Editorials

The Internet's challenge to health care provision

The unprecedented growth of the Internet presents a defining moment at the end of the millennium.¹ 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.² 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.³ 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.⁴ But despite the obvious benefits, the Internet presents many challenges, both to users and suppliers of the information (p 49).⁵

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.⁶

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of information varies widely, from the most up to date practice guidelines produced by leading clinical bodies to out of date or inaccurate recommendations.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.⁷ 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.⁸

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.⁹ The Bolam principle was overturned by an Australian court last year, and the same may happen in Britain.¹⁰ 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.¹¹

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 Collaboration¹² 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 equiped 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.¹³ 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.¹⁴ 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.¹⁵ 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.

ewc@hplb.hpl.hp.com Senior project manager Hewlett-Packard Research Laboratories, Stoke-Gifford, Bristol BS12 6QZ

Enrico Coiera 

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