The Internet, intranets and reproductive medicine

J.M. Jenkins

Division of Obstetrics and Gynaecology, St. Michael's Hospital, Southwell Street, Bristol BS2 8EG, UK

The Internet (net) is an ever-expanding, worldwide, computer network connecting millions of computers providing many services, the most notable of which is the world wide web (web, www or W3). The web provides an exciting way to navigate (surf) between documents, incorporating multimedia, held on computers throughout the world. Although open access to information provided by the Internet is one of its greatest strengths, often security of access to information is essential, thus many organizations employ internet technology in closed networks termed intranets. Intranets may be completely separated from the Internet or connected to the Internet through security systems called firewalls. Already this technology is being applied in reproductive medicine and the use is likely to increase substantially in the future.

The Internet

In the late 1960s the US Department of Defense funded the Advanced Research Projects Agency to design a network, which allowed computers on different types of networks to communicate with each other (Coiera, 1997Go). In the event of war the strategic importance of communication was recognized, and prior to this project there were many incompatible networking technologies that could hinder communication. The Internet addressed this problem using special computers called routers to connect between the different networks, and a set of rules describing how to transmit data: the Transfer Control Protocol (TCP) and the Internet Protocol (IP). Each computer connects to the Internet by a unique numerical address (IP address), which routers use to guide the information packets from source to destination. A system also exists to register the numeric IP address as a text address such as `http://www.nominet.org.uk' . The router computers select the best route to transfer information at any time. In the event of a nuclear strike wiping out a large part of the US network, communication would thus remain intact as the router computers would automatically redirect communication channels. Not only did the Internet thus satisfy the principal goal of this project, the Internet opened the door for many other possibilities.

World wide web

In 1990, to keep track of large research projects the European Laboratory for Particle Physics (CERN) in Geneva, Switzerland produced a document management system incorporating hypertext, which when introduced to the Internet formed the web. Computers termed `servers' make documents accessible on the network, to be viewed by other computers using computer programs termed `browsers' (http://www.w3.org/History.html). Hypertext permits a link to be inserted anywhere in a body of text to other documents located anywhere on the network. In 1991, CERN made a browser freely available that could run on many computer systems and browse text documents over the Internet. In 1993, collaboration with the University of Illinois made a more sophisticated web browser (Mosaic) freely available, that could view images as well as text, and rapid development of web servers followed. In 1994, one of the developers of Mosaic helped to establish a company that produced an even more advanced browser `Netscape Navigator' (http://www.netscape.com). In 1995, the computer giant Microsoft introduced the first version of its web browser, `Microsoft Internet Explorer' (http://www.microsoft.com). The following years have seen incredible developments in browser functionality (http://www.download.com/Browsers/).

Although most web browsers are able to display web pages which conform to basic standards, technological innovations have led to many enhancements that are not uniformly accessible by all browsers. These differences may do no more than make the appearance of the web page differ between browsers or they may completely prevent display, such as the ability of modern browsers to display a view comprising multiple web pages within frames. Some differences are trivial, such as the ability to type directly into modern browsers a web address such as `www.spa.org', without the need to prefix the web address with the code `http://' to tell the browser that the address corresponds to a web page. Other differences are crucial, such as the ability for modern browsers to run computer programs integrated with the web page using a wide range of programming methods (http://www.gamelan.com). The functionality of web browsers may be extended by programs which may be installed on computers to provide such features as audio-visual broadcasts on web pages (http://www.realaudio.com) or the ability to move within three-dimensional virtual worlds (http://www.sdsc.edu/vrml/). To limit the incompatibility between web browsers there is a consortium that aims to define common standards for web pages (http://www.w3.org), although commercial competition to produce the best browser limits the effectiveness of this group. It is important to recognize that the sophisticated, freely available, modern web browsers require high specification modern computers to work optimally, although improvements in cost per performance of computers makes this an affordable option. In order to gain the most from the Web it is important to use the most up-to-date web browsers.

Finding information on the world wide web

There are a number of aids that may help find information on reproductive medicine amongst the billions of web pages on the Internet. There are a number of websites that aim to catalogue the whole Internet and provide search facilities (http://www.spt.com). Other websites aim to restrict their catalogue to medical Internet resources (http://www.hon.ch) with one website specifically cataloguing reproductive medicine sites (http://www.ReproMED.net).

Large sections of the biomedical literature may be searched and viewed at many websites. Catalogues of the biomedical literature such as MEDLINE are available at many websites often funded by sponsorship (http://www.healthgate.com). Certain websites directly link from the catalogues to individual full text articles with illustrations (http://www.ovid.com). Other websites provide full text journals, either freely available (http://www.bmj.com), or as an extended option for individuals who subscribe to the paper published copy (http://www.oup.co.uk/humrep/). The BioMedNet website provides a range of biomedical literature and additional features with fees charged for certain information (biomednet.com). The rapid dissemination and ability to update articles centrally makes the Internet particularly useful for evidence-based medicine publications. Abstracts of the Cochrane collaborations are freely available, or full text may be viewed at a modest charge (http://www.cochranelibrary.net/). The guidelines of the Royal College of Obstetricians and Gynaecologists (RCOG) are one of many resources freely available on the RCOG website (http://www.rcog.org.uk).

A web browser may provide access to extensive databases such as those managed by the US National Center for Biotechnology Information (NCBI). The Online Mendelian Inheritance in Man (OMIM) edited by Dr McKusick and colleagues provides a searchable catalogue of human genes and genetic disorders with extensive textual information, pictures, and references (http://www3.ncbi.nlm.nih.gov/Omim/). An incredible amount of molecular biology data and bibliographic citations may be accessed from a series of integrated databases referred to as WWW Entrez (http://www3.ncbi.nlm.nih.gov/Entrez/). This resource provides sophisticated search facilities for DNA sequences, protein sequences, genome and chromosome mapping data, three-dimensional protein structures and a bibliographic database containing citations for nearly 9 million biomedical articles from the MEDLINE and pre-MEDLINE databases.

Individuals may find information of particular relevance to them from informal sources or intelligent search clients. A typical informal source of information is the address of a particular website of personal interest, provided by a colleague with similar interests. `Intelligent search clients' are computer programs that may be programmed with an individual's specific requirements, to search the Internet and report back relevant information.

In reality it is probably impractical for any single group to rate the quality of websites (Jadad and Gagliardi, 1998Go), thus users must be able to determine the value of any information they obtain on the Internet. The provenance of the information is important, thus the views of independent professional bodies are of obvious value (http://www.ReproMED.org.uk). Independent treatment centres may provide extensive information, whose value may be assured by the reputation of the centre (http://www.ReproMED.co.uk). Patient support groups may provide useful information, although care should be taken that all information may not be from medically qualified sources. Although a website sponsored by a single commercial company might be expected to demonstrate product bias, there are examples of good quality web sites funded in this manner (http://www.Ferti.Net). Important regional variations in reproductive medicine exist throughout the world, thus it is important to consider if the information you find is appropriate for your region. It is possible that some information held on a website is out of date, thus it is important to consider the current validity of any information. If information were found to be inaccurate in any respect, it is helpful to draw this to the attention of the administrators of the website. Ultimately the viewer of the website must decide how much reliance to place on any information, and it is probably wise to confirm information from several sources where possible.

Using the Internet to communicate

The Internet provides a wide range of asynchronous and synchronous methods to communicate beyond viewing information held on web pages. Electronic mail (e-mail) is extremely popular to send messages along the Internet using either specific e-mail programs or a web browser (http://www.hotmail.com). Despite the great popularity and usefulness of e-mail it is important to recognize the limitations of this technology to avoid inappropriate use. In a large survey commissioned by Novell, over half of the respondents had received abusive e-mails from colleagues or superiors (Fisher, 1997Go). The report suggested that: `e-mail is completely void of the physical and tonal clues that face to face and voice communications provide to interpret meaning. Instead e-mail is immediate, often impetuous and consequently wide open to misuse'. Although it is possible to send computer files attached to e-mails, it is preferable to use a file transfer programme (http://www.crc.net.au/ftp/124.html) when moving large files from one place on the Internet to another. Caution should be taken when receiving computer files from the Internet, and it is always wise to use a computer programme to scan the files for computer viruses prior to use. However, many e-mail messages warning of viruses are hoaxes (http://ciac.llnl.gov/ciac/CIACHoaxes.html).

Although e-mail provides an excellent method of distributing news to many people, e-mail is less efficient for electronic discussions, which may be better conducted on the electronic equivalent of a bulletin board. The Usenet is a collection of thousands of discussion groups for individuals to post messages for others to see, and add their replies. The messages are automatically erased in due course to ensure the system does not become too cluttered. In certain parts of the Internet there are discussion areas where only registered users may post messages in moderated sessions (http://www.Ferti.Net). The value of electronic bulletin boards to complement reproductive endocrinology education has been demonstrated (Letterie et al., 1996Go).

There are many synchronous communication methods on the Internet that are steadily improving as technology develops. More importantly as more individuals gain access to compatible synchronous communication methods, this technology will become useful. Telnet is a long established programme that allows a user to connect from a remote point on the Internet directly to a distant computer system, and thus work with this system exactly as if in the same office. Using a variety of methods it is possible for some one to enter text on a web page and for this text to be simultaneously displayed on other web pages elsewhere on the Internet. Using such a method it is possible to chat with Dr Perloe in Atlanta Reproductive Health Centre Monday evenings local time (http://www.ivf.com). Over the Internet it is possible to communicate with audio and even low quality video using programs such as NetMeeting (http://www.microsoft.com/netmeeting/). Given the size of the Internet, it is useful that the technology now exits to page individuals on the Internet wherever they may be connected (http://www.ichat.com). An excellent example of Internet conferencing for reproductive science is provided at http//www.ivf.net.

In contrast to a user choosing to view a web page, it is possible to send information directly to a user using `push technology'. At a basic level, an individual may choose to be kept updated regarding information held on a single web page. Whenever this web page is changed the latest version of the web page is sent directly to the individual's computer. More complex sets of information may be defined in what are termed push channels, to which an individual may choose to subscribe. Examples of this could include personalized news on forthcoming reproductive medicine meetings or content lists of selected journals with hypertext links to full text articles.

Education on the Internet

There are sound, well-established educational principles to develop computer-assisted learning (CAL) programs, which the Internet may make available to a very wide audience (Jenkins, 1997Go). Teaching sociology students over the Internet has even been suggested to be superior to teaching by more conventional means (Brake, 1997Go). The Ferti.net website (http://www.Ferti.net) not only provides public information on infertility with regional information for individual countries, but also provides a range of useful educational facilities within a password protected area for professionals. The ObGyn website (http://www.obgyn.net) provides a wealth of useful educational information, including calendar of events, an image library, and discussion forums, with a specific members-only area providing endometriosis education (http://www.endozone.org). During 1997, a systematic study was performed throughout the South West of England to evaluate the potential of CAL to support the training of junior doctors (Draycott et al., 1997Go). Despite the limited access to computers, inadequate computer skills of doctors and lack of appropriate learning material, the doctors' learning styles and the logistics of developing a structured educational programme suggested the Internet could prove very useful. In 1998, a structured Internet distance-learning programme in reproductive medicine was successfully piloted for registered participants as a model for other programmes to follow (http://www.SWOT.org.uk).

Research

The Internet provides considerable support for reproductive medicine research beyond even the access to biomedical databases, biomedical literature and communication facilities. Researchers are increasingly likely to work in relative isolation in an academic department with only limited opportunity for discussion at national meetings. Following the first meeting of the National Ovarian Workshop in 1995 at the Royal Free Hospital, it was thus resolved to provide selected abstracts with relevant e-mail addresses on a web server – the Virtual Ovarian Workshop (http://www.ReproMED.org.uk/VOW/). This website has continued to expand (Jenkins 1996Go), complemented by a free e-mail discussion list (http://www.nottingham.ac.uk/ssf/ov_email.html).

Intranets

Intranets use the same networking technology and protocols as seen on the Internet but provide secure connections between a number of computers on an organization's network. The intranet may be confined to a single building or distributed throughout the world. If desired an intranet may be connected to the Internet using a firewall. This is essentially a computer that applies a set of rules to determine whether information may pass between other computers. Different firewalls provide different levels of security to prevent unauthorized access. Highly secure intranets may hold confidential information such as a patient's clinical record, audit records of consultant performances or junior doctors' training progress.

Electronic data interchange (EDI) allows direct transfer of information between computer systems, where information may be stored using very different database designs. A variety of methods may be used to provide highly secure EDI and an intranet provides the ideal route for transferring the information. The UK National Health Service now has a secure intranet (NHSnet). In 1997, a survey of the 75 licensed in-vitro fertilization (IVF) clinics in the UK revealed overwhelming support for electronic transfer of statutory information to the Human Fertilisation and Embryology Authority (Jenkins, 1998Go).

By providing access to clinical information using a web browser, the training of staff to access multiple information sources becomes much simpler. It becomes possible to access seamlessly many separate databases and even search remote information sources which may aid clinical decision-making. It will take time to change the face of all reproductive medicine information systems requiring proof of benefits to justify costs of development. The security provided by intranets is likely to be of particular benefit to manage confidential clinical information and sensitive audit data.

Conclusions

Although the Internet has existed for many years, it has only recently attracted wide-scale interest. The introduction of the web has been the principal focus for this interest with easy access to extensive information including interactive multimedia. Intranets bring the benefits of Internet technology to closed networks with firewalls providing a link to the Internet. Many aspects of reproductive medicine are benefiting from these technologies. Although there are complaints of slow access to information on the Internet, many technologies are developing to greatly increase the amount of information the Internet can carry utilizing existing copper wire telephone lines through Digital Subcriber Line (DSL) technologies, coaxial television cable, electricity power supply cables and even various wireless methods. It is impossible to forecast future developments of the Internet, but unnecessary to understand the intricacies of the technology to access the benefits. The first step is to have access to the Internet with a modern web browser and a starting point such as: http://www.ReproMED.net).

Acknowledgments

Mr Jenkins' involvement in Internet/intranet developments include the following: membership of the Royal College of Obstetricians & Gynaecologists Internet working group (http://www.RCOG.org.uk, Training Programme Director for Obstetrics & Gynaecology in the South West (http://www.SWOT.org.uk), membership of the editorial board of Ferti.Net (http://www.Ferti.Net), academic director of the centre for learning technology in medicine (http://www.ilrt.bristol.ac.uk), medical advisor to the national computers in teaching initiative centre for medicine (http://www.cticm.bristol.ac.uk) and originator of the ReproMED project (http://www.ReproMED.org.uk).

References

Brake, D. (1997) The Net benefits of learning from home. New Sci., 2067, 5.

Coiera, E. (1997) Guide to Medical Informatics, The Internet and Telemedicine. Chapman & Hall Medical, London, UK.

Draycott, T., Rennie, A., Jenkins, J. et al. (1997) A pilot study to assess the role of the Internet to provide structured training in obstetrics and gynaecology. Health Informatics J., 3, 76–80.

Fisher, P.J. (1997) Shot down in flames. Personal Computer World, August, p. 45

Jadad, R.A. and Gagliardi, A. (1998) Rating health information on the Internet. Navigating to knowledge or Babel? J. Am. Med. Assoc., 279, 611–614.[Abstract/Free Full Text]

Jenkins, J.M. (1996) Electronic publishing over the Internet: an extension of research workshops. MEDNET `96 – European Congress on the Internet in Medicine. In Arvanitis T.N. (ed.), The Internet in Medicine. Excerpta Medica, International Congress Series CD-ROM 1138.

Jenkins, J.M. (1997) Computer assisted learning. Curr. Obstet. Gynaecol., 7, 139–144.

Jenkins, J.M. (1998) Medical informatics in assisted reproduction. In Brinsden P.R. (ed.), A Textbook of In Vitro Fertilization and Assisted Reproduction. Parthenon Publishing, Carnforth, UK.

Letterie G., Salminen E.R., McClure G.B. (1996) An electronic bulletin board for instruction in reproductive endocrinology in a residency in Obstetrics and Gynaecology. Fertil. Steril., 65, 883–885.[ISI][Medline]

Submitted on July 22, 1998; accepted on November 18, 1998.