How is the average hospital likely to fit into the much-hyped "information superhighway"? One likely answer isn't to be found in the endless committee meetings of the Clinton administration, or even in the strategic plans of software vendors or telephone companies.
Instead, it's being cooked up after hours and on weekends by computer programmers and graduate students. For free. Just for fun.
In the past six months, increasing notoriety has surrounded the international computer network called the Internet, so far the most concrete manifestation of the "Infobahn." Everyone's heard about the 20 million Internet users, mostly students, academic researchers and government employees who get the service for free, along with the growing number of ordinary citizens who purchase access through commercial services.
Everyone's heard of the Internet's ability to make a computer halfway around the world seem like it's just down the hall. A physician in Kansas can solicit second opinions from colleagues in Boston or Berlin through electronic mail, without running up a dime in long-distance charges.
There has also been wide coverage of the chaotic and confusing wealth of information available on the thousands of computers that make up the Internet: everything from Securities and Exchange Commission filings to movie reviews to the human genome.
Now comes the World Wide Web: a set of programming techniques and a way of navigating the Internet that's as simple to use-easier than many-as a personal computer.
On a relatively inexpensive computer, the Web can display images, sounds, text and even short movies, and for the first time makes many of the Internet's vast resources easy to find and use. With any of several software packages-all so far available for free-users can jump among computers around the world just by clicking a mouse on highlighted keywords.
The most popular "Web browser," a program called Mosaic, was developed at the National Center for Supercomputing Applications at the University of Illinois at Urbana. The center has given away more than 1 million copies since fall 1993 and is jammed with requests every day.
Originated in 1989 at CERN, the European laboratory for particle physics in Geneva, Switzerland, as a way to share data among research groups, the Web quickly expanded its mission to encompass all network-accessible information.
The number of "Web sites" or "Web servers"-computers on the Internet programmed using these new software tools and devoted to information from specific institutions, companies or even individuals-has grown from a few dozen in early 1993, when the first test version of Mosaic was released, to thousands today.
Web explorers can read reports from the World Bank or the United Nations, peruse a NordicTrack brochure, find out how to get their payload on the space shuttle, or choose a restaurant in Palo Alto, Calif.
Or, they can see radiology images from Brigham and Women's Hospital in Boston or Indiana University in Indianapolis (among others), read clinical practice guidelines at the Agency for Health Care Policy and Research, or browse through the latest international research on cancer treatment at the University of Pennsylvania's "OncoLink" (See story, p. 52). Soon, they can see pictures of all 160 physicians at the Palo Alto Medical Foundation, with summaries of their experience and training, perhaps the Web's first example of overt healthcare marketing.
There are now more than 120 medicine-related Web sites (See chart), and the number is growing rapidly, said Keith Robison, a genetics researcher at Harvard who uses his Web site to maintain a list of biomedical Web sites. Visitors need only click a mouse on any listing in Mr. Robison's directory to jump instantly to the relevant site. More than 10,000 people "visit" the list each month, from all over the world.
And who's creating these medical Web sites? Often, it's one or two programmers or graduate students who become intrigued with the Web and teach themselves how to use the new Web programming tools. They work on their own time, on existing equipment. The software they need is free. Since they don't ask for any money, the management of their institution often doesn't know what they're up to.
At least one head of information systems (who requested anonymity) was surprised to learn from a MODERN HEALTHCARE reporter that his institution had a Web site.
Another, John Glaser of Brigham and Women's Hospital, commented, "Web use is not an officially sponsored (information systems) initiative, but we're so laid-back and easygoing that whatever they want to do is cool by us."
Ethan Fener, director of radiology information systems at Brigham and Women's, said the Web site was born when one radiologist demonstrated Mosaic to his department chairman, who said, "This is fantastic! We should put our teaching files here and let the world browse." The hospital's radiology residents assembled 20 multimedia studies of selected cases, using images and diagnostic reports.
Even the National Institutes of Health-which operates an elaborate Web server that includes information on clinical protocols, molecular biology, NIH grants, a calendar of events, a library of NIH consensus statements and a link to the National Library of Medicine-doesn't have anyone assigned to the project full-time, said Peter FitzGerald, chief of computational molecular biology and the caretaker of the site.
Grover Browning, proprietor of the Indiana University radiology Web site, put it together in his spare time a year and a half ago. He sees the World Wide Web as a tremendous potential boon to rural hospitals in particular. "You can be stuck in one small hospital and have the opportunity to search databases at all the major medical centers," he said. "You've just increased your knowledge base by a factor of 10 or 100."
John Hoben, a consultant for the Atlanta office of First Consulting Group, thinks the Web, or something like it, will help hospitals gain inexpensive access to external databases for clinical quality measurement (soon to be required by the Joint Commission on Accreditation of Healthcare Organizations). "The Internet and the Web are a de facto standard in the R&D community, and they're providing a lot of infrastructure for expansion," he said.
How does a community hospital begin to take advantage of this growing knowledge base, now confined to a network that's historically been inaccessible to non-academics? It's getting easier and more affordable, said Mr. Hoben, who's been developing a package of services to help non-university hospitals get connected.
Most of the pieces are usually already in place or relatively inexpensive:
A computer, preferably a Macintosh, a Windows-compatible PC, or a Unix work station. The Web can even be visited by a machine that displays only text, though some of the flashier elements are lost.
A fast modem. Mr. Browning recently bought a 14.4-kbps modem, a relatively speedy one, for $110. Mr. Hoben says 28.8-kbps modems, twice as fast, are available and dropping in price.
An Internet connection and an account. This is the hardest part, but it's getting easier, said Messrs. Browning and Hoben. Internet access providers are springing up everywhere, offering simple telephone connections for a few dollars a month, plus a few dollars an hour for time spent on line. Mr. Hoben recommends hospitals start with a Serial Line for Internet Protocol (SLIP) connection, offered by Sprint and several other companies for as little as $18 a month plus on-line time charges.
Web browser software. The Internet access provider should either give this to the hospital or explain how to download it from various sources on the Internet.