CLINICAL DIABETES MEDICAL COMPUTING Medicine on the Web – Continued Lawrence Blonde, MD, FACP The World Wide Web continues to expand, evolve, reinvent itself, and dramatically change our lives. Fortune1 magazine recently reported that business school graduates have contracted ".com fever," spurning offers from prestigious mainstream U.S. companies to join Internet start-ups. The Web invasion of medicine is proceeding at a slower pace, but it is in sight. www.Drugstore.com and www.planetrx.com/ are challenging established pharmacy retailers. Healtheon (www.healtheon.com) and its newly acquired WebMD (www.webmd.com) seek to integrate the incredibly diverse information resources involved in medical practice. Their goal is to create an Internet-based health care network that connects physicians, hospitals, third-party payors, and patients to a virtual world of medical information, tools, and services. www.Drkoop.com, which offers health information for consumers, has affiliated with America Online, one of the world's largest Internet service providers, as well as with many community providers of health care. The company is attempting to "empower consumers to become active, well-informed participants to better manage their health care."2 Several other Web sites long to be the portal that commands the attention of health professionals, as well as patients and the public with questions about or an interest in health-related information. After attracting a critical mass to their sites, they could generate revenue through advertising, sale of products and services to their audience, or sale of information about their registrants to others. Hopefully, they would ask permission to do the latter. Enticements being offered to attract registrants include continuing medical education (CME) programs (http://www.medscape.com), discipline- and disease-specific aggregations of information present elsewhere on the Web (www.medmatrix.org), and medical news (www.reutershealth.com). The Web promises to revolutionize all of medical education but particularly CME programs. Organizations such as the American Diabetes Association (ADA) conduct popular and highly evaluated CME meetings. However, only a small fraction of those who would like to attend or would benefit from these programs can arrange to attend them in person. Each year, there are many more valuable CME programs than anyone can possibly attend. The ADA and other CME sponsors are beginning to provide some of their meeting content on their Web sites. Session summaries from volunteer reporters, sometimes including key graphics from the presentations, are becoming more common. Some sites are providing more extensive communication of the presentations, including multimedia elements. Medscape adds key slide graphics from the presentations about which it reports. For many presentations, it also adds images of speakers and an audio file including a brief interview with the presenter. Other sites, such as the Vascular Biology Working Group (www.vbwg.org), offer online presentations with actual slides and their accompanying talking points. Still other sites (www.lipidhealth.org) allow one to view or download PowerPoint presentations that also contain talking points incorporated in the notes view of each slide. Lipidhealth also provides case studies, as do many other Web sites aimed at physicians. As bandwidth increases and the ability to access audio and video from the Web increases in concert, one will be able to readily transmit actual presentations from meetings. This will allow all of us, independent of our busy schedules, to select and obtain (sometimes purchase) specific presentations from meetings that occur throughout the year and throughout the world. Obviously, this will fundamentally change CMEs. People will still attend live CME presentations, not only because they like to ski in Vail and eat in New Orleans, but also because of the opportunity to network in person with both the faculty and other registrants. But the Internet will allow each of us access to many more CME programs and presentations each year. The real challenge, however, will be for the producers of these CME products to develop applications that take greater advantage of the electronic medium by including more images and links to actual references and to entire Web sites that contain additional information. This will allow users to navigate through the information according to their own interests rather than simply following the organization decided on by the presenter. These added enhancements may also encourage even those attending the presentations in person to purchase some of these CME products. Furthermore, we all need to learn whether different types of information have greater value in different formats (images, text, video, audio) or may be of greater value to some users in one format and to other users in different formats. Of course, the above is really a new form of medical publishing. But traditional medical journal publishing is also being transformed by the Web. Publishers of most major medical journals now have Web sites. Most provide the table of contents of each issue online with links to citations, often including abstracts. Many also have links to the full text of selected contributions. Increasingly, publishers are making available to subscribers of print editions the full text of each issue online as a value-added service, with or without a small surcharge. Publishers of many journals in MEDLINE have provided links to their journal Web sites. Clicking on such a link in PubMed (a version of MEDLINE made freely available on the Web by the National Library of Medicine) will take you from a citation of interest to the journal Web site and usually access to the full text of the original article. User registration, a subscription fee, or some other type of fee may be required to access the full text of the original articles in some journals. Conversely, when a subscriber is viewing the full text of a journal that includes links to the PubMed citations of the references cited in the articles, a click on the reference number will take you to the reference, and a click on the reference will take you to the PubMed Web site and the complete citation of the reference, including abstract if available. Moreover, if you wish to find additional papers devoted to the same topic, a click on PubMed's "find related" button will automatically return a list of additional references. Thus, a reader can navigate from a phrase in an article to the full reference including the abstract, to a list of similarly focused papers that can be used to further explore a topic. The ability to link to MEDLINE references clearly illustrates a major benefit of having literature in electronic form and is provided to subscribers of ADA journals as well as many others. Many journals, including those published by the ADA, are beginning to allow a user without a subscription to obtain the full text of an article of interest for a transaction fee. For example, if one accesses the table of contents of Diabetes Care (http://www.diabetes.org/DiabetesCare/default.asp), the ADA will make the full text of some articles available to all at no charge. Those with a subscription can have access to the full text of any article. But those without a subscription may obtain any article in full text as an HTML or PDF (portable document format), which can be viewed with the free Adobe Acrobat Reader file. Users simply click on the article link and confirm that they wish to purchase it. If they have registered a credit card, a download is immediately enabled. There are many examples of medical textbooks online (e.g., http://www.harrisonsonline.com, http://www3.ncbi.nlm.nih.gov/omim, and http://www.samed.com ), and e-medicine (www.emedicine.com) has announced development of a new networking online writing software package that allows authors and editors from around the world to write textbooks online quickly and efficiently. But as frenetic as these diverse technological advances appear, they are but an early harbinger of much more dramatic changes that the Web will bring to medicine. Physicians are increasingly communicating with their patients via e-mail and through their own Web pages. Already, physician services including prescriptions are being offered on the Web. Obviously, this raises a number of legal and professional issues. Can a cybervisit ever substitute for a face-to-face real-time visit to a physician in his or her office? If so, what are the virtual interactions and services that could appropriately take place? I don't think we presently know the answers. Perhaps electronic communication can supplement the increasingly time-constrained office interactions between physicians and their patients. Perhaps before an office visit, patients could communicate information about their status (self-monitoring of blood glucose values, blood pressure measurement, symptoms, etc.) to their physician and receive recommendations and educational information from their physician. Then the office visit itself could be more efficiently used to address specific issues needing more clarification and the accomplishment of tasks (such as a physical examination) that at present require an in-person office visit. REFERENCES 1Morris, B: MBAs get dot.com fever. Fortune. 140 (3):60-66, 1999. 2 http://www.drkoop.com/aboutus/ Lawrence Blonde, MD, is head of the Section of Endocrinology, Diabetes, and Metabolic Diseases and vice chair of the department of medicine at Ochsner Clinic and Alton Ochsner Medical Foundation in New Orleans, La. Copyright © 1999 American Diabetes
Association For Technical Issues contact webmaster@diabetes.org |