Informatics, Telemedicine

We commonly think of telemedicine as a video link between a primary care physician and a specialist. By the author's definition, it is remote communication of information to facilitate clinical care and includes voice, images, elements of a medical record, and commands to a surgical robot. While telemedicine deals with communication, medical informatics focuses on the use of information.

Dr Coiera, an MD and a computer scientist, is a well-known authority in Europe and Australia. His present work offers physicians with self-taught and fragmentary knowledge in computer skills a comprehensive view of medical computing, laying a solid basis for this new discipline. The book, however, is not an easy, undemanding manual or a source of medically interesting Web sites, newsgroups, or mailing lists. It is a standard textbook and an introduction to a medical specialty. As such, it fulfills the expectations of the serious student.

The volume has 21 chapters in seven major parts. Part 1 gives an intriguing theoretical view of informatics in general, which in later chapters helps in understanding computer models and their limitations. The other parts deal with information systems in healthcare, protocol-based systems, language, coding and classification, communications systems, the Internet, and intelligent clinical decision support. Each chapter ends with an excellent summary. References are numerous and interesting, and a glossary of computer terminology gives special attention to medical computing. The index could have been a bit more comprehensive.

Contrary to the introduction, this book is probably somewhat demanding to read for physicians new to the field, which is to be expected with a standard text in a new specialty. To take full advantage, the reader should have some computer literacy.

Each part begins with thoughtful, usually historical quotes pertaining to the subject matter. The text is sprinkled with interesting references and analogies to general medicine, genetics, and even psychology and philosophy. Especially insightful and novel is the comparison of DNA to a computer's memory, a sort of an encrypted database: "The symbolic language of DNA, and thus the ability to interpret DNA, resides in the surrounding cellular structures. Without these molecules, there would be no way that we could decode the symbolic meaning of DNA—the data stored in the DNA would be uninterpretable."

After reading this book, one should feel comfortable understanding and discussing medical informatics and telemedicine and will have insight into the work of computer scientists and program designers and the limitations and potentials of medical computing. Such a text should be required reading for every physician intending to enter a fellowship program in medical informatics, and it is also highly recommended to every doctor and medical student interested in this emerging medical specialty.

Why should practicing physicians consider an electronic textbook over the print version? This edition represents about 2500 pages of medical text, which can be handily accessed when called at home; the CD or your notebook computer can be carried in your shoulder bag or briefcase on rounds or used for study on trips. The CD also contains a pharmacopoeia that is similar to the better known Physicians' Desk Reference, with cross-references between the textbook and the drug database that allow much more ease of flipping back and forth through a bulk of information than can be done with thousands of pages (5749 to be exact). Also noteworthy is the price, reduced from $299 in the previous edition to $165.

The folks at McGraw-Hill have imported photographs from infectious disease and cardiology color atlases that are not available in the print version of Harrison's 14th edition. Another advantage are the MEDLINE abstracts that link to the text, thus adding power to make the text more of a clinician's research tool. Also, full-motion video function is used to illustrate relevant neurological disorders. There was no video in the previous CD release. The Challenger Continuing Medical Education (CME) program requires a separate installation, which you will need to complete after the textbook installation. This allows access to CME credit available on disk. Free update disks are sent to users until the 15th edition appears (usually Harrison's has a new edition every 3 years). The two planned update disks will include enhanced video offerings.

The table of contents can be expanded or collapsed by double-clicking on a section. Key features include Search Sets, which allow creation of custom groups of frequently sought subjects. The "Quick Find" function saves the last 10 finds in case the user wants to return to study the subject in more detail or share it with another viewer. The search engine allows low-, medium-, and high-precision settings for running topic searches. I found "Search with Thesaurus" to add more breadth to topic searches. The CD allows you to see helpful hints and tool bar tips at start-up, then to delete this option once the CD has become familiar to you. Search preferences can be customized.

Navigation is fairly easy. The table of contents outline has a synchronize option, so it will follow you through your searches keeping you from getting lost. I had the feeling I was able to beam myself back and forth from a satellite view of the world of current medical knowledge to a bedside or even microscopic view of a disease process. The functionality of the searches is pretty much the same as in the previous Harrison's CD release. Potential buyers may want to note that an Internet version is in β testing, which, when released, would be accessed via a purchased password. That edition will be continuously updated but may also be limited by the relative slowness of current Internet graphic capabilities, compared with the available CD-ROM version.

In summary, I found this new edition enhanced a familiar textbook and an unfamiliar database by making their bulk no longer unwieldy. I felt the large amount of knowledge was more easily in hand (and thus in mind) than the last five print editions I have used. The hyperlinks between chapters on the CD thoughtfully illuminate relationships between areas of knowledge much better than the index of the print edition. The print and electronic 14th editions emphasize treatment and therapy more than previous editions of Harrison's have done; this makes the textbook more practically useful for the busy clinician.

I decided that the best way to review the new CD-ROM version of the Cecil Textbook of Medicine, 20th edition, was to use it in my office practice for a week. I figured that would be the most accurate way to assess whether the CD-ROM format facilitated information retrieval as compared with a standard textbook. I must say at the outset that I went into this effort as a textbook-oriented reader; I enjoy the heft of a book and the ability to quickly turn to particular pages. Nevertheless, by the end of the week, I was awed by the searching power that the CD-ROM provides.

That is not to say that I always searched for things in the quickest, most productive manner. The CD comes with an information driver called folio views, and I recommend that you read the introductory material carefully a number of times before wading into the material. Searching the CD for information on a particular topic was, at least for me, quite different than turning to the index or table of contents in the textbook. You can search either by query, drug name, section title, abstract, or chapter. I found that clicking open the table of contents was faster for finding the chapter that I wanted than when I tried to search by a certain chapter name, I was unsuccessful. (For example, I searched for "coronary artery disease," which is not a chapter, but in contents found it under "Disorders of the Coronary Arteries.") Searching a topic by query is not as direct at times—for example, putting in "relapsing polychondritis" takes you to the index and a chapter on aortic aneurysms before you reach the actual chapter on polychondritis.

Those who are computer literate will probably search with much greater elegance. But with use, even I became quicker and, furthermore, came to enjoy searching for a topic and arriving in locales in which I might not have thought to look. The programmers have provided a number of nice features for users still adapting to not having an actual page before them—there's the ability to highlight (in yellow or in blue) or put in bookmarks at key sites. The tables and graphs are easily accessible, and it is easy to jump forward and backward to the pages found in each query.

I cannot say how much time I saved by using the CD-ROM vs the actual textbook. There were times, I suppose, when the CD took me longer and other times when it was quicker. The advantage of the CD-ROM is that, in this world of laptops and computers at nursing stations, it is significantly more portable than the 2000-page textbook. The database of about 800 drugs on the same CD is helpful as well, as you don't have to open a second textbook to get prescribing information. The other advantage, obviously, is that Cecil is one of the oldest and most venerated medical texts with distinguished contributors and a readable and informative style. While there might be people who continue to prefer the weight of the actual textbook, current search engines now available can open the text in varied and powerful ways. I look forward to gradually acquiring the expertise that will allow me to use this tool as effectively as possible.

Proper patient education is a critical factor in the successful treatment of asthma. Better understanding of what causes asthma, why symptoms develop, and how most effectively to alleviate and control this all too common illness greatly enhances therapeutic management. There is a vast array of informational material about asthma available to the professional and lay public, mostly printed and to a lesser extent audiovisual. Asthma Explored is one of the most recent comprehensive software packages made available to patients.

Asthma Explored is the first title in a Web/CD-ROM set called The Health Empowerment Series, a proprietary program specializing in adapting and developing health care information for multimedia presentations. This particular program was developed by Avraham Kadar, MD, a former staff fellow at the National Institutes of Health and currently in private practice in New York city, where he specializes in the treatment of allergy and immunological disorders. Making full use of the interactive capabilities of the CD-ROM format, Dr Kadar has put together a highly innovative and informative educational tool.

The program is in two sections, one for adults and one for children. The children's "side," best suited for the younger child, is in the form of a cartoon with a circus theme. Nevertheless, a broad array of topics is covered quite completely. The adult side is more extensively developed and contains sections on "History," "Definition," "Anatomy," "Theory," and "Causes/Treatment," each of which in turn has multiple subsections. The older child and teenager will especially enjoy the subsections in which film footage taken during bronchoscopy is used to illustrate the anatomy of the airways and the physiology of gas exchange. A section to be enjoyed by all is "Quizzasthma," an interactive game modeled somewhat after a popular television game show.

Asthma Explored also includes a connection to http://www.asthmaline.com, the only Web site available to enable physicians to monitor their patients' asthma symptoms daily using a multicalendar interface and proprietary diagnostic graphs. The Web connection also provides patients with up-to-the-minute news and information on their illness, along with environmental reports and other pertinent data. No drug advertisements appeared on the Web site. The program, which will offer continuing medical education credits, apparently is being expanded to include a physicians' version.

The weakest part of this program is the "Treatment" section, which covers therapy in too general a manner. Pharmacology is the one area about which the consumer should be most educated. There is a paucity of information about specific classes of drugs and their modes of action, as well as basic information about the pharmacological agents themselves. In addition, there is little information about the epidemiology of asthma and its impact on inner-city populations. Some information about possible familial and genetic influences might also have been helpful. Perhaps the physician's version of the program will address these concerns.

As currently formatted, Asthma Explored is a highly instructive visual tool for patients and the families of patients who suffer with asthma. It does not cost much more than most popular music CDs, thus putting it well within the range of the average consumer. Of course, this assumes that the population to whom the product is marketed has access to a personal computer. The major advantage of the CD-ROM is that the user sets an individual pace and adapts various exercises to suit personal interests and needs. The software package should also find ready use by physicians and other primary and subspecialty health care providers in their offices and as part of their educational outreach efforts.

This CD-ROM contains the proceedings of the European Congress of the Internet in Medicine that convened October 14-17, 1996, in Brighton, England, (MEDNET 96). MEDNET 96 proceedings include 56 papers concerning digital medical libraries, electronic publishing in medicine, medical education, telemedicine, information policies and ethical issues, Internet security, access to health and medical information, and clinical applications on the World Wide Web (WWW). The proceedings are published in Hypertext Markup Language (HTML) format, requiring viewing with an Internet browser such as Netscape's Navigator or Microsoft's Internet Explorer.

Besides the advantages of hypertext links within each paper and among papers, the HTML format provides the potential to link MEDNET 96 papers to relevant and current WWW information. This is only a potential advantage, since about 20 of the proceedings papers contain no WWW links, about ten papers contain one WWW link, and about 20 more papers contained ten or fewer WWW links. Constantly changing WWW information presents a problem, so about 15% of 220 MEDNET 96 WWW links (excluding one paper with 84 links) are invalid because the linked WWW sites no longer exist or have been relocated. The proceedings provide the e-mail addresses of most authors, making it easy to contact authors (especially if an Internet mail program is integrated into the Internet browser).

Most MEDNET 96 papers are too specialized to be of practical value for using the Internet to practice medicine. For example, a paper on advanced reconstruction algorithms for single photon emission computed tomography (SPECT) is only appropriate for engineers or computer programmers. On the other hand, there is a very useful paper on Internet orthopedic information, which contains 84 current WWW links.

The essential prerequisite of a functional Internet browser to use this CD-ROM is not mentioned on product packaging or in advertisements. Many of the WWW sites linked to MEDNET 96 contain frames or tables or require a Java-capable Internet browser for full utilization. It is unclear why this CD-ROM requires 3 MB disk space, since it can be viewed on a CD-ROM drive. No appropriate installation or operating instructions accompanied this CD-ROM. A readme.txt file in the CD-ROM root directory mentions that an Internet browser is required and that the proceedings may be viewed by opening start.htm in the CD-ROM root directory. The MEDNET 96 proceedings occupy about 5.6 MB of the 650 MB CD-ROM, so including an Internet browser with extensive installation and operating instructions on the CD-ROM would have been no problem.

The proceedings link to the MEDNET 96 WWW site at http://www.mednet.org.uk/mednet. Here one finds abstracts for all the MEDNET 96 CD-ROM papers (with many of the same WWW links) as well as 40 additional abstracts not on the CD-ROM. Most of the MEDNET 96 WWW links are in Europe. I accessed these linked WWW sites during peak daytime Internet traffic on a 10 megabit per second Internet connection in the United States and encountered WWW site transmission delays as long as one minute. Several of the linked WWW sites are not written in English.

MEDNET 97 has already convened. The abstracts for this meeting can be accessed from the MEDNET 96 WWW site. Eighteen months is an excessive time to produce and disseminate MEDNET 96 proceedings on CD-ROM. The Internet in Medicine provides specialized information but does not fully use the WWW. Access to the CD-ROM WWW links from the United States will probably be slow for most users. This product provides no appropriate installation and operating instructions. It is advisable to review the MEDNET 96 WWW site abstracts before buying this product.

Consider the effort required to publish something. Ideas must form; the ideas must be elaborated or refined; they must then be described and connected in a coherent form; vocabulary must be carefully chosen; and the grammar, syntax, and the very appearance of words on the page must be carefully prepared. Thus, attempting to publish has involved a great deal of intellectual and manual labor. Every thought that reaches paper has been placed there by someone, and spending hours tapping at keyboards is not a particularly stimulating or pleasant activity.

If a manuscript requires revision, the labor involved in publication then has become repetitive. Some of us have grown accustomed to producing our own documents directly, including actually pounding out the thousands of keystrokes required to have in hand a manuscript of any length. Computers, of course, have changed the process. Certain words are probably disappearing from the vocabulary, for example, "erasable bond." These days, of course, everything is "word processed."

There is something new under the sun. This document has been produced essentially without a keyboard using computer-based voice recognition. After dictating the bulk of the review directly into Dragon NaturallySpeaking, I copied and pasted it to MS Word, made a few corrections, and submitted it. (This review describes the Personal Edition; other editions mentioned above were not evaluated.)

Over the period of the past several months, I installed Dragon NaturallySpeaking continuous speech recognition software on an IBM clone with a Pentium 166 MHz processor. At first, I spent a few minutes training the software with a series of five or 10 minute speech exercises, which consisted simply of reading statements from the computer screen into a microphone connected to the personal computer. It was quite exciting to immediately thereafter begin to dictate to my computer.

As time went by, I became dissatisfied with the rate at which speech appeared on the screen in a window in front of me. While I could speak in a natural voice with natural cadence, more or less as I would speak in conversation with a friend, sometimes the words lagged far behind my expression of thoughts, and so, by the time the words were appearing on the screen, I had moved on to another thought. Then I upgraded my computer to about a 100 MB of RAM.

With the upgrade in place, words appear on the screen nearly as quickly as I can speak them. If I notice an error in the word appearing on the screen, I simply articulate "correct that," and a second window appears displaying multiple alternative "interpretations" of what was just uttered. One then simply clicks on the correct phrase or taps a few keystrokes and resumes one's train of thought.

Needless to say, the professional vocabulary of each physician undergoes a lengthy period of development, and each individual physician uses scientific terms that bear only a distant relationship to ordinary conversational language.

So how, then, does one develop a functional professional instrument from off-the-shelf Dragon NaturallySpeaking? The answer is simple: it is possible to use existing word processor documents to "train" the software to recognize virtually any professional vocabulary. Using Microsoft Word files with needed terms entered, one can incorporate a custom vocabulary into the standard vocabulary delivered with the product. By repeatedly training Dragon NaturallySpeaking, the frequency of correct incorporation of words as they are spoken increases rapidly and dramatically.

My experience after months of careful examination and use of Dragon NaturallySpeaking suggests that any medical professional who is currently using a dictation service should carefully consider the savings to be realized by acquiring this inexpensive piece of software running on a properly outfitted personal computer. Those who would like to write more but are put off by existing barriers should check into voice recognition as a means to move forward.

Ultimately, the labor required to produce clear crisp documents of every sort will begin to diminish substantially when products like Dragon NaturallySpeaking are in widespread use. Currently many of our thoughts are simply lost because it is just too difficult (or expensive or inconvenient) to move them to the page.

Of course "voice processing" is not the end of the revolution unfolding in the movement of words, thoughts, ideas, and theories throughout the biomedical community. Just as quickly as conceptual matter can now reach the printed page, it can also reach the Internet. Previously, professional refereeing created a barrier between thinkers and readers. With tens of millions of individuals throughout the world using the Internet daily, the posting of this burgeoning body of thought has entirely transformed the concept of publication. A bright child with a personal computer, the right software, and an Internet connection can create electronic documents that can be posted and then found by any Internet browser in the world. Individuals who use listservs may choose to broadcast what they write to dozens, hundreds, or thousands of subscribers to groups of choice.

We are in the golden age of information wherein everyone who has use of a personal computer can retrieve just what is needed quickly, easily, and inexpensively. Soon the capacity to create and distribute thoughts, ideas, knowledge, and, hopefully, wisdom will be simpler and less laborious than at any time in history.