Interactive media enhances medicine.

When all is said and done, we will look back on the late 1990s as the time when we reached a critical mass of computers sharing multimedia information, using the Internet's World Wide Web standards. The paradigm shift from personal computing to personal networking is occurring right now. The personal computer has changed from a device primarily for independent computing, especially for authoring documents, to one that gives users access to information on countless other computers around the globe.

Information technology offers physicians a myriad of options for education, research, and communication. Listed here are some of the interactive media applications that physicians can use to enhance diagnosis, learning, and information sharing.

Diagnostic decision support systems

Many physicians, primarily internists, are testing diagnostic decision support systems from a variety of developers. These products for personal computers, running under Windows or Macintosh operating systems, originated in academic medical centers for use by house officers and medical students as research projects on mainframe and large minicomputers more than 10 years ago. Quick Medical Reference (QMR), is derived from Internist, developed at the University of Pittsburgh. Iliad was developed at the University of Utah. DXPLAIN was created at Massachusetts General Hospital.

These decision support systems perform something like automated textbooks and electronic consultants: Enter a patient's history, including symptoms, findings on physical examination, and diagnostic test results, and the programs will give you a differential diagnosis. The problem is that complex patients with numerous symptoms can require 10 to 20 minutes of data entry. Most physicians will not take that much time during busy clinical work. They may refer to these programs in the evening, at lunch, or on the weekends when they have more time. In addition, they are expensive to maintain, because treatments and diagnostic tests change frequently. Finally, while they tend to serve clinicians well when a patient has one ailment, they often give unrealistic differential diagnoses when they have more than one clinical disorder.

Therapeutic decision support systems

Therapeutic decision support systems focus on selection and prescription of medications. They automatically check for drug-drug interactions with other prescribed and over-the-counter medications, and more sophisticated ones suggest optimal dose and administration based on data about patients' weight, height, age, sex, renal, and liver function. Such systems have been developed for office practices and run on personal computers. The most popular is AskRx Plus, from First Data Corporation.

Multum Corporation is creating a sophisticated system for hospital electronic medical records, which will advise physicians on the medication, dosage, and route of administration based on laboratory findings (creatinine, electrolytes, hemoglobin), recorded allergies, weight and age of the patient, and cost of alternative treatments. Of course, for these decision support systems to achieve their greatest effects, clinicians need to interact with them by entering their orders themselves. This is more likely to occur in an academic health center, where house officers are expected to write the orders. These systems lead to more legible orders, fewer errors, and more thorough documentation of the reasons for orders, because clerks are not entering orders they must try to interpret from physicians' handwritten notes.

Patient education systems

In the past five years, with the availability of inexpensive multimedia personal computers, many firms have created automated patient education systems. While patient education modules still appear on videotape and pamphlets more often than in digital form, the interactive medium is gaining preference. The computer can interact with and teach the patient, according to instructions he or she has given it.

For instruction in dieting, management of hypertension and diabetes, reduction of stress, and management of AIDS, a system tailored to individual patients works best. Videotapes are viewed linearly, without variation or interaction. Computer programs can be much more engaging. Health risk assessments that patients complete on computers, that produce for each patient a specific set of instructions on how to change personal habits and reduce his or her likelihood of suffering specific chronic diseases in the future, are much more effective in changing patients" behavior than general purpose videos describing the consequences of bad habits.

Patients who complete structured educational sessions are better informed about their ailments, or their impending procedures, more compliant with their treatments, more likely to complete a course of therapy, require a shorter and less expensive post-operative recovery period, and use health care resources more prudently. One program AskAdvice, from First Data Corporation, produces instructional material about pharmaceuticals prescribed for patients. Patients appreciate the detailed documents, in layman's language, that the program provides.

Physician continuing education online

Computer's can help physicians obtain continuing education in their offices and homes by completing automated educational software and managing simulated cases. The computer can test physicians' understanding of material it has just presented, and track accurately the time a physician spent working on the system. Interactive continuing education via the Internet may become the next big opportunity for physicians to pursue their knowledge of new treatments and interpretations of patients' ailments.

The Internet is a window on a much larger world, arid the physician using it has access to millions of computers and users. Continuing education programs are available for credit without the physician needing to install any software. Computers can store vast amounts of data, including images, on small optical CD-ROM disks, and access more data over the Internet, making continuing education more convenient and complete than can be obtained from occasional sessions presented in the hospital and paid for by pharmaceutical firms.

The National Library of Medicine has funded the vast Visible Human project, of which the Visible Woman is more complete and more detailed than the Visible Man, but for each a human cadaver has been serially sectioned in millimeter slices, imaged completely, and all images stored in digital format to allow three dimensional computer reconstruction of organ and musculoskeletal systems. With these data, virtual reality training of physicians in anatomy will be much more thorough and accurate. The Visible Human is available on CD-ROM disks and via the Internet. There is now a magazine entitled The Journal of Medicine and Virtual Reality. It shows many ways in which virtual reality applications help clinicians learn how to perform surgery, understand anatomy, and visualize the distribution of metastatic malignancies.

Telecommunication technology

Telecommunication technology gives physicians access to computer-based medical records from a distance, any distance, and confidence that, protected by encryption technology and passwords, people not intended to access it will be unable to do so. Communication with colleagues, health care facilities, pharmacies, utilization review firms, insurers, and public health services can be electronic, secure, and immediate. Many physicians already rely on electronic mail for their work. They communicate with colleagues on consultations, and with facilities to schedule patients by E-mail.

Soon, E-mail will become multimedia, and physicians will send marriages, video, and sounds via E-mail for consultation requests to other physicians for second opinions. Teleradiology and telepathology already lend themselves to multimedia E-mail. Scheduling two physicians in a busy practice to participate in a simultaneous video conference is difficult, but sending the same information by multimedia E-mail makes a lot of sense. It allows the sending physician to record a set of questions and store textual data and pertinent images about the patient(s) in question in a multimedia file, send it to a consultant, and wait for the consultant to check his electronic mail and download the file for interpretation.

As physicians obtain digital telephone service for electronic communication with ISDN, at 128,000 bits per second, or, at home using ISDN or cable modems, obtaining these large multimedia files will be much less time consuming than it is now with modems operating at 28,800 bits per second, at best. But no one should doubt that these faster digital telephone and cable connections are just around the corner, so to speak, and available in many urban areas now.

Marshall Ruffin, MD, MPH, MBA, FACPE, is President of The Informatics Institute, Falls Church, Virginia. He may he reached at 810 Gatehouse East, #401-Fast, Box 11, Falls Church, Virginia 22042, 703/205-3901, fax [phone]. You can also reach Dr. Ruffin online at Marshall@ Ruffin.com.