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The Internet is a difficult entity to define. Physically, it is a global web of interconnecting computer networks that was developed over 25 years ago. This "network of networks" allows any computer attached to it to talk to any other using the Internet Protocol. Originally conceptualized and subsidized by the U.S. government during the 1960's, the Internet evolved from what was called ARPAnet in the early 1980's to the incredibly complicated and largely unregulated "super-network" it is today(1). Increasing use of the Internet by business and academia has gradually decreased the amount of federally-subsidized dollars, thus, the private sector's influence on the Internet has now surpassed that of the federal government. Current trends indicate that individual consumers will increase the use of the Internet sixteen-fold in the next two year period(2).
The individual computer networks connected by the Internet share a common communication standard known as Transfer Control Protocol / Internet Protocol (TCP/IP), which allows them to maintain smooth communication, and allows all connected networks to be accessible to one another. When coupled with the recent proliferation of high-bandwidth telecommunications (e.g., ISDN), the exchange of information and ideas is even easier. Yet even this standardization leaves much to be desired for the average user trying to "surf" the Net for specific information. Speed and compatibility do not necessarily mean user-friendliness nor usability.
Several applications were developed in an attempt to answer this lack of "user-Net" ease. Gopher is a prime example of an adept, if unexciting, interface which allows for access to huge volumes of information, but is limited to a text-only format. This and other applications still leave much to be desired as a means by which standard computer users can access information available via the Net. Thus, despite huge volumes of information made accessible over Gopher, public use continued to be on a minor scale, and the resulting benefit to the clinical and academic medical community remained minimal.
The need existed for a tool which would unify Internet resource access in a manner which would serve the general computer user populace, a group which has become accustomed to attractive graphical user interfaces (GUI's), pointing-and-clicking, and simple interfaces masking complex software functions. This need prompted the creation of the World Wide Web (often referred to as WWW, the "Web," or W3) at the European Center for Nuclear Research(2). The Web's set of common standards for navigation, its graphical interface models for individual accessibility (which first appeared in 1993 via NCSA's Mosaic[a]), and its client/server structure largely satisfied the user interface problems. In fact, the Web for the most part has driven the vast increase in the use of the Internet in recent months, and promises to serve as the standard for Internet communication for the foreseeable future(1,2).
Documents, or Web pages, can be published on the Web using the HyperText Markup Language (HTML), and can then be accessed using HyperText Transfer Protocol (HTTP), with Web-browsing software. Currently, the most popular package, with a 70% market share, is Netscape Navigator(b). This new Net interface allows users to access documents that combine text, graphics, sound, and even motion video through a simplified GUI. Web pages published in HTML usually contain hyperlinks which are graphic portions of the computer screen hiding a transfer command to another HTML page. A "link" from one hypertext page to another can be activated simply by clicking on the word, icon, or graphic image linked to the new page. The hyperlink, when activated, transfers the user to another document, hypertext page, or server, which may itself contain its own hierarchy of links. The easy jumping from page to page afforded by hypertext links makes the interface intuitively menu-like. Thus, with current Web navigating software it is now far easier to present information to the Internet community; the learning curve for new users has been considerably shortened.
Further, the relative simplicity of HTML authoring allows the creation of Web pages after only a short learning period. Additionally, there are a wide variety of software packages available which reduce the amount of HTML the author needs to know[c]. These products are increasing in power and number, and promise to accelerate Web development, especially among professional groups such as clinicians and their academic colleagues, for whom time is precious.
There are a large number of academic institutions with presences on the Web. Many of those academic sites are medical schools, so there is no shortage of sites on the Web related to academic medicine(d). A large number of these sites attached to medical schools are limited to general information about the medical schools themselves, presented in a format calculated to provide information to potential applicants or current students. Curriculum, admission requirements, course content, and similar information makes up the bulk of much of the information presented at these sites. Also, links to biographical information and resumes of faculty are often included.
Some universities and medical schools present research results on the Web, either in a hyperdocument or in journal article text format. Browsing through a list of university sites will often lead to these pages of research results, which can then be printed by the user. This kind of publishing on the Web shows much promise for the future exchange of information. However, the frequent lack of peer-review and lack of lay interpretations make this information potentially dangerous when access to the information is made public, as most Web documents are.
There is an ever-increasing number of academic medical Web pages that offer links to a broad spectrum of medical information. This information may be in the form of published articles, as described above, or in hypertext format. Thus, items may be selected from menus of hyperlinks to gain access to a particular subset of data, a specific catalog of digital images, or even to an interactive educational site which can be configured to test users and grade their responses. Though these Web pages are relatively few and often difficult to find, they are increasing in number, and promise to set a new standard by which medical Web sites will be judged in the future.
There are also a large number of hospitals(e), group practices, and individual physicians that now maintain pages on the Web; in many cases this is a representation of the growing use of the Web by business and commercial interests. Hospital Web sites often provide lists of associated physicians, public relations material, and other information, such as the location of the hospital, demographics of the city in which it is located, and current research or expansion plans of the hospital. These lists are often hyperlinked to more detailed information about the physicians, public relations projects, or research plans, allowing for a hierarchical organization of information which in turn allows for a more efficient search for the desired information.
Some of the more progressive hospital sites offer some exciting features to which the medical community in general should pay heed. For example, there are a number of hospitals with interactive chat pages, to which patients may submit questions and receive a response from a physician within ten or fifteen minutes(f). Cursive browsing through these pages often reveals potential patients reporting symptoms, and responding physicians listing differential diagnoses. Remote consultation will increase as the patient population becomes more computer-literate. This is, once again, a potentially dangerous use of the Web requiring some restrictions on access.
A number of chat pages also exists at many hospital sites designed to facilitate communication between physicians within the hospital. Some are designed specifically as a forum for residents. Most of these chat pages will not allow external Web surfers to participate by posting their own communications, but the dialogue can often be witnessed as it progresses. Peer-to-peer communication among physicians in a hospital promises to simplify the exchange of patient data and increase the efficiency of the hospital's clinical staff; the beginnings of this trend are already in operation.
Private practices publishing Web pages sometimes produce sites which can be quite informative to the casual browser, offering detailed information about the methods, techniques, and principles of the physicians of the individual practice. For example, there are plastic surgery sites with links to comprehensive libraries of digital images of before-and-after cosmetic procedures performed by the publishing group, along with associated descriptive text and cost figures(g).
However, some of these pages on the Web offer little more than basic information about the chief physician of the practice. Others focus almost exclusively on soliciting business. Some Web pages contain detailed referral information so that the prospective patient can gain access to the nearest physician of the particular specialty in question (at least the nearest physician who has submitted his or her name to the administrators of the page). The Web presence of this commercial information is rising rapidly as the population of Web browsers increases and the interest of establishing a wider client base remains constant in private practices.
Some of the promise that the Web holds for medicine has been tentatively explored. However, the Web's potential as a means of exchanging information, increasing diagnosis resolution, facilitating multi-physician consultation, improving medical education, and increasing the use of previously inaccessible data remains largely untapped.
The graphical user interface promises Web-based accessibility to full motion animation sequences, sound support, and interactive interfaces, the use of which could be invaluable to the educational process. This same interface will serve to allow image-based clinical specialties such as radiology, pathology, ophthalmology, and dermatology to share cases in a consultative fashion. The increasing resolution of digital images and the growing level of efficiency in data compression promises near-instantaneous image exchange in the near future, which can be easily transferred between users anywhere in the world.
The unique design of hypertext pages on the Web allows for the creation of private discussion groups, which may be constructed to serve the needs of specific medical specialties. These discussion groups could serve as a forum for presentation and discussion of difficult cases, and with the data transmission capabilities of the Web, could provide the same benefit as face-to-face meetings of the involved physicians. Groups could also be constructed for patient support, moderated by clinicians and other appropriate health care personnel.
The World Wide Web will allow dedicated support to isolated practitioners who link to special sites for support in difficult cases. These isolated practitioners could exchange case histories, MPEG images (a current standard for efficient compression of digital pictures), and other data, and get responses from responding specialists. The international support of TCP/IP and accessibility to the Web will allow this data exchange worldwide, so that consultative support could be extended to clinicians in crisis areas around the globe, and to medical facilities in third world countries.
The accessibility to databases afforded by the Web promises the construction of huge data "warehouses" specifically configured to store and hold data from, for example, outcomes research or clinical trials. A nationally- or internationally-fed data repository would have many advantages as a source of clinical data; its huge sample size, its broad cross-section, and the rapid accessibility for data retrieval would serve the research efforts of countless scientific endeavors. This becomes increasingly practical as the security of digital information increases, and as the Web's friendly GUI sets the standard as the tool for access to digital information.
1. Zelingher, Julian, MD. Exploring the Internet. MDComputing, Vol. 12, No. 2. 1995.
2. Verity, JW, and Hof, RD. Planet Internet: How the center of the computing universe has shifted. Business Week, April 3, 1995.
3. Rowe, BH; Ryan, DT; Therrien, S; Mulloy, JV. First-Year Family Medicine Resident's Use of Computers: Knowledge, Skills, and Attitudes. Canadian Medical Association Journal, Vol. 153, No. 3. August, 1995.
4. Florance, Valerie, PhD. Computers in Surgery: Building the Surgeon's Virtual Library. Contemporary Surgery, Vol. 47, No. 1. July 1995.
a) NCSA Mosaic [http://ncsa.uiuc.edu/SDG/Software/Mosaic/]
b) Netscape [http://home.netscape.com/]
c) Bob Allison's Web Masters Page [http://gagme.wwa.com/~boba/masters1.html]
d) MedWeb's list of Medical Centers and Schools [http://www.cc.emory.edu/WHSCL/medweb.schools.html]
e) HospitalWeb's list of Hospitals on the Web [http://132.183.145.103/hospitalweb.html]
f) On-Line Cancer Treatment Forums [http://www.meds.com/mol/forums.html]
g) The Body Electric [http://www.surgery.com/body/]
h) Yahoo [http://www.yahoo.com/]
i) MedWeb's root index [http://www.cc.emory.edu/WHSCL/medweb.html#toc3]
j) Search Engine Index [http://cuiwww.unige.ch/meta-index.html]
k) InfoSeek [http://www2.infoseek.com/]
l) WebCrawler [http://webcrawler.com/]
m) Lycos [http://www.lycos.com/]
n) Sandia National Laboratory's HTML Reference Manual [http://www.sandia.gov/sci_compute/html_ref.html]
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