Use of Internet in Healthcare – By Dr. B. Hussain & Dr. S.A.Rajput
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.
