An experiment in Cleveland provided inexpensive terminals to people with AIDS allowing them to connect to a community network. The experimenters used this network to provide them with information, and decision assistance. The experiment was such a success that the system continued after the study was complete. In another study of handicapped persons, emotional support and communication were found to be significant benefits. It is easy to see how patients with rare diseases or communication impediments would stand to benefit.

It has been proven that access to health information promotes the cost-effective use of health services. In 1989, a randomized study showed that students who had access to electronic information services which provided them with answers to anonymous health questions, symptom specific algorithms, physician referral information and medical news articles decreased their ambulatory visits by 22.5% without a compensatory increase in hospitalizations. The Internet now provides the ability of delivering personalized health information when the patient needs it in a way that they can both see and hear. Health questionnaires can be completed online and can provide immediate feedback on lifestyle changes that will improve their health. Web pages could enable users to modify different risk factors in the questionnaire and see how it effects their probability of disease and life expectancy. Pregnant women can enter the date of their last menstrual period and get a personalized calendar of what to expect during their pregnancy.

This network also has vast potential for health care providers. It can facilitate the collaboration between specialist and generalist in the delivery of care.

E-mail messages may contain clips from a patient's chart. These would include items which are easily sent by FAX today but could also include full resolution ECG's, MR scans, Doppler echoes, endoscopy photos or videos from vascular studies. As the medical chart becomes automated, sharing this information will become easier. E-mail distribution would allow the distant physician to view and respond at her leisure.

Current copies of treatment recommendations and evolving practice guidelines can be made available on line so the provider may be made aware of an accepted treatment plan when encountering a controversial issue or an unfamiliar problem. These could be readily accessible from within the automated chart and selected in advance based on information extracted from the chart by the search tool.

The Internet is a cost-effective way to keep abreast of changing issues. It is currently possible to send an interest profile to a service that will continuously scan several sites on the Internet looking for items that match the subscriber's profile. Once found it can then forward these items to the subscriber's e-mail box or display it on the screen while the computer is idle. This could be quite useful to a practitioner with a very focused area of interest so that he may be kept abreast of any new developments in his area.

The network would make it easier for providers to check the latest eligibility and insurance requirements specific to the patient in their exam room. Drug formularies for the patient's plan along with current wholesale prices can be within easy reach of the provider.

The Internet and the World Wide Web provide an ideal platform upon which to deliver a multimedia textbook for use by the provider. The provider, while wrestling with a particularly difficult problem, could use an interactive teaching tool. Once completed the provider could be given a series of questions demonstrating her knowledge of the material. This could then be submitted for educational credit. Publishers could maintain up-to-date CME resources by modifying the information at the Web site instead of having to format, print and distribute documents or updated CD-ROMs. Learning is enhanced when it occurs when it is needed at the point of care,

Using Web tools, a medical record system no longer has to be tied to a particular computer system. This allows the authenticated user access to a patient record regardless of the type of computer he is using or the type of machine upon which the record is stored. The Web can provide a common language and consistent interface for information display. There are several institutions developing Web based hospital information systems allowing secure access to patient records from inside and outside the facility.

One clear beneficiary of this network and what may become the driving force behind its development for health care is the managed care organization. Cost containment, practice guidelines and outcomes research are all facilitated by this network. Providing health information to patients has been proven to reduce cost. Electronically linking diagnoses and treatment plans to outcomes across the practice network will allow for more efficient guideline development. Blue Cross and Blue Shield of Massachusetts has a Web site that provides an example of the link between the heath plan and the enrollee.

Just as the network can allow secure access to patient records, it can also allow different levels of access depending on the individual's health plan. A well designed page providing access to relevant health and fitness information could attract health conscious consumers to participate in the health plan.

The Internet evolved as a network to allow collaboration between distant researchers using different computer systems. Consequently it is well suited to support a geographically distributed organization such as a health care system. As the Internet reaches into rural communities, it becomes easier for the health system to utilize existing networks to link distant facilities. Data could pass over this growing infrastructure in a secure fashion using encryption algorithms developed for secure commercial transactions.

Provider lists, maps to their offices, health plans, specialty services, parking facilities, average wait times, results of patient satisfaction surveys and countless other items could all be provided to the consumer in an interactive fashion.

Because if its recent popularity, the Internet is reaching into more and more American homes. Since it was designed to allow different computer systems to interact with each other and has maintained this "platform independence" it has become the ideal medium to link together information from all kinds of large computer systems and deliver it to a variety of personal computers. In addition, it creates a level playing field for information sharing. Since the Internet was designed to link computers as "peers" it enables anyone with a computer connected to the Internet to become a publisher. Finally since the commercial sector sees the Web as having tremendous opportunity for commerce, designers of Web client and server software are working aggressively to create secure robust systems that will become the dominant platform. This ubiquity, platform independence and competition has set the stage for a continued rapid evolution of this network with features ideal to help facilitate the delivery of quality health care.

"The Medical List" an excellent list of medical resources on the Internet assembled by Dr. Gary Malet:
http://www.medmatrix.org/index.asp

Blue Cross / Blue Shield of Massachusetts - has an interesting physician locator among other tools:
http://www.bcbsma.com/

American Academy of Family Physicians - patient information and information for members:
http://www.aafp.org/

Paul Kleeberg, M.D.          O   o         Paul@Allina.Com

Allina Health System        -+---+-    Voice: 612-775-1338

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