While you were out . . . a patient called for a new prescription, a colleague asked for a consult, a scheduling conflict arose, your nurse had questions about an upcoming surgery, your secretary needed a chart revised, your spouse called to schedule a social outing, the deadline loomed to submit abstracts for an upcoming scientific conference, you missed a hospital committee meeting, your partner had a few ideas he wanted to discuss, researchers 700 miles away successfully treated a tumor patient with a new drug protocol that might be helpful to one of your patients, and the expressway you normally take home is clogged with traffic because of unexpected road repairs.
If this sounds like a typical day in your practice, and your staff considers one of the most “challenging” aspects of their job as trying to “catch” you between surgeries, appointments and meetings — it may be time to put the Internet to work for you.
New computer technologies and the World Wide Web on the Internet cannot only help save time and money, but also help you to provide better patient care.
“Computer technology surrounds us in the operating room and a neurosurgeon wouldn’t dream of doing a procedure without first having utilized the benefits of CT scan or MRI computer technology,” said William A. Friedman, MD, past editor of the AANS/CNS Web site, NEUROSURGERY://ON-CALL®. “However, many neurosurgeons haven’t fully realized the benefits of computer technologies, the Web and e-mail in managing their practices and providing patient care. These tools are the ultimate in efficient communication, data management and information accessibility.”
Beyond the “gee whiz” status it has achieved over the past two years, the Internet has begun to transform the way the world communicates and does business. Today, according to the Nielsen research company, 23 percent of the U.S. population over the age of 16 is connected to the Internet. For physicians, the Internet has opened up access to a world of research information. Neurosurgeons are faced with a sometimes bewildering array of online services that can make life easier – or more challenging. This overview of the Internet, as well as the accompanying resource listings, is aimed at helping you benefit from all that the ‘Net has to offer.
Internet Background
The Internet is a complex network of computers that links together thousands of other computer networks. A network consists of two or more computers linked together to share files and electronic mail (e-mail). The Internet connects government agencies, schools and universities, businesses and other commercial entities, libraries, nonprofit organizations (like the AANS), and millions of individual users. As networks go, the Internet is small in comparison to the worldwide telephone network, but because it links computers instead of telephones, its power and reach are much greater — thousands of people from all over the world can “talk” and exchange information at the same time. The Internet was actually developed in the 1960’s when the U.S. Defense Department’s Advanced Research Projects Agency (ARPA) began experimenting with linking computers together via phone lines. It was originally designed as an exclusive, high-speed communications network for universities and military research sites. Today, the Internet has expanded to include private and commercial users as well. It also has become the ultimate free marketplace – no one owns it (it is a cooperative) — and as a result, it is often chaotic. There are some standards for the way information flows over the Internet, but no one nation or individual dominates it.
Throughout the 1980’s, those first users plied the Internet through electronically transferred mail, information, data bases and images. In the 1990’s, anyone can find just about anything (and do about anything) on the Internet. The World Wide Web is part of the Internet and is essentially a collection of sites from around the world that are linked together. Each Web site has its own address, or URL, (for example, www.neurosurgery.org) and can be reached from any computer with Internet access. The information a Web site contains varies greatly depending on who sponsors it. Some sites have entire databases searchable by key words while others allow you to play games, listen to music, shop, and just about anything else imaginable.
Chat rooms can often be found in Web sites or as part of an Internet Provider’s services. Simple chat rooms act similar to a telephone call with two or a group of people interacting about a subject. Some chat rooms have set times and topics for chats while others invite guest speakers to facilitate a chat.
Information on the Web can be updated continually in a matter of seconds to keep the news fresh. Newspapers, magazines and other news sources update their sites with the latest breaking news throughout the day. During an April blizzard in Boston, for example, more than three million people followed the storm via the Internet on a site called boston.com.
Net “surfers” can send and receive e-mail around the world in seconds, download free software, conduct scientific research, read the latest news, plan business trips, watch NASA space shuttle astronauts perform experiments in space, reach the world’s leading authority on French Impressionism, and so on. There are literally thousands of special interest sites on the Internet, and finding information in such a vast storehouse of data is not easy because there’s no road map to show the way. But, that’s why “surfing the net” is so entertaining – and challenging.
How to Get There from Here
Most individual computers are not directly connected to the Internet, but are connected to a central server which, in turn, has direct access. Information travels from server to server over phone lines before it reaches an individual computer.
“A good analogy is to compare the Internet to the U.S. Postal Service,” explained David Reid, Director of Information Services for the AANS. “The postal truck that picks up mail at your house in New York isn’t the one that actually delivers it to its destination in Los Angeles. The piece of mail goes from the truck, to a local post office, to a central processing station and so on until it finally ends up in someone’s mail box in LA. The address on the envelope tells the post office where the mail needs to go just like a computer’s address tells a router where to send or search for information.”
Getting connected to the Internet is relatively easy with an initial investment in basic equipment and software. Either a PC or Macintosh computer that’s equipped with a modem (with a suggested minimum speed of 28,800 baud) can be used. It’s certainly possible to use a less powerful modem, but expect extended download times. A dedicated phone line is also needed (if speed is essential, go the extra mile and install an ISDN line or T-1 connection).
The Advantages of E-mail
Electronic mail is sent over the Internet from one computer to another. There are addresses just like regular “snail mail” and the e-mail is received and viewed by those to whom it was directly sent. Once connected to e-mail, you will be able to send messages to colleagues in any part of the globe, check in with your kids at college, order on-line reports for electronic delivery, as well as leave and receive messages for and from your staff (no more piles of pink phone slips on your desk at the end of the day!).
“The biggest advantage of e-mail is that a surgeon can read and answer at his or her own convenience,” said John Oro, MD, current editor of N://OC®. “This saves an incredible amount of time and allows you to fit much more into a busy schedule.”
Documents and images can be attached to an e-mail message and can be edited and sent back without retyping. For example, a letter written in Microsoft Word can be attached to an e-mail and the receiver could open the letter, make changes and then forward the letter back to the original sender or someone else. E-mail can save money on long distance phone bills and overnight shipping expenses. Most e-mail software programs offer an address book feature that lets a user store e-mail addresses, as well as groups of addresses, so mail can be sent without typing in the addresses each time. “While working on enhancements to NEUROSURGERY://ON-CALL®, e-mail has been essential,” Dr. Oro said. “I can send an e-mail report or document to the entire editorial board and have everyone’s response in by the end of the day. Normally, committee work like this is painfully slow.”
News services and other organizations, regularly send e-mail updates on a variety of topics. For example, a customized newspaper, weather report, sports scores and other information can be e-mailed every morning. If after reading a summary, the reader wants more information, he or she would click on the story and a variety of resources would appear.
Medscape publishes a weekly electronic newsletter called MedPulse that is e-mailed to over 325,000 physicians each Friday. The newsletter not only summarizes the week in medicine, but includes peer-reviewed articles and an Exam Room Section. The Exam Room presents actual patient cases, complete with diagnostic tests, and invites physicians to consider a diagnosis. The patient’s actual diagnosis and treatment are then discussed.
“All of the major newspapers are on-line and if that doesn’t meet your need, you can develop your own customized newspaper that will arrive each morning like clockwork,” Mr. Reid said. “Most news services give subscribers a paragraph summary and then allow them to link to full text articles if they wish. You can scan the headlines of the Wall Street Journal in less than five minutes and have a pretty good idea of what’s happening in the financial world today.”
The World Wide Web and Neurosurgery
Medical sites on the World wide Web number in the 10’s of thousands and are maintained by hospitals, government agencies, drug companies, patient advocacy groups, and even individual doctors. These sites provide everything from simple patient education pieces to abstracts from scientific journals and other clinical information, and have proven to be popular with both physicians and patients. For example, Angel Neurosurgical Information Resource, a Web site operated by the University of Southern California Department of Neurosurgery, recorded over 54 queries within its first two months of operation. Inquiries came from physicians (26) and patients (15).
“The information exchange that occurs has many different levels of complexity, depending on the needs and educational background of the inquirer, ” John Gruen, MD, who helps manage the Angel site, said. “One of our first inquiries came from a rural Idaho internist who wanted to know if calcium channel blockers intended for treatment of cardiac arrhythmias could be used for prevention of vasospasm following SAH. By posting the question on the site, we were able to give him a clear and concise information without days worth of phone messages and telephone tag.”
Another advantage to searching for information on the Web is that documents can be linked through “hypertext,” a method of programming that allows posting of information in abstract form with the option for obtaining greater detail by letting the user “click” with his or her mouse on the screen. One page on the Internet can “link” to thousands of other documents written by other authors instantly — much like footnoting, except the entire document pops up on the screen in a matter of seconds. As documents are viewed, they can be “downloaded” into a personal computer, saved and printed out. In general, things in cyberspace go “up” to the Net and “down” to you.
“The amount of information you can find on the Web is boundless,” Dr. Friedman said. “You essentially have almost every piece of information from every library in the world at your finger tips.” Neurosurgeons have the unique benefit of NEUROSURGERY://ON-CALL®, the official AANS/CNS site on the World Wide Web. N://OC® is one of the largest medical Web sites on the Internet and provides one-stop access to everything from on-line abstract submission, to scientific literature searches, as well as the exclusive electronic journal, Neurosurgical Focus Launched in April 1996, N://OC® has showed steady growth in content as well as usage. According to the most recent utilization report, N://OC® received over 498,500 requests for April and May, averaging 8,768 and 9,862 daily requests for each month respectively. These figures represent an increase in site usage by 140 percent since December 1996.
Newly-added Public Pages are off to a great start, according to Allison Casey, AANS Interactive Communications Specialist, who notes, “The Public Pages section of NEUROSURGERY://ON-CALL® has generated 13,317 requests since its inception in mid-April. The new section is aimed at patients, referring physicians, and the media.” Within the Public Pages, “Find a Neurosurgeon” and “Patient Resources” proved to be the most visited sections with 4,559 and 4,480 hits respectively.
Most physician offices use software to help schedule patients, automate billing, and word process, but few take advantage of the often free services available on the Internet. “One of the most important services we provide to a private neurosurgical practice through NEUROSURGERY://ON-CALL® is Coding Coach,” Mr. Reid said. Coding Coach allows neurosurgeons, or their office staff, to input procedures and obtain the proper CPT codes. It is designed exclusively for neurosurgeons, and over 1,000 neurosurgical practices accessed Coding Coach in 1996. The program also gives the optimal order for the codes to maximize reimbursement.
“With the recent changes in coding and managed care, this resource is invaluable,” Mr. Reid said. “We are currently working directly with the AMA to expand this section of the site to include more in depth explanations of which code to use in complex cases.”
Neurosurgeons can register for continuing medical education classes and can often submit abstracts for scientific journals and meetings via the Web. Over 60 percent of the abstracts submitted for the 1997 CNS Annual Meeting came through N://OC®. Interactive Web sites also allow neurosurgeons to earn CME credits right from their personal computers. “We are working on plans right now to offer several different learning programs over N://OC® that will offer Category 1 CME credits,” says Nancy Bashook, Director of Professional Development for the AANS. “Participants will be able to view slides, listen to presentations and be tested on their knowledge without ever leaving their offices.”
The Outcomes and Guidelines Committee of the Joint Section on Cerebrovascular Surgery has developed Outcomes Reporting Instruments for carotid artery surgery and intracranial aneurysm surgery that are now available on N://OC®. The Outcomes software can be downloaded from N://OC® and neurosurgeons can develop their own local databank. The next step will be to submit those outcomes and other pertinent information to a national databank. “Analyzing outcomes in this way allows a neurosurgeon to compare his patient’s progress with similar patients around the country in a matter of minutes,” Dr. Friedman said. “Large, national outcomes studies are far and few between right now because of the massive amount of work that goes into managing a large study. With the Internet not only is the work much less intensive, but the studies also will be more in-depth.”
The impacts of the Internet and the Web on neurosurgery and medicine are far from over, or even fully comprehensible at this time. “It’s like when the telephone was first invented and users had to hand crank the lines and access was limited,” Mr. Reid said. “An Electronic Revolution has definitely started, but it is still in its infancy. As technology advances and programs become even more efficient, we’ll see wider use of the Internet in our everyday lives.”
Larger teaching hospitals today are involved in telemedicine programs that allow rural physicians to electronically transmit CT scans and MRI images to city hospitals for a consult in a matter of minutes. “To do a program like that now you need special software on both ends,” Mr. Reid said. “In five or six years, it will be possible to attach the file for an entire CT scan to an e-mail message and send it to a colleague across the country in a matter of minutes for a consultation.” In the early 1990’s, the Internet moved data at a rate of 1.5 million bits per second. Several years later the rate had reached 45 million bits per second and by 1996, the Internet moved at a rate of 2 billion bits per second, which is fast enough to send the entire Encyclopedia Britannica across the country in under two seconds.
“The technology expands on a weekly basis,” Mr. Reid said. “Allowing us to do things faster, easier and of a higher quality. Not only will the Internet be expanding over the next few years, other online programs, like video conferencing, will also be growing by phenomenal rates.”Improving Reimbursement
CME On Line
Outcomes Data
Telemedicine and the Future