Indian Pediatrics 2000;37: 481-485
Cybermedicine: Promises and Perils
internet is said to be an ongoing world wide conversation. It began
as a tool by the American Defense Department who wanted to create
an information network that would continue to function even if a
few links in the grid were destroyed by the enemy. The anatomy of
the internet is a collection of computers connected via telephone
lines or satellite links, which transfer information to and fro
based on certain rules or transfer protocols. But information does
not travel in a straight path from the sender to the receiver. Instead
information is broken into discrete packets of information, each
of which travels a different route to finally coalesce at the target
computer. A breakdown in any one of the links does not break the
system and it is difficult to intercept any significant information
en route. Today the internet is accessible to users around the globe
by logging on to servers. One can search large databases of information
on various computers worldwide using a variety of search engines,
one can transmit messages via electronic mail, one can discuss any
topic under the sun on specific discussion groups, one can put up
notices for huge audiences using electronic bulletin boards or one
can shop and one can be entertained all at the click of a mouse
What the internet has done is to make available a lot of information to a lot of people. What is the significance of this? Claude Shannon who devised the information theory, a mathematical definition of information, said information is the reduction of uncertainty. If a doctor advises antibiotics for an infection and the patient also knows this, this is not information. But for the patient who is unclear whether antibiotics are to be taken or not, the doctors prescription becomes information and hence valuable. Access to information is always empowering, but specially so in the case of physically handicapped people.
The second crucial nature of this information is that it is asynchronous(4). In a regular lecture, the information exchange is synchronous, which means both the student and teacher have to be present simultaneously. On the internet lectures may be stored as data on the computer, with the student accessing it at his convenience. This is a vital feature if doctors are to continue medical education along with their busy clinical practice.
Since computers thousands of miles away are linked, now distances are becoming irrelevant. Geography as they say is now history. This means a student may be able to learn from the best teachers in Harvard Medical School, sitting in Hyderabad. It means district hospitals can log onto the web site of the Medical college miles away and take a specialist’s opinion thus cutting down cost and time lost in unnecessary referrals. It also means a patient can consult his doctor wherever in the world he may be. Perhaps they will call it net practice.
Telemedicine essentially involves long distance consultations and review of digital images and records by specialists. In India, Chennai Medical College is soon to be connected via an integrated services digital network (ISDN) line to the local hospital in Thiruvallur. And in Latin America, satellite links between hospitals in Mexico City and 10 rural hospitals in the province of Chiapas have reduced needless referrals to specialists by 60%(5). Cheaper alternatives using text based email for telemedicine has been used in Nepal and may be more appropriate in poor countries. WorldLink is an organization trying to provide telemedicine services to hospitals and doctors in Nepal(2).
Importantly a doctor may refresh himself on almost any subject such as, the latest recommendations of the American Academy of Pediatrics on febrile seizure without moving out of his clinic. Hence, it is also prophesied that with widespread connectivity by the net, the number of people living in cities will reduce. More doctors may be willing to settle in smaller places if they know intellectual stimulation and academic support is available online.
Hyperlinks are another feature of information on the net. When one is reading an article but wants to understand it better by reading a related article, it is simply a matter of clicking on the hyperlink and you are transported to it. This is a wonderful way to learn where each student explores different areas according to their existing knowledge base. These apparent seamless fields of information foster curiosity and consolidate knowledge. Even so upto now, for researchers accessing data it was difficult to go from one journal to another for related articles because publishers being different, journals were often on different servers. Now starting early 2000 AD, 12 publishers of leading scientific journals including Oxford University Press, Elsevier Science, etc. have decided to link their journals online.
Fortunately or unfortunately on the internet, the same information is available to all, in our case both patient and doctor. It is not uncommon today for a patient to walk into the consulting chamber with a medline search on his child’s illness. Where this has put pressure on doctors to keep upto date, it has sometimes resulted in unnecessary pressure to prescribe especially, life style drugs in the United States. An internet based survey regarding use of an online Dermatology Atlas revealed that in Canada and USA, more consumers used it rather than health care professionals whereas the opposite was true in Spain and Brazil(6).
the internet’s special ability to connect with a large number of
people almost instantaneously means that it has been used to disseminate
public health information. During the Andhra Pradesh cyclone, some
organiza-tions effectively used the web and email campaigns to mobilize
Since anyone can put up any information on the web, it puts a big question mark on the reliability of information. Data varies from extremely useful to totally incorrect(8). Quality control of data on the internet may depend on "upstream filtering" by regulatory bodies or filtering services. But this may not be the solution because internet information changes too rapidly, rating cannot take account of users context and needs and very few users would spend time in specifically checking it’s rating. "Downstream filtering" by users, manually for quality criteria is too cumbersome. The answer may lie in automatic downstream filtering. The World Wide Web Consortium has developed technical standards called PICS (platform for internet content selection) by which digital works can be embedded with labels to automatically indicate whether an item is appropriate for an audience such as children, patients, researchers, etc. It also provides source rating such as highly trustworthy or often misleading. So a person may indicate in the beginning that he wants information "for a patient, in the Indian context, of fair reliability". The fascinating field of "cybermetrics" which studies the mathematical patterns of user behavior, user patterns and complexity of the site is also expected to reduce the need for human evaluations while assessing impact of websites(9).
In many places in the United States, medical advice and drugs are being prescribed on the basis of online information provided by the patient. Last year a pregnant attorney in Missouri found that she could get a drug contraindicated in pregnancy by filling in an online questionnaire from an internet pharmacy. This resulted in the pharmacy being fined $ 15000. The American Medical Association has strongly condemned these unethical practices.
But the real threat of the internet may lie in the fact that in country like India where telephone density is 1.9% and possession of a computer is by 1 per 1000 people, it compares extremely poorly with the United States which with only 5% of the world’s population has 50% of the interent users(5). This would mean that the great divide between the have’s and the have not’s will only increase. Further internet access is mainly urban centered and the medium used is largely English. Local language information is minimal. However plans to increase rural accessibility are on. Thousands of Internet Community Centers are being planned in Kerala, Tamil Nadu, Andhra Pradesh, Gujarat, Bengal and Maharashtra. In Bangladesh a rural initiative to use information technology is called DRIK-LEARN. At LEARN centers, students from various schools are linked and taught to create local information databases on population, health and agriculture which are renewed 6 monthly by fresh batches of students(7).
In a field where speed, innovation, and entertainment are integral, can misadventure be far behind. Gloomy prophesiers predict the doom of the internet at the hands of cyber-criminals. The US government has earmarked a cool $ 2 billion to combat cyber crime and may enlist hackers, detectives and lawyers to track cyber thugs. Patient information especially genetic information may be misused by insurance agencies to discriminate against patients with a gene which may increase their risk for various diseases in the future.
with unlimited access to data, information overload may lead to
confusion in health professionals and the birth of a new breed of
cyberhypochondriacs amongst consumers.
While data compression using information theory has resulted in large amount of information being transmitted online, there is still a technical limitation of the narrow band networks in use today. Broad band networks which imply ability to transmit large amounts of data using fibre-optic cables are still not widely available. These will dramatically improve the quality of images and video that is transmitted on the net(4). Advances in virtual reality and simulation software will improve our ability to train surgeons without spilling a drop of blood and perhaps even operate from a distance. The plan to publish ebooks (or electronic books) as recently declared by Microsoft along with a major book publisher in the United States will mean that the cost of many expensive medical texts may reduce long term. Money has become virtual on the net and everyone including doctors will have to become familiar with e-commerce. And the development of artificial intelligence or what Bill Gates calls softer software may just make doctors redundant some day.