An Introduction to Cyberspace for Medical Professionals BY Sheldon Chang, MSPT Physical Therapist

The day to day life of a health care provider is already packed with more than enough complications and worries. New legal issues always threaten to change the way health care can and cannot be delivered, reimbursement schemes must be juggled, standards of care are jeopardized by needing to cost cut, and developments in the scientific issues of one's profession demand attention. In light of the things that already demand time and energy, facing the steep learning curve of integrating new and unproven technologies may be a red herring that leads clinicians away from more critical things that demand immediate attention.

Going back to the fax machine analogy, a computer and a modem are only as useful as people they open access to. If the majority of the profession continues to rely solely on the traditional printed forms of media, the advantages the on-line medium may offer will stagnate. Implementations of technology tend to demand full commitment to be effective. When new technologies are only embraced halfway, both the old way of doing things and the new way suffer. [46] In an institution as old and conservative as medicine, resistance to changes is likely.

Productivity? What Productivity?

It's been said that technology improves nothing, but merely changes them. The increased productivity gained with fast computers and modern software is balanced on the other end by the downtime suffered from devastating system failures, fixing software, and learning new programs. [44, 45] Cost cutting schemes involving computers do not always result in decreased costs. Even after the initial investment in a modern computer system is accounted for, technical support, programming, software development, and other unforeseen needs for computer services may necessitate further expenditures. Outside of the immediate work environment, software incompatibilities between different healthcare facilities may result in difficulty exchanging data. When computer technology works, it works magnificently. When it fails, it is often complete. [44]

In past studies of computer usage in the business world, computers have not been shown to be a consistent productivity booster. Beside the obvious computer problems, they may also hinder the primary productivity of the more computer literate individuals within an organization by requiring the need for their time as informal tech support. Better formal tech support services may eliminate the need for members within departments to spend time performing computer services, but to implement computer technology into non-computer oriented organizations, there appears to be a specific need for within department informal tech support. [46]

Though the media likes to highlight healthcare disasters via the Internet, the truth is probably that more often than not, patients benefit from having access to medical information on-line.

New applications and upgrades to existing software present another piece of the computer productivity puzzle. Computer-literacy is not a level of achievement, but a dynamic skill. [48] Many people who are good at using computers are not so much knowledgeable with technology than they are intuitive with it. When familiar software is upgraded or replaced altogether, it frequently also changes the way the program is used. Everyone who was able to use the computer before by a static procedural knowledge is suddenly lost (and unproductive).

The lack of universal standards in any corner of the market driven Internet world only exacerbates the difficulty of becoming adept with computers and the Internet. At a time of rapid growth as the Internet is currently in and will continue to be in for some time to come, standards are impossible. The charm of the Internet's open information and software environment is that it allows for innovation that would otherwise be stifled. The tradeoff is its characteristic lack of structure and consistency that makes it so confusing for many people.

Cutting edge information and products may sometimes reward those who put up with the chaos of the Internet, but unfortunately, the open environment and rapidly changing applications of computer programs also creates profound technical and user problems that can cascade into a computing and information nightmare. Computer crashes, software compatibility issues resulting in unusable information, copyright fears, and questions over validity of information among other things make transition into the on-line world a difficult one.

The Internet in healthcare practice is not for everyone needless to say. The notion that everyone else is doing it, is not a good rationale for changing the way things are done. Not everyone has to be (nor should be) a pioneer. Medicine and society will always need the consistent steadfast traditionals who remain guardian, developers, and promoters of the classic values and skills of a profession. Careers will not fall apart for the sole reason of being non-computer literate.

Getting on-line does not equal being on-line

Even if a large percentage of professionals in a given field are on-line, they still need to become proficient in basic on-line skills to gain much practical use out of the Internet. Point and click alone only gets you so far. Developing a nose for good information, understanding social context on-line, and communicating effectively across a non-verbal channel of mass communication are only a few on-line skills that may require several years of experience to master.

The Internet in general has become a place of too many "newbies" and too few mentors. The chaos that results from the dramatic growth in the user count of the Internet is evident in the messages of almost any mailing list, newsgroup, or other group forum. Most new users know just enough about computers and the Internet to make life more difficult for other people on-line.

For many of the old timers on the Internet, the attitude toward the growth of the Net has been a love-hate relationship. While the more people there are on-line, the better the chances are for quality information getting on-line, a greater danger of decreasing the signal to noise ratio also exists. Prior to the rapid expansion of the Internet, new users who broke the rules and were of annoyance to on-line communities were quickly and sternly corrected by veteran users. In recent years, the rapid growth has overwhelmed the socialization process that once earned the Internet the label of a "functional anarchy."

Even with the proliferation of access to the Internet allowing for better cost efficiency of long distance medical care, it may still be too early to tell if the strongly interpersonal medical professions are ready to integrate "virtual patient care" into their daily routines. The evidence of history suggests that we are less than ready, especially when considering that the medical professions generally are somewhat conservative in their ways and behind the times in taking advantage of technology. It would not be reasonable to expect health care providers who do not use computers in their daily practices to suddenly integrate smart video conferencing software such as CUSeeMe into their daily practices.

...for the healthcare provider stumped with the task of providing a patient with information about rare conditions, quick and useful answers may finally be at hand on the Internet.

Though better and better applications are being developed that are easier to use and rely on a better developed infrastructure than in past telemedicine failures, the brisk march of technology may make current developments "obsolete" by the time we are ready for them. Even if all goes well on the development and integration end, the commercial sector of telecommunications is a confounding variable rarely mentioned. Telecommunication company dominance on high end services such as ISDN previously resulted in high prices and complaints of poor service quality, [19] effectively keeping smaller institutions and individuals from utilizing and contributing to on-line healthcare resources.

If telemedicine flops again this time around, the new opportunities now available for telemedicine practices may remain around as a cult following. They will work and even prosper, but once again at the cost of a bill too large to justify for fringe success.

Some of the drawbacks of the electronic forum have nothing to do with ability to use computer technology, but with new ways to be struck by old dangers. The risks of plagiarism and copyright infringement have never been higher than they are on-line. Electronic texts are easily reproduced and ideas can be stolen with little evidence to authenticate the original owner of the intellectual property. [9] To make matters worse, existing laws are not yet equipped to handle the special cases of copyright infringement and plagiarism on-line since the Internet has not been prominent for very long and few precedents exist to model legal action after.

The problem with the inability to authenticate information on-line is currently being dealt with by developers of software and hardware technologies. One possible way to protect intellectual property is through emerging "watermarking" and like software applications that create visible or invisible "fingerprints" into digital images and documents to verify ownership to the author. [9] Another solution currently being sought is through the registration of documents and other information with copyright companies that hold a client's data and run programs that checks questionable information against the registered copy to indicate likelihood of plagiarism. Encryption programs can also be used to protect information from being stolen by restricting the number of people who have the "keys" to view the information. [9]

Unfortunately, all of the solutions proposed to date have major holes that allow them to be easily bypassed one way or another. [9] It will be some time before any reliable solutions mature, but in the future it may be possible authenticate original work as well as limit reproduction of intellectual property.

Next to misinformation, one of the most often cited concern about the Internet for healthcare purposes are privacy and security issues. The Internet was not designed with security in mind and the UNIX computer operating system upon which keeps most of the Internet going has many security holes of its own. [57] The bulk of all traffic that is sent across the Internet is unsecure, meaning that there is a remote chance that it can be viewed by someone else or "harvested" by surveillance programs that scan for a specific type of information.

Regular e-mail is one of the most open applications to eavesdropping. E-mail that is stored on an Internet Service Provider's servers may be accessed by system administrators. In workplaces, the invasion of privacy is sometimes increased by employers who regularly police incoming and outgoing e-mail for unauthorized uses of organizational resources. On occasion, e-mail can even end up in the wrong mailbox by freak accident, but such incidences are very rare. In eleven years of being a regular user of e-mail, the author of this paper has only once received someone else's e-mail.

Most security issues can be handled by a variety of software encryption technologies, the most popular one being the Pretty Good Privacy (PGP) line of encryption programs. (Note: Versions of PGP and other US made encryption devices may be illegal for export.) Snooping is still possible even with encryption, but for most purposes, impractical due to the level of computer and financial resources required to uncrack encrypted information.

Internet communications can be made a more secure environment, but the hassle and time required to install and use security devices prevent most people from using them. Aisde from security features built into the two major web browsers used for credit card and other secure transactions, usage of encryption technologies is in a minority population. Partially due to the massive size and sheer volume traffic sent over the Internet, the lack of security and privacy safeguards over the Internet is not a greatly voiced concern of most people.

Finally, many medical professionals must be questioning the wisdom in allowing for large amounts of clinical knowledge to be made indiscriminately available to laypeople and health care providers alike. [24] With any knowledge comes the responsibility to use the knowledge wisely. There exists the potential for patients to attempt to access information and draw their own diagnosis's and treatments from them, but the Internet makes little new information available, it only makes it more easily accessible. Regardless, one study of a pediatrics link collection showed that the lay public had a preference for accessing information written to their level of understanding such as patient education type of information. [27, 55] With the right resources and a little direction, the Internet can be used to help patients become more active participants in the medical services they receive.

Yes, the danger of reckless self treatment does exist and may even be increased by the ease of finding medical information on-line, but if health care providers don't attempt to satisfy the natural curiosities of their patients, someone with no medical background might. Like infocommercials on late at night, hucksters could have an unchecked monopoly on the propagation of sometimes convincing pseudo-scientific thought. At the least, on the Internet, you're likely to find opposing bodies of challenging thought juxtaposed next to each other. Douglas Rushkoff put it best when he wrote, "The Net is dangerous to your world views." [42]