The Internet in Gynaecology and Obstetrics

The Internet is a system for connecting computers as tools for communication. It enables us to send images, sound and data to selected individual or multiple (group) delivery points. With the addition of the World Wide Web (WWW), we can transmit graphic information with an interactive user interface. It is hard to believe that only 6 years ago the WWW did not exist. Before the principles of the WWW were invented, many medical professionals around the world had already begun communicating via email and list servers or discussion groups. For obstetricians and gynaecologists the earliest discussion list was OBGYN-L, established in 1994 by Dr. Geffrey H. Klein.

A brief history
A primitive form of the Internet was first described in 1961–1962 at the Massachusetts Institute of Technology by L. Kleinrock and J.C.R. Licklider [1]. By the end of 1969, four computers were connected into the first form of the Internet called ARPA-NET (Advanced Research Projects Agency net). In the early 1970s the TCP/IP protocol was in place. Its purpose was primarily to support military communications. This meant that what would eventually become the Internet would need to be relatively failsafe. The system was designed to stand on its own: if a packet of information did not make it to its destination then it would automatically be re-sent, gateways and routers operated independently and automatically, and there was no global control at the operations level. This was an automatic operating system that could repeat sending messages by any route available, even if large segments of the system were destroyed in (nuclear) warfare. It is this design that makes it so difficult for any one group or government to control the Internet. The first users of this communications system were the military and selected university researchers.

Other networks grew before the ARPA-NET was open to the public. Among these were Usenet, BITNET, CSNET EDUCOM, BBSs (Bulletin Board Systems), Fidonet and a host of others. The WWW gave a boom to the use of the Internet, which rapidly took over communications throughout the world. This new paradigm of communications allows the user to follow a thread of thought around the world and back. Each webpage contains ‘links’ to other pages on other computers. By simply clicking on the link, the PC connection is transferred to the new location, which may be on the other side of the world. This is indeed remarkable. All of these sites exist on a ‘server computer’ at a university, government office or other institution supporting that little part of the Net. The server computers are linked to the Internet by telephone line links to satellites. Some servers require users to pay a fee and obtain a password to log on, but the vast majority, hundreds of thousands in fact, are free.

Internet requirements
In order to search the Web, one needs hardware, software and an Internet ramp or Internet service provider. Most people today are familiar with the hardware and software. The minimum hardware is a PC or an Apple Mac, the faster the better, as well as the connection. The monitor, printer and the type of hard disk required cannot be properly covered within the confines of this introduction. Software for the Internet is made up of communication software and Web browsers. Browsers are software programs used to crawl, surf or move around the Web. They are HTML interpreters. The browser loads the HTML language and turns it into text and graphics on the computer screen. Mosaic was the first, but Netscape and Microsoft Explorer have taken over and are in common use today.

Internet providers
There are a great number of providers to choose from today. Most provide a variety of services at a range of prices. Rates may be as low as e 0.50 per hour as long as you are online, or e 16.00 per month with unlimited access time, more or less depending on the services provided. Many providers even deliver their services free of charge, but in doing so they expect you to see the advertisements that supply their source of income. The choice of provider may depend on how you want to use the Internet. If you want to use email only, you need fewer services than if you want to have a personal webpage. In the latter case be sure to find out whether you will get any server disk memory space (you will need about 5 MB), whether the provider has a help desk, and which other services are provided. A basic package would include email, web access and memory for a webpage, news groups and Telnet access.

Confidentiality/security
Not all Internet sites are sufficiently secure for financial transactions. Nevertheless, credit card transactions have become increasingly common. Another, possibly more important security issue concerns personal privacy. After you have been on the Web for a while, do a search on your default drive for a file named ‘cookies.txt’. These are crumbs of information that websites place on your computer. They gather information about some of your Internet activities. Supposedly the information can be used for marketing. There have been demands for legislation that users must be notified when a website places something on their computer or gathers information without their knowledge or permission. We should pay attention to these issues. While they seem relatively unimportant now, they could become important in the future if the system is abused.

Consumers/patients and the WWW
As soon as the WWW becomes used for medical purposes (answering questions, giving a second opinion, drug prescriptions), quite another aspect of privacy must be considered. This is a problem that will be solved within a few years, but which nevertheless poses a problem today. This is one of the major barriers to why electronic patient records/electronic health records are not yet fully operational. In spite of this, more and more patients/consumers are searching the Web for health care information. In December 1999 the number of women on the Web surpassed that of men. It is well known that for women, information about their health (and the health of their children) is a major topic of interest, which is why websites about women’s health are very popular.
In the very interesting Dutch report ‘Patient and Internet’ [2] it is suggested that within a few years doctors will use a website to communicate with their patients as a substitute for the telephone. This so-called asynchronous communication has many advantages and can be very economical.

Evidence-based medicine
Professionals in obstetrics and gynaecology mainly use the Web for scientific activities. In a survey we carried out among medical specialists (Ob/Gyn) (Figure 1), number one on the list of things they would like was evidence-based medicine. The extensive and readily accessible databases make it very easy to search for recent scientific literature, for example in Medline or in the Cochrane database.

Figure 1: Online services most important to medical professionals

The Internet is gradually taking over the role that paper publications have played and still play in peer-reviewed information. The speed of the Internet can enable publication some 6 months earlier than in a paper journal. In addition it provides unlimited space, is less expensive (e.g. for colour illustrations) and is interactive in that letters to the editor can be shown linked directly to the article. It can also be searched easily. It comes as no surprise that publishers of large websites are increasingly tending to create an environment for evidence-based medicine, clinical trials and other peer-reviewed information.

Acknowledgement
I am very much indebted to Terry DuBose for his contribution to the history of the Net.

References:

References

1. Leiner BM, Cerf VG, Clark DD, et al. A brief history of the Internet. http://www.isoc.org/internet-history/

2. Raad voor de volksgezondheid en zorg. Patient and Internet. March 2000. http://www.rvz.net/internet/engels.htm

*Re-published on OBGYN.net with permission from MFI