Why will the Internet be important to clinicians?

Five years ago, when a health care community began to consider seriously how, its members would implement an electronic communication network between workstations in all the locations of care, there were few options. Three proprietary firms were active in the business of bringing electronic data interchange to physician's offices: Integrated Medical Systems (IMS), now a subsidiary of Eli Lilly; Health Communication Systems (HCS), a subsidiary of Blue Cross of Virginia; and Ameritech Health Connections, a subsidiary of the midwestern telephone company Ameritech.

These firms - and they have other competitors too numerous to mention - license software for a communications hub and server to support messaging for electronic mail between participating providers, route laboratory and radiology results from regional laboratories and hospitals, and verify eligibility and benefits with payers. They also license software for client workstations that permit them to interact with data on the server. The software is proprietary. Every copy installed costs the sponsoring health care provider money. Each workstation needs to be set up, and any interference with other business applications on any physician's or hospital workstation must be corrected. A community health information network (CHIN) linking hospitals and clinicians can amount to millions of dollars in licensing fees to the vendor, hardware costs for the communications devices and servers, and expertise to install the software and train staff.

Is there a more economical architecture for a community health information network than the proprietary designs of IMS, Ameritech, HCS, and others? Today, the alternative is an extended Intranet. Using World Wide Web (WWW) browser software, as well as servers that adhere to the WWW standards, an Intranet is a private network, usually a local-area network inside a single office suite or building, or a wide-area network linking various sites of a business. Until recently, most private corporate networks were isolated from public networks like the Internet. Then, the World Wide Web became so enticing to users that corporations began modifying their networks to allow any workstations on them to communicate outside of the private network, through firewall computers to digital telephone connections to Internet Access Providers and the Internet.

As the popularity of the Internet's World Wide Web exploded in 1994 and 1995, corporations began adopting the browser software called Mosaic (and its derivatives) for their networks. Why? That same software can be used to "surf" the Internet. Since Intranets are easier to maintain and less expensive, they are replacing the more expensive "groupware" applications based on client-server architectures that corporations installed over the past five years. These Intranets are based on widely-available technologies designed for the Internet, not proprietary software designed for a relatively few customers.

The World Wide Web standards on which an Intranet is based become a kind of inexpensive interface gateway, allowing any corporate application to communicate electronically with any other corporate application. On an Intranet, the interface to the patient accounting svstem will resemble the interface to the order-entry, results-reporting system, which will resemble the interface to the laboratory system and the computer-based patient record.

The features of these various points of access to corporate data in different computer systems are produced by HTML (hypertext mark-up language), common to all applications on the world wide Web. And now, with a huge installed base of Web users, the Web browser software vendors (Netscape, Microsoft, Spry, and others) can invest hundreds of millions of dollars improving their products, but still afford to charge minimal fees to license them to individuals.

These econonlies of scale will dictate that the World Wide Web standards become universal for health,care communication networks, and drive the proprietary designs out of business - the only ones available, at any price, not long ago. I predict that every physician will choose to connect his or her office to a communicating health infonnation network based on the World Wide Web standards in the next few years.

Finally, the physician's patients will be communicating by Intranets and the World Wide Web, as well. In parts of the U.S., nearly 40 percent of people have Internet addresses either at work, at home (through CompuServe, Prodigy, America Online, and Microsoft Network), or both. As the public adopts the World Wide Web for electronic communication, and the Internet for electronic mail, providers will have all the more reason to adopt Internet standards for their office practice networks and the regional communication networks they share.

If they adopt the ubiquitous standards of the World Wide Web, physicians will be able to communicate with many of their patients electronically without having to install and maintain expensive proprietary software on patients, and health plan members, computers. Then the networks will truly be community health infortnation network - patients and health plan members will have the benefits of continuing education on health promotion and disease prevention, and the secure transmission of laboratory results and E-mail that their providers enjoy.

Security is an important issue. The security features of major Web browsers will be much more robust than those of proprietary community health information networks with fewer customers and less capital for maintenance and modernization. VISA and Mastercard have agreed to a sophisticated security methodology to protect financial transactions over the World Wide Web. Those same features can be used to make clinical communications secure, even over public phone lines between physicians' homes and offices, and computers used by health plan members and patients.

Organizations with communication networks integrated with their transaction systems and electronic medical records will be more effective in managing health care resource - and more attractive to employers and insurers for managed care contracting.