Dr. Joseph Woo *
About 240 million people around the world now goes on-line. The world wide web grows by roughly a million pages per day and the number of web pages double every 3 months. The number of Internet hosts has reached 55 million of which over 200,000 sites are health-related. The implications of the Internet for healthcare are increasingly understood as scientists, healthcare workers, patients and health administrators envision new applications, new means for communicating about health issues, and new ways of accessing pertinent health information at the point of care. A phenomenal amount of medical information is now present, facilitated by the virtually unrestricted ability to publish on the Internet.
Sight, sound, and even touch will be integrated through powerful computers, displays, and networks. Patients will eventually be able to videoconference with their healthcare providers, and the internet will increasingly be used for transmitting clinical data, linked with and integrated into educational resources and clinical information systems. The access and dissemination of medical information towards the next Millennium is likely to take another quantum leap. I would like here to outline some of the eventualities.
The Internet will transform and revolutionarize science itself by opening new ways of scholarly communications and publication.
The e-journal is now getting some 40,000 access each week. A questionnaire survey of website visitors showed that the eBMJ is reaching people with little previous contact with the journal and one third of them has never seen the paper version. It was also found most would still prefer to keep a copy of the paper journal.
Papers published using the world wide web has a good number of important advantages and some fundamental differences to that of a paper publication:
Although commercial concern have to be addressed, many journals will follow suit to put up their e-versions on the Internet. It will be important to see who will eventually make these decisions, how these decisions will come about and how new rules will be implemented.
More and more omnidirectional Health sites, or Health Portals as they are now called will spring up despite harsh commercial competition. As Information Technology stocks climb to unrealistic heights money is injected into providers of these health information. A recent study from Georgia in the United States showed that at least 5% of Americans visit a health website regularly everyday.
Many of these Web sites do provide up to date and accurate medical information which may not be readily accessible through the ordinary paper publication and journals. These website pages appear also to have become the preferred medium for acquiring focused medical and health information, as compared to listservers, discussions groups and newsgroups.
The Medical community will eventually have to develop quality guidelines and perform scaledown peer-reviews. Solutions proposed also include self labelling of medical information by web authors in combination with a systematised critical appraisal of health related information by users and third parties using a validated standard such as the PICS (platform for internet content selection). Doctors, medical societies, and associations could critically appraise internet information and act as "label services" to rate the value and trustworthiness of information.
The Internet has experienced a truely exponential growth in the last decade. The inventors of the Internet some 30 years ago could not have possibly conceived the importance and significance of their creation on communication, retrieval and dissemination of information in the public domain and how it has now affected the life of so many. The Internet provides a communication media superceding in many folds that of the conventional telephone or television. Via apparantly complicated hypertext protocols that embody browser-based graphics, text, animation and streaming media computers talk to each other through simple clickable interfaces bipassing geographical boundaries and conventional humanistic rituals that is commonplace in communication.
v Electronic Medical Publishing comes of age
v Rapid growth of Internet Health Portals and Consummerism
v Medical Education and Continuing Medical Education running on
Intranets, digital subscriber lines (DSL) and Internet2
v Mobile medical database and Multimedia Virtual Congresses
v Personal data gets onto the Internet and smart chips, online
consultations and vertical portals
v Telemedicine consultaion, image transmission, tele-surgery
and tele-mentoring
v Education in Medical Informatics and Research moving ahead
Electronic Medical Publishing comes of age
Full-text articles are presently retreivable on many medical journals websites including the Lancet and New England Journal of Medicine. The electronic versions are opened however only to registered users who hold a subscription of the paper journal. Such is the philosophy behind electronic publishing for a long time which is considered financially sound and logistically acceptable. The British Medical Journal (BMJ) launched it's free full text website in April 1998, with the mission "to continue to help doctors worldwide practise better medicine and influencing the international debate on health", rather than strictly for a commercial concern.
A good example of an e-article which embraces some of these advantages can be seen here.
The entire practice of medical publishing will change with the growth of the Internet. Problems will no doubt emerge involving areas such as editorial organization, copyright, commercial logistics and attitudes of contributors.
Rapid growth of Internet Health Portals and Consummerism
High traffic and the idea of making some good money out of a heathcare website encourages the launching of newer, larger and more comprehensive and innovative sites. In May, WebMD, a website providing medical information to doctors and consumers, which began operating only six months previously was sold for a staggering 5.5 billion US dollars. Another consumer/provider healthsite Drkoop.com was valued at 48 million US dollars at its initial public offering in June. The site is currently having an online traffic of 4 million hits per month. 
CBS bought a 35% stake in Medscape, a reputable website for doctors which has just been recently extended to consumers (renamed CBS HealthWatch). HealthAnswers.com, another big brother in the healthcare website arena, has recently expanded their operations in Hong Kong and the growing Chinese speaking market.
More and more consumers have also been noted to be looking for information from professional medical websites. For the first time in Medicine's history consumers have the same access to the knowledge database as the medical personnel. Annual MEDLINE database access has increased from 7 million in 1996 to 200 million in 1999, and the increase has been attributed to lay public involvement. These informed patients will be a driving force for clinicians to update themselves, particularly via the Internet to know what their patients are reading and would become more aware of the mechanics of evidence-based-medicine. Health professionals will also face increasing pressure from the public to use these evidences.
In a recent survey from HON, the Health on the Net Foundation which monitors the quality of health websites on the Internet, it was found that consummers prefer first to visit not-for-profit Web sites and then hospital Web sites. (An international initiative, HON is a not-for-profit organisation headquartered in Geneva, Switzerland. HON is dedicated to realising the benefits of the Internet and related technologies in the fields of health and medicine.)
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It is still a matter of debate whether the typical patient can translate what they read directly into better health, or becoming confused and hypochondriac to their ailments. The question of how much patients' ability to access more information about their disease really effects their quality of life is still open. Nevertheless many patients will probably use this information to outsmart their physicians by confronting them with "anecdotes" from the internet. This is often referred to as being one of the negative sides of medical information on the internet as it puts strain on the patient-physician relationship, although we can also regard this as a positive incentive for doctors to learn how to use the electronic evidence based resources.
Results of trials of surgery plus radiotherapy versus surgery plus radiotherapy plus chemotherapy from a paper: Chemotherapy in non-small cell lung cancer in the BMJ (1995;311:899-909)
Some of the more educated patients are reading materials like this and will question the clinician's decision basing on these and similar articles
Medical Education and Continuing Medical Education running on Intranets, Digital subscriber lines and Internet2
Medical education is poised to undergo another step in its evolution. Biomedical knowledge is developing rapidly, adding up to the information overload already evident in the traditional curricula. Doctors can neither carry the entire knowledge that comprises medicine in their head, nor can they readily keep it up to date. Storage in the electronic media appear to be a practical alternative.
The Internet combined with browser-based graphics, animation and streaming media offer a voluminous venue to educate and communicate. Already many medical schools is having their entire lecture schedules and curriculum running on intranets of local area networks (Lan) and wide area networks (Wan). Intranets are private Internets running on the same Internet protocols and using the same hypertext markup language (HTML). The speed for downloads and data transfer are many time faster then the phoneline-modem network.
Students may be able to download multimedia lectures, view announcements and scores, joint in discussions, and hand in their assignments while working from home or their dormitories. Internet technology has also allowed a higher level of communication between staff and students and student to student than would have been possible with traditional means.
High capacity broadband transmissions basing on Asymmetric digital subscriber lines (ADSL) and cable-modems will soon become commonplace allowing hundred times faster transmission abilities (1.5 Mbps). ADSL facilities are already widely accessible in the United States and prices have come down quite drastically in the past 6 months. The Internet2 initiative which has been off the drawing board since early 1999 is a new network administered by the University Corporation for Advanced Internet Development (UCAID), a consortium of private and educational organizations. Its goals are to promote development of advanced research, educational and health-care applications, such as distance learning, digital libraries and "collaboratories"; support advances in communications infrastructure - particularly quality-of-service improvements; and coordinate the transfer of technology from Internet2 participants to the commercial Internet. Internet2 willl be focused on the needs of academia first, but is expected to develop technologies and applications that will eventually make their way into the rest of society.
At the present, Internet2:
- is supported by 150 academic Institutions in the United States,
- has been funded by large companies such as IBM, Cisco, Lucent, Microsoft and Nortel,
- transfers data at 2.4 gigibits/sec, or 45,000 times faster than a 56K modem,
- will have no bottleneck along the transmission path,
- allows a number of applications to be developed including the innovative nanoManupulator technology which uses "force-feedback" to "feel" a distant object.
The Next Generation Internet (NGI), another networking initiative partly funded by the US government concentrates on the development of advanced and ultra-high speed networks. It seeks to connect U.S. universities and national laboratories with high-speed networks that are 100 to 1,000 times faster than the Internet. NGI plans to knit two test beds out of four high-speed networks run by NASA, the National Science Foundation and the departments of Defense and Energy. The commercial and 'public' Internet will soon benefit and be transformed by these Initiatives.
The internet itself is the largest source of CME information. In the next decade it is forseeable that those who have no access to the Internet may be considered non-compliant to CME and Continuing Professional Development (CPD).
According to a recent study from Iowa, United States, University-sponsored Internet sites were the most common sites providing any CME information (44%). The next most common sites were commercial sites (26%). However, most (75%) university-sponsored sites offered only schedule information for traditional CME courses only. By contrast, 42% of commercial sites offered on-line CME. Thus, in absolute numbers, more commercial sites than university sites offer on-line CME content. Out of these, between 60 and 80% of the sites offering Online CME provide good quality reviewed material. University sites are better than commercial sites in terms of standards.
The Internet is beginning to provide opportunities for more commercially runned physician CME and with more and more attention being paid to standards. Universities may eventually be losing their traditional leadership in CME basing on the new Internet medium. The CME Gateway for example, which is published by the Medical Education Collaborative, is a leading and high quality CME provider in the United States. Commercial sites however may have a market agenda in providing information and many of the commercial sites providing CME do not charge for the CME credits. Academic bodies such as the Accreditation Council for Continuing Medical Education (ACCME) in the United States can however be set up to oversee standards and integrity of CME materials and accreditation.
Important papers presented at selected conferences are currently posted by sites such as Medscape and users can earn CME points at home without physically going to these conferences.
Mobile Medical Database and Multimedia Virtual Congresses
Not before long, doctors doing ward rounds will be carrying with them mobile palmtop PCs, where medical data and patient management information are downloaded every month from the Internet. Drug dosages, interactions and management options and protocols basing on evidence-based data can be looked up instantaneously before, during and after a ward round.
One can also get quick answers to questions like "Does famotidine intereact with sildenafil? " or "Does hormonal replacement therapy after menopause increase the risk of breast cancer?" from these portable PCs. Such database will likely be marketed from commercial providers who will compete heavily on the comprehensiveness of contents and ease of navigation.
There may be far-reaching implications to the practice of clinical medicine, probably to the benefits of all parties concerned, as doctors will become immensely knowledgeble and accurate, or at least they will be expected to be so. More advanced and user-friendly Hospital Information Systems will be developed which will incoporate these as well as patient's database for downloading on to the mobile PCs.Wearable computer components such as CPUs and TFT eye-screens may catch on and soon become practical and fashionable.
Virtual congresses are layout like an ordinary congress with a conglomerate of lectures, seminars and workshops accessible via the Internet. They can be on-going like a Broadway show! A good example is the recent Congress hosted by the Australasian College of Surgeons.
More of such will come particularly with the advent of broadband digital subscriber lines (DSL) internet access. Using javascripts language, active server page technology (ASP), XML (Extensible markup language) and other authoring protocols, the client side application will be able to listen to streaming audio and watch streaming video of speakers on stage along side their synchronised powerpoint slides in an adjacent window.
Microsoft also holds a number of their Internet seminars in these fashion to teach their applications. Take a look at one of their Windows 2000 online course-seminar here. With broadband and ADSL coming into the scene not for long, smooth full screen streaming videos will become common place. It is also anticipated that large scale International events such as the Olympic games will be broadcasted on the computer monitor. It has a greater advantage over the television in that one can click and select which event to watch and with all the accompanying text data.
It remains to be seen if these Congresses will be commercially viable and popular.
Personal data gets onto the Internet and smart chips, online consultations and Vertical portals
The practice of Medicine may undergo a dramatic change with patient's detailed medical data uploaded onto the Internet either for record-lookup-retrieval purposes or assessment and consultation by a third party. Security problems though may be present is likely to be easily overcome.
A digital portfolio of a patient can be put up on the Internet, containing vital and pertinent data of that patient such as blood pressure, blood group, past health, allergies, special precautions, and other relevant informations such as lab test results and biopsies results. They could be used for a third party consultation or more importantly such information can be made available to a physician at the time of emergency when he or she may be travelling outside of his country. In 5 to 10 years time a person's entire medical history (including possibly the entire sequence of his or her genome) may also be stored on a smartcard, or in a bracelet on his wrist or somewhere embedded in his body.
Cancerfacts.com is one of these new sites which uses a patient profiler engine to assist patients to put up these data on the Internet. They can use the facilities at the site to gain more insight into the management and treatment options of his particular disease.
These type of 'Vertical' portals is likely to flourish. Putting up data on the Internet would involve some form-filling and a brief security exercise ( passwords, for example), the whole procedure being free of charge and carries the very real promise of saving lives at the time of emergency.
Online Consultations and e-medicine as it is called has been commercially available for some months. CyberDocs.com takes non-urgent as well as emergency medical consultations wordwide and charges a fee. Medical dispensing is also available although the health implications of these practices will need to be carefully evaluated.
Telemedicine consultation, image transmission, tele-sugery and tele-mentoring
The field of telemedicine has been moving forward very rapidly in the past 2-3 years.Temedicine is the delivery of health care and the exchange of health care information across distances using telecommunications technology. It can include the transfer of basic patient information over computer networks , the transfer of images such as radiographs, CT scans, MRIs, Ultrasound studies, pathology images, video images of endoscopic or other procedures, patient interviews and examinations, consultations with medical specialists, and health care educational activities. An excellent article on the technical developments of tele-medicine in the next decade can be found here.
Research and advances are progressive in areas of compression, storage and internet/non-internet transmission standards, networking (ATM, ISDN, ADSL, TCP V4,5), medical Image tranfer, high data rate satellite communications, biomedical sensors and telemetry for remote monitoring of patients (RMP), tele-surgery and virtual reality and visualization tools for medical education and diagnosis.
Home consultation and monitoring have already been implemented in a number of centers. Researchers are actively experimenting with the Internet as a tool to monitor patients' chronic conditions at home basing on Internet videoconference technology. A number of patented new devices for this purpose are already on the market.
The vision of telesurgery comprises a multitude of new communicative elements influencing the way physicians and surgeons will treat their patients in the future. Certainly this may take some time to realise. Surgery will no longer be limited to what can be seen with the naked eye or felt by the human hand; 3D imaging and telepresence surgery extend the reach beyond these limits.
Experimental telesurgical procedures are already in progress (see an Australian telesurgery demonstration in Sydney) and surgeries are carried out using computer robotics many miles away. At the Human Machine Systems Laboratory (MMSL Telesugery) website at MIT, one can find pictures of the setup. Several IT firms such as "Intuitive Surgical" in the United States have already developed an array of systems to operate surgical instruments using remote controls via special phone lines. A new journal "Computer aided Surgery" has been launched devoting to the subject.
Tele-education and tele-mentoring will permit further extension of the educational process directly into the operating room. Observation of the surgeon's performance through video-conferencing and tele-illustration forms the mentoring process. The question arises whether this same capability will be used for certification through CPD (continuing professional development) revalidation. A number of nontechnical and ethical issues must be resolved before there can be widespread acceptance.
Education in Medical Informatics and Research moving ahead
There is growing awareness that education and training in Medical informatics should be an integral part of Medical education as the doctor will eventually be involved one way or the other with either a hospital informational system, a community based data collection project or simply information retrieval on the Internet.
The implications of the Internet for Healthcare are increasingly understood as scientists, health workers, patients and health admisnistrators envision new applications, new means for communicating about health issues, and new ways of accessing pertinent health information at the point of care. It is important to study not only the new technologies themselves, but to recognize that the optimal use of these technologies requires new skills by users.
Health Informatics program has now been incoporated into the medical curriculum at the University of London and many North American Universities. At the University of Melbourne, students are taught the use of computers in clinical practice (both in a hospital as well as a clinic setting) so that they will be proficient and comfortable with their use after graduation. Case-based and problem-based modules are being used to teach students computer skills in Information retrieval and management. Internet and email skills are mandatory learning modules as well as the stratification and qualitization of data.
Diploma or certificate courses in Medical Informatics are important towards this goal as well as for the purpose of Continuing Professional Development in this modern era. The curriculum should contain the use of electronic information services and apllications, databases, presentation and analysis tools, comparison of softwares solutions, electronic communication and collaborational tools. There should also be a broad understanding of the field of Health and Medical Informatics, including basic computing concepts, advantages (and disadvantages) of the application of IT in Healthcare situations and the concept of professional healthcare workers as knowledge workers and information users.
Research in Medical Informatics should follow the same stringent rules of research in other areas of Medicine. Projects on the Impact of the Internet on Public health, Use on online CME engines for delivery of CME, effectiveness of clinical trial data entry websites, effectiveness as specific web-based Information excahnge in medical education, health networks, legal and ethical issues as well as issues relating to the quality of online material should be studied systematically with the same rigorous conventional statistical methodology.
With so much technology push and consumer pull, there is little doubt that the internet will experience dramatic changes as we move into the very first decade of the next millennium. One major revolution that is anticipated by many will be the "quantitative leap," basing on ADSL transmissions, 'Internet2' and the 'next generation internet' Initiatives to free today's internet from some of its technical limitations.
Accompanying that would be the constant transformation of the quality of information, linking as well as retrieval possibilities. Server page technologies, authoring languages and protocols will be extended to tag contents rather than the page layouts, which will further open up unforseeable connecting capabilities between human readable material and machine understandable information.
The Internet as it is today is already opening up a formidable amount of opportunities for endless future developments. It's forseeable impact on consummerism, medical education, CME, electronic publishing, clinical information systems, telemedicine, medical practice ideology, and acute and chronic patient care cannot be overstated. Disciplined research in medical Internet applications will be necessary to complement and make use of the rapid progress in Internet technology. On the other hand, humanistic, social, ethical and behavioural factors must be taken into account and carefully evaluated although effective methods for doing so have yet to be determined.
* Dr. Joseph SK Woo is an Obstetrician and Gynaecologist in private practice, and is a Fellow of the Hong Kong College of Obstetricians and Gynaecologists.