Health Care and the Next Generation Internet

The Internet phenomenon-spurred on since the early 1990s by the creation of its most successful application, the World Wide Web-has had a remarkable impact on our global society in just a few years [1]. The penetration of the Internet into our homes, schools, and workplaces has arguably exceeded the rate at which earlier popular consumer technologies (such as television and video-cassette recorders) were adopted. The world of medicine and health care has not escaped the impact of the Internet, and health-related sites are among the most frequently accessed information resources on the Web. Medical observers are rethinking the optimal methods for implementing electronic medical record systems that are based on Internet technology [2], and distribution of biomedical information through the Internet is increasingly commonplace and accepted [3]. This issue includes two articles that describe both the promise and the problems related to the expanding uses of telecommunications in health care. Grigsby and Sanders [4] summarize the burgeoning activities in the area of telemedicine, acknowledging the logistic, fiscal, and regulatory barriers that have prevented more rapid adoption of these promising methods. de Groen and colleagues [5] describe a clever Internet application that monitors for rare diseases that previously would have defied efficient or comprehensive tracking. We should anticipate many more such applications as our horizons broaden and more health care workers realize how networking infrastructure can support new and innovative biomedical applications. Biomedicine is not a recent initiate to the world of the Internet. Medical research computers (such as the National Institutes of Health-funded SUMEX-AIM resource at Stanford University, Stanford, California) were connected to the ARPAnet (the predecessor to today's Internet) as early as the 1970s. Scientists began to realize that this marvelous, federally funded network was potentially a great boon to biomedical research and would allow collaboration among scientists around the United States in ways that would previously have been unthinkable [6]. Some 25 years later, despite remarkable advances and the transfer of the network to the private sector, we see our fragmented health care system only beginning to understand and adopt the Internet as a tool for health care delivery and information access. With proper leadership, investment, and commitment, the networking technology that is already available to us will provide great opportunities for innovative medical uses. But despite growing enthusiasm for the Internet, any Web user can attest to its severe limitations. Recognizing that significant research questions need to be addressed in promoting the continued growth and usefulness of the Internet in the decades ahead, the federal government has committed substantial, incremental fiscal year 1998 research dollars to the creation of the Next Generation Internet (NGI) program; ongoing investments are anticipated in fiscal year 1999 and beyond. (Information about the federal program is available at http://www.ccic.gov/ngi.) The federal research programs have strong bipartisan support in Congress and are cooperating with a consortium of academic institutions that are investing heavily in improving their own campus networks while seeking government support for test-bed experiments. The consortium, initially known as Internet-2, now has more than 100 U.S. member universities. It recently created a not-for-profit corporation, the University Consortium for Advanced Internet Development (UCAID, http://www.ucaid.org), which will continue to promote experimentation and demonstrations using high-speed networking of a sort that is not yet generally available to the Internet community. What will the future networking infrastructure mean to the practice of medicine, to personal health practices, and to health science education? Imagine the day when citizens will no longer have several medical records scattered in the offices of various physicians and in the medical record rooms of numerous hospitals. Instead, their records will be linked electronically over the Internet so that each person has a single virtual health record, the distributed but unified summary of all of the health care they have received in their lives. Furthermore, this record will be secure, treated with respect and confidentiality, and released to providers only with the patient's permission or under strictly defined and enforced criteria at times of medical emergency [7]. The work of de Groen and colleagues [5] presages what will someday be possible in clinical investigation. These authors have demonstrated that current Internet technology can already facilitate the secure sharing of patient information for purposes of data pooling and analysis, thereby supporting the integration of clinical practice with clinical research. With further standardization of patient-record formats and clinical terminology [8], linkages to the Internet will in turn support cross-institutional research coordination and multicenter trials. But the Internet's implications extend well beyond its impact on linkages among distributed medical records. For example, today's early telemedicine experiments, such as those summarized by Grigsby and Sanders [4], depend on specialized equipment and expensive communication lines. We can anticipate that as the Internet evolves and supports higher-speed communications, it will become the standard vehicle for linking medical experts with other clinicians and patients at a distance. Clear, full-motion video images will be transferred; high-fidelity audio links will allow physicians to listen to patients' hearts and lungs; and common computing platforms at both ends of the link will help to make this kind of medical practice cost-effective. Patients will avoid unnecessary travel from rural settings to major medical centers, primary care clinicians will have personalized expert consultation delivered to them in their offices, and patients will accomplish in single office visits what now takes several visits and imposes major inconvenience. Before long, a medical student who is on an orthopedics rotation and is preparing to observe her first arthroscopic knee surgery will use the Internet to access and manipulate a three-dimensional virtual reality model of the knee on a computer at another location, such as the National Institutes of Health. She will use new, immersive technologies to enter the model knee, to look from side to side and learn the anatomic structures and their spatial relationships, and to manipulate the model with a simulated arthroscope. This will give her a surgeon's-eye view of the procedure before she experiences the real thing. Physicians will soon be able to prescribe specially selected educational video programs that will be delivered to home television sets by a direct Internet connection. Our hospitals and clinics will use video servers over the Internet not only to deliver such materials to patients but also to provide continuing medical and nursing education to staff. Health science schools will similarly provide distance-learning experiences through the Internet for postgraduate education, refresher courses, and home study by health science students. Furthermore, the video link into the home will be two-way, allowing physicians to move beyond the simple use of telephones and to use visual senses to manage patient problems at a distance. Patients will have home visits through video links, avoiding unnecessary office or emergency department visits, and physicians will have important new tools for monitoring patients and for emphasizing prevention rather than crisis management. Early experiments show that patients are remarkably enthusiastic when familiar physicians and nurses provide videoconferencing or Internet-based interactions for disease management in the home. The examples I have cited here have one thing in common: They could not be effectively and reliably implemented on today's Internet. Each requires transmission speeds that are currently unavailable, but the problems are more significant than speed alone and point to the research agenda that motivates the NGI projects. We clearly need faster speeds, but many applications will fail to be effective or accepted if the quality of that information-carrying capacity (bandwidth) is also inadequate. How do certain kinds of applications obtain guaranteed transmission speeds, even if they are only needed for a short period? How can we best deal with the problems of latency, the inherent delays caused by the time required for transmission of signals? A surgeon who is attempting telepresence surgery over the Internet and is bringing specialized expertise to an operating room hundreds of miles away will be unable to assist directly in the procedure if the movements he makes with hand devices are not instantly reflected in what is happening, and what he sees happening, with the actual instruments at the other end of the link. How do we ensure that the necessary bandwidth for the applications I have proposed is available not only on the major backbone networks but also on the last segment of wire, cable, or wireless network that comes into our homes and offices? The research agenda for the NGI is being defined and, as was the case in the early days of the ARPAnet, it will need an effective partnership between government and academia that is informed by and coordinates with the changes occurring in industry. We would not have an Internet today if the government had not created the ARPAnet 30 years ago [9]; industry would not have made the long-term investments necessary to create the technology and to gradually demonstrate its use and practicality. It was 1995 before the national backbone network was finally fully handed off to the commercial sector. Leaders in the telecommmunications industry acknowledge that the inno