Critical Care and the Internet: A clinicians perspective

David Crippen, MD. FCCM

Clinical Assistant Professor

University of Pittsburgh

Associate Director, Department of Emergency and Critical Care Medicine

St. Francis Medical Center

Pittsburgh, PA 15201

What is the Internet?

The Internet had begun life long before it was discovered by working clinicians. It's obscure UNIX operating system rendered it effectively out of reach from non-computer literate individuals until the popular press discovered it and technological advances allowed

access using graphic interfaces. The number of armchair information seekers exploded with the advent of America on Line (1) and other user friendly proprietary access services. Armed with only a rudimentary knowledge of English language commands, an "Internet surfer" could access extremely large banks of data anywhere in the world in seconds.

In addition, armchair pundits discovered a unique property of the Unix operating system that allowed transfer of written messages across phone lines to individuals and groups. Interest groups found they could correspond with each other on subjects of mutual interest using Internet "bulletin boards" such as USENET (22) and LISTSERV's (21) which were available only to subscribers. Messages sent from individuals could be delivered simultaneously to other kindred cyber-spirits. Because of easy access and minimal technical requirements, the stage was set for working physicians to develop and maintain dramatically new ways of accessing medical information.

Clinicians and the Internet

For busy clinicians, access to medical literature is problematic.

Medical journals are expensive, difficult to index and bulky to store. Visits to medical libraries require travel time and most of the literature goes out of date quickly. Journal clubs are inefficient and time intensive. In the beginning, accessing medical data banks via the UNIX based File Transfer Protocol (FTP) (13) allowed clinicians to literally roam the globe, pulling out whatever seemed to be of interest and printing it out for individual use without worrying about most copyright restrictions. However, in the early days, the only information that cold be accessed was simple newsprint. The National Medical Database- MEDLINE (19), with it's ponderous Boolean Logic search language was methodology-intensive and difficult to manipulate. Information seekers needed a graphic interface to seek out not only written but graphic information in a more interactive fashion.

Continued technological advances developed the World Wide Web (WWW), and with it the ability to access high resolution graphics (25), movable and user interactive interfaces (17) and most importantly "search" devices allowing users to find data using graphic prompts instead of language (6). Simply "clicking" the computer's mouse device on contrasting "Hypertext" within one document allowed immediate transport to another document having desired reference features. The advent and refining of Hypertext Markup Text Language (HTML) programming allows visualization of luxuriant graphics such as roentgenographs, pathological specimens, CAT scans and similar graphic data (3).

At the current rate of knowledge accumulation in clinical medicine, outdated data becomes useless quickly. The multidisciplinary specialty of Critical Care Medicine depends on rapid access to highly technological information, and the Internet, with a few caveats, is ideal for individual critical care physicians to reap and maintain a stockpile of the latest educational information (23). Information access from the World Wide Web is exploding exponentially. Search engines have become so sensitive and specific that the most obscure requests produce volumes of multinational references (14). Interactive sites deal out information in an introspective fashion, making the user and the database a private, personal unit.

But nothing has reduced the furthest locale in the geographic world to a position only around the corner of the new global cyber-village than the advent of medical bulletin boards.

The progenitor of subscription services was the USENET (22).

Messages posted on these public bulletin boards could be read by anyone who happened to open up the archive via a universal application. USENET soon became so crowded, with so many interest groups that it became untenable due to sheer weight. In addition, the new-tradition of "flaming" allowed the most vocal and aggressive contributors to intimidate groups and viable information deteriorated to the supremacy of the most vocal and manipulative.

As a refinement of USENET, The advent of LISTSERV technology allowed users "closed" discussion groups serving only those whom the moderator of the LIST chose to serve, on the basis of subscription (18). Using a LIST Server, messages sent from one individual could simultaneously be sent only to other subscribers. Unwanted "browsers" could effectively be screened out, narrowing the spectrum of interest and protecting the voice of more timerous subscribers.

Critical Care Medicine and the Internet

Among the first LISTS were those related to the specialty of anesthesiology, since there was a high degree of computer literacy among their ranks (12). In August, 1994, CCM-L (Critical Care Medicine-LIST) the first medical bulletin board dedicated to the specialty of critical care medicine was founded (4). The first subscribers initially came from the existing multinational

anesthesiology LISTS and, as the popularity of the Internet exploded, health care providers discovered it first by word of print and then by search engines. The purpose of the Critical Care LIST was to provide a forum to discuss and maintain a data bank for the following subjects:

1) The holistic daily care of the patient as it uniquely pertains to the ICU setting including drug therapy and medical/nursing management.

2) The use and management of high technology life support systems

3) Determinations of resuscitation (code) status, and the realistic dealing with death and dying as it pertains to the ICU setting.

4) The management of scarce resources in the ICU setting, including the evaluation of problems associated with limitation, withholding and withdrawal of life support.

There are currently no major Internet sites comparable to CCM-L other than AIC-L (Anesthesia Intensive Care-LIST) in Australia (2) and PICU (Pediatric Intensive Care-LIST) (20). AIC-L leans more toward hard science linking anesthesiology and, critical care, high tech Internet conferencing productions and archiving of huge amounts of material. In contrast, CCM-L is more chatty and explores more of the social and philosophical aspects of medicine. AIC-L and CCM-L are not competitors. The Pediatric ICU group functions similarly to CCM-L except for pediatric patients exclusively. They are ships passing in the night, each with valuable resources for the mere asking.

At the time of this writing, a multinational contingent of about 1300 CCM-L subscribers including physicians, pharmacists, nurses, medical ethicists, researchers and other interested groups access a sophisticated mail server located at the University of Pittsburgh, Pennsylvania, USA. About half live and work outside the USA. The CCM-L WWW site (7) has logged over 20,000 access hits since Sept of 1996 (two years).

CCM-L offers the following educational services for medical subscribers:

1) 24 hour-a-day electronic mail services including resources for the CCM-L Consult Service. Health care providers wishing to access the experience of a multinational repository of expert clinicians, researchers and ancillary personnel can present case histories involving problems. The CCM-L moderator and others also frequently present a critical care case history designed to bring out discussion about topics of interest including medical ethics, socio-politics and patient care management. Meaningful responses are usually accessed in a matter of hours, sometimes minutes and are specific to immediate problems at hand. Case histories are altered to protect confidentiality.

In essence, CCM-L has maintained an "Exclusive Club" in the global village where expert clinicians can drop by, sit right down and join the conversation with no formal introduction. In that regard, CCM-L has benefited from a huge and diverse resource of experts who ordinarily would have little voice in the very entitled world of interest, sanctioning and lobbying organizations. The capability of transcending traditional ways of moving information and reacting quickly, across an incredibly diverse multi-national populous of experts is unique to CCM-L and it's vehicle, the Internet. As the nature of problems confronting medicine in general and critical care in particular evolve, so does the ability of the CCM-L Real-Time Consult and journal club service to adapt to it.

2) The CCM-L World Wide Web page services, including an archives of readily downloadable "Published and Unpublished Manuscripts of Interest" and archives of previous CCM-L Case Studies. Each of the critical care case studies previously discussed is archived, with comments of the major discussants. Authors of these manuscripts must hold copyright or agree to Internet visibility. Easily accessible links to other WWW and Internet sites of interest for clinicians are

also available. A click of the mouse will immediately transport the used to hundreds of medical information sites involving all the specialties, pharmacy, medical devices, and especially medical education.

Problems and Pitfalls of the Internet

A comical but fairly accurate definition of the Internet was recently given by Technopundit Jim Vandewalker (24): "The information Superhighway is a misnomer. Nothing could be further from the truth.

Suppose the highways were like the Internet. A highway hundreds of lanes wide, most with potholes. Some lanes would vote to demolish single occupant. Privately operated bridges and overpasses. Ad Hoc traffic laws. No Highway Patrol. Two hundred and thirty on ramps at every intersection.

No signs. Wanna get to Ensenada? Holler out the window for directions. As we rejoice over our new position in the shrinking global village and the monumental amounts of information available to us for the asking, we must be ever vigilant to keep the propriety of the Internet in perspective. Technically, the Internet is a global network of computer technology covers the globe. It is the most intellectual community ever devised by man; a worldwide collaboration of thought and resources (15). However, it is not without obstacle and challenge.

In order to explore the potential downside of the Internet, it is necessary to conjecture it's future. In as little time as three years ago, it required substantial technical acumen to even get into the Internet much less get anything useful out of it. But technology marches on, and TV cables loom on the future. When that happens, a traditional computer will not be necessary or even desirable for Internet access. It will then only be a matter of time before every hovel in the world will have a solitary TV tube, and EVERYONE has interactive access to each other just like Aldous Huxley predicted, and with also the same capability of someone shaping shaping society on the basis of spin (and monopoly of information).

A big value of the Internet is its ability to find, access and consolidate resources quickly and easily. But the ability of a populace to access information does not necessarily guarantee its accurate interpretation. Witness the literal explosion of information concerning (American) presidential indiscretions, which hit the Internet well before it hit the major newspapers and with an equal amount of spin but no authoritative commentaries from trusted and experienced journalists. Similarly, CCM-L produces a large amount of opinion and some or all of it may wash on the basis of spin doctoring rather than stark reality.

Opinions, in particular, tend to be accepted on the basis of eloquent presentation rather than the authority of the articulator compared to some absolute standard. And the Internet has created legions of seemingly authoritative voices with no track record. The sum total of this phenomenon forces the Information Age to progress so rapidly there is no time to even identify social problems resulting from it, much less solve them. Where all this is leading us is anyone's

guess. Is it possible that there is no stark reality in the universe that can be understood by anyone except after it's spun? The big question then becomes; who will do the spinning and for what purpose?

These issues will only clarify as the Internet evolves and we evolve with it. We can only stand back and watch where it takes us, without any real method of steering any of it. Part of the uniqueness and strength of the Internet in general and of CCM-L in particular has always been the ability to react quickly and seemingly effectively to change. As the nature of problems confronting medicine in general and critical care in particular evolve, so does the ability of CCM-L and the CCM-L Real-Time Consult Service to adapt to it.

Regulation and the Internet

From it's inception, the Internet has reflected a pioneer spirit with an anti-establishment coloration. These same free spirited features attract the twin headed debacle of censorship and regulation, casting a pall over the Internet's potential. The necessity for regulatory sanctions assume that perceived threats to society are real and require injunction, the threat can be regulated by legal means and that there are no other means to control the threat. The validity of these conditions have not, as yet, come to any convincing fruition. An exceedingly small part of the whole is evoted to anti-social activities. Any kind of pornography found on the Internet can also be found in most bookstores and videotape establishments, all legally. The small amounts of such behavior on the Internet pale in comparison to everyday unregulated activities in the rest of society. Those who have an interest in these things will always find them. Those who do not, will not be bothered by them.

In fact, the responsibility for limiting on-line enterprise should not rest with government regulatory agencies. Parents should take responsibility to insure that their children have a life beyond downloading pornographic photos. There are easy methods that families can use to limit access to potentially objectionable material for minors. Software dedicated to this purpose is appearing daily in the marketplace. Proprietary on-line access companies are more than happy to block out these sources on request. We believe that those who have an interest in regulating them should do so at the micro rather than the macro level.

There will always be a small amount of societal deviancy that cannot be controlled except ineffectually at a high administrative cost to taxpayers, for whom most are not affected. Any regulation calculated to stop communications objectionable to the few has an equally good chance of impinging on free expression of ideas, especially those some consider politically incorrect. We feel that the rights to free expression of ideas is one of the most important treasures in our society and we are willing to endure a small faction of deviancy in order to protect the whole.

In addition, the regulation of an entity that is difficult or impossible to uncover in space or time virtually guarantees the promotion of a spirit and incentive to beat regulators at their own game by creative deception. The relatively few sources of objectionable materials could easily "go underground", defying outside manipulation. In addition, Any regulation calculated to stop communications objectionable to the few has an equally good chance of impinging on free expression of ideas, especially those some consider politically incorrect. The rights to free expression of ideas is one of the most important treasures in our society and we are willing to endure a small faction of deviancy in order to protect the whole. Therefore, regulatory sanctions are probably unenforceable, and the administrative costs would be exorbitantly high and will have the potential to do far more harm to rights of free expression than it does to rectify an institution that cannot be accurately identified, much less effectively regulated.

Clinical Pathways and the Internet

Clinical pathways were devised to standardize treatment across many levels of care (8). All these paths encompass the same circuits that occur in the minds of knowledgeable, trained and experienced physicians. What is the need to formalize it in writing? The answer to this question is twofold:

1) To bring up the lower level of those who have the authority to make decisions but not the expertise. There is a natural distribution of physician expertise in real life. On one end there are those who practice brilliantly and on the other some who have less ability and training. Each has equal authority to make decisions in clinical medicine, and each is difficult to regulate. As a practical matter clinical pathways are a two edged sword. They exist to direct the least knowledgeable practitioner from making mistakes or diversions in care plan implementation but the resulting standardization of medical practice detracts from the care of those patients who are not algorithm-friendly.

Pathways by their nature work best when they are standardized, and so the resulting care becomes equally conformed to the standardization process. Standardization is the key. If the algorithms are subject to change at any iteration, their authenticity and authority suffers in proportion. The more they're tinkered with, the less effective they become. But to have a protocol that covers every possible deviation would be so complex as to be useless. Adjustment is necessary to make them adapt to changing conditions. Those same adjustments dilute protocols out to the point of subjectivity, whereupon they are neither authoritative or accurate.

2) A natural consequence of standardizing the practice of medicine is to facilitate conformity. When normally subjective decision making processes are standardized, the results are more predictable and uniform which pleases bureaucrats and regulators immensely. If an adverse event occurs in the course of treatment, and a physician tries to explain his or her decision process to lawyers or administrators, that approach can be made quite simple by referring to a standard clinical pathway. Conversely, if a physician chooses to depart from a protocol, for whatever reason, they do so at their peril if complications develop. Physicians will find themselves at great pressure to go with the established flow and the flow definitely weaves through the pastures of the establishment. The incentive is just to let the protocol dictate the course and follow an algorithm that covers "most" of the potential patient care situations. But in so doing, the care of outliers that don't fall well into the standard and may require individualized care may suffer.

But the fact is that once a knowledgeable physician enters the decision making process, there is little need of formalizing the decision making process by an objective protocol. It simply increases the propensity that gatekeepers can find more to standardize for the sake of conformity, not efficiency. In the near future, the Internet will allow and facilitate easy acquisition of useful data that will add to the decision making ability of knowledgeable physicians without locking them into rigid pathways.

Individual physicians will be able to tap into enormous multi-national databases containing outcome data for "what-if" questions in real time. A real patient's vital statistics and many other unique qualities concerning that individual would be entered and sample treatment choices queried. Many different parameters of variables could be tried. Placing or a pulmonary artery catheter or not? Changing doses of vasopressors? Optimum doses? Adding or taking away medications?

A push of the button would reveal a normal distribution curve on how 1,000,000 such patients fared in the short and long term. Physicians would have the benefit of evaluating hundreds of variables before implementing a care plan. In this way physicians could juggle the variables in their heads head rather than being forced to try them on a rigorously standardized protocol. It would be informative but not regimented. It would provoke thought but not action and would be outcome rather than procedure based. In addition, such databases would tend to bolster decisions to withhold and withdraw futile life support. If a query showed that any continuing invasive treatment under consideration kept 1,000,000 other similar patients in unresponsive on mechanical ventilation and dialysis for an average of 1.2 years then they died, this information would be useful for families to consider.

What is the future of the Internet and clinicians?

The real power of the Internet, especially for the solo critical care practitioner with little other real time contact with a pool of experts, is rapid accumulation of up to date data directly impacting the practice of medicine (11, 16). But in addition to making it powerful, it also must be made authoritative and that is the biggest single problem facing anyone managing an Internet service today (9).

Information comes and goes on the Internet and someone must be held accountable for expert moderation, lest dangerous practices be carried forth (10, 5). There are no clear answers in sight

presently and so Individual users must be ever vigilant, wandering about the void with the proverbial lantern looking for clues at the scene of the crime.

References:

1. America on line. "http://www.aol.com"

2. Anesthesia Intensive Care List. "aic-l@gasbone.herston.uq.edu.au"

3. BrighamRad: Radiology teaching homepage

"http://www.med.harvard.edu/BWH/BWHRad.html"

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7. CCM-L, the International Critical Care Discussion Group homepage

"http://ccm-l.med.edu"

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"http://ccm-l.med.edu/discussion1/Clinical/protocol.html"

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"http://www.bayanet.com/bioscience/geneinfo.htm"

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telemedicine using the Internet. J Telemed Telecare 1998;4(2):89-94

19. Paper Chase: a MEDLINE search engine

"http://enterprise.bih.harvard.edu/www2.htm"

20. PICU: the Pediatric ICU homepage Homepage "http://PedsCCM.wustl.edu/"

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information professionals: uses and users of MEDLIB-L. Bull Med Libr

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22. Seaboldt JA, Kuiper R: Comparison of information obtained from

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Syst Pharm 1997 Aug 1;54(15):1732-5

23. Society of Critical Care Medicine home page "http://www.sfhs.edu/sccm/"

24. Vandewalker, J. Personal communication.

25. The Virtual Hospital

"http://indy.radiology.uiowa.edu/VirtualHospital.html"

26. Wright, A.J. list of CCM Resources

"http://www.eur.nl/FGG/ANEST/wgt1_3.html"