The World Wide Web is coming soon to an organization near you.

HEALTH CARE BYTES

The World Wide Web, a subset of the Internet, is coming soon to an integrated delivery system, hospital, group practice, health plan, IPA, PPO, PHO, or MSO near you. You will use it for patient care and public, health plan, IPA, PPO, PHO, or MSO near you. You will use it for patient care and public health and organization management before you know it. It will replace the few proprietary community health information networks that exist now and will catalyze growth of electronic medical communications of all sorts between physicians, patients, facilities, payers, regulatory agencies, and members of the general public. It will allow you to videoconference with your colleagues, teleconfer with your patients, test yourself on new medical knowledge without visiting a testing center, and select a clinician for your new medical complaint form the comfort of your own personal computer.

Many experts argue that the Internet is the next paradigm shift in computing, the one after the personal computer. They predict the standards that define the Internet will accelerate the arrival of the information superhighway as a ubiquitous, standardized computing platform. It is already capable of transforming many of the ways in which physicians practice medicine. It is changing the ways in which our patients learn about their conditions, how they care for themselves, how they learn how to avoid ailments, and how they reach medical attention when they need it.

The World Wide Web (WWW), sooner than any of us would have predicted two years ago, has defined, and is defined by, a set of standards and technologies that allow us to construct true community health information networks, linking electronically all members of the community involved with our health care services. The WWW provides the technical design necessary for standardized, vendor-independent, computer-based patient records to flourish.

So, forget all-that you have heard about community health information networks that require your organization to contract with a vendor of proprietry software, supply a copy of that software to every potential user of the network, and support that software with staff. Consider instead what a global open standard network can do for you, your patients, your organization, and your community. And the same standards that make global, ubiquitous computing possible allow organizations to place Internet-standard network servers (computers themselves) with information proprietary to those organizations on corporate local and wide-area networks to make that information available to employees in electronic form-=such as documents for personnel policies and operational instructions and directories of employees, with photographs, graphics, sound and video clips of them. The WWW and intranets using software share standards for digital networking that may undermine the market value of many proprietary systems, because they establish a vendor-independent, personal computer-based, platform for computing, networking, and teleconferencing.

The World Wide Web of the Internet is available to anyone who has an account with a computer communication services firm or with an Internet access provider. An intranet is a corporate network proprietary to a corporation that uses the same communications protocols, standards, and technology that define the World Wide Web, over the Internet. Intranets are burgeoning as corporations discover that they can purchase and install World Wide Web servers that give their employees many of the benefits of multimedia documents, interactive forms, accessible databases and other features of the most advanced public Internet sites. They can do so at far less cost than they might otherwise spend to maintain proprietary document management systems on their networks that have fewer, and more slowly developing, features than those available for the Internet. The computing standards that define the Internet are becoming more advanced, more replete with features, and more exciting than those of proprietary vendors' networking products because there are so many vendors writing for the Internet, and many fewer writing for proprietary systems.

Internet standards have existed for 30 years. The basic Internet standards for communicating data were developed for the Department of Defense. The standards, Transmission Control Protocol (TCP) and Internet Protocol (IP), together make up the TCP/EP protocol stack that allows computers to break up files to be sent electronically between them into packets of data. Each packet is given specific bits that identify the computer that created them, the computer that is to receive them, and the total number of packets that must move from the sending machine to the receiving machine before all the parts of the digital file are received at the receiving machine.

TCP/IP protocols also include rules that the computers follow to keep track of which packets they have received and which they have not. If packets are lost in transit because of some failure or artifact of the network, the recipient computer signals the sending computer to resend specific packets that did not arrive. The recipient computer knows which packets it lacks because each packet contains instructions on how many packets there are and in what order they must be received at the recipient computer for it to have all the data that make up the file. The file is useless to the recipient computer until all the packets are received and reassembled. The Internet Protocol established the conventions for addressing computers on the Internet so sending, receiving, and intermediate transmitting computers know where to send packets as they produce and receive them.

This design puts the intelligence of routing messages into the messages themselves and obviates the need for a central computer to decide how to move data from one computer to another. Without the need for a master switch, the entire network is far less vulnerable to unintentional, or intentional, failure. In fact, the network was designed with routing instructions embedded in the packets to make the network far less susceptible to damage from nuclear attack than it would have been had it contained a central switching site. Remember, TCP/IP protocols were designed in the 1960s, at the height of the cold war, to protect communication of data electronically among computers in government facilities, universities, and defense contractors that were used by the Department of Defense for research purposes.

So, why does this design lend itself to corporate and community computing, and why has the use of these Internet standards exploded in popularity with the general public? Use of the Internet was limited to communication of e-mail messages in alphanumeric text and digital computer files between universities, government agencies, and a few private firms for all but the last two of the past 30 years, with the general public and commercial firms paying little attention. Then, in 1992, researchers at the European Laboratory for Research Physics in Cern, Switzerland, created a set of software protocols for moving text, images, and all other digital files over the Internet with a graphical user interface on client workstations. They called the subset of computers (clients and servers) on the Internet using those protocols the World Wide Web.

In September 1993, programmers at the University of Illinois released the first browser software for the World Wide Web for IBM-compatible personal computers running Microsoft Windows, and called it Mosaic. It was free of charge for anyone who knew how to access the server on which the binary files for it were stored. Interest in Mosaic quickly grew huge. Graduate and undergraduate students at universities all over the world notified each other by e-mail messages about its location and copied the files for Mosaic to their servers to make more copies of Mosaic available on the Internet more quickly. Interest and use of Mosaic, and the World Wide Web, grew exponentially. People now had a relatively easy way to access multimedia documents on computees all over the world by simply pointing and clicking on text names in other documents on the WWW.

The principle beauty of the World Wide Web, and the browser software Mosaic, is that addresses of computers on the WWW are in natural language; their arcane numeric computer addresses are hidden from view. Users simply click on the words Stanford University, embedded in text on a home page (an introductory multimedia document on the WWW) of another computer on the Internet to visit the home page of Stanford University. In that document may be a reference to a document on a computer in Japan. Through simply clicking on the name of the document in Japan, the handles the complex routing instructions to download that document off a server in Japan to the user's workstation using the Mosaic browser, no matter where the user's computer is located.

The ease of surfing the Internet is staggering, compared to the mystery of programming logic and the hassles of text menus that preceded the point-and-click interface of the WWW. Operators of most of the servers on the Internet are converting their server software to make them compatible with VAM standards so they can contribute their information to anyone on the WWW inclined to visit their sites with browser software compatible with client protocols.

The World Wide Web technology of the Internet is being adopted rapidly as the standard client/server computing platform within corporations to create intranets for their internal communications. Corporations can maintain the security benefits of their own private local and wide-area networks and still enjoy the benefits of rapidly emerging new products and services for intraorganizational, client/server computing based on open standards. Use of these standards for electronic computing may grow from 35 million people today to more than 120 million people in three years. With such a huge market for shared standards, suppliers of products and services will produce more exciting applications for users than any one firm controlling a proprietary set of standards could ever produce.

What does all this mean for health care services and your own organizations? I see two areas of enormous opportunity for health care organizations that choose to use the Internet standards for electronic communications:

* Internal organizational communication, including interactive and secure communications.

* External organizational communication with members of the community, including participating physicians, other allied providers, health plan members, patients, and the general public.

Without the Internet, organizations may communicate by proprietary means internally and with allied external entities to whom the organization has given the software to permit electronic communications, but organizations will be hard pressed to distribute and support such proprietary software to permit allied providers, health plan members, and the general public to communicate with them electronically.

What could a health care corporation do with an intranet? It could disseminate manuals and documentation of all sorts to its stakeholders. Placing most corporate policy manuals, telephone directories, schedules of events, electronic mail directories, corporate histories, and all documents usually made public on the corporate intranet allows any employee with an Internet browser on his or her personal computer, and a password to the system, to access them. The corporation increases the number of persons with legitimate needs who can see them, and peruse them, while reducing substantially the costs of production and distribution in paper. In electronic form, they can always be kept current without having to print thousands of new copies for each new edition.

Far more important, in the long run, to corporations are the new functions for creation of data entry forms in client VAM browsers so people at their workstations can enter data, and launch applications, on servers elsewhere on the Internet. Employees could enter data into transaction systems and launch search routines in corporate transaction systems to find data important to their work. Physicians can search medical records using their software, after entering through a security checkpoint, and read, but not to write, to the databases into which they make inquiry. Health plan members and patients can access databases about services, including classes, available through the health care organization. They could check simple rule-based guidance systems for symptoms or questions about procedures and treatments they may have and gain access to answers to their questions when their providers are not available to them.

The ACPE debuted its presence on the Internet at its Future Forum in La Jolla, Calif., at the end of January 1996. Already that site on the WWW is busy with "hits" (electronic visits) by members of the ACPE, and those not now members who want to learn more about the ACPE and its services. Included throughout this article are images from the ACPE site on the World Wide Web. We captured screen prints from the current home page for the ACPE and the pages for Educational Seminars, which one can reach by simply clicking on the button with that title on the original home page. Anyone can complete a form to register for a course, or purchase a publication, from the ACPE, by typing information needed by the ACPE into a form made available by hypertext link on the bottom of every page describing publications or seminars.

Similar order entry screens can be used in many health care and medical settings to allow many different stakeholders of health care organizations--employees, affiliated physicians, or members of the general public--to have access to documents placed on a WWW server. For instance, patients can complete health risk assessments or functional status and satisfaction surveys on-line from their homes or offices, having been alerted by electronic mail when they are due to complete them. A forms interface allows members of the public, or health plan members, to enter their complaints into an expert system that can give them counsel on the best means to manage their conditions and reduce the cost of nurses, clerks, and physicians answering the telephone and trying to deal with such questions, without the benefit of standardized answers in front of them.

Some patients and health plan members enjoy searching a database on participating physicians to see pictures, read text descriptions, and even hear statements from physicians describing themselves and the types of patients they serve best, all as a way to help patients or health plan members select physicians for their care. Physicians can send laboratory results to patients who want to receive such messages by electronic mail. Some patients have security clearance to dial in and check on the results of their laboratory studies directly, which is a convenience for patients on coumadin, diabetics, and those with chronic renal failure, all of whom need to be active in their daily care.

Physicians, or their staffs, find it very convenient being able to dial into an Internet server to check on the benefits and eligibility of people who appear in their offices for treatment, and to obtain lists of providers participating in specific health plans to whom they can make referrals. With standardized documnts and forms already on the Internet server they access from workstations in their offices, the processes for obtaining prior approval for planned treatments and for sending requests for consultations to subspecialists is made much easier and faster. Patients scheduled for specific procedures, or preparing to take specific medications, can look up explanations of their ailments and instructions on preparation for procedures or other treatments on their health care organization's WWW server. Office staffs can print such documents, saving their physicians time in reciting what the documents spell out in print. The forms function can be used to allow providers to submit claims in standard HCFA 1500 format by the WWW server and, with sufficient security protection, even schedule hospital facilities for procedures on patients and order medications with an on-line signature. Participating pharmacies receive prescription orders from physicians' offices in the same way.

Anyone familiar with community health information networks (CHINs) has probably already commented that all the functions mentioned above, and more, can be performed on proprietary networks offered by a number of vendors. That is true. But, the likelihood is very small that individual proprietary vendors will keep up the standards of their software to compete with those emerging for the WWW. Once an organization has adopted the standards for communications between clients and servers on the WWW, it can concentrate its resources on enhancing the functions it puts on those servers, and it can avoid the costs of maintaining and enhancing, networking technologies for a relatively small group of people, compared to the entire world of users of WWW standards.

This is an exciting time to be practicing medicine and managing health care organizations. If you are not already doing so, we predict with utmost confidence that you and your organization will choose to "surf the net" much sooner than you would have predicted before you read this article.

Marshall Ruffin, MD, MBA, MPH, FACPE, is President and CEO of The Informatics Institute, Falls Church, Va. This column is copyrighted by The Informatics Institute.