Use of Internet in Healthcare

Basit Hussain August 1, 1997

Non-Technical
Technical

Abstract

Advances in information technologies over the Internet are being
used to reduce the cost of healthcare delivery. Internet can be used to
improve the quality of healthcare, increase availability of healthcare
in remote areas, disseminate healthcare information for general public
and the continued education of healthcare professions. Computer networks
are already being used for billing, financial and administration systems
of hospitals. Clinical laboratory automation systems are also being used
widely. Network based applications are available for patient registration,
nursing, radiology information systems, picture archival and communication
systems (PACS), intensive/emergency care systems, pharmacy systems and
nursing care systems. These systems support healthcare personnel in their
day-to-day work. However, there is a need to integrate these systems through
Internet so that the patients medical records are available remotely from
any location. Furthermore, recent developments in information technologies
suggest new applications to telemedicine, education and research.

Introduction

As a result of the continued pressure to control the cost explosion
in healthcare, payers and providers are increasingly looking for information
technology to help them improve and optimize their information systems.
This article examines how computers, computer networks and Internet are
currently being utilized. We will also discuss the future direction.

Computers are good at processing, storing, and retrieving information.
They are routinely used for formatting and presenting information. Unlike
humans, they provide consistent results. By taking over routine repetitive
operations and performing them flawlessly, they reduce the operating costs
dramatically. Computer networks are interconnections of many computers
through physical connections like cable, optical fiber, twisted pair wires,
hubs, bridges, and switches. The basic purpose of computer networks is
to carry information from one location to another quickly and transparently.
Computer networks provide independence of location for work and cost. They
also reduce cost of communication.

Internet is the most popular informal interconnection of thousands of
networks that effectively spans the entire world. Internet makes it possible
to search and retrieve information from anywhere in the world. It is also
possible to dispense information to selective groups or if desired to anybody
who seeks that information. Internet and computers are bound so closely
together that it is virtually impossible to talk about one without bringing
up the other.

The healthcare organizational structure is naturally distributed, consisting
of geographically spread medical centers, regional hospitals, and individual
general practitioners. This distributed structure offers comprehensive
medical care at a local and regional level. Each medical facility is autonomous
and delivers a particular set of services, but it is desirable that different
medical centers, offering complementary services or different levels of
expertise, exchange relevant patient data and operate in a cooperative
working environment. Information sharing is the key to improvements in
productivity and quality. The diversity of hospital organizations, the
complexity of clinical protocols and procedures, and the different preferences
of various user groups make it extremely difficult for a single information
system to serve the needs of an entire healthcare structure. Internet is
an ideal environment to permit the effective integration of distributed
and heterogeneous components, ensuring overall integrity in terms of functional
and information interworking.

We will see how internet is being used to improve access to healthcare,
enhance overall quality and reduce costs. We will also see that it is being
used to improve healthcare education and for raising general awareness
about healthcare issues. By replacing the paper based manual systems for
recording, retrieving and duplicating information, Internet is reducing
the costly and some times fatal human errors in healthcare. Internet can
also be used to enhance healthcare research by quickly gathering vital
data. We will also see how Internet will affect the healthcare in future
by fully utilizing technologies that are already available.

Because of these benefits, we witness a greater demand for exchanging
healthcare information between facilities and hospitals. The need for storing,
processing, and retrieving information from multiple sources and types
at any location destination is increasing rapidly. This will enable any
physician to look for complete history of his patient even if the patient
is traveling. Due to the ever increasing mobility of Americans, this is
vital to quality healthcare.

From a technical point of view, healthcare information may consist of
images and audio as in a Picture Archiving and Communication Systems (PACS),
other graphical and textual data resulting from laboratories and acute
care systems, as well as audio/video data. At this time, the systems available
are mostly based on textual information because in the past the cost of
storing, retrieving and carrying audio/video information on computers and
Internet was prohibitive.

The primary purpose of Internet use in healthcare today is the re-use
of data captured by one facility in another. However, it's utilization
is expected to increase when medical decision-support, quality control,
administrative decision-support and knowledge acquisition systems become
integral part of healthcare. With the advancements in high speed optical
networks, interconnected through private and public Broad Band communication
facilities that utilize SONET and ATM technologies for physical communications,
such inter-linking of medical devices and systems has been demonstrated
in actual healthcare systems. However, they are not used widely so as to
benefit the general public.

Existing Healthcare Systems

Traditionally most hospitals and clinics have operated patient administration,
registration, billing, administration and clinical laboratory automation
systems. In more recent years, radiology information systems or picture
archival and communication systems (PACS), intensive/emergency care systems,
pharmacy systems and nursing care systems have been added to support healthcare
personnel in their day-to-day work. .The least common denominator is a
system that maintains a summary of a patient's medical records in textual
form.

The use of computers is rather limited in healthcare because the technologies
five years ago could not handle all forms of information over the computer
networks effectively. Most of the healthcare systems deployed today are
constrained by storing and transporting only textual information. Furthermore,
each system is developed for stand-alone operation which makes information
exchange with other systems very difficult. Most of the current systems
are based on textual information but progress is being made. For instance,
although many medical imaging devices produce digital images, it has been
generally impractical to transmit or access these images interactively
over wide area networks. However, the use of compression, the widespread
acceptance of medical imaging standards, and the greater available bandwidth
have made interactive access to these images a reality.

Billing and Financial Systems

Billing and financial systems were the first ones to evolve in healthcare.
These systems include systems for automatic billing at local facilities,
systems to maintain patient accounts and links to insurance companies and
other financial institutions that take the responsibility of paying for
the services. These systems are based on textual information so they are
well established.

Administration

These systems are similar to an administration system of any other industry
and are used to maintain administrative information like personnel payroll,
and inventory systems.

Patient Registration

Patient registration systems are used to gather preliminary information
about the patient when the patient first visits the facility. These systems
are also text based and are used to capture information about patients
such as demographic, next of kin, allergies, health alerts, family medical
history and insurance.

Pharmacy

Pharmacy systems are one of the most uniformly deployed systems. These
systems are used to transfer prescriptions from doctors to pharmacies,
and from one facility to another within a healthcare organization. Systems
are also used to automatically detect depletion of inventory and to automatically
place orders to pharmaceutical companies.

Laboratories

Most of the laboratory equipment is computerized. However, most of them
are isolated so that the patient information has to be entered in every
equipment. Furthermore, the results are re-entered into the patient's medical
record often in textual form. This can lead to inconsistencies in data
and human error.

Radiology

Typically, almost all medical images have been printed on radiology
film for storage even though they were acquired electronically. This film
is too expensive, easy to misplace, and usually only one copy exists, thus
limiting the number of persons who have simultaneous access to the images.
In recent years, large PACS systems have been developed to reduce or eliminate
the need for the film. PACSs receive digital images from various imaging
modalities in the hospital and store or archive them in a central location.
These images can then be downloaded to any client workstation for display
across a local or wide area network. This eliminates the hassle and cost
of lost film, and supports viewing of the images at multiple locations
simultaneously. It also allows digital image manipulation of images for
better diagnosis.

Most advanced radiology systems today provide these facilities to transport
images from the scanners directly into the central computer through computer
networks. However, often these systems too lack the luxury of obtaining
the patient information directly from the registration system and providing
results back to the central computer.

Future Applications

In future, it is expected that more healthcare systems will become compatible
with each other making it possible to retrieve information on-line through
Internet from virtually any location in the world. In this section we list
the resulting future application of the Internet in healthcare. Some of
these applications have already started to appear but they still need acceptance
by majority of healthcare professionals.

Audio and video information exchange is the most recent invention on
the Internet that promises to dramatically reduce the cost of real time
or off-line transport of audio and video information. The exciting applications
for healthcare that we discuss here rely on audio and video information
exchange. These applications are still evolving. The need for standards
is felt very badly. Unless such information exchange can conform to standards,
it will make information exchange between different facilities very difficult.

Telemedicine

Telemedicine can be defined as the provision of healthcare through a
combination of telecommunication and multimedia technologies such as those
that are widely available on the Internet. Telemedicine is now feasible
due to confluence and affordability of ongoing technical advances in multimedia,
imaging, computers, telecommunications and information systems. Systems
are now being designed which integrate these technologies to unlock some
of the untapped potential in diverse applications.

Telemedicine reduces or eliminates the time and expense of travel necessary
to bring the patient to the doctor or the doctor to the patient. Quality
of care is improved by providing the needed services in a timely fashion
and expanding the pool of medical specialists available to a given facility.
Larger pool of specialists makes it more likely that a given case could
be handled by an expert if necessary.

Telemedicine facilitates remote consultation, diagnosis and examination
of patients over the Internet. These systems are aimed at reducing the
cost of healthcare and improving its quality. Typical applications for
remote telemedicine include emergency healthcare supervision by professional
physicians at the site of accidents, remote surgery, and natural disasters
or delivery of healthcare to remote areas where it is too expensive to
provide or maintain a specialist.

The area of Telemedicine can be further subdivided into fields based
on the specific field of medicine. The fields discussed here are teleconsultation,
telediagnosis, telepathology, teledermatology, telecardiology, tele-endoscopy
and telepsychiatry. We discuss these areas in following paragraphs.

Teleconsultation is the interactive sharing of images and medical
information in which primary diagnosis is made at the location of the patient.
The purpose of teleconsulation is to provide a second-opinion by a remote
specialist. This helps the local physician in arriving at a correct diagnosis.
This is carried out by simultaneously displaying the patient's records
at both locations and providing an audio or an audio/video connection between
the consulting physicians.

Telediagnosis is the sharing of images and medical information
in which primary diagnosis is made by a doctor at a location remote from
the patient, therefore, it requires a high quality video conference. In
trauma, telediagnosis can be used in an emergency situation in which a
decision on whether or not to evacuate the patient needs to be made.

Telepathology is used to examine tissues under a microscope remotely.
In some cases, pathologists can examine tissues resected from the patient
for signs of cancer while the patient is still anesthetized in an operating
room to decide whether more resection is necessary. Using interactive telepathology,
the pathologist can remotely control the microscope while observing the
image obtained and transmitted from a camera attached to the microscope.
Teledermatology resembles telepathology, except that it images the
skin of a patient instead of a specimen under a microscope.

Telecardiology involves examination of images of the heart remotely.
In ultrasound telecardiology, a sonographer positions an ultrasound transducer
near the patient's heart, and a dynamic image sequence of the heart is
transmitted that can be viewed remotely by a consultant. The consultant
can direct the sonographer where to position the transducer, and makes
a diagnosis. In certain cases, only the heart sounds are transmitted over
the remote connection making it appear as a long distance stethoscope.

Tele-endoscopy is remote examination of images captured by an
Endoscope - a device used to image the inside structures of the body. As
with telecardiology, a remote specialist can view the video sequence and
direct the local doctor controlling the endoscope.

Telepsychiatry is a form of telemedicine supporting the remote
practice of psychiatry. This requires video conferencing, including two-way
audio and video with remotely controllable cameras. The most recent virtual
reality environment programs can also be useful for psychiatry treatments.

Computerized Patient Record (CPR)

Hospital records classify patients healthcare records based on administrative
boundaries, which means each department in the hospital, each specialist
and each physician maintains records of their patient. However, when viewing
this information, it is most beneficial if these records can be viewed
simultaneously from a single location as a single unit centered around
the patient and not as being distributed across artificial administrative
boundaries.

A computer-based patient record (CPR), sometimes also referred to as
the EPR (Electronic Patient Record) is electronically maintained information
about an individual's lifetime health status and health care. Ideally,
they should provide the entire scope of health information in all media
forms. The components of well defined health records can include family
healthcare history, as well as current health problems, findings on physical
examinations, diagnoses, lab results, image studies and referrals, plan
of treatment, drug information, and result of treatment. These records
can include voice dictations, graphs, pictures, and video all combined
in a unified information package. Traditional Patient Records include only
textual information such as summarized results deduced by specialists.
This severely restricts the information that might be useful for future
diagnosis.

In order to allow individual administration units to maintain ownership
of data of their patients but still allow complete access to the CPR of
a particular patient, a promising approach has been recommended. This approach
allows autonomy of individual subsystems at the data instance level. The
objective of this approach is to achieve patient information integration
over distributed and potentially heterogeneous systems while allowing them
to operate independently and concurrently. Thus a large distributed set
of computerized patient record components can be seemingly integrated into
a single patient record. It will provide aggregation and navigation facilities
to allow personalized utilization of the CPR by respective functional units
or healthcare providers. This approach this will provide access to all
stored data for a particular patient, whether it is textual, images, audio
or video based.

Education

Classical techniques for education require provision of educational
materials. Internet is an ideal tool for dispensing such material quickly
and cost effectively. These materials can include text information with
images, and video information that can be on-line or off-line.

Internet also provides option for introducing more advanced tools for
education that include shared documents, simulations, and interactive environments
similar to video games that will put the students in real-life like situations.
The students can have hands-on experience in these environments without
risking live subjects.

Research

Internet is a natural tool for gathering healthcare statistics. This
can even be done automatically by (ideally) linking all the healthcare
systems and picking all the healthcare information automatically for each
patient. Care will have to be taken in order to filter the patient's personal
information and only passing the specific healthcare information.

Obstacles and Concerns

There are some obstacles that have to be dealt with in order to fully
utilize Internet in healthcare. These obstacles can be broadly sub-divided
into two categories

Non-Technical

The legislature of providing healthcare services over Internet is non-existent
. There are several important issues that need to be settled. For example,
most of the physicians are registered only in the local state. Their services
might be required remotely in another state. There is also the issue of
reimbursement policies for service provided over the Internet. Another
obstacle is the discomfort felt by most physicians and healthcare professionals
with the Internet environment. Furthermore, Internet tends to reduce the
control of the flow of information across administrative boundaries. This
is disturbing to some people who are used to controlling such information.

Technical

Unavailability or cost of high quality communication resources in certain
areas limits the type of consultation that can be provided remotely.

Patients and physicians are often concerned with the confidentiality
and integrity of patients healthcare state. Cryptographic security techniques
can be used to satisfy this requirement. In fact these techniques can provide
greater protection of information that is currently available by using
paper systems.

One of the greatest hurdles in the wide spread use of Internet in healthcare
is the incompatibility of systems that are already deployed and the systems
that are still being deployed. These incompatibilities are a result of
independent efforts of different vendors and different requirements of
distinct healthcare areas. Healthcare communication standards are being
developed to facilitate communication between healthcare equipment.

The costs of such systems are high because the hospital environment
requires diverse types of medical equipment that are not directly compatible.
In such environments, addition of a new unit to a healthcare facility required
a custom developed interface for each communication link as the systems
run on variegated hardware and software platforms. This is time consuming,
costly and unreliable because a small facility will typically have limited
resources to tackle such problems.

To deal with the problem of inter-linking different medical units and
systems, several healthcare standard bodies have emerged in the past couple
of decades. Each US healthcare standards development body focuses on a
particular area of the healthcare industry, which may or may not overlap
with some other standards. With the advent of healthcare standards, the
complexity related to inter-linking has been reduced considerably.

[1]
TRC Inc., Tampa, Florida.

[2]
University of Miami, Miami, Florida.

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