A Survey of Internet Clinical Medicine Applications

Gary Malet, MD

Introduction | Clinical References and Textbooks
News and Peer Reviewed Journals
Decision Tools | A Global Clinical Medicine Case Database
Clinical Guidelines and Current Therapeutic Standards
Multimedia Modules and Continuing Medical Education | Patient Education Documents
Interactive Forums | Web-Based EMR and Patient Record Sharing | Summary | The Author

Introduction

The Internet is a rapidly expanding network for computer to computer communication. It connects over 50million users and 15,000,000 computers. This high level of connectivity presents unprecedented opportunities for global cooperation, networking, information access, and sharing. The Internet provides search tools, a support network, and an immense database of digital information for those interested in health.

The point and click graphical interfaces from Netscape, Microsoft and other browser providers make the Internet attractive and accessible to a broad audience. These browsers give users the ability to search worldwide databases of formatted text, pathologic slides, radiographic images, sounds, or other graphical images and display them within seconds. The National Library of Medicine and most professional medical associations and medical schools have become part of these pioneering efforts to provide multimedia access to global health resources.

The Medline database is on the Internet through a number of vendors. Medline is a vast compilation of international medical journal articles. Medical text, statistics, and programs are also available in information archives at medical schools and universities and are key word searchable.

Members of the Internet community can find discussion groups and share medical knowledge on many disease or therapy topics. Medical special interest groups, universities, and individuals are rapidly creating directories, newsgroups and mailing lists on the Internet. News, product information, and conference announcements are posted to the Internet well before they may arrive by print media.

A key feature of the Internet is the ability of any user to become a resource provider and offer files to others. The Internet has the potential to bring an unlimited wealth of video, text, and multimedia information to computer and cable users.

The vision of medical providers accessing computer consultation networks, electronic patient records and worldwide databases of text and images was partially realized in 1996. A vast collection of clinical medicine teaching files, news briefs, peer reviewed journal materials, cases, and interactive forums came online. Clinical patient record sharing and the integration of knowledge sources into the workflow of healthcare workers will define the new frontier for "Internet Medicine." Large numbers of clinicians are installing desktop computers and selecting valuable resources to enter on "hot lists" as they take advantage of the increasingly friendly navigational tools offerred by Netscape and Microsoft. The breadth of global medical knowledge and the analytic ability of high speed computing have begun to be applied to clinical practice problems.

Traditional medical information providers have begun to take advantage of the multimedia potential of the Internet. Medical societies and universtities are offerring subsidized full content journals and databases. Traditional peer reviewed publications are taking careful strategies to protect intellectual property, academic integrity, while they maintain their financial support. In early 1997, publishers are making available institutional full text access and database searches. They are hopeful that in the near future the general public will exchange cybercash to read the full content of articles.

Clinical References and Textbooks

A number of point of care reference guides are available on the Internet. The Merck Manual, 1992 version, is a searchable hypertext presentation of the world's most widely used medical text. The Family Practice Handbook, a National Library of Medicine sponsored project from the University of Iowa's Virtual Hospital, provides a searchable guide for primary care practice. Outlines in Clinical Medicine at Avicenna provides a review of internal medicine in the form of hyperlinked text pages categorized by disease topic.

Physician's Desk Reference provides search access to complete entries of brand and generic drugs and includes indications, dosing, adverse affects, and contraindications. The database can be searched by generic or brand names and by drug category.

Free Internet Medline has been presented by the National Library of Medicine's using the NCBI's PubMed interface.

The U.S. Government Centers for Disease Control and Prevention's WWW Server offers a clickable map that delivers country specific information. It informs the public and health providers regarding current disease concerns, vaccinations, and preventive measures to be taken during international travel.

The Health Explorer offers a search engine that retrieves patient education documents based on keywords.

News and Peer Reviewed Journals

Clinical news services and peer reviewed medical journals have all emerged online and battled for position as information providers in this new medium. JAMA, from the American Medical Association, the world's most widely read medical journal, the New England Journal of Medicine, the British Medical Journal, and the Annals of Internal Medicine have come online with abstracts and selected full text.

Reuters and Medical Tribune have attracted large audiences with professionally produced journalistic efforts. The free-for-all nature of the Internet allowed for innovative efforts in pointing or ordering or categorizing diverse materials on the Internet. For example, WebMedLit presents daily news in various subject areas by way of links to resource providers.

Decision Tools

Modules such as a "Heart Attack Survival Calculator" are the first examples of decision support system distributed over the Internet. The program accepts clinical values such as known coronary occlusions and estimates probability of hospital survival have become available.

The integration of knowledge sources at the point of care is taking place primarily over intranets such as Kaiser where algorithms and practice guidelines are delivered to physician users. DXplain, from Harvard University, authored by Octo Barnett, is a full medical decision support system available to subscribed physicians over the Internet.

A Global Clinical Medicine Case Database?

In each specialty authors are offerring documents that simululate the experience of real patient encounters. Pathology, radiology, or dermatology images with text annotations increase the number of comparison references for practitioners and medical students as they treat patients. An archive of cases from the weekly "Clinical Challenges" series is offered for general medicine by Reuters. An archive of cases in dermatology is available from the University of Erlangen's Image Database, and for pathology at the University of Utah. A radiology museum of classic teaching images is offered by the Central Middlesex Hospital Trust. The Interactive Patient simulates an actual patient encounter with prompts and suggestions in response to diagnoses offerred by users. Internet based, universally accessible databases of clinical cases are emerging.

Clinical Guidelines and Current Therapeutic Standards

The National Library of Medicine's HSTAT service is an electronic resource that provides hypertext access to the full-text of AHCPR clinical practice guidelines developed as part of a large U.S. national effort. HSTAT includes other documents useful in health care decision making: National Institute of Health Consensus Statements and the U.S. Preventive Services Task Force Guide to Clinical Preventive Services.

CancerNet is offerred by the prestigious National Cancer Institute and presents state of the art Cancer Treatment Statements for Physicians. The American College of Cardiology Clinical Practice Guidelines presents statements from the College regarding issues such as myocardial infarction management and cardiac catheterization.

Multimedia Modules and Continuing Medical Education

Commercial vendors have found a niche in offerring fee based CME case based modules that are particularly attractive to rural clinicians. cmeWEB Medical Education for Physicians offers emergency medicine and primary care tests for physicians with on-line registration, credit card payment, and online certificate of participation. OncoLink is a well developed and well maintained multimedia Internet cancer resource directed to physicians, health care personnel, social workers, patients and their supporters. The Virtual Hospital is an extensive medical multimedia database that takes full advantage of the Internet medium and incorporates functions such as free text searching, video and audio clips, and high-resolution images. It provides invaluable patient care support and distance learning. The University of Washington offers well constructed radiology digital teaching files available for CME credit hours. The Virtual Medical Center has pointers to thousands of teaching files and cases and highlights continuing medical education courses. A novel use of interactivity and multimedia is demonstrated by an Advanced Cardiac Life Support Module.

Patient Education Documents

There has been a proliferation of disease descriptions, treatment protocols, nursing information, news sources, drug information, and patient education documents on Internet.

Med Help International, is one of the larger databases.

The University of Montana's Healthline service offers topics of general health interest. It covers topics of physical and mental health including sexuality, drug & alcohol information, academic tips and dietary facts.. Healthlines's documents have been subject categorized at Jonathan Tward's Multimedia Medical Reference Library.

The Communicable Diseases gopher of the NY State Department of Health, offers detailed fact sheets on a large number of infectious diseases in a PDF format.

Interactive Forums

One of the benefits of Internet connectivity is the ability to form networks and projects among colleagues and participate in a global collaborative decision making process. As medical practitioners join the Internet, they are exchanging new developments, case studies, treatment protocols, employment opportunities, and remote consultations. MedConnect permits users to follow a web based discussion thread on various clinical topics. In the Medical Journal Club on the Web, internal medicine articles from the recent medical literature are summarized and reader comments are appended to the article. Many sites are appending threaded comment areas to specialty directed information sites to encourage followup discussion on current issues or cases. Specialties and interest groups are rapidly creating newsgroups, and mailing lists.

Web-Based EMR and Patient Record Sharing

Hospital-to-hospital health data transfers are taking place over the Internet using consensus standards. Many web-based demonstration projects are available on the Internet that demonstrate the intense activities of vendors and research. A list of web-based Electronic Medical Record System Demonstrations is available at Columbia. A journal, Health Data Management, presents full text of the latest developments in this field. It has become a common view that the web browser will be the electronic medical record interface for the 1990s.

Medical Matrix

In 1992 the power of bulletin boards on Compuserve and Prodigy was becoming obvious to health professionals who enjoyed computing. Users were sharing resources, volunteering knowledge, combining expertise, and solving problems in ways that were revolutionary. A group of pioneers including Doctors Paul Kleeburg, Michael D'Lessandro, and Keith Ruskin, and Loren Buhle began to create resources and consider how this universal access to a universe of information could be applied to medical education and the difficult decision making of clinical practice.

At that time because of its Unix based interface very few physicians were using Internet. Lee Hancock at the University of Kansas fashioned the first directory of Internet Health Science Resources List. This grew into a collaborative effort to annotate and maintain a clinical medicine text database called "The Medical List". With the release of Mosaic the database was converted into HTML by Dr. Gary Malet and presented as Medical Matrix with the University of Kansas hosting the resource. The Internet Working Group of the American Medical Informatics Association was formed in 1994 to serve as a focus for a core group of physicians and information specialist to promote online health and medical resources and explore methods to improve global networking in healthcare.

Medical Matrix offers annotated pointers to a hierarchial, comprehensive database of global resources that can assist in patient care. This Internet medical resource list is offered in hard copy, as an online text document, and as an Internet hypertext, hyperlinked database accessible using World Wide Web browsers like Netscape. It is designed as a "homepage" for a physician's or healthworker's desktop computer. The criteria for entry selection and ranking include utility for point of care clinical application, quality, currency, and unrestricted access. All resources are "full text" unless otherwise specified. Sites are reviewed by an editorial board drawn from the Internet Working Group of the American Medical Informatics Association An archive of "Medical Matrix- What's New" documents is searchable at http://www.uoeh-u.ac.jp/MML/MMS-e.html. These entries are categorized by topic and presented in the database "Medical Matrix" at http://www.medmatrix.org. Medical Matrix entries are continuously updated and verified. These links to resources are offered to users who are interested in the fastest possible access to knowledge on a clinical topic.

Gopher access to this document is also available. Gopher allows key word searching and email to any Internet address.

Medical Matrix uses icons and keyword searches to locate on line medical resources easily.

The most current updates of Medical Matrix will be maintained at the Internet addresses above.

Summary

In 1997, the Internet is taking hold in clinical medicine and has demonstrated an ability to present multimedia medical resources at the point of care to affect clinical decision making. Internet sound, images, and video simulate actual cases and can optimize learning. It is anticipated that Internet clinical references may become universal to meet the intense information demands of clinical practice. It is a challenge to project how search utilities and interlinking medical multimedia documents may offer a new paradigm for sharing clinical studies and scientific developments. Programs designed specifically for hypertext multimedia access with modem transmission speeds ten and a hundred times what we have today will have even greater utility. Internet medicine links documents across geographic boundaries and medical disciplines and promotes an integration of clinical knowledge that may revolutionize medical practice.

The Author

Dr. Gary Malet is a family physician based in San Francisco, California. He is a Medical Informatics Fellow at the Oregon Health Sciences University, Portland, Oregon, and Co-Chair of the Internet Working Group, American Medical Informatics Association. Dr. Malet has been one of the founders and is currently the coordinator of Medical Matrix, a major clinical medicine resource directory. He is also a member of the Editorial Board of the Intermedic Magazine. Email: gmalet@healthtel.com

Copyright 1997, Healthtel Corporation. Healthtel Corporation