The Internet for Physicians 3rd Edition

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 THE

INTERNET FOR

PHYSICIANS
T H I R D E D I T I O N
With 93 Illustrations

ROGER P. SMITH, M.D.

University of Missouri–Kansas City School of Medicine
Kansas City, Missouri
USA

123 Includes
CD-ROM
Roger P. Smith, M.D.
Professor, Department of Obstetrics
and Gynecology
Vice Chair and Program Director
University of Missouri–Kansas City
School of Medicine
Kansas City, MO 64108
USA
[email protected]

Library of Congress Cataloging-in-Publication Data

Smith, Roger P. (Roger Perry), 1949–
The Internet for physicians / Roger P. Smith.—3rd ed.
p. cm.
Includes bibliographical references and index.
ISBN 0-387-95312-4 (s/c : alk. paper)
1. Medicine—Computer network resources. 2. Internet. I. Title.
[DNLM: 1. Internet. 2. Medical Informatics. W 26.5 S658i 2001]
R859.7.D36 S54 2001
004.67′8′02461—dc21 2001032809
Printed on acid-free paper.

© 2002, 1999, 1997 Springer-Verlag New York, Inc.

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Preface to the Third Edition

In only a matter of months, the computer went from a device that dealt with in-
formation contained internally to a communication device. We have moved
from manipulating data that we directly possess to borrowing information from
locations we can’t even identify, all because of the extraordinary growth and
adoption of the Internet. What was once the province of propeller heads and
pocket protector-toting computer “geeks,” is now a staple in kindergarten class-
rooms and trendy coffee shops. We have gone from thinking a URL was a form
of alien presence, to viewing it as natural footnote to bus advertising.
Like the Internet itself, interest in computing (both local and distant) has
grown exponentially. When the first edition of this book was published, it was
mainly the technophile fringe that was “surfing.” Now grandmothers send
e-mails to their stockbrokers, meals are planned and the groceries purchased
across the Web, music videos can be previewed or concert tickets pur-
chased—all with the help of the Internet. When our children come home from
school, they are as likely to sign on to the Internet as they are to turn on the tele-
vision. The Internet is a truly universal commodity. It seems everybody needs to
be connected to the Web, just as they all seem to need to make cell-phone calls
while changing lanes in heavy traffic.
This rapid and fundamental change in the role of the Internet has resulted in
three very different editions of this text. The first edition attempted to introduce
the concept of information transfer and communication and point the way to-
ward a tool of the future. The second edition attempted to assuage trepidation in
the use of this emerging tool and suggest the why and wherefore of being con-
nected. The needs that drove those goals have almost completely disappeared.
As a result, the bulk of the is edition can be more focused on the medical aspects
of the Internet and its use, and much less on the nuts and bolts of connecting and
communication through the Web.
Again in this edition, I hope to pique your curiosity and give you the adroit-
ness and confidence to pursue the excitement of discovery. Be forewarned that
the Internet is addictive: small doses give pleasure, leading to a desire for more;
larger doses result in euphoria, loss of social contacts, and an enormous tele-
phone bill. Don’t blame me, it just happens. I just hope to get you involved in
the habit.
Enjoy!

Roger P. Smith, M.D.

Kansas City, Missouri
Acknowledgments

The author is deeply indebted to the folks at Springer-Verlag, New York, for
their encouragement, support, and technical expertise. Deserving of special
thanks are Laura Gillan, the editor, cheerleader, and critic; Michelle Schmidt, a
dedicated Web surfer who has tirelessly verified the validity of the Web sites
listed in Appendix II, and MaryAnn Brickner, who has kept the format and look
of the finished product something we can all be proud of. The author is also in-
debted to his tolerant family, and to the electronics industry for making it possi-
ble to do word processing in airports.

Roger P. Smith, M.D.

Kansas City, Missouri
Contents

Preface to the Third Edition v

Acknowledgments vii
1. The Web...................................................................................... 1
What It Is and Where It Came From ............................................................................ 2
What It Can Do..................................................................................................................... 4
Electronic Mail................................................................................................................ 5
Goods and Services........................................................................................................ 5
Remote Presence............................................................................................................. 5
Patient Care...................................................................................................................... 5
Information Retrieval .................................................................................................... 6
Database Searching....................................................................................................... 6
Remote File Access......................................................................................................... 6
2. Connecting and Communicating on the Web .................................. 7
Getting Connected............................................................................................................... 8
Direct Connection to the Internet............................................................................. 8
Connecting Through Another’s Gateway.............................................................. 8
Connecting Through a Commercial Service Provider...................................... 8
Connecting Through an Indirect Service Provider............................................ 9
Hardware........................................................................................................................... 9
Dedicated Hardware.................................................................................................... 10
Specialized Computers and Devices ........................................................................ 10
General Computers...................................................................................................... 10
IBM vs. Mac;—A Matter of Religion...................................................................... 10
Desktop vs. Laptop...................................................................................................... 11
Memory, Speed, Peripherals, and All That............................................................. 11
Speaking to the Outside World.................................................................................. 12
Software........................................................................................................................... 13
Providers......................................................................................................................... 15
Information Transfer........................................................................................................ 16
Internet Addresses ....................................................................................................... 17
FTP and HTML............................................................................................................. 20
Using the Web to Communicate ................................................................................. 21
E-mail............................................................................................................................... 21
Sending Your Message ............................................................................................... 22
Anatomy of an E-Mail Message................................................................................ 22
Do You Have that Address Handy? ......................................................................... 24
Know the Code............................................................................................................. 25
x Contents

Mailing Lists................................................................................................................. 25
Legal Issues................................................................................................................... 26
Voice ................................................................................................................................. 27
Video................................................................................................................................. 27
Security Issues.................................................................................................................... 28
Viruses.............................................................................................................................. 28
Cookies............................................................................................................................. 29
Security and Credit Card Fraud ............................................................................ 29
Secure Transmissions................................................................................................. 29
Encryption....................................................................................................................... 30
Firewalls.......................................................................................................................... 30
Internet Security Tips ................................................................................................. 30
Final Thoughts ................................................................................................................... 31
3. Finding the Information You Want .............................................. 33
Building a Strategy........................................................................................................... 33
Past Experience.................................................................................................................. 34
The Direct Approach ....................................................................................................... 35
Referrals (Portals and Directories)............................................................................. 36
Shopping Services (Search Engines)......................................................................... 37
Search Agents................................................................................................................ 39
Start Your Engines ........................................................................................................... 40
Ask Jeeves..................................................................................................................... 41
AltaVista........................................................................................................................ 41
Excite.............................................................................................................................. 41
Google............................................................................................................................ 42
HotBot............................................................................................................................ 42
Lycos .............................................................................................................................. 42
Northern Light.............................................................................................................. 42
Yahoo ............................................................................................................................. 42
Meta Search Engines and Metabrowsers................................................................. 42
General Search Secrets ................................................................................................... 46
4. Becoming a Presence on the Internet............................................. 48
What Is a Web Page?....................................................................................................... 48
Why Have a Web Page?................................................................................................. 49
Web Site Construction.................................................................................................... 49
HTML Codes...................................................................................................................... 50
Tips for Effective Web Pages....................................................................................... 52
Security and the Internet ................................................................................................ 54
5. Patient Education and Information............................................... 55
Computers and Patient Education............................................................................... 55
What Your Patients Are Seeing................................................................................... 59
General Sites.................................................................................................................. 59
Organizations................................................................................................................ 64
Direct Marketing.......................................................................................................... 71
Finding Quality.................................................................................................................. 72
Resources............................................................................................................................. 74
 Contents xi

6. Patient Care............................................................................... 76
Diseases and Diagnosis Assistance............................................................................ 77
Research that Actually Helps ....................................................................................... 79
Drugs and Prescribing..................................................................................................... 82
Medical Record Keeping ............................................................................................... 87
Telemedicine and Remote Presence.......................................................................... 92
Resources............................................................................................................................. 94
7. Medical Literature, Publishing and Informatics ............................ 96
Publishing and the Web.................................................................................................. 96
Information for Authors............................................................................................. 97
Peer Review.................................................................................................................... 99
Manuscript Transfer and Editing......................................................................... 100
On-line Journals............................................................................................................... 101
MedLine and Literature Repositories...................................................................... 103
Textbooks and References........................................................................................... 104
Special Text Resources................................................................................................. 107
8. Finding Medical Information ...................................................... 109
Medical Information Searches................................................................................... 109
Search Engines and Tools ...................................................................................... 109
Filters ............................................................................................................................. 111
MedLine and PubMed................................................................................................... 112
9. Continuing Medical Education.................................................... 122
Direct Education.............................................................................................................. 122
Paths to Traditional CME............................................................................................ 128
Resources........................................................................................................................... 132
10. Medical Practices and the Web ................................................... 133
Getting Started (Literally)............................................................................................ 134
Practice and Personal Management ......................................................................... 135
Practice Development and Promotion..................................................................... 138
E-mail and Medicine...................................................................................................... 140
Pitfalls and Provisos....................................................................................................... 144
Resources........................................................................................................................... 145
Sources of Additional Information 147
Health-Related Internet Resources 159
Glossary 264
Index 280
1
The Web

What It Is and Where It Came From................................................ 2

What It Can Do ............................................................................. 4

Electronic Mail................................................................................................................ 5
Goods and Services........................................................................................................ 5
Remote Presence............................................................................................................. 5
Patient Care...................................................................................................................... 5
Information Retrieval.................................................................................................... 6

We sell information. That is what we do in medicine. That is what we have al-

ways done. Today the difference is that we do it in an age of information. In-
formation, medical and otherwise, is all around us. From pocket pagers that de-
liver stock quotes and sports scores to pocket digital assistants that wirelessly
connect to the Internet, information is achieving the status of oxygen1—it is all
around us and invisible. Today, information is managed, moved, and organized
in ways never thought of in the past and will soon be managed in ways not yet
conceived. In medicine, information is vital, but the exponential growth of
knowledge available requires new approaches to its dissemination, access, and
use. Central to this is the Internet. Information is now the province of anyone
with a computer. This has led to “disintermediation”: the ability of consumers to
go directly to the source of information (or goods and services) directly, by-
passing the intermediate steps of providers.
The Internet is nothing less than a library card to the world! One moment
you can be browsing through the Library of Congress or looking at pictures
from the National Library of Medicine and the next moment conversing with a
colleague in Indonesia. At the most basic level, the Internet is a high-speed Web
of worldwide computer-based information resources connected together. It is
often defined as a network of computer networks. From its beginnings as a
method of linking up 13 universities to allow the high-speed transfer of research
data, the Internet has evolved to a system of millions of sites (computers) con-
nected throughout the world. At the time of this writing, the Internet gains the
equivalent of the entire population of Great Britain each month as new users. It
has been estimated that in the United States, 8% of all the electricity generated
goes to power the Internet, the computers connected to it, and the associated
1
Oxygen is also the name of a computing project at the Massachusetts Institute of Tech-
nology that is aimed at achieving this goal.
2 The Internet for Physicians

hardware. According to the American Internet User Survey, more than 41.5 mil-
lion adults in the United States are actively using the Internet. Of these Web
users, 51% use the Web on a daily basis. The Internet auction service eBay will
mediate over $7 billion in sales between its more than 22 million users during
2001.
Because the Internet is an invisible infrastructure of electronic links (like the
telephone system), there is no master list of what information or resources are
available or where! This is actually an advantage. Because there is no overall
structure, the shape and face of the Internet are constantly changing to meet the
needs of those who use it. Unlike the telephone system, which is planned and
managed by a handful of readily identifiable organizations, the Internet has no
corporate body. Rather, it is made up of loose associations of individuals, insti-
tutions, and corporations. As a result, the character of the Internet, indeed one of
its founding premises, is that of change. Even in the catalog of sites listed in this
book (Appendix 2), there are entries whose location has changed from the time
we wrote about them to the time you try them.
The real power of the Internet is in the people and information that all those
computers connect. The Internet is really a community that allows millions of
people around the world to communicate with one another. People voluntarily
share their time, ideas, and products, for the most part without any personal or
financial gain. Although it is the computers that move the information around
and execute the programs that allow us to access the information, it is the infor-
mation itself and the people connected to the information that make the Internet
useful!

What It Is and Where It Came From

The need to transfer information between computers was recognized soon after
computers were developed. At first (the early 1960s), this type of information
transfer was done with magnetic tapes or punch cards. These were then physi-
cally carried to the other computer to be used. Computer scientists then began
exploring ways to directly connect remote computers and their users.
In 1969 the U.S. Department of Defense Advanced Research Projects
Agency (ARPA) funded an experimental network called ARPANET. The main
goal of the ARPANET research was to link together the Department of Defense
and military research contractors (which included the University California at
Santa Barbara and the University of California at Los Angeles, SRI Interna-
tional, and the University of Utah) and to develop a reliable network (Fig. 1.1).
A “reliable network” involved the concept of dynamic rerouting. Dynamic
rerouting, from the military perspective, allows communications on a network to
be rerouted if part of the network is destroyed by an enemy attack.
 1. The Web 3

Figure 1.1. The original structure of the ARPANET as outlined in December 1969.
(http://www.computerhistory.org/timeline/topics/networks.page)

Figure 1.2 demonstrates the idea of dynamic rerouting. Assume there are
normally direct communication links between all four locations, A, B, C, and D.
In Figure 1.1, the direct link between locations A and B has been severed (more
likely by a backhoe than by hostile action). A and B cannot communicate di-
rectly along the dotted line. However, A can still send messages to B in a num-
ber of different ways, as indicated by the solid lines in the figure. For example,
the message could be routed from A to D and then to B or from A to C and then
to B or from A to D to C and then to B. On the Internet, there is always more
than one way for the message to move from you to its intended recipient.
To accommodate the growing number of sites, the network had to be able to
add and remove new sites easily and to allow computers of many different types
to communicate effortlessly. This led to the development of the TCP/IP network
protocol. TCP/IP (Transmission Control Protocol/Internet Protocol) is the lan-
guage used by computers connected to the Internet to talk to each other. From
the mid-1980s on, several physical networks were developed as increasing de-
mands forced successive refinements and expansion.
Today, a number of suppliers maintain network backbones such as ANS
Communications, AT&T, Compuserve, DIGEX, GTE Internetworking/
BBNPlanet, IBM Global Network, PSINet, Sprint IP Services, UUNET, and
others. As a result, when we refer to “the Internet” we are not referring to a sin-
gle set of wires or paths any more than there is a single telephone system that
links the United States or the world. Each of the component networks are inter-
connected at various points by routers that pass the packets of information trav-
eling the Web back and forth until they reach their destination computer.
In 1993, the World Wide Web (Web or WWW) was introduced and dramati-
cally changed the face of computing. The Web, like Usenet and other networks,
is just a portion of the Internet. The difference is that information on the Web is
presented graphically using a standardized language that allows images, sound,
and video information to be accessed and displayed graphically without knowl-
edge of computer commands (those are taken care of for you by the Web
browser).
4 The Internet for Physicians

A B

C D

Figure 1.2. Dynamic rerouting allows multiple pathway for information transmission.

In many countries, the “backbone” of the Internet is funded by government

organizations. In the United States, the National Science Foundation (NSF) cur-
rently funds such a backbone. To provide universities and research centers with
remote access to supercomputer centers, the NSF funded a backbone network
(NSFNET) that connects these centers. NSF also provided the funding for con-
nections to the backbone for regional networks.

What It Can Do
Despite what your children may tell you, not everything is better on “The Net”
and there really is life as we know it in homes and offices that are not connected.
Despite this, approximately 40% of North Americans have access to the Web.
The Internet is full of contradictions: it is blindingly fast and agonizingly slow, it
is a loose confederation but works more reliably that systems that are tightly
controlled, it is elegant and crass, it is public yet carries one of the most secure
methods of communication available to the general public. Material that is vital
to commerce mingles with sophomoric humor, and fine art passes smut in the
electronic ether. It is these very contradictions that make surfing so compelling
to many users.
A decision to connect to the Internet must be based on your needs and those
of your family or office. It will be based on your practice style, volume, and
personal needs. The uses of a small office will be different from those of a large
multispecialty group; those of your grade school children will be different from
those of a college student, and so on. One word of warning: the Internet is addic-
 1. The Web 5

tive. It is easy to lose track of time while surfing. Simple tasks such as reading
e-mail can be accomplished in a matter of minutes; exploring all the Web has to
offer cannot be completed. Like television, fishing, needlepoint, or other hob-
bies, some limits should be set.

Electronic Mail

Electronic mail was the first Internet application and is still the most popular
one. E-mail is not limited to the Internet; e-mail messages can be moved through
local or organizational networks, or through gateways to other networks and
systems, such as CompuServe or America Online (AOL). Many, if not most,
organizations have an internal e-mail system allowing rapid and open communi-
cations within the organization and, via outside connections, communications to
organizations and individuals anywhere computer networks reach. Your hospital
or university may be willing to provide e-mail services to you at no cost.

Goods and Services

The fastest-growing segment of the Internet is business. Full-scale Internet

showrooms allow you to do everything but touch the merchandise; virtual reality
movies allow you to look at an item in three dimensions, move it about, listen to
it, change its color, get technical information, and ask questions—all without a
salesperson hovering near. You may purchase items directly using credit cards
(directly, by e-mail or telephone confirmation) and have them shipped overnight
to arrive the next morning. You can even send “virtual flowers” (a bouquet of
flowers with your personal message that arrives by electronic mail or directions
to a special Web site) when you miss a special event.

Remote Presence

Remote presence at one time meant the ability to work on a computer from a
distance just as if you were actually sitting at the keyboard of that machine. The
Internet now allows remote presence to include such things as video
conferencing and telemedicine. Whether it is checking a cardiogram, consulting
on a radiograph, or evaluating fetal heart tones, the Internet is almost the next
best thing to being there.

Patient Care

Patient care has been (or may be) enhanced through the use of the Internet. Pa-
tient records may be sent or retrieved (with appropriate privacy controls) by way
of the Internet, allowing labor rooms to have the most recent prenatal records, or
surgeons to have the biopsy report from an out-of-state hospital. Drug interac-
tions may be checked, the most recent journal article may be scanned, or a con-
sultation with a distant colleague may be completed by connections to the Inter-
6 The Internet for Physicians

net. Patients can get information (both authoritative and otherwise) on their con-
dition, treatment, and alternatives via Internet sites.

Information Retrieval

Information can take many forms: from the traditional, such as the response to a
query about a patient’s blood count, to pictures, sound, or video images. Infor-
mation on the Internet resides in many places and forms. When you are con-
nected to the Internet you can access these repositories in many ways.

Database Searching

In the same way that you conduct a database search in a hospital or university
library using a card catalog (if your library still has one) or CD-ROM tech-
nology, you can search databases through the Internet. You can access many of
the same databases, such as MedLine, Toxline, CINAHL, and others just as you
would through your library but without having to go to the library and wait your
turn. The Internet also allows you to search resources anywhere on the globe
with the same ease as you would in your local library. A specialized version of
database searching occurs when you ask the hospital computer for a patient’s
laboratory results. In many locations, even these data (with suitable security
controls) may be accessed from remote locations, through (you guessed it) the
Internet.

Remote File Access

When computer users give their permission, files placed in their computer’s
storage device (generally a hard drive or other mass storage device) may be
accessed by others connected through the Internet. This ability to “download”
(take from) or “upload” (give to) files from one computer to another allows
users access to the latest versions of information. If you have set up your home
computer to allow such transfers (and it is turned on), you can access your own
files from a hotel room anywhere in the world. (OK, it does have to have a tele-
phone line, you have to have a computer that can talk on the telephone, you have
to have access to an Internet service providers, etc., but you get the idea.)
2
Connecting and Communicating
on the Web

Getting Connected ......................................................................... 8

Hardware........................................................................................................................... 9
Software .......................................................................................................................... 13
Providers......................................................................................................................... 15
Information transfer .................................................................... 16
Internet addresses ....................................................................................................... 17
FTP and HTML............................................................................................................ 20
Using the Web to communicate...................................................... 21
E-mail............................................................................................................................... 21
Voice................................................................................................................................. 27
Video................................................................................................................................. 27
Security issues ............................................................................. 28
Viruses ............................................................................................................................. 28
Cookies............................................................................................................................ 29
Security and Credit Card Fraud............................................................................ 29
Secure Transmissions................................................................................................. 29
Encryption...................................................................................................................... 30
Firewalls......................................................................................................................... 30
Internet Security Tips................................................................................................. 30
Final Thoughts ............................................................................ 31

Unlike with telephone in the era of AT&T or today’s cable television, there is no
primary local provider or standardized hardware to fall back on. To connect and
communicate on the Web you will need some basic computer hardware (much
of which you may already have) and a method of making the electronic connec-
tion. The choices of how, with what, and with whom are the next issues we need
to address.