The unprecedented growth of the Internet presents a defining moment at the end of the millennium.[i] The information age, long predicted, seems at last to be upon us. Yet the speed of its arrival has left most of the medical profession ill prepared to participate in it and unable to foresee its consequences for clinical practice.
Through the Internet, the public has access to a growing supply of information on health and disease, often of variable quality and relevance.[ii] As a result, providing information on health will no longer be the exclusive remit of health care professionals. The quantity of information on the Internet will continue to grow over the next few years, as will the proportion of people with access to it. Access is already widespread in some populations. In 1994, 46% of patients in one Californian clinic had access to email, 89% of them through their place of work.[iii] In some areas, proportionately more patients than doctors will have access to the Internet.
Health care information on the Internet has potential major benefits for patients. Numerous electronic discussion groups already allow patients to share experiences and some health related Internet sites offer email advice on a fee for service basis. Other organisations, including the BMJ, provide free access to information.[iv] But despite the obvious benefits, the Internet presents many challenges, both to users and suppliers of the information (p 49).[v]
Firstly, the Internet is accessible from most parts of the globe, and access and dissemination is largely uncontrolled and uncontrollable. Even the proposed NHS network, with built in security measures to protect patient confidentiality, cannot be completely isolated from the outside world.[vi]
Secondly, the quality of information varies widely, from the most up to date practice guidelines produced by leading clinical bodies to out of date or inaccurate recommendations. In countries where patients can participate in the choice of treatment the Internet could potentially be a rich source of information on treatment options, but meeting patients' expectations and managing their requests presents an important challenge for providers of health care.
Thirdly, in countries in which health care is more centrally managed, widespread use of the Internet is likely to aggravate existing conflicts between patients' expectations and provision of health care. Patients will soon have access via the Internet to information on best practice from a variety of sources and will increasingly demand such information. But the. health service's resources are limited, and it must attempt to ration treatment.[vii] Treatments that have been shown to be the most cost effective for a particular disease in population terms may be favoured over treatments with greater efficacy. This could cause conflicts between the informed desire of patients to obtain the best treatment for themselves as individuals, and the system's ability to deliver. Will people who have an almost unlimited access to information but limited access to health care resources tolerate suboptimal care? The recent case of Jaymee Bowen ("child B") in Britain, in which a regional health authority refused to provide a second bone marrow transplant for a child with leukaemia, is a prime example of the type of conflict that could arise where there is a free market in information and a controlled market in health care.[viii]
Fourthly, doctors may be exposed to more frequent legal challenge. While patients may be motivated to seek out the most recent literature for their condition and can invest considerable effort in that search, most practising doctors cannot. The Bolam principle, established in 1957, protects a doctor against a claim of negligence if colleagues would have acted in the same manner.[ix] The Bolam principle was overturned by an Australian court last year, and the same may happen in Britain.[x] If the law were to judge a doctor negligent for failing to institute recognised best practice, the continuation of an informed patient population and an overworked clinical community provides a recipe for increasing litigation.[xi]
This problem has been recognised in the move towards evidence based medical practice! In providing information on which to base best practice, bodies like the Cochrane Collaboration[xii] have become pivotal, as has the development of clinical tools for rapid and accurate access to such information across the Internet. Pooled practice guidelines will be a resource not only for doctors but, in all probability, for patients as well. Faced with an enormous quantity of information of variable quality, and ill equipped to separate the wheat from the chaff, patients are likely to welcome access to guidelines that have been certified by recognised medical bodies.
This leads on to a final challenge posed to health care providers by the Internet: the mismatch in the speed with which new scientific results can be disseminated and the length of time required for careful peer review. Innovative approaches to scientific publishing may make it possible to use the Internet itself to redress this imbalance.[xiii] It should at least be possible to provide guidance for Internet users on the best available sources of health care material. The organising medical networked information (OMNI) initiative is an example of just such a service.[xiv] Sponsored by leading groups like Britain's National Institute for Medical Research, OMNI is attempting to provide a gateway to high quality biomedical information for the higher education and research communities. The speed with which the Internet can deliver information should thus not be seen as a liability. Indeed, it offers a solution to some of the increasingly complex communication issues facing the health care system. For example, the recent controversy over how the British government advised the public on the potential risks of some formulations of the oral contraceptive pill before informing many doctors could have been avoided. If clinicians had routine access to the Internet, they could rapidly receive the government's advice before it reached the media and the public.
It is clear that the changing nature of information delivery brings with it enormous implications for the delivery of health care.[xv] There is a pressing need for dialogue within the profession to understand the impact of communication and information technologies on the provision of health care. Some sections of the profession are already actively experimenting with the technology. However, the implications of the Internet extend far beyond the technology itself We should now, and with some haste, be examining its implications for the future of medical practice.
ENRICO COIERA ewc@hplb.hpl.hp.com Senior project managerHewlett-Packard Research Laboratories Stoke-Gifford Bristol BS12 6QZ
i. Coiera E. Medical informatics. BMJ 1995 ;310: 1381-7.
ii. Weale S.,Surfer, heal thyself Guardian 1995 Sept 20:13.
iii. Fridsma DB, Ford P, Altman R. A survey of patient access to electronic mail: attitudes, barriers and opportunities. Proceedings of the Symposium on Computer Applications in Medicine. Journal of the American Medical lnformatics Association (symposium supplement) 1994:15-9.
iv. Home page: http://www.bmj.com/bmj/
v. Sellu D. Clinical encounters in cyberspace. BMJ 1996;312:49.
vi. Anderson R. NHS-wide networking and patient confidentiality. BMJ 1995-311:5-6.
vii. Klein R.Priorities and rationing: pragmatism or principles? BMJ 1995;311:761-2.
viii. Ham C.Health care rationing. BMJ 1994;310:1483-4.
ix. Bolam v Friern Barnet HMC 19571 WRL 582.
x. Doctors m the dock. Economist 1995 Aug 19:23-4.
xi. Hurwitz B.Clinical guidelines and the law. BMJ 1995:311:2.
xii. Godlee F. The Cochrane Collaboration. BMJ 1994,309:969-70.
xiii. LaPorte RE, Marler E, Akazawa S, Sauer F, Gamboa C, Shenton C, et al. The death of biomedical journals. BMJ 1995;310:1387-9.
xiv. Home page:http://omni.nott.ac.uk
xv. LaPorte RE. Global public health and the information superhighway. BMJ 1994 1308: 1651-2 . see also Letters: Accessing the Internet is far from easy
Potential benefits for people with disability or phobias
Virtual reality is an interactive, computer generated environment that simulates the real world. Accessible via an interface that has been adapted to the human senses, it provokes in the user the sensation of immersion, like Alice in Wonderland crawling down the rabbit hole and finding herself in a new fantastic world.[i] A dataglove wired with fibreoptics to record the degree of bending of fingers and wrists, a head-mounted display, and an exoskeleton surrounding the user's limbs to give feedback, project the user into the virtual environment and report back on his or her actions within it. The user can react intuitively to the virtual world, any actions being detected by position and movement sensors placed strategically on his or her body. A computer calculates the changes occurring in the virtual world according to the rules chosen by its creator and feeds the results back to the user. applications appeal to disabled and non-disabled persons alike[ii]: telepresence, for example, allows specialists to operate on patients in remote hospitals. Three applications of immersive virtual reality in rehabilitation,[iii] two of them therapeutic, are discussed below:
Physically disabled students are often excluded from participating in laboratory experiments because of their reduced mobility and manual capabilities or the risk that they might lose control when in a hazardous environment. A virtual laboratory for disabled students has been studied.[iv] Because the interface has to meet the special needs of the user, the researchers selected a relatively homogenous population. The students all had spinal cord injuries ranging from C2 to T1 and were of at least average intelligence and emotional stability. The objects in the virtual laboratory included a representation of a traditional laboratory, with symbols representing information and illustrating principles of physics, and a virtual vehicle that allows users to experience the physical phenomena under investigation, such as the acceleration created by a force. The students encountered few problems acting within the virtual world, but some were not able to put on the equipment independently or adjust it over time to avoid painful pressure points.
Acrophobia or fear of heights is another condition in which virtual reality may have a role. Rothbaum et al[v] performed a controlled trial of graded exposure to heights using virtual reality. Sufferers were randomly assigned either to treatment or to a waiting list. The treatment group had seven weekly 35-45 minute sessions on virtual balconies, high bridges, or in the glass elevator of a skyscraper. A therapist watched and commented on the exposure, during which the patient's subjective discomfort was monitored. Before and after treatment, anxiety, avoidance, distress, and attitudes were measured using standard questionnaires. The results were comparable to those of standard therapy with stepwise exposure to real, frightening but sustainable stimuli. However, there was no comparison group on conventional treatment, no follow up data, and the numbers were small. Also the subjects were volunteers, rather than people actively seeking treatment.
The third application is akinesia or freezing gait in Parkinson's disease. This debilitating symptom is characterised by progressive shortening of the patient's stride and ultimately the inability to move forward at all. Treatment with drugs is marred by on-off effects and side effects such as dyskinesia. However, patients with akinesia can walk over objects or through doorways with little effort, an effect known as kinesia paradoxa. Using a virtual reality technique called augmented reality, Weghorst et al projected virtual objects on to the patients' physical world to give them the impression that they were walking over or through them, thereby restoring their mobility.[vi] They suggested various approaches to mimic steady objects on the ground while the patient is moving. However, existing visual displays are not bright enough to compete with ambient light, while severe akinesia demands the creation of a highly realistic and static representation of the obstacle. Dyskinesia, too, was found to respond to augmented reality, suggesting a more complex mechanism underlying kinesia paradoxa.
Using virtual reality techniques in rehabilitation raises ethical considerations, especially when mentally challenged or very young people are involved.[vii] (In the examples given above, all the patients gave informed consent.) In addition, virtual reality could have undesirable side effects due to equipment failure, fatigue, or motion sickness.[viii,ix] It could also cause unintended changes in the patient's attitude and behaviour, worsen existing difficulty in distinguishing between reality and delusion (for example in patients with schizophrenia), or cause distress from the virtual experiences themselves.
The applications described above. exemplify how virtual reality can help even severely disabled people to participate and contribute safely even in hazardous and complex tasks. The new technology can provide corrective experiences that can ameliorate attitudes and anxieties. It could also yield new insights into disease mechanisms while providing ingenious and effective tools to re-enable handicapped people. Many more examples could be cited,[i-iv,vi] some of which will be presented at a conference on medicine and virtual reality in San Diego later this month. To reduce the cost, the optical resolution and complexity of the environment can be kept low in most rehabilitation applications. The new technology offers great potential benefit in rehabilitation but remains to be properly explored and evaluated.
MICHAEL HENNING ANDREAE Research studentBagrit Centre for Biological and Medical Systems Imperial College of Science, Technology and Medicine London SW7 2BX
i. Pimentel K Virtual reality through the new looking glass 2nd rev ed. New York: McGrawHill, 1995.
ii. Loeffler C, ed. Virtual reality casebook New York: Van Nostrand, 1994.
iii. Greenleaf WJ, Tovar MA. Augmenting reality in rehabilitation medicine. Artificial Intelligence in Medicine 1994;6:289-99.
iv. Nemire K, Burke A, Jacoby R Human factors engineering of a virtual laboratory for students with disabilities. Presence 1994;3:216-26.
v. Rothbaum B, Hodges LF, Kooper R, Opdyke D, Williford JS. Effectiveness of computer-generated (virtual reality) graded exposure in the treatment of acrophobia. Am J Psychiatry 1995; 152: 626-8 .
vi. Weghorst SW, Prothero J, Furness T, Anson D, Riess T Virtual images in the treatment of Parkinson's disease akinesia. In: Morgan K, Satava RM, Sieburg HB, Matheus R, Christensens JP,eds. Medicine meets virtual reality II 1995;30:242-3.
vii. Being and believing: ethics of virtual reality [editorial]. Lancet 1991;338:283-4. viii. Mon-Williams M, Wann JP, Rushton S. Binocular vision in a virtual world: visual deficits following the wearing of a head-mounted display. Ophthalmic Physiol Opt 1993;13:387-91.
ix. Regan EC, Price KR. The frequency of occurrence and severity of side-effects of immersion virtual reality. Aviation, Space, and Environmental Medicine 1994;65:527-30.