Unfulfilled Promises

The Internet gets a mixed review for improving the practice of medicine so far - but with the reminder that this new technology is still less than a decade old.

THE PAGES OF MEDICAL JOURNALS have been deluged in recent months with articles about the Internet's impact on medicine. By now every medical practitioner is familiar with the phenomenon of the conscientious patient bringing in reams of printouts from the Internet pertaining to his or her condition, with questions highlighted in the margins. The Internet has greatly improved the accessibility of medical information to the lay public, and provided instant access to on-line references and journals for physicians.

But, has the Internet fundamentally improved the practice of medicine? Can it do so in the near future? As the century of innovation ends, I have compiled a list of unfulfilled promises of a global network for the practice of medicine, and how these promises might come to fruition in the new millennium.

Instant Access to Patient Records
One of the Holy Grails of Medical Informatics, the discipline at the intersection of medicine and computer science, has been the computerized medical record. Imagine having instant access to all of a new patient's past medical history, from immunizations, previous procedures and findings, to laboratory results, medications used, actual images from radiology studies, full-motion video of endoscopic procedures, and so on. All this could be available for any patient anywhere, not just patients who have been coming to your office for years.

This sounds fantastic, and yet today such a system is no longer science fiction. The same technology that allows Amazon.com to track hundreds of thousands of books, and that allows millions of secure transfers of sensitive financial information per day, could be used to create an on-line, nationwide patient records system with secure access from anywhere on the Internet. The improvements in efficiency and patient outcomes that could be realized could be enormous, and would truly impact the practice of medicine by enabling physicians to make quicker and better decisions regarding patient care.

Although many hospitals and offices utilize some form of computerized records today, these systems are disconnected; paper printouts are still the lowest common denominator for information exchange. This severely limits their usefulness for maintaining a longitudinal record of a patient's health status. The Internet, serving as a common backbone for information exchange, has the potential to unify all these separate databases into one logical, easily accessible whole. ¹The connection of every office and hospital to a global network has created the fertile ground on which a networked, integrated patient record system could finally be realized in the near future.

Education
The Internet has greatly increased the availability of medically related information, both to the physician and the lay audience. There is ample room for improvement and innovation. First, the quality of information available to the public has been questioned in several highly publicized studies. In the ultra-democratic world of the Internet, a flashy commercial website tailored to the public can carry as much weight as a peer-reviewed article, and in fact can be much more easily accessed by a lay audience.

What we need to preserve the quality of information for patients is a sort of electronic "seal of approval" from legitimate organizations, such as universities, professional organizations, and disease-oriented associations. This way, a consumer could be assured that an article on, for example, prostate cancer carrying a seal of approval from the American Cancer Society contains correct and up-to-date information. The technology for this exists today in the form of electronic signatures, which are widely used in e-commerce.

Secondly, most medical education websites contain electronic versions of pamphlets, journal articles, or textbooks, with a few enhancements such as search capability, automatic updates, and the like. But almost all of them ignore an essential aspect of the Internet - its interactive capability. Although we can look up information in the on-line version of Harrison's Principles of Internal Medicine ², or view full-text JAMA articles culled from a quick Medline search, it is not yet possible for a medical student to interview and examine a virtual patient on-line, interact with a simulated Krebs cycle, or practice an aortic valve replacement.

This is understandable, since the technology is still in its infancy. However, several local innovators have started to create interactive web content for medically related applications. Rick Lasslo, a fourth-year medical student at UC Davis, has created the Neurological Eye Simulator. ³Harry Matthews, a professor of biochemistry at UC Davis, has introduced an interactive biochemistry lecture and quiz program based on the web, which is used in his medical school course. ⁴The author's own interactive histology quiz allows medical students around the world to hone their microscopic anatomy skills with a web-based guide. ⁵As the web becomes a more popular medium for web-based education, we should expect to see more examples of interactive medical education.

Decision Support
The use of computers to support humans in making medical decisions, such as making difficult diagnoses or choosing complicated treatment plans, has a long history going back to the 1970's. ⁶Such systems usually incorporate a database of disease signs and symptoms and an artificial intelligence program to help with difficult diagnostic or treatment problems.

In a typical interaction with such a system, the physician would enter vital information about a patient's health status, including signs and symptoms, laboratory values, and other data, and the computer would return a differential diagnosis list ranked by probability. Although such programs have been successful in some settings, they tend to quickly become out of date as information about disease prevalence, diagnostic tests, drug resistance, and new treatment strategies is rapidly evolving.

The Internet could add a new wrinkle to such systems by allowing the programs to learn from their own mistakes. Physicians using such a system over the Internet for initial diagnosis or treatment could give feedback to the program once the diagnosis becomes clear or the correct treatment is selected, thus "teaching" the computer about its mistakes. Over time, a network-based system could improve and adapt to changing disease patterns and treatment recommendations, thus never going out of date. The DXplain system from the Massachusetts General Hospital and Harvard's Laboratory for Computer Science ⁷is a first step toward web-based diagnostics.

Quality Control
At its core, the Internet is a technology for bringing people together across space and time. This ability could be used to improve quality control in medicine, a topic which has recently garnered significant attention among the media and government. One way to do that would be a web-based equivalent of the morbidity and mortality conference in which any physician across the world could participate. Such a service, which could be run by physicians and restricted to medical personnel, could act as an anonymous repository for iatrogenic complications, adverse reactions and other experiences from which the medical community as a whole could learn. The web's potential for quickly and efficiently disseminating information could help us learn from the mistakes of our peers.

Getting in touch with patients
E-mail-based communication with patients between appointments is becoming popular in many practices, and is a particular hit in the high-tech patient Silicon Valley. Widespread use of networks could provide patient monitoring options which seem fantastic today. One possibility would be to connect a patient's glucose meter to the net, giving the physician an accurate and up-to-date record of a patient's glycemic control between visits, with an alert if predetermined parameters were exceeded. One could also monitor peak flows, blood pressures, and other parameters which could be easily measured and transmitted over the network with the appropriate Internet-connected appliances.

A study at UC Davis is investigating similar technology for the home management of congestive heart failure. ⁸A Japanese firm is even testing a prototype of a toilet which analyzes user urine glucose levels, protein content, presence of blood, and several other parameters, and alerts the user if it finds a problem. ⁹Could the automatic relaying of that information to the doctor via the Internet be far behind?

Conclusion
Overall, I give the Internet a mixed review for improving the practice of medicine so far. At the same time, it is unfair to blame a technology less than a decade old for not completely revolutionizing a practice whose roots go back several millennia. Perhaps physicians need to advocate for quicker and more efficient uses of Internet technology in the practice of our profession.

In the early 1960's, when computers first started their exponential increases in speed and miniaturization, early workers in the fields of artificial intelligence and sociology looked ahead to the end of the 20th century. They seriously worried about the impact on society from what they thought was the inevitable arrival of intelligent machines in a few decades. Yet, artificial intelligence still remains an unattained dream.

In the same way, we must be careful not to oversell the promise of existing technology. However, most proposals mentioned in this article are based on novel applications of existing technology and the unique opportunities offered by a globally connected world. If physicians are willing to consider new approaches to the practice of medicine, the computer and the Internet will open up new possibilities for healing and teaching our patients in the next millennium.

grogalski@ucdavis.edu

References
1. Ron Risley, MD, a local physician, has synthesized the issues of privacy and accessibility in medical records systems (www.risley.net)
2. www.harrisonsonline.com
3. cim.ucdavis.edu/Eyes/eyesim.htm
4. trc.ucdavis.edu/coursepages/bcm410a/1999/login.cfm
5. cim.ucdavis.edu/courseware/histoquiz/
6. Miller, RA, "Medical Diagnostic Decision Support Systems-Past, Present, and Future", JAMA vol 1, No. 1, Jan/Feb 1994, p.8.
7. www.lcs.mgh.harvard.edu
8. cim.ucdavis.edu/CHF/
9. Magnier, M, "Japan is Flush with Obsession", LA Times, 12/13/99.