Southampton General Hospital Tremona Road Southampton SO16 6YD, UK
As with many technological developments that eventually benefit mankind, the original intention of the Internet was for military advantage. Following the launch of Sputnik by the then Soviet Union in 1958, President D. Eisenhower of the USA set up the Advanced Projects Research Agency (ARPA) in an effort to regain the world lead position in science and technology. As the cold war deepened, ARPA was tasked by the US Air Force to develop a system that would enable control and command of the military and missiles to survive a nuclear attack. They assigned this project to civilians at Americas top universities who developed the Internet in 1969. But just as ultrasound, Teflon and other military inventions found their way into every day medical use, so too has the Internet. However, no other technology to date has had as great an impact on medicine and society. It has revolutionized the ways in which we may learn and practise our art.
Communication
For most civilians, the revolution started with electronic mail (e-mail). As the cost impediment has disappeared, this method of communication has become widely available. Indeed, times have moved on since Oystons1 online worldwide survey in 1997 showed that mainly male American doctors in university hospitals were using e-mail. It is now the key method of personal communication. Most professional and official communications also take this form. International correspondence is easily and cheaply achieved via e-mail. The British Journal of Anaesthesia and most other anaesthetic journals allow the submission of articles for publication via e-mail, although a signed letter is still required for copyright reasons. Some anaesthetic departments now distribute rotas and memoranda via e-mail.
More directly, interactive methods of communication have also been developed. In 1993, Ruskin and Tissot2 reported online case conferencing. In 1994, Ruskin and colleagues set up a worldwide anaesthetic forum,3 which has evolved into one of the premiere anaesthetic websites (Gasnet, http://www.gasnet.org). These days, case conferencing can easily occur at an international level, utilizing software such as NetMeeting (©Microsoft Corporation, Seattle, WA, USA) that allows both instant voice and video communication with the option of sharing files and data at the same time.
Another method of communication is via the bulletin board. Participants can post their opinions on a subject matter online and, thus an informal discussion may ensue. Indeed, Mentzer and colleagues4 extolled Ruskins bulletin board as a paradigm of the Global department of anaesthesia, allowing the exchange of opinions and sharing of ideas about areas of controversy in anaesthesia.
World Wide Web
This was developed by CERN (European Organisation for Nuclear Research) in Switzerland and was made available to the public by the WWW Consortium in 1992. A standard protocol (hypertext transfer protocolHTTP) allows computers to log on and upload/download files for display and use from another computer (known as a server). Most websites have gone beyond the rudimentary page merely providing contact details, to sophisticated web pages that provide a multimedia experience.
A multitude of anaesthetic websites has been published in the last few years. A web search using the key words Anaesthesia and United Kingdom using the Google search engine (http://www.google.com) revealed 14 514 web pages. They take many forms and shapes. Some belong to professional organizations and associations (these formed the majority of the top 100 hits from the search). These mainly provide information about the activities of the various groups. The Association of Anaesthetists of Great Britain and Ireland (http://www.aagbi.org) and the Royal College of Anaesthetists (http://www.rcoa.ac.uk) have such websites. There are also non-affiliated websites that provide anaesthetic information as either a collection of references or as chapters of an electronic textbook. Some of the better-known anaesthetic websites include the Global Anaesthetic Server GASNet (http://www.gasnet.org), the Virtual Textbook of Anaesthesia (http://www.vitual-anaesthesia-textbook.com), and the Oxford Pain Website (http://www.jr2.ox.ac.uk/Bandolier/painrej/painpag/index.html). They provide a wide breadth and depth of information to satisfy the needs of trainees and consultants. Other websites such as the New York School of Regional Anesthesia (http://www.nysora.com) lead the way in utilizing the web. This site contains well-described text and diagrammatic annotations, and streaming video demonstrations of regional blocks. Another category of anaesthetic website is the Patient Information site. Some professional organisations provide Patient Information subsections on their websites (http://www.rcoa.ac.uk/public.html), but there are a significant number of websites that are based on individual accounts by patients who have undergone anaesthesia.
Many would agree that one of the most important features of the World Wide Web is the medical search engine. Foremost is the American National Health Librarys Medline.5 Initially limited to collections of abstracts on proprietary CD-ROMs that could be searched using MeSH (Medical Subject Headings), this system involved hours spent in the library sifting through CD-ROMs. However, with the advent of the Internet, the National Library for Health publicized its catalogue online, allowing free access to anyone. Now one may perform a Medline search either on PubMed (http://www.ncbi.nlm.nih.gov/PubMed), or many other combinations and permutations of the medical search engine. The NHS is in the process of setting up its own online national electronic medical library (http://www.nelh.nhs.uk).
What has made things more exciting for the speciality is the fact that anaesthetic journals are now going online and are establishing searchable electronic archives. One can look up subjects of interest and get the full articles while online. For example, the British Journal of Anaesthesia (http://www.bja.oupjournals.org) is available online with full text accessible to all journal subscribers. However, not every journal provides free access to full articles. Some institutes, within the confines of copyright law, will allow their employees to have online access to full articles of journals that they keep in their libraries.
More exciting developments such as the development of web-based live databases of patients with difficult airways,6 and individuals susceptible to malignant hyperthermia,7 only serve to reinforce the versatility and potential of the web.
Problems for anaesthetists
Quality assurance
As medicine moves into a new era of evidence-based practice, it is important that our common sources of information have statements based on facts. Journals have struggled for a long time to ensure that only quality material is published. One of the strongest methods of ensuring quality in print journals is through the peer-review system. The standards that have taken so many years to attain in print should be applied to the web as well. Many authors in recent times have worried about how the great potential of the Internet may be lost due to the apparent abundance of dubious medical information.810 Anaesthetists have several options to rate the credibility of web sites.
Professional organization endorsement is one method. For example, both the Association of Anaesthetists and the Royal College of Anaesthetists have links pages on their websites. While not directly responsible for the content of the web sites listed on these pages, in general, both professional bodies by implication are happy for their members to obtain information from these websites. A further extension of this practice is to have independent body adjudication of web site content with subsequent award of a credit rating. Med411.com and Health on the Net (http://www.hon.ch/home.html) are examples of such organizations.
Peer review is a tried and tested method that can easily be extended to the Web. Some organizations already have this method of quality assurance in place, for example, the Virtual Textbook of Anaesthesia. Other websites attain credibility by clearly stating the qualifications of the authors. The World Federation of Anaesthetists follows this model and has a very successful website (http://www.nda.ox.ac.uk/wfsa) that is designed to provide updated information for anaesthetists in developing countries.11
There are counter arguments to all these strategies for quality control. Following Shapira and colleagues12 concerns about use of web-based resources as revision material by residents, Allen13 questioned the objectivity of peer review by stating that authors tend to support their own opinions. He advocated the process of critical appraisal, encouraging authors to explain how the literature search was performed, why individual articles were utilized, and how areas of disagreement were dealt with. He suggests critical appraisal is a valuable tool that should be implemented in the authoring of medical websites.
Copyright matters
The question of intellectual property is a difficult one. While it is quite reasonable to argue for copyright protection, some are of the opinion that copyrighting academic material has the negative effect of increasing the cost of access to these materials. This only worsens the plight of those with less financial resources. Some organizations have started to tackle this particular problem. Academic powerhouses such as the Massachusetts Institute of Technology (http://web.mit.edu/) have taken the bold and unprecedented step of putting all their course material online without any restriction but still retaining copyright. The World Federation of Societies of Anaesthetists (WFSA) has placed material online with the specific goal of reaching many anaesthetists in the third world who have less access to costly print journals (http://www.nda.ox.ac.uk/wfsa/index.html).
Some rightly argue that authors have worked hard in preparing their material for publication and should receive recognition for it. Furthermore, their material should not be plagiarized for material gain. Others would argue that in academic circles the only true goal of any academic publication is to enhance knowledge. The only people who would gain from having this knowledge are practising anaesthetists. Should this information and knowledge be protected from free distribution? Currently some academic journals charge for a reprint of a single article. For example, those journals published by Blackwell Science and Munskaard (http://www.Blackwell-synergy.com) charge US$16.00 for a reprint of any of their articles. However, others, such as the British Medical Journal (http://www.bmj.com), provide a free-for-all online archive of all their journals since 1994. The British Journal of Anaesthesia is currently between the two extremes, allowing full online access to its archive to subscribers of the print journal. A number of anaesthetic trainees (usually around the time of their examinations) have compiled anaesthetic databases for use on handheld computers, and most have made these free to download from the Internet. This is a trend that will continue into the future. We would welcome other anaesthetic journals contemplating these bold new steps.
Security
As with most things in life, there is a downside to this wonderful technology. While the lack of a control structure has been its strength, in some instances it is also its Achilles heel. There is an ever-present worry of a hacker attacking a site and altering the site content or worse, gaining access to confidential patient information.
Many suggestions have been put forward regarding Internet security. Some organizations with high-value data use intranets to allow only a select group of individuals to have access to their information. These take the form of local area networks. Most NHS trusts in the UK have such set-ups. Trust policies, guidelines, protocols, and databases can be posted on a website limited to an intranet. For information that is designed to have a national or a worldwide audience, firewalls have tended to be used to help protect the integrity of the published data/text. Data encryption is now becoming a well-recognized method of protecting information submitted on the Internet as well as by electronic mail.14 Digital signatures can combine with encryption to improve security.
Despite all these potential problems, the Internet remains a wonderful invention with a great future. It is a testimony to the potential of the Internet that most of us have been presented with information obtained from the web by our patients. Sometimes we have to be wary of these facts and warn our patients that a little knowledge may be dangerous. But we all should welcome this information revolution. Patient empowerment is important for the patient and the practitioner. Without appearing to be paternalistic, there are ways of directing patients to credible websites. These include our professional organizations websites as well as those that belong to our individual institutions. The web addresses can easily be placed on anaesthetic information leaflets that patients receive at pre-clerking.
We need to encourage surveys and studies in the literature that look at the quality of website contents. It is encouraging to see a few journals featuring reviews of medical websites (e.g. New England Journal of Medicine, http://www.nejm. com). We also need to encourage our anaesthetic journals to feature web-related material over and above the few articles that have been published in recent years.1519 The authors would welcome monthly or bi-monthly reviews of websites.
The future
The authors envisage an anaesthetists operating list for next week being delivered by e-mail together with an attachment detailing anaesthetic pre-assessment pro-formas, filled in by the surgical house officer at pre-assessment clinic. Results of any tests performed including high-definition images of x-rays, CT scans and ECGs would be included. Red-flag conditions such as malignant hyperthermia or rare medical syndromes would have resulted in an automatic request being sent to the medical records department so that the patients notes could be delivered, in advance, to the anaesthetist for perusal. Prior to departing on an inter-hospital transfer, the anaesthetist could send an electronic file with all relevant information to the receiving consultant. This allows a full appraisal of the patient and preparation for his/her arrival.
The patient who is preparing to come into hospital prior to a major operation can log on to the hospital website and select the anaesthesia section. Here he/she finds out information about what to expect during a general anaesthetic. The patient is comforted by the experiences of previous patients who have published their opinions on this website. He/she is also able to access information for patients on the Royal College of Anaesthetists website (http://www.rcoa.ac.uk/public.html).
The trainee gets home after a day at work. He/she checks their e-mail to see what delights next weeks duty roster holds. The trainee then logs on to British Journal of Anaesthesia online (http://www.bja.oupjournals.org) to review the article that was being discussed earlier in the day with his consultant. The trainee checks availability and books a place on an examination revision course online. Finally, he/she spends half an hour doing practise MCQs online (e.g. http://www.anaesthesiauk.com) before eventually logging off.
All of us can see that this future fantastic is just round the corner. We must continue to keep pushing the boundaries and maintain our reputation as the speciality at the cutting edge of technology.
References
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8
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14
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