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

On-line education has advanced quickly and convincingly enough that even major traditional Universities are putting together distance learning opportunities as part of their degree programs or in supplement to them. In 1996, Duke University graduated it's first class of virtual business students with masters degrees. [61] Virtual universities with no physical campus already offer undergraduate, graduate, and postgraduate degrees through a range of program offerings. Some experts predict distance learning as a large part of the future of higher education in the United States, possibly even replacing a large part of the university as we know it today. [28]

While there may never be a substitute for the interpersonal learning environments of traditional education, good implementations of distance learning opportunities are effective [47] and allow educational opportunities to those who do not have the physical access to classroom and workshop settings. Continuing medical education and virtual seminars can also be delivered over the Internet.

A growing number of professional institutions and associations have started offering CME modules on-line complete with examinations that can be e-mailed or otherwise returned electronically immediately after completion. Though many of the on-line CME modules are also available as mail-away packets, the on-line versions have an overall quicker turn around time and can be instantly scored. On-line education modules can also be programmed for interactivity to enhance the learning process.

One such organization that offers CME credits is the National Institutes of Health (NIH), who base their modules on their expert consensus statements developed for various subject areas. The NIH's develops its consensus statements through conferences attended by recognized panels of experts to improve clinical consistency in controversial practice areas. A sampling of their current on-line modules (you don't have the take the exam to read the modules) include topics such as optimal calcium intake, physical activity and cardiovascular health, and treatment of chronic pain.

CME credits are also available through commercial medical information companies such as MedScape and Healthgate who offer modules similar to the ones offered by the NIH. MedScape offers CME based on a selection of their collection of full-text peer reviewed clinical medicine articles in addition to module based exams and Healthgate teamed up with the Boston University School of Medicine to develop its CME topic areas.

Improvements in information technology may soon reach a point that would allow members of the medical community who do not have comfortable access to metropolitan areas to attend seminars and conferences virtually over the Net. The XI International Conference on AIDS in Vancouver, Canada was one such conference that was "netcasted" in supplement to the physical conference to allow for more rapid spread of information presented at the conference. Synopses and commentary were posted as presentations and discussions were being entertained at the conference for the Internet audience. The XI International Conference on AIDS' live netcast demonstrates how the Internet may be used to distribute important and time dependent information quickly and effectively.

In the summer of 1996, the first Internet broadcasted global symposium on using the Internet to access medical resources was held in Brazil and over 1,000 people world-wide attended in the flesh or through their computer screens. They found such a project, with its live audio and video feeds to be too slow on a large scale, and it was suggested that the next time an Internet exclusive symposium was held, that the video feed be cut and only a live audio feed be kept. Similarly, a group of orthopedic surgeons testing the viability of the Internet to demonstrate a surgical procedure across several continents over the Internet found similar results with data loss and "splashy" videos. [5]

...as telemedicine becomes a more familiar practice and more third party payers begin to reimburse distant medical consult, some providers may find themselves following up and caring for patients through a computer.

Medical video conferencing via the Internet, has not yet enjoyed wide-spread success and its practicality will rest heavily on the coming technological developments in increasing transmission rates of low cost data transfer either through better compression or faster transmission speeds. Currently, the computers that most people use to connect to the Internet are already sufficient to handle video feeds, but the bandwidth of the network infrastructures used to connect people are not yet adequate to handle live video, [5, 52] especially outside of the United States.

Although lack of low cost high speed connections may hinder presentations of video or audio based information over the Internet, software developments may circumvent some problems. With the development of multi-platform programming languages such as Java, attendees of a virtual seminar could conceivably download a special program and pre-recorded video clips before the real-time event. During the seminar, the downloaded software could be prompted to play certain video clips at specified times, keeping bandwidth free of bulky video data and open for communication between audience and presenter. Other multi-platform applications such as Adobe Acrobat, which allow for the creation of multi-platform electronic multi-media presentations, also offer possibilities in creating educational opportunities on the Internet.

Telemedicine is a precarious umbrella to fit Internet medicine under because of the associations to failure and superfluous spending that the word carries from past mishaps. [4, 52] In its most basic definition, telemedicine is the delivery of healthcare with the patient and provider in different locations [11, 52]. Telehealth focuses on the performance of professional and consumer level health education, research, and administration of services.

In the past, lack of network infrastructure was an expensive problem for telemedicine, but in recent years with the world being wired over, telemedicine has received a shot in the arm. Judging by the medical institution's impressive change of heart over computers and the Internet in the past year, we are finally almost ready (if not ready now) for telemedical applications.

Like in the case of distance learning, telemedicine will make its greatest impact in rural and other areas lacking access to urban resources. [51, 52] As more Internet providers begin to sprout up in remote areas, healthcare in those areas can begin to have better and faster access to specialty opinion that would otherwise only be available in urban centers [52]. Still, an Internet connection over a modem and a phone line is too slow to be practical for some telemedical applications and many remote areas still lack reliable Internet service. [52]

In the US, as part of the Telehealth Act of 1996, federal grants and loans will be provided on a national level for medical pioneers who wish to bring high speed network resources into rural areas to develop medical Internet applications [53]. In a report to the US Congress in January of 1997, the Joint Working Group on Telemedicine recommended providing rural areas with T1 connections that could deliver over 1.5 million bits per second (Mbps) meaning a full resolution x-ray that would take over an hour to send on a 28.8K modem would only take four minutes to transmit [52]. At the recommended speed, rural areas would be able to take advantage of more advanced telemedicine applications including videoconferencing.

Also as part of the Telehealth Act of 1996, Medicare also plans to reimburse the delivery of appropriate telemedicine services [53] in the future. In the state of California, a state law was recently passed that will require third party payers to reimburse for telemedicine services as part of normal healthcare delivery. Where the California law seems to be generating most press is in clinical psychology fields who may benefit immediately from the passage of the law since psychological counseling and group therapy do not require high end telemedicine applications and can be reliably done via everyday modem and keyboard.

Currently, the most utilized telemedicine applications are in radiology, followed by cardiology, orthopedics, and dermatology, [52] but other practice areas are developing exciting new uses for Internet medicine. Telepharmacy is a recent development and promises to grow explosively in the coming year by allowing rural towns that lack pharmacies to obtain medications at their doctors' offices. Automated Drug Dispensing Systems (ADDS) in Billerica, Massachusetts have developed a drug dispensing machine with fail-safe mechanisms and safety checks. [39] As of summer 1997, the company had four units in service and expected to put another 200 into operation by 1998. The machine, which contains up to 90 percent of the most commonly prescribed drugs may be operated by physicians or nurses to automatically dispense a prescription for a patient or controlled remotely by a pharmacist who may have the option of videoconferencing with patients as is currently being done by the University of Utah in one of their remote satellite clinics affiliated with their main hospital.

In orthopedics, movement analysis can be performed remotely through video capture sent to a movement kinematics laboratory. [22] Through the Internet, central disease databases can be accessed, a valuable option underscored by a network based diagnostic tool, OophAssure, used to perform remote diagnosis of ovarian cancer with 89% accuracy. OophAssure is able to detect ovarian cancer in its early and more treatable stages through performing a remote analysis of a woman's serum from serum laboratory or other medical facility and checks for disease patterns against a central database at its headquarters [37].

Telemedical applications also include the use of networked computers in transmitting patient information. Sharing of patient records through Community Health Information Networks (CHINs), which are centralized electronic patient record databases and information sources, is one example that is strongly evidenced to both cut costs and improve patient care, enough that insurance companies in the US were expected to spend $6 billion on information systems in 1996 [11]. Computerized patient records that contain entire health histories of individuals for universal and interdisciplinary use is one of the most talked about implementations of using networks and information technology to improve healthcare services. Already some services on the web geared toward travelers offer electronic storage of password protected and encrypted medical information accessible through the web. Paper records often transfer illegibly, too slowly, or not at all.

The challenges to establishing central sources of electronic patient information are great and numerous. With accessibility, privacy and security concerns are sometimes tradeoffs [11] that need to be examined and minimized. A multi-disciplinary record also needs to share a common set of terminology [2] across many disciplines--already a difficult goal within just one discipline. Widespread accessibility, implementation, and technology issues are some of the other challenges.

Obviously, telemedical applications hold a great potential to improve healthcare delivery while reducing costs, [2, 11, 52, 53] but only if utilized on a widespread basis by a sufficiently computer literate medical community. Even then, the gross failure of telemedicine as a cost effective intervention in the past, suggests that caution should precede optimism. [4]