Delivering Clinical Information Over the World Wide Web

The speed at which the Internet and World Wide Web have been accepted has not often been matched in the history of new technologies. While the Internet was invented in the 1960's, it did not become commercially available until the late 1980's. Yet, today, both are household words. Consumer print and television advertising commonly contain advertisers' World Wide Web addresses. Previews in movie theaters contain World Wide Web addresses of studios producing the movies. Even children's magazines have their own web sites.

Potential uses of these technologies in health care are great. According to noted author and professor of management, Peter Drucker, health care is one of the most information intensive industries. James Barksdale, CEO and founder of Netscape, says "the Internet is the printing press of the technological era".

The Internet was created in the 1960's as a backbone communication network to provide reliable communications in the event of war. Over time, access to the Internet was granted to universities and research institutions working on Department of Defense research. In the early 1980's, most military and government usage had shifted to a new networked called MILNET and the operation of the Internet was turned over to the National Science Foundation. [Muscarella, Jeffrey and Hoben, John. "Delivering Information Services Via The World Wide Web". Proceedings of the 1996 Annual HIMSS Conference].

In the 1980's, the Internet began growing at a greatly accelerated rate. In 1983, the Internet consisted of 500 host computers in the military and universities. By 1987, the Internet had grown to over 28,000 host computers. By 1993, the Internet consisted of over 3,000,000 host computers. [ibid.] Today, there are estimated to be over 100,000 networks connected and at least 40 million regular users of the Internet in the U.S. and at least another 40 million users worldwide. [Hardin, William and Masys, Daniel and McDonald, Clement and Voran, David. "Medicine Across the Internet", Proceedings of the 1997 Annual HIMSS Conference]. Before 1991, the Internet's primary purpose was to provide a method for scientists to exchange information electronically. The National Science Foundation, which governs use of the Internet, had a policy that significantly restricted for-profit use to the Internet. In 1991 the National Science Foundation relaxed its restrictions on commercial uses of the Internet and today, the for-profit uses of the Internet are virtually limitless.

It is said that the World Wide Web did for the Internet what Microsoft Windows did for Microsoft DOS - made it easy to use so people would want to use it. The World Wide Web harnesses the power of the Internet and its supporting technologies so the public at large can use it easily.

The Web began to address the document sharing needs of a group of geographically diverse scientists associated with a European research organization called CERN. They wanted to share documents among themselves so that a scientist, anywhere in the world, could view the work of any other scientist in the group. They envisioned a system by which documents could be posted electronically and linked to one another through visible links. This technology was called hypertext. Their proposal was to create a web of linked documents that was available around the world, hence the name, World Wide Web. By 1990, they had implemented the user interface called a Browser. Over the next several years, a number of organizations developed software to support the World Wide Web. One organization worthy of note was the National Center for Supercomputer Applications in Champaign, IL. They developed a Browser called Mosaic. Mosaic was significant in that the Browsers that are most common today are based upon Mosaic.

Browsers are important because they are the user interface to the World Wide Web. A Browser can be thought of as being similar to the remote control for a television set. The content on television is arranged on channels: NBC, CNN, HBO, for example. The television remote control allows one to -surf+ the channels on the television to select available content. Information on the World Wide Web is contained on Pages. The Browser allows one to "surf" the pages of information contained on the World Wide Web.

Besides providing the communication infrastructure to support open exchange of information between computers and users around the world, the Internet offers several related technologies that make the Internet useful.

Electronic Mail lets users address messages to other Internet users around the world simply by knowing their Internet address.

List Servers provide a tool for automatically forwarding electronic mail messages to a large group of users.

News Groups are electronic bulletin boards where Internet users can post messages for the rest of the Internet community. Messages posted in News Groups can be replied to by any Internet user. There are thousands of News Groups on every subject imaginable.

Internet Relay Chat or IRC is a tool for establishing real time communication between two or more users of the Internet so that they can converse dynamically. IRC is the Internet equivalent of a telephone conversation.

Uniform Resource Locators or URL's are the mean by which the pages of information on the World Wide Web are identified. URL's are denoted using a notation like this:

Hyper Text Transfer Protocol, or HTTP, is the protocol or rules used to transfer World Wide Web information through the Internet.

Hyper Text Markup Language, or HTML, is the language used to define pages of information on the World Wide Web.

The appeal of the Internet and World Wide Web as information delivery vehicles is the wide acceptance of technology among the general public. It is estimated that over 12.7 million households will have access to the Internet and World Wide Web by the end of 1996. [Athanassiades, Dean. "Internet Usage by HIMSS Member", Georgia HIMSS Quarterly Newsletter, June 1996].

In a survey directed to members of the Healthcare Information Management and Systems Society (HIMSS), seventy-three percent of the respondents either have or plan to have Internet and World Wide Web access. ["Delivering Information Services via the World Wide Web", Proceedings of the 1996 Annual HIMSS Conference]. Eight percent of respondents to the 1997 HIMSS/Hewlett-Packard Leadership Survey indicated that they plan to implement data delivery systems that would connect all computers and databases in their enterprises to one another using the "browser" technologies created for the World Wide Web and global Internet.

Among health care professionals, it is hard to imagine a recent college graduate who has not been exposed to the World Wide Web. The nation's medical and nursing schools are producing graduates who are World Wide Web knowledgeable and feel comfortable accessing information in this manner. For this reason, delivering clinical information in this format can make sense.

Research suggests that Internet and World Wide Web usage by physicians is significantly greater than the general population with 25-30 percent or more of all physicians currently on-line. ["Medicine Across the Internet", Proceedings for the 1997 Annual HIMSS Conference]. Some physicians regularly communicate with their patients through the Internet. At the University of Kansas, Dr. David Voran estimates that nearly thirty percent of his patients use the Internet to communicate with him. [ibid.]

There are thousands of pages of information on the World Wide Web that could be of interest to clinicians. Following are examples of World Wide Web pages that can deliver useful clinical information:

Hospital Net is resource a for doctors, nurses, patients, and medical students. [Hospital Net Web Page: http://www.hospital.net]. It contains:

Columbia-HCA's page has received many awards for its format and content. [Columbia-HCA Web Page: http://www.columbia.net]. It is one of the most heavily accessed sites anywhere on the World Wide Web. Besides marketing and financial information that is directed towards consumers, Columbia's page contains a section where nurses are invited to gather and post information of common interest.

Modern Healthcare Magazine's page is a good example of electronic publishing related to health care.[Modern Healthcare Web Page: http://www/modernhealthcare.com]. It is updated on a daily basis. It contains industry news and back issues of the printed publication.

HealthSeek is a product of Reuters Health Information Service. [HealthSeek Web Page: http://www.healthseek.com]. It contains a variety of services including sections on:

Advanced Practice
Allied Health
Anesthesiology
Biomedical and Biotechnology
Cardiology
Chiropractic
Dental
Dermatology
Emergency Medical
Hospitals

Nursing
Optometry/Ophthalmology
Pharmaceutical
Pediatrics
Podiatry
Psychiatry
Respiratory Therapy
Surgery
Telemedicine

Grateful Med is the Internet version of the commercially available Medline database. Medline is the premier database of references and abstracts maintained by the National Library of Medicine. Almost 50,000 physicians have Medline accounts compared with a handful just a few years ago. In 1995, 7.3 million searches were done on Medline, with over 4 million of them relating to patient care. [Jaklevic, Mary Chris. -Medical Data Accessible on Internet+, Modern Healthcare-May 6, 1996:82].

Onco Link is the University of Pennsylvania Cancer Center+s page on World Wide Web. [Oncolink Web Page: http://www.oncolink.upenn.edu]. It was the first comprehensive multimedia cancer information resource on the Web. Its author developed it as an experiment to see if this type of communication media would be useful for the distribution of cancer information to patients, physicians, and health care workers.[Magellan Internet Guide Web Page: http://magellan.mckinley.com]. Two months after its launch, it won a Best of the Web award for professionally developed Web sites.

The Interactive Patient page developed by Marshall University gives medical students and physicians the opportunity to examine simulated patients and match their diagnosis with the actual case. This page received a four star award from the Magellan Internet Guide for its content.[ibid.]

Medscape is a free Web site for health care professionals. Practice oriented information is peer-reviewed and edited by leaders in the fields of AIDS, infectious diseases, urology, and surgery. Continuing Medical Education credit is available on articles in each topic. [Medscape Web Page: http://wwwmedscape.com].

The Children's Hospital of Alabama has developed a comprehensive Web presence that includes many examples of education directed towards clinicians and patients. Their Child Safety Forum page highlights safety issues for young children [Hardin William and Masys, Daniel and McDonald, Clement and Voran, David. -Medicine Across the Internet+. Proceedings of the 1997 Annual HIMSS Conference.

The University of Alabama Medical School has taken grand rounds presentations and converted them to Internet based education complete with text, computer graphics, and images. Courses include a post-test, an e-mail ask-the-professor capability, and the ability to obtain CME credit. The University also has an effort underway to offer portions of the Medical School's core curriculum over the Internet. [ibid.]

Virtual Electronic Medical Record The University of Virginia Medical Center, Virginia Neurological Institute, and Hewlett-Packard collaborated on a project to enable viewing of patient records in a paperless environment. The application, called the Virtual Electronic Medical Record (VEMR) collects patients information form the Medical Center+s vast array of information systems and presents it, in hypertext, using the NetScape Browser [Kazmer, James and Crosby, Alexander and Oliver, Katie. "The Creation of a Virtual Electronic Medical Record". Proceedings of the 1996 Annual HIMSS Conference].

Columbia-Presbyterian Medical Center has developed a prototype that demonstrates some possibilities for accessing information through the World Wide Web. This application ties patient information with test results, discharge summaries, radiology reports, and images from ECG's and x-rays. It allows querying of the medical centers clinical data repository. The application also contains links to other applications on the Internet like Medline and the Physicians Desk Reference [Columbia-Presbyterian Medical Center Web Page: http://www.cpmc.columbia.edu/cisdemo]

Kansas University Medical Center has developed a link between its e-mail system and its radiology system. When a radiologist's dictation is transcribed by the radiology system, it is automatically e-mailed to the attending physician. The physician can also log on to the clinical web server and use a web browser to view the x-ray which is presented as a digitized image and download it to a local personal computer. Once downloaded, the physician can use standard office productivity tools to attach it to a document, annotate it, and if the patient has e-mail, actually forward the x-ray image to the patient ["Medicine Across the Internet", Proceedings of the 1997 Annual HIMSS Conference].

Software companies that have developed clinical systems are Web-enabling those systems based to meet market needs. Hewlett-Packard Company+s Medical Products Group is a developer of a number of departmental clinical information systems. At the 1996 HIMSS conference, they demonstrated a Web-enable version of their HP Care Vue critical care clinical information system.

Security is most often described as a major obstacle in deployment of these technologies. Clinical information can be confidential if it deals with patient records. Any electronic delivery system must provide appropriate levels of security.

When exchanging patient-identifiable information over a network, it is necessary to:

The Web has made it simple to disseminate information around the world instantly. With this capability comes increased responsibility on the part of users to validate their sources. For example, the contents of printed medical journals are validated by its editorial board before publication. This provides a high degree of confidence in the accuracy of the contents of these publications. However, anyone can publish on the Web. It is up to the user of the information to validate that information.

Future uses of the Internet and World Wide Web to Deliver Clinical Information

In the future, several factors are likely to increase the use of the Internet and World Wide Web to deliver clinical information:

These factors will enable clinicians to obtain information over the World Wide Web in ways that can make a significant impact on the health care delivery system. As information appliances are developed to enable easy access to the Web from home, patient education will be conducted over the Web. Interactive capabilities will allow the education to be delivered in a self-paced manner but also allow real-time interaction with a clinician when needed. Also, new types of measurement appliances in the home will collect physiological measurements from patients without requiring a visit to the doctor's office.