How will medicine benefit from a faster Internet?
New technologies may help physicians, but some fear that medicine will take a back seat to business
From the October 1999 ACP-ASIM Observer, copyright © 1999 by the American College of Physicians-American Society of Internal Medicine.
By Howard Wolinsky
As researchers build a faster, better Internet, many in medicine are looking forward to the benefits that the new technology is expected to bring. But there are also concerns that because medicine is not driving the development process, physicians may see fewer gains than they had hoped for.
Two separate projects are expected to make the Internet faster and add features like high-quality video and better security. While such projects could change the way physicians practice medicine, critics are concerned that the defense and science industries, not medicine, will benefit the most from Internet advances.
One of the projects, the federally funded Next Generation Internet (NGI) Initiative, aims to provide Internet connections up to 1,000 times faster than those currently available today. Eventually, such speed would allow the Internet to better handle multimedia functions like live videoconferencing.
'Information technology has never been a prominent part of the agenda for the medical research community.'
—Edward Shortliffe, FACP
The other project, known as Internet2, also wants to speed up the Internet, in part so it can handle multimedia applications for research and education. Unlike the NGI project, Internet2 is funded by a private coalition of more than 150 universities. Earlier this year, many of those universities began testing a high-speed fiber-optic network code named Abilene.
Although the Abilene network is being developed separately from the current Internet, officials stress that Internet2 will not replace it. Instead, they say, technology developed on the separate network will eventually be transferred to the existing Internet.
Ted Hanss, director of applications development for the University Corporation for Advanced Internet Development, the organization that is coordinating Internet2 research, explained that the current Internet is "too congested for this kind of experimentation." Moreover, Internet bandwidth, a term that refers to the amount of data that a network can handle at any given time, is simply too small.
Help for physicians
How might the results of these projects help physicians who use the Internet? For one, physicians could send and view clinical information—even bulky images like X-rays—online. When Internet2 made its debut at a demonstration this spring, an audience in Washington, D.C., got a glimpse of its potential as they viewed a high-quality video of gallbladder surgery transmitted live from a hospital in Ohio. The purpose of the demonstration was to show how an improved Internet would allow physicians to collaborate in real time—even if they're hundreds of miles apart.
ACP-ASIM Regent Edward Shortliffe, FACP, who serves on the President's Information Technology Advisory Committee, said he hopes that such live videoconferencing will one day become routine. "Physicians may want to communicate about cases by sharing live images rather than sending them as attachments to e-mail," said Dr. Shortliffe, who is associate dean for information resources and technology and professor of medicine and computer science at Stanford University School of Medicine.
Mr. Hanss said that future versions of the Internet could allow for full-screen, real-time broadcasts of rounds, CME courses and videoconferences as well as telemedicine. Using Internet2 to store the full text of patient records would also make referrals easier. Internet2 researchers are also working on ways to enhance built-in security features to help overcome physician concerns about sending confidential patient data over the Internet. While it is not clear when these new technologies will be introduced, some experts have predicted that advances could be seen in a year or two.
Current Internet technology is limited in several ways. Try to view a video file online, for example, and you'll find that the images tend to jump around. That's because the Internet handles so much traffic, file transmission often gets delayed. When that happens, the image slows down or stops playing, creating a jerky picture that starts and stops as the data stream across the Internet. As a result, it is difficult—if not impossible—to do live consults on the Internet.
"Current technology is not medical grade," said Michael Ackerman, PhD, chief of the office of high performance computing and communications at the National Library of Medicine, which is overseeing medicine's interests in the Next Generation Internet. "What if you are looking at a patient where you are doing a gait analysis, watching somebody walk across the floor for a neurological exam? Or an echocardiogram where you're looking for that nice smooth beat and valves flapping, and it has a staccato-like motion to it? How do you do a diagnosis?"
Future versions of the Internet will likely solve this problem in two ways. First, they will have enough bandwidth to allow large numbers of users to simultaneously retrieve large video files without jamming the network.
Second, the technology will likely incorporate what is commonly referred to as "quality-of-service guarantees." Currently, all data being sent across the Internet are treated equally, whether a video clip of a home movie or an X-ray image. With quality-of-service guarantees, information being sent across the Internet would be ranked according to importance. Theoretically, medical data would receive a higher ranking than most other data, helping guarantee prompt delivery of patient information.
"We would like certain packets to have a 'Red Cross' in their header, to be like an ambulance," Dr. Ackerman said. "Come hell or high water, this information has got to get through at the highest priority. Push the red button, and it travels like an ambulance through the network."
Some are concerned, however, that medicine may fall behind other industries when it comes to Internet innovations, largely because health care does not receive the same level of funding as other industries.
For example, Dr. Shortliffe said that health care is often treated like a poor relation to the hard sciences in the government's NGI program. He pointed out that the National Library of Medicine, which represents health care's informatics interests in the NGI project, has received only $5 million out of the $105 million budgeted for the NGI project. Other departments, like the Department of Energy, the Department of Defense and NASA are faring better.
"Information technology has never been a prominent part of the agenda for the medical research community," explained Dr. Shortliffe regarding the disparity, "whereas the computing components of the military, the Department of Energy and NASA are very large parts of these agencies." To alter that course, medicine needs to lobby for more funds, said Dr. Shortliffe, and learn to better understand the importance of information technology to its future.
Even with stronger efforts on the part of medicine, the needs of business will likely get a higher priority as high-speed applications and networks are developed. "By and large, business as a whole doesn't have the same sensitivities or requirements as health care," explained Daniel R. Masys, FACP, director of biomedical informatics and associate clinical professor of medicine at the University of California, San Diego School of Medicine, who has worked on an advisory committee for the Internet2 project. "It is not clear that health care is a big enough player in the market to cause Internet service providers to do things for health care that they wouldn't do for any other reason."
As a result, medicine's needs will be met primarily because other business users have similar needs—and the cash to develop technologies to meet those needs. "The technology will be there not because of health care," said Dr. Masys, "but because businesses want those services."
That arrangement, he said, is not so bad. He predicts that over the next few years, the business community will make quality-of-service guarantees possible. While business information, not medical data, may get the top priority under such a system, Dr. Masys said that physicians will stand to benefit. "It may not be an absolute guarantee that your information will be sent in a specified number of microseconds, but it will receive preferential routing," he said.
Howard Wolinsky is a Chicago-based freelance medicine and technology writer.
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