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Conference Report
Highlights of the 10th World Congress on the Internet in Medicine
(WCIM - MedNet)
December 4-7, 2005; Prague, Czech Republic
Antonios Liolios, MD
Medscape Critical Care. 2006;7(1) 2006 MedscapePosted 02/22/2006 Introduction
The Internet is a unique innovation in the history of mankind. From its inception more than 35 years ago, it is still evolving with an ever increasing momentum.[1] From a practical perspective, the Internet is more than the sum ofnetworks, connected computers, and servers. It has the capacity to change the way we practice medicine.
Concepts such as telemedicine, unlimited database access, and open access medical literature have transformed the way we acquire our knowledge and apply it to everyday medical practice.[2] Dr. Pavel Kasal, from the Karlovy University of Prague and president of the local scientific committee, opened themeeting by outlining the research efforts, trends, and projects in medical informatics. The European Union (EU) hasbeen supporting e-research through its various programs. Eumed ( is a Czech initiative thatoverviews the EU programs in the field of medical informatics in scope of the Framework Programme (FP),providing a coherent European framework for supporting research and technological development. The 6th EU FPfocuses on knowledge acquisition, decision making, and clinical information systems. There are several runningprojects in the context of the 6th FP. Some of them are BIOPATTERN (Computational Intelligence for BiopatternAnalysis in Support of eHealthcare), ALLADIN (Natural Language-Based Decision Support in Neuro-rehabilitation)and DOC@HAND (Knowledge Sharing and Decision Support for Healthcare Professionals). Additionally,telemedicine is strongly endorsed by the EU. Although the number of participating countries in the 6th FP and eachsuccessive MEDNET meeting is increasing, it is important to coordinate the surplus of available data to avoidreplication and confusion. The existence of so many different languages and cultures in Europe makes coordinationof all efforts a particular challenge.
Internet-Based Prescribing
Miles Jones, MD, from Liberty, Missouri, presented an interesting aspect of modern medical practice: online,real-time prescription. Dr. Jones has been operating an online clinic via his Web site nce1998. Although there is email availability, there is no direct contact with patients. The patient clicks on a menu ofavailable medications and, after making a selection, is directed to a long form with detailed medical questions. Thepatient is not asked why the particular medication is requested but is required to answer all the pertinent safetyquestions. Subsequently, the answers are then reviewed by a physician and the medication is dispensed and mailedif approved. Available medications are Viagra, Cialis, Levitra, Propecia, Cipro, Xenical, and Vaniqa. The physician may call the patient if there are points that need clarification. A previous report by Eysenbach and colleagues[3]stated that after ordering Viagra from 11 similar Internet prescribing companies, 66 pills were delivered within 6 to34 days, despite the fact that Viagra was contraindicated. Among the concerns cited in the report were incompletehistory taking, inappropriate medical terminology, and only 2 companies provided a physician who reviewed thecases and identified himself.
In contrast to this report, Jones and colleagues[4,5] compared 2104 Internet patients seeking Viagra prescriptionsonline between June 14, 1998, and March 1, 1999. They found that of the 2104 requests, 2100 were granted. Ofthese, 310 requests were for medication refills. No patient reported being dissatisfied. There were no deaths orserious complications reported, the incidence of adverse effects was not elevated compared with a regular and the Internet-obtained medical history was more complete. Dr. Jones stated that his service is n aking available to patients medications associated with sexual activity, lifestyle, or cosmetics. They that is safe, fast, and cost and time effective. The consultation fee is US $50. He plans to offer a wivariety of medications in the future.
Online Counseling
Online medical assistance has been used in addressing pediatric conditions such as obesity and bedwetting, whichare often associated with embarrassment that may prevent children and adolescents from seeking medical advice.
Robert Pretlow, MD, from Kirkland, Washington, operates and sites that encourage pediatric patients to share their concerns and health problemswith other patients via anonymous supervised chatting. He reported that in an anecdotal series of 516 patients whoparticipated in this self-care Internet intervention for obesity, there was a 14% reduction in body mass index. Thedrop-out rate associated with the intervention, however, was high, with 1237 children originally participating and 520(42%) not continuing in the program. The same intervention is currently ongoing with the addition of school nursesand physical education teachers acting as mentors. Continuous vigilance of the supervising committee is required inorder to identify and expel unwanted intruders.
Algorithms
An algorithm is a structured approach to a particular problem or situation that follows similar patterns and is thuspredictable to a point. There are several types of algorithms, including decision, diagnostic, functional stateevaluation, grading, risk determination, and prognostic. The benefits of a medical algorithm are numerous:Algorithms can potentially reduce medical errors and support-evidence based medicine as they substitute subjectivejudgment with objective data, assist in medical care in areas with a low physician/patient ratio, become incorporatedinto electronic medical records, perform background checks, and provide alerts whenever a medical decision istaken and applied. Yet their usefulness outside a computerized model is low as they are seldom used at thebedside.
To solve this problem, the medical algorithms project (MEDAL, ) was created in 1999 by JohnR. Svirbely, MD, a pathologist in Cincinnati, Ohio, and M. Sriram Iyengar, PhD, an informatics research scientist atthe NASA Johnson Space Center, Houston, Texas. It includes 8000 algorithms organized into 45 medical sections.
Most sections are in Excel spreadsheet format while 250 are in Web-based forms. MEDAL is intended forhealthcare providers and not for the lay public and requires free registration. It is now available in Spanish andprovides the supporting PubMed references. Over 1000 unique visitors visit the site daily, most of them betweenMonday and Friday. There are 90 new users daily. The majority of users (42%) are physicians. As of December2005, there were 29,690 registered users from 191 countries, the United States and United Kingdom ranking first.
Most users were hospital employees. Future plans include support for multiple languages, integration with hospitalinformatics or e-records, and PDA availability.
MEDAL led to the development and application of specific tools for algorithm utilization. Medical computationalproblems (MCPs) are defined as medical problems, the solution of which incorporates algorithms and deals withmathematical or statistical models and estimation of corresponding parameters. When dealing with MCPs,collaboration of different kinds of scientists is required, and despite the abundance of Internet-based information,there is significant confusion and often misunderstanding in this area. The interaction of physicians, mathematicians,physicists, and informatics specialists often leads to complete chaos. A solution to this problem has been suggestedby Charalambos Bratsas, PhD, University of Thessaloniki, Greece. The key is to provide an infrastructure that willfacilitate the different scientists to organize and visualize the above knowledge in a structured manner.
Consequently, the concept of MCP ontologies has been developed. Ontology is an explicit specification of aconceptualization of a domain that allows more effective data and knowledge sharing by modeling and managingMCP information in a flexible, easily interchangeable, and powerful way. More simply, an ontology is a systematicarrangement of all of the important characteristics of objects or concepts and their relations. They can allowautomated reasoning about described entities and can be composed from smaller ontologies. With the assistanceof a specific ontology Web language, the user is able to access the unified medical language system (UMLS), whichis a database designed by National Library of Medicine integrating a large number of biomedical terms (100sources in the 15th edition as of November 2004). UMLS uses clinical vocabularies or classifications (MeSH,SNOMED, RCD, ICD9CM, HL7, etc.) and has 3 parts: the Metathesaurus (5 million terms), the Semantic Network(134 concepts and 54 relations), and a Special Lexicon (Natural Language applications). The user inserts his MCPsearch query in commonly used terminology, and with the assistance of specialized Internet techniques, the UMLS,and MEDAL, the user is eventually directed to a structured algorithmic approach and solution information. When theproject is fully developed, it is expected to greatly facilitate medical data retrieval and synthesis by variousresearchers.
cal Libraries and Medical Journals
The face of the medical library and medical data access is rapidly changing. In the middle of the 1990s, severalmedical journals started offering online full text and PubMed became freely accessible to all. Today, most majormedical journals are available online and there are several databases offering full-text access. Despite theabundance of e-journals and free full-text online access by various medical libraries, medical search is stillcomplicated. Having access to one database is not enough, and searching several different databases can be timeconsuming. There are over 20 large international medical databases available. While PubMed indexesapproximately 4700 medical journals, there are probably over 20,000 biomedical journals available worldwidecovered by other databases such as EMBASE, Web of Science, and others. A solution to this problem waspresented by Gus van der Brekel, Electronic Services Coordinator at the Groningen University Medical Center inThe Netherlands. RUGCombine, software developed at Groningen University, offers an overview of numerousresources that can be personalized and categorized. In an attempt to make searching more user-friendly, they haveadded the QuickSearch Library Toolbar, which searches the large amount of databases and journals held by theUniversity Library of Groningen and lists full-text citations when available. QuickSearch helps direct the user to themost important search engines, databases, journals, and e-books and offers global access to the Digital Library.
Open Access
When not provided by a library, full-text online access may be very expensive. To counteract this problem, theopen-access concept has recently evolved. Several medical journals offer free access to articles at or shortly afterpublication. This is available in both peer-reviewed and nonpeer-reviewed journals. An interesting new twist to thepeer review process was also noted. There are now journals in which the author can pay for the peer reviewprocess and the publication of the article and legally maintains his/her own copyright. The original work is then freely available via the Internet to all or to specific interested individuals or organizations.[6] Does open access work? Data presented by Gunther Eysenbach, MD, from the University of Toronto, Ontario,Canada, compared open-access article citations with more traditional access-restricted articles at time points postinitial publication. It was shown that open-access articles were twice as likely to be cited in the first 4-10 monthsafter publication (open access = 2.1, restricted access = 1.5-2.9). This increase became even more significant at 10-16 months after publication (open access = 2.7, restricted access = 1.4-5.2).[7] Patient Education
To facilitate patient access to information, the Structured Evaluated Personalized Patient Support (STEPPS) wasdeveloped by Persephone Doupi, MD, PhD, a senior researcher at the Centre of Excellence for Information andCommunication Technology (OSKE) and the National R&D Centre for Welfare and Health (STAKES; in Finland. The project was tested for its ability to deliver personalized, tailored patienteducation based on the integration of electronic patient record data and material derived from online health information resources.[8,9] STEPPS selects, on behalf of the patient, among online health information those pagesthat contain the most relevant and reliable material. STEPPS automatically extracts relevant data from theelectronic patient record and uses these data to search among Internet health information pages. The most relevantpages are selected, their quality is assessed by a team of experts, and this personalized information is presentedto the patient. The efficacy of the system is currently being assessed in a formative evaluation study in whichSTEPPS retrieved data are compared with those obtained by random resource selection and online searches usingGoogle.
Internet Reliability
Reliability and quality of the medical information available via the Internet is a growing concern. A firm control overthe Internet's content cannot be established because of its nature. An Internet Corporation for Assigned Names andNumbers (ICANN) study group proposed the creation and licensing of top level domains (TLDs) sponsored by theWorld Health Organization. These domains would be in the form "dot.health" (.health). This goal was neveraccomplished. Several quality initiatives have evolved in an attempt to safeguard the quality of the providedinformation. Some of these are the Health on the Net (HON) Code of Conduct (/Conduct.html), the European Project Worldwide Online Reliable Advice to Patients and Individuals (WRAPIN;), Collaboration for Internet Rating, Certification, Labeling and Evaluation of HealthInformation (MedCIRCLE; ), Quack watch (), and others. Still,there is no established central agency or network that would assure content reliability of health-related Internetinformation. Currently, consumer education, encouraging self-regulation of Internet health data providers,comprehensive third-party and peer-review evaluation, and enforcement of the law when deceitful information is ted are the most promising regulations and actions in this regard.
nitoring
The wide availability of high-bandwidth public wireless networks has given rise to new mobile healthcare services.[10] MobiHealth () is a mobile healthcare project funded by the EuropeanCommission that allows patients to be fully mobile while undergoing health monitoring. The system takes advantageof the available GPRS/Universal Mobile Telecommunications System (one of the third-generation mobile phonetechnologies wireless systems) to transmit mobile patients' vital signs over the Internet to the healthcare provider.
The patients wear a lightweight monitoring system -- the MobiHealth BAN (Body Area Network) -- that iscustomized to their individual health needs. MobiHealth has been tested in several European Countries, and theannouncement of the results are due in the near future.
Conclusions
We live in an amazing era. Approximately 10 years ago, the Internet started invading everyday public and privatelife and today many aspects of our society would be nonfunctional without it. Medicine is one example. The Internethas infiltrated all aspects of medicine: patient evaluation, patient and physician education, medical record keeping,[11,12] diagnosis,[13,14] imaging, monitoring, therapy, research and clinical trial recruiting,[15] and follow up. Yet thereare certain features of the Internet that should make us very cautious. At this point, no predictions about the futurecan be made. The Internet is a very helpful tool and should remain as such. Personal relations and human contacthave always remained the cornerstones of medicine, and the Internet can help improve patients' care and welfare ina more pleasant, easy, and efficacious way.
References
1. Hankins J. The Internet. Adm Radiol. 1991;10:69-71.
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4. Jones MJ, Thomasson WA. Establishing guidelines for Internet-based prescribing. South Med J.
5. Jones MJ. Internet-based prescription of sildenafil: a 2104-patient series. J Med Internet Res. 2001;3:E2.
6. Eysenbach G. Peer-review and publication of research protocols and proposals: a role for open access journals. J Med Internet Res. 2004;6:e37.
7. Eysenbach G, Trudel M. Going, going, still there: using the WebCite service to permanently archive cited web pages. J Med Internet Res. 2005;7:e60.
8. Doupi P, van der Lei J. Towards personalized Internet health information: the STEPPS architecture. Med Inform Internet Med. 2002;27:139-151. Abstract 9. Doupi P, van der Lei J. Design and implementation considerations for a personalized patient education system in burn care. Int J Med Inform. 2005;74:151-157. Abstract 10. Konstantas D, van Halteren A, Bults R, et al. Mobile patient monitoring: the MobiHealth system. Stud Health Technol Inform. 2004;103:307-314. Abstract 11. Goossen WT, Jonker MJ, Heitmann KU, et al. Electronic patient records: domain message information model perinatology. Int J Med Inform. 2003;70:265-276. Abstract 12. Roukema J, Los RK, Bleeker SE, van Ginneken AM, van der Lei J, Moll HA. Paper versus computer: feasibility of an electronic medical record in general pediatrics. Pediatrics. 2006;117:15-21. Abstract 13. Razzouk D, Mari JJ, Shirakawa I, Wainer J, Sigulem D. Decision support system for the diagnosis of schizophrenia disorders. Braz J Med Biol Res. 2006;39:119-128. Abstract 14. Verikas A, Gelzinis A, Bacauskiene M, Uloza V. Towards a computer-aided diagnosis system for vocal cord diseases. Artif Intell Med. 2006;36:71-84. Abstract 15. Wei SJ, Metz JM, Coyle C, et al. Recruitment of patients into an internet-based clinical trials database: the experience of OncoLink and the National Colorectal Cancer Research Alliance. J Clin Oncol.
2004;22:4730-476. Abstract Antonios Liolios, MD, Attending Staff Physician, Intensive Care Unit, University Hospital Saint Luc, Brussels,
Belgium
Disclosure: Antonios Liolios, MD, has disclosed no significant financial relationships.

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