Peter J. Duffy, MD
Ottawa Hospital - General Site and University of Ottawa
John Oyston, MB BS
Orillia Soldiers Memorial Hospital
Objectives:
Introduction
Although the Internet had its beginnings in the 1960's, anesthetists did not go on-line
in significant numbers until March 1993, when the first anesthesia discussion group was
established. Since then, there has been a virtual explosion of anesthesia resources on the
Internet. ACCRI, an acronym for "Anesthesia and Critical Care Resources on the
Internet", went on-line in September 1994, and at that time had only a few pages of
resource listings. Today ACCRI has 100's of resources including 48 discussion groups and
over 200 web sites. This continues to grow with each month's update. This growing level of
interest and involvement has significantly expanded both the quantity and quality of
anesthesia resources available on-line. This trend shows no signs of slowing and
anesthetists are now taking advantage of the Internet in numerous ways. We are using it
for communication, education (both teaching and personal CME), research, clinical
activities, and interacting with the public. Today, we will introduce you to some of these
resources.
What is the Internet?
Simply defined, the Internet is the global networking of computer networks. A network
is two or more computers sharing information through a common connection. The Internet is
the infrastructure that allows computers around the world to communicate with each other.
Approxi-mately 15,000 regional, national, and international networks are currently linked
together to form the Internet. Many of these large networks are operated throughout the
world by major companies, universities, governments, and even hospitals.
Recently more elaborate and ambitious descriptions are appearing, such as this one from
an article in a May 1996 edition of the Toronto Sun: "...a convergence of existing
telephone, cable TV, satellite TV, wireless phone systems and broadcast systems, which can
carry voice, data, video, and other services simultaneously in one seamless web of
communications." This is the direction in which the Internet is headed.
The content of the Internet may appear less sophisticated than that of film or
television. However, the Internet is a new medium that gives users much more control and
flexibility over content than traditional media does. The primary advantage of the
Internet is that it makes information from anywhere on the planet instantly available on
your desktop. "The Economist" magazine described this phenomenon as the
"death of distance." This is an important concept when we think about the
application of the Internet to medicine. For both the public and physicians, distance is
no longer a barrier to communication and interaction. It may eventually help us create a
global or world society of anesthetists.
How to Get Connected
Getting connected to the Internet involves two basic decisions. First you must select a
service provider. Second, you must select the most appropriate technology for making the
connection. That is, you must consider who will provide the access and then, how
you will physically connect your computer. Many new technologies are being developed for
faster and more reliable access. Today, we will consider current or soon to be available
technologies: modem, satellite, ISDN, cable modem, and high speed connections.
Internet Service Providers
Numerous companies and groups can provide us with the path to the Internet. Today,
there are two basic ways in which most physicians obtain Internet access: connect via a
dedicated link at the hospital/office/library or via a modem from home.
Hospital or Academic Service:
With this type of link, your workplace computer will be linked to the Internet
twenty-four hours a day with dedicated access. The connection from the computer is
typically a direct network link requiring network hardware and software. For security
reasons, these services rarely allow logging-in from home. They usually run behind a
firewall, an almost impenetrable barrier designed to prevent access by any computer not
directly linked to the network. As well, Internet access is not a top priority for most
institutions, therefore technical support may be poor.
Home Link:
Connecting from home is currently the best option for making the most of what the
Internet has to offer. The home link can follow one of two paths. You may choose an
ISP (Internet service provider) or a commercial on-line service
such as CompuServe, the Microsoft Network, or America Online, to name a few. ISP's range
from small local companies (eg. Magma) to large
national companies (eg. IStar). Among these, the
extent of services and costs vary widely. The commercial providers have always offered a
host of specialized on-line services on their own (non-Internet) networks. However, with
the growth of the Internet, they have begun providing Internet access as well. Many are
moving all of their services to the Internet. A listing of ISP's can be found at http://thelist.iworld.com/. A good listing of local
and national providers is found in the yearly addition of "The Canadian Internet
Handbook".
Modems
Analog modems are currently the most common and most economical choice for home users.
The modem is installed on your computer and uses a standard telephone line for making the
connection. Most users run such analog modems at a speed of 28.8 Kbps, although a
significant number of 14.4 Kbps modem are still used. Faster 33.6 and 56 Kbps modems have
recently become available. With the rapid expansion of multimedia on the Internet, 14.4
Kbps connections are becoming too slow for most graphical WWW sites but are still fine for
simpler non-graphical functions such as e-mail. Even the faster modems are not up to speed
when more advanced technologies, such as video, are used.
Satellite
Several American companies have begun using satellite transmissions to provide Internet
access. These usually provide very fast downloading of information to your computer via
the satellite dish. However, information and requests from your computer are still sent to
the Internet via the (slower) telephone line. This service is not available in Canada as
yet. Satellite access costs are competitive with modem access.
ISDN
ISDN, Integrated Services Digital Network is faster than the standard analog modem and
is widely available. An ISDN connection is analogous to two 64 Kbps modems with a maximum
speed of 128 Kbps (almost 4.5 times faster than the standard modem). The problem with this
is the hardware requirements, cost, and technical complexity of the set-up. For example,
you will need an ISDN modem and a new ISDN phone line installed in your home. A technician
from the phone company will have to perform the setup in your home/office. In addition to
the initial fees, you will have to pay monthly Internet ISDN access fees and another
monthly phone bill for the new line. As a result, ISDN is only for the die-hard surfer.
Cable Modem
This service brings the cable TV companies on-line. A cable modem attached to your
computer is connected to the coaxial cable coming into your home (the same one your TV
uses). Since cable companies already had one way cables bringing information into your
house, their main problem was to build the line out. Roger's has been adding these lines
since last year in preparation for their service called "Roger's Wave". It is
currently being installed and is expected to be widely available in Canada sometime in
1997 (300,000 homes are connected across Canada now). Coaxial transmission is technically
much simpler and hundreds of times faster than ISDN and phone modems. This large increase
in speed will allow future technologies such as real-time video-conferencing to become
mainstream. Unlike a standard analog modem which prevents regular telephone use while you
are online, cable modems can be used to access the Internet while still allowing use of
cable television channels. In fact, there is no need to dial in, you will be on-line on a
continuous basis. The cost of Roger's Wave is $55-65 per month including the cable modem
rental. There is a setup fee of $150 (PC) $200 (MAC). On the downside, lines from the
cable company to individual residences have to be "hardened" or made more
resistant to outside signal interference than conventional cable TV hookups. We will have
to wait until this service is more widely available to assess its true speed potential and
reliability. See http://www.wave.ca/ or call
1-800-THE-WAVE.
Large Scale
Large scale users such as ISP's, hospitals, and Universities connect directly to the
Internet with dedicated, twenty-four hour a day connections via T1 or T3 lines. These high
bandwidth lines are very expensive. The institution must set up a server computer with
special server software and maintain a constant presence on the Internet. The startup
costs of hardware, software, and support run from a small scale low of about $50,000 into
hundreds of thousands of dollars for a large scale project.
Speed Comparisons
This table demonstrates the relative speed of downloading 10 megabytes of data from the Internet. This is roughly equivalent to about 2000 pages in a word processor
Bandwidth - Time to download 10 Megabytes of Data |
|||||
14,400 |
28,800 |
ISDN Line |
T1 |
Coaxial |
T3 |
14.4 Kbps |
28.8 Kbps |
128 Kbps |
1.5 Mbps |
500 Kbps |
45 Mbps |
93 min |
46 min |
10 min |
53 secs |
8 secs |
1.7 secs |
From: Welz - IW Guide to Multimedia on the Internet
E-mail & Discussion Groups
E-mail is the useful low-tech workhorse of Internet communications. Using Internet
e-mail you can send plain text messages, to anyone anywhere in the world who has Internet
e-mail, regardless of the type of computer that person uses. There is no choice of colored
text or font, and there are no graphics. E-mail can work well on old, slow computers with
low-speed modems, and is therefore much more widely available (e.g. in third world
countries) than the Web, which places much greater demands on the telephone system and on
users' computers.
To use e-mail, you open an e-mail program such as "Eudora" or
"Pegasus", or the e-mail facility built into Netscape or Microsoft Internet
Explorer. You enter the e-mail address of the intended recipient, which will be in the
format of "name@domain", e.g. relliott@magna.com. Then you type a
subject for the message. This is very important as many people get a lot of e-mail and the
subject heading is widely used to decide what is (most) worth reading. Finally, you can
type the text of the message and end by selecting an electronic signature or "sig
file". This automatically adds a few lines to the end of each message and is usually
used to give your name, affiliation, and phone number (other information can be added).
Selecting the "send" button transmits the message to your ISP, typically
using a modem and a regular phone line. The ISP has a computer called a server, which
forwards your message as a series of packets onto the Internet. Within seconds the message
is reassembled at the ISP belonging to the recipient (which is identified by the
"domain" part of the e-mail address). It then waits there, like regular mail in
a post office box, until the recipient picks it up by selecting "Check for new
messages" in his or her e-mail program.
Advantages of e-mail:
It is quick and cheap. Once you have paid for Internet access, which can be as little
as $10 per month, you can send unlimited e-mail anywhere in the world at no additional
cost. Most e-mail programs include a "reply" feature, which allows you to answer
the message, e.g. "Is 9.00 on Thursday OK for you?" by simply adding the word
"Yes" and hitting "send reply". Also, most programs allow you to set
up a group of people and send the same message to the whole group by entering the name of
the group. For example, during the recent physicians dispute with the Ontario government,
the Chief of the OMA Section of Anesthesia was able to e-mail a group of about 40
anesthetists with updates within a couple of hours of each meeting. It would be difficult
to keep such a large and widespread group so well informed so rapidly with any other
technology.
E-mail messages can avoid "telephone tag" or messages mislaid by secretaries.
Almost all the work organizing this presentation was done using e-mail.
E-mail can be a practical way of communicating with colleagues overseas, even in
countries like Malawi and Croatia where users may have old computers with ancient modems
and intermittent telephone links. It also avoids problems with time zones.
Disadvantages of e-mail are:
One cannot be sure the message arrived and was read. Usually, if the system fails (e.g.
because of an invalid e-mail address), an error message will be returned. However, many
people do not read their e-mail regularly or get so many messages that some get lost or
missed. At present, most e-mail users cannot set up a system to automatically return a
message such as "I will be on vacation until Monday", which is a common and
useful feature of voice-mail and telephone answering systems.
E-mail messages are often very informal, but without the expressiveness of voice-mail
messages. This means that jokes and dry wit can be misinterpreted. Emoticons, such as ;-)
for a wink, partly resolves this problem.
Security is a potential problem. It is relatively easy for a hacker to get access to
messages en-route across the Internet. Most e-mail is of no interest or value to
strangers, but confidential information such as identifiable patient data should be
encrypted before being sent by e-mail.
Present e-mail systems are text-based. Additional information, such as graphics or
programs, can be added to e-mail messages as "attachments" but sometimes they
are in a format which cannot be used by the recipient. More advanced types of e-mail, with
color, fonts, and graphics built in, are likely to become common during 1997.
Beyond E-mail: Newsgroups and Mailing Lists (Discussion Groups)
Newsgroups are public forums on the Internet where anyone can post messages of
potential interest to that specific newsgroup. There are currently over 24,000 newsgroups,
representing a wide range of interests from useful support groups such as
alt.support.sleep-disorders, to groups of dubious value, such as rec.nude and
alt.sex.bestiality.hamsters! None are directly related to anesthesia, but there are
several related to medical issues, politics, and diseases. There are also groups dedicated
to computing and the Internet which may be of interest.
Like e-mail, newsgroups are text-based but require a specific news reader, which is
built into some Web browsers (such as Netscape and Internet Explorer). One way to get a
feel for newsgroups is to use the World Wide Web and the AltaVista search engine (http://www.altavista.digital.com). Select
"usenet" instead of "web", then enter a subject. This will return a
list of recent postings to various newsgroups, which can be clicked on and read as Web
documents.
Mailing Lists (aka discussion groups) are private lists of people with a similar
interests, who use regular Internet e-mail to communicate with each other. Messages sent
to the computer serving the list are forwarded to the whole group. You have to ask to join
the list and people who use it inappropriately can be excluded. Some lists even have a
moderator who reviews each message and only forwards those deemed appropriate for the
list. The aim is to ensure that the messages are of interest to the group. There are many
anesthesia mailing lists, the busiest of which is the Anesthesiology list from Yale which
has over 16,000 members. There are lists devoted to Intensive Care, Pediatric Anesthesia,
Regional Anesthesia and many more. A full list, with instructions on how to join each one,
is available at the ACCRI web site:
http://www.eur.nl/FGG/ANEST/wright/contents.html.
Every mailing list has two addresses. One is for the computer which manages the list
and includes a word such as "listserv", "listproc", or
"majordomo". This address is for administrative messages such as subscribing to
and unsubscribing from the list. The other address, which is usually in the format of
{name of the list}@{domain for list}, is used as an alias for the entire list. A message
sent to this address goes to every member of the list. Subscribed members will get annoyed
by receiving your "unsubscribe" message, intended for the list server. Another
way to annoy the members of a list is to respond to a message on the list by pressing the
"reply" option and adding your message. Most mailing programs will then copy the
whole text of all the preceding messages and send that to every member of the list with
your message. Be careful to delete all unwanted material before pressing "send".
Once these details of "netiquette" are learned, the mailing lists provide an
incredibly useful way to keep up with thoughts on anesthesia around the world. It was
fascinating to hear about Japanese experiences with sevoflurane shortly before it was
released in North America, for example.
World Wide Web (WWW)
The World Wide Web is the fun, multi-media part of the Internet. Before the WWW, the
Internet was a tool for academics and computer nerds who used clunky tools such as File
Transfer Protocol and Telnet to do rather uninteresting things like access catalogues and
download programs from remote computers. The World Wide Web only became popular in 1993
with the development of the Mosaic "Web Browser", a program which allowed
Internet users to see colors and images. It also allowed the user to navigate the Internet
with relatively intuitive methods, such as selecting an item from a menu, or clicking on a
highlighted word, or on an image such as a "Start" button. Very rapidly, the
underlying technology was expanded to include animation, sound clips, and later, video.
Image maps, where selecting on part of an image produces an appropriate response (e.g.
click on Belgium in a map of Europe to find information about that country), added another
way of navigating. The use of forms to submit information to a Web site, allowing it to
produce a specific response such as a list of Web sites on a specific topic or details of
a particular product from a large catalogue, added another useful dimension. The World
Wide Web now includes millions of sites, catering to almost every interest.
It is very cheap and easy for anyone to contribute information to the World Wide Web.
Anyone can buy storage space on an Internet Service Provider, type up a page in HTML (the
word-processing language for the Internet), add some graphics, and be published by sending
that information to the ISP. This has created an incredible opportunity for thousands of
people with the urge to create who previously had no way to express themselves. They can
now set up Web pages which can be read by millions of people around the world for as
little as $10 per month! Unpaid amateurs have created some fantastic sites such as the Web
Museum and the Internet Movie Database. They have also contributed such pointless items as
personal diaries, lists of CDs they own, views of the fish tank in their office, and the
contents of their wallet.
So how does one find the "good stuff" amongst all these sites? One of the
first efforts was "Yahoo", an attempt to list all the good sites in a directory
format. For example, after entering the "Yahoo" web site (http://www.yahoo.com) one could select "Health"
from a list of choices, then select "Medicine" from within the list of
Health-related sites, and then "Anesthesiology" to get a list of Anesthesiology
related sites. This branching structure works fairly well, provided you understand the
categories and realize that, for example, Anesthesiology can be reached via
"Health" and "Medicine". Yahoo gives a good overview of what is
available in a category. It is created by real people, who visit the site and decide how
to categorize it. This makes it slow to pick up new sites, but does provide some quality
control.
A more high-tech approach is taken by search engines, such as AltaVista (http://www.altavista.digital.com). These
engines use high-powered computers to send "spiders" to roam the net, attempting
to follow every link from every existing web page, then copy the information and analyze
it. AltaVista currently has records of web pages. When a user submits a search request, it
looks at that information, and within seconds provides a list of pages with text which
matches the search request. It provides a few sample lines from the site, gives the size
of the document, and a link to the original page. This is an incredible feat of
technology, but unfortunately it is not as helpful as one would wish. Putting in
"anaesthesia" results in 6,000 hits, and using the American spelling
"anesthesia" results in 20,000. Fortunately, AltaVista tries to put the best
ones first(where anesthesia appears early, in the title or in special "meta"
tags", or very frequently). A quick peak at the links reveals many useless links
(e.g. schedules for resident seminars, anesthesia books for sale). Searches for more
specific subjects are more useful. However, one will miss options available in Medline
searches such as "review articles only" or "human subjects only" or
even "English language". Most search engines allow complex searches (e.g. pages
with both of two subjects but without a third), however they all rely on searching the
document as a list of words. For example, most search engines would not list a site about
"movies" if asked to search for "cinema".
Useful tips include:
Incidentally, there are some sites, such as OVID (http://gateway.ovid.com),
which allow Medline searching, some for free. They usually provide abstracts for free, and
may provide full text for a fee. A complete listing of free Medline sites can be found at
Dr Felix's Free MEDLINE Page.
Computerized search engines may not be the best way to find relevant information. A
useful alternative is to find a page with a list of useful links. Fortunately, many
Internet users are keen on finding all the best pages on a favorite topic and publishing
that list on the Internet. Also, some businesses feel that such a list of relevant links
would attract a lot of traffic and be a useful place to advertise. As a result, pages with
lists of links have proliferated. Fortunately, there are some good lists of medical links,
such as Medical Matrix and WebDoctor, which allow one to navigate through a directory tree
like Yahoo. As with Yahoo, these sites are created by humans, who exercise editorial
control over which sites are listed.
For anesthesia, the place to begin is ACCRI,
"Anesthesia and Intensive Care Resources on the Internet", a comprehensive list
of links created by A J Wright, a medical librarian in Alabama. This lists every
anesthesia department's web site, every journal, every mailing list, and every
organization with an e-mail address. A truly amazing effort! But closer inspection reveals
there is nothing there about anesthesia! It is entirely a list of sites by type without
any direct links to information about patient care. Another major resource is GASNet, set up by Keith Ruskin at
Yale. It includes many resources, one of which is the "Global Textbook of
Anesthesiology", which contains a dozen or so useful articles on various
aspects of clinical anesthesia. Useful but by no means a comprehensive resource. The next
evolutionary step is the "Virtual Anaesthesia Textbook".
Chris Thompson, an Australian anaesthetist, recognized that many anesthetists and
departments were posting useful clinical information, but they were spread over different
Web sites around the globe. He decided to set up a global index resembling a textbook. As
editor-in-chief, he set up the table of contents then asked for volunteer editors to pick
a chapter and create an annotated list of links to sites relevant to that chapter. This
has created a useful resource, however, like any multi-author textbook there are problems.
Some chapters never attracted an author (Chris would be very pleased to hear from
volunteers). Some chapter organizers are diligent and keep their pages up-to-date while
others have created a list like ACCRI with few links to relevant content.
The following is a list of some of the better anesthesia/medical Web sites:
| Title | URL |
| ACCRI | www.eur.nl/FGG/ANEST/wright/contents.html |
| Virtual Anaesthesia Textbook | gasnet.med.yale.edu/mirror/vat/VAT.html |
| GasNET | gasnet.med.yale.edu |
| Canadian Anesthetists' Society Homepage | www.cas.ca |
| Canadian Medical Association | www.cma.ca |
| Canadian Anesthesia List | www.anesthesia.org/professional/can_anes.html |
| Ontario Medical Association | www.oma.org |
| Anaesthesia Meetings | www.oyston.com/anaes/meet.html |
| Canadian Internet Anaesthesia Job Registry | http://c38t.lhsc.on.ca/CanAnaesJobs/cananaes.htm |
| Visible Man | www.npac.syr.edu/projects/vishuman/VisibleHuman.html |
| WebDoctor | www.gretmar.com/webdoctor/home.html |
| Medscape | www.medscape.com |
| Doctor's Guide to the Internet | www.pslgroup.com/docguide.htm |
The technology is in place to make the Web a valuable resource for medical education
and CME in all fields, including anesthesia. The challenge is to provide suitable CONTENT
in a way which takes advantage of the new medium. This requires substantial resources in
terms of both time and money and it is unclear at present how this effort could be funded.
Conclusion
In Anesthesia, as in many fields, we are just starting to see the potential of the
Internet as a tool for communication, education, research, and academic endeavors. This is
leading us away from a time where information has been supplied in a linear and ordered
way with rigid standards for peer-review, research, and publication. For some, the
Internet may seem to have created information chaos that challenges standards and
traditions. However, the Internet's benefits assure that its application to anesthesia is
sure to increase in the future. Now is the time for anesthetists to step in, make the
decisions, and provide the direction necessary for the best application of new
technologies in our education, our research, and our practice. Where we are going
obviously depends on how we proceed. There are challenges but there are also endless
possibilities !
"The Internet is the medium that puts the power of publishing and broadcasting in the hands of almost any individual. The technology is present to allow the human race to make a transition from old forms of mass media in which power was concentrated in a few hands to a new one in which power is widely dispersed and diluted, in which every voice has a nearly equal opportunity to be heard and the premium is on what that voice has to say."
Gary Welz (http://found.cs.nyu.edu/found.a/CAT/misc/welz/internetmm)
Questions
For each of the following questions, select the one best answer.