Some Internet & Some Internet & Healthcare ChallengesHealthcare Challenges

An introductionAn introduction

Dr Daniel DÉSIRDr Daniel DÉSIRGeneral SecretaryGeneral Secretary

Belgian Hospital AssociationBelgian Hospital Association

History of Internet (1)History of Internet (1)

19621962 - Advanced Research Project Agency (ARPA) builds a small network - Advanced Research Project Agency (ARPA) builds a small network (ARPANET)(ARPANET) to promote the sharing of super-computers amongst US to promote the sharing of super-computers amongst US researchers. researchers.

19691969 - ARPANET connects 4 universities : - ARPANET connects 4 universities : Stanford, UCLA, UC Santa Barbara, and U of UtahStanford, UCLA, UC Santa Barbara, and U of Utah

19701970 - E mail most popular application of ARPANET - E mail most popular application of ARPANET

19731973 - ARPANET goes - ARPANET goes international international (London and Norway)(London and Norway)

19821982 - The term - The term 'Internet''Internet' used for the first time. used for the first time.

19821982 - TCP/IP, common language of Internet computers - TCP/IP, common language of Internet computers

19851985 - E-mail part of life at many universities - E-mail part of life at many universities

19881988 - "Internet Worm" temporarily disables 6,000 of the 60,000 Internet - "Internet Worm" temporarily disables 6,000 of the 60,000 Internet hosts.hosts.

History of Internet (2)History of Internet (2)

19911991 – Birth of the World Wide Web – Birth of the World Wide Web

19911991 - Tim Berners-Lee (CERN) : - Tim Berners-Lee (CERN) :

hypertext markup languagehypertext markup language (html) (html)

19921992 - More than 1,000,000 hosts are part of the Internet. - More than 1,000,000 hosts are part of the Internet.

19941994 – – Netscape CorpNetscape Corp. Pizza Hut accepts Net orders. . Pizza Hut accepts Net orders.

19961996 - Nearly 10 million hosts online. - Nearly 10 million hosts online.

20002000 - 6 billions of electronic messages yearly - 6 billions of electronic messages yearly

20012001 - 111 millions hosts and 1 billion pages available. - 111 millions hosts and 1 billion pages available.

Internet users (2001)Internet users (2001)

North America 193 (50 %)

Europe 88 (23 %)

Asia 69 (18 %)

Oceania 17 (4 %)

South America 17 (4 %)

Africa 3 (0,7 %)

Total 387 (100 %)

(millions of users)(millions of users)

« Fairy tales » billionnairs« Fairy tales » billionnairs

Yahoo ! (Stanford - 1995) :Yahoo ! (Stanford - 1995) :Yet Another Hierarchical Officious Oracle !

– 1 million USD became once 10 billions USD

– 100 billions USD billions USD max market capitalization (2000)

– 8 billions USD today

– Revenues 2000 : 1,11 billions USD billions USD

– Net income 2000 : 70 millions USD70 millions USD

– 120 millionsmillions users monthly worldwide

Yahoo ! QuotationsYahoo ! QuotationsNASDAQNASDAQ (1996-2001) (1996-2001)

WWW in the year 2000 :WWW in the year 2000 :English language English language

imperialism is vanishingimperialism is vanishing

327 millions users with :327 millions users with :

– 160 millions English users (49 %)160 millions English users (49 %)

– 167 millions non English users (51 %)167 millions non English users (51 %)

Diabetes mellitus on the Web Diabetes mellitus on the Web (n pages - july 2000)(n pages - july 2000)

Altavista NorthernLight Fast

Diabetes 874 000 868 000 716 000

Diabète 16 000 13 000 15 000

Suikerziekte 4 500 1 700 1 700

Internet & HealthcareInternet & Healthcare

• About 100 000 medical and health sitesAbout 100 000 medical and health sites

• 40 millions visitors each year40 millions visitors each year

• several thousands of focused associationsseveral thousands of focused associations

• 11stst reason to surf (more than stock exchange reason to surf (more than stock exchange entertainment or weather forecast)entertainment or weather forecast)

• « the good, the bad and the ugly » :« the good, the bad and the ugly » :– free & validated scientific information free & validated scientific information – no quality label(s)no quality label(s)– unregulated quackeryunregulated quackery

Internet & HealthcareInternet & Healthcare

• NorthernLightNorthernLight• AltavistaAltavista• MetacrawlerMetacrawler• Fast Fast (alltheweb.com)(alltheweb.com) • GoogleGoogle

• YahooYahoo• LycosLycos• MedHuntMedHunt

Some (meta) search engines :Some (meta) search engines :

Références : http://hopitalerasme.org/

Internet & HealthcareInternet & Healthcare

Some Web sites on general topics :Some Web sites on general topics :• PubMed (NIH - Bethesda)PubMed (NIH - Bethesda)

• British Medical JournalBritish Medical Journal

• New England Journal of MedicineNew England Journal of Medicine

• Health On the Net Foundation (Genève)Health On the Net Foundation (Genève)

• MedscapeMedscape

• Agency for Healthcare Policy and Research (USA)Agency for Healthcare Policy and Research (USA)

• Centers for Diseases Control and Prevention (USA)Centers for Diseases Control and Prevention (USA)

• World Health OrganizationWorld Health Organization

• Ministries of Health (France, UK, Canada)Ministries of Health (France, UK, Canada)

• CHU de ROUEN (French)CHU de ROUEN (French)

Healthcare :Healthcare :

Who is Who is surfing ?surfing ?

Healthcare :Healthcare :

What areWhat arelay surferslay surferslooking for ?looking for ?

Internet & HealthcareInternet & Healthcare

Main characteristics :Main characteristics :

• dominating consensus to avoid any kind of dominating consensus to avoid any kind of regulationregulation

• no meta-editor, no control of contentno meta-editor, no control of content• no authority, no peer reviewno authority, no peer review• health = youth, beauty, fitnesshealth = youth, beauty, fitness• priority : trade (and not public health)priority : trade (and not public health)• ubiquitous US imperialismubiquitous US imperialism

(hardware, software, routers, browsers, search (hardware, software, routers, browsers, search engines, data banks, ...)engines, data banks, ...)

Internet, Health and TradeInternet, Health and Trade

To sell :To sell :

• « Beauty - Body -Fitness » products« Beauty - Body -Fitness » products• diets and vitaminsdiets and vitamins• prescription drugsprescription drugs• insuranceinsurance• books on « health » and « medicine »books on « health » and « medicine »• travels and congressestravels and congresses

Patients & InternetPatients & Internet

• distance between North-American and European realities

• agreement to avoid anonymous encounters (patients-providers) and overflow (flood)

• skills, open mind, education, equipment and availability of physicians ?

• Is it ethically mandatory to answer to electronic requests of your own patients ?

Notification about early-release articlesNotification about early-release articles

New England of Medicine :New England of Medicine :

• frequent early-release papers since 1999frequent early-release papers since 1999• > 70 000 members of the E mailing list> 70 000 members of the E mailing list• > 50 000 subscribers for the E Journal> 50 000 subscribers for the E Journal• 125 000 visitors of the Web site each week125 000 visitors of the Web site each week

Campion EW, NEJM 341 : 2085, 1999Campion EW, NEJM 341 : 2085, 1999

Quality of health and medical Quality of health and medical information on the Web ?information on the Web ?

Criteria ?Criteria ?

Actors ?Actors ?

Tools ?Tools ?

Internet e-Health Internet e-Health ethical guidelinesethical guidelines

• Candor - Honesty

• Quality - Professionalism

• Privacy - Informed consent

• Responsible partnering

• Accountability

• Disclosure of authorship / interests

Internet : Credibility of sources ?Internet : Credibility of sources ?

++• universities

• reknowned scientific journals

• hospitals

• public agencies

• groups of experts

• thematic organisations

-• individual practicionners

• individual experts

• leagues of consumers

• associations of patients

• sponsored associations

• commercial and advertising Web sites

Credibility = « capacity to inspire a belief »Credible = « providing acceptable grounds to be believed »

Quackery sites on the WebQuackery sites on the Web

General Characteristics :

Any site used to market herbs or dietary supplements, typically including :

(a) lack of full disclosure of relevant facts,

(b) promotion or sale of products that lack a rational use, and/or

(c) failure to provide advice indicating who should not use the products.

Any site used to market or promote homeopathic products. No such products have been proven effective.

Any site that generally promotes "alternative" methods.There are more than a thousand worthless "alternative" methods.

Any site that promotes "nontoxic," "natural," "holistic," or "miraculous" treatments.

Source : http://www.quackwatch.com/

Quackery on the WebQuackery on the Web

Common false statements about nutrition :Common false statements about nutrition :

• Everyone should take vitamins

• Vitamins are effective against stress.

• Taking vitamins makes people more energetic.

• Losing weight is easy.

• Special diets can cure cancer.

Source : http://www.quackwatch.com/

Quackery on the WebQuackery on the Web

Other widespread false statements :Other widespread false statements :

• fluoride supplements are dangerousfluoride supplements are dangerous

• immunizations are dangerousimmunizations are dangerous

• Mercury-amalgam filings make people sickMercury-amalgam filings make people sickSource : http://www.quackwatch.com/

Usefulness of Usefulness of a hospital Web site ?a hospital Web site ?

• passive information - business card

<http://www.hospitals.be/>

• active information retrieval

• active interaction (data, parameters, protocols, appointments, consultations et al.)

Review by Price-WaterhouseReview by Price-Waterhouse(march 2000)(march 2000)

8585 Belgian hospitals (Flanders and Brussels) :

• 3333 sites Web sites (39 %)

• providing general information (42 %), illustrated by pictures and photos (33 %)

• Less than 25 % of sites regularly updated (several not updated since july 1998)

Internet in Belgium ?Internet in Belgium ?

For surfers / patients / lay people :For surfers / patients / lay people :

• cost of telecommunications (telephone to cable)• distrust in electronic shopping, banking, ...• slow and obsolete equipments• few providers of information in a small local market• cultural and socio-economic gaps ?• Training ? Poorly available

Internet : slow pace in Belgium ?Internet : slow pace in Belgium ?

In Belgian hospitals :In Belgian hospitals :

• IT priority to Y2K and « Euro » challenges• Web « communication » is not a priority• willingness to discard advertisement practices• distrust with regard to e-insecurity• fear of « me-too » and fashion effects• « a lipstick on a bulldog face ? »• cultural obstacles ? (« a tool for teenagers »)• confusion ? IT / communication

Web Site of Hôpital Érasme Web Site of Hôpital Érasme (Brussels)(Brussels)

http://intranet/http://intranet/

http://hopitalerasme.org/http://hopitalerasme.org/

http://www.ulb.ac.be/erasme/http://www.ulb.ac.be/erasme/

3 500 pages - 1 full-time operator3 500 pages - 1 full-time operator

Editorial board - 10 membersEditorial board - 10 members

Web site Erasme : Web site Erasme : 1999 / 20001999 / 2000

n visitors / month : n visitors / month : 853 to 3 755853 to 3 755

n countries visitors : n countries visitors : 27 to 5127 to 51

% visitors (erasmians) : % visitors (erasmians) : 66 to 36 %66 to 36 %

% visitors (Belgians) : % visitors (Belgians) : 89 to 66 %89 to 66 %

E mail - IntranetE mail - Intranet

1 400 connected PC (Intranet) :1 400 connected PC (Intranet) :

• Professional use ?Professional use ?

• Who is actually reading the messages ?Who is actually reading the messages ?

• Who is really mastering the tools ?Who is really mastering the tools ?

• Who is abusing ? What kind of abuse ?Who is abusing ? What kind of abuse ?

• Are there « Webholics - On-lineholics » ?Are there « Webholics - On-lineholics » ?

Electronic mailElectronic mailFour principles : 4 "D"sFour principles : 4 "D"s

• DumpDump

• DelegateDelegate

• Do Do

• DelayDelay

Electronic mailElectronic mail

• No naive trust in self-learning capabilitiesNo naive trust in self-learning capabilities• intensely - but roughly - used tool intensely - but roughly - used tool

(attached files, links, html ?)(attached files, links, html ?)• under-utilized equipmentunder-utilized equipment• mail not read (> 50 % ?)mail not read (> 50 % ?)• exasperating spamexasperating spam• ubiquitous need of training, help desk and ubiquitous need of training, help desk and

maintenance teamsmaintenance teams• vulnerability in front of budget cutsvulnerability in front of budget cuts

Visions of the future ...Visions of the future ...

• "I think there is a world market for may be five "I think there is a world market for may be five computers."computers."

Thomas Watson, chairman of IBM, 1943Thomas Watson, chairman of IBM, 1943

• "There is no reason anyone would want a "There is no reason anyone would want a computer in their home."computer in their home."

Ken Olson, founder of Digital Equipment Corp.,1977

• "640K ought to be enough for anybody.""640K ought to be enough for anybody."

Bill Gates, Microsoft, 1981

Experts ?Experts ?

Not all predictions of experts are true !Not all predictions of experts are true !

Not all predictions of expertsNot all predictions of experts

that are truethat are true

will impact you !will impact you !