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exclusion of the others. Trade-offs are often made between the capabilities embedded in different levels of the system,4 and networking can make issues associated with other levels more important. Security, for example, takes on wholly new dimensions in a networked environment in which information can be readily transferred among entities and stored in computers that are attached to a public network. Yet, many of the mechanisms for addressing security concerns will be implemented not in the network itself but in the devices or computers attached to the network. An individual's access to health information in such an environment, and the circumstances under which such access is allowed, will be determined by a confluence of organizational and national policies for protecting health information.

The strong interrelationships between the network, other technology, and organizational and national policy introduce great uncertainties into the evolutionary path of the Internet with respect to health applications. For example, although many would agree that the Internet will enhance the role of the consumer in health care, the future of specific applications, such as remote medical consultations or online access to patients' medical records, is more difficult to discern because of the range of technical, organizational, and policy issues to be resolved (as detailed in later chapters of this report). Further research and experimentation are needed to understand these issues more fully and develop workable solutions. Consistent with the charge to the committee, this report does not attempt to resolve these policy issues, but by highlighting their significance in enabling effective and safe applications of the Internet for health care it may hasten their resolution. In the end, the report recommends ways of helping the Internet better serve a range of health interests. It identifies both long-term needs that will require R&D and steps that must quickly be taken to help people and organizations adopt and adapt to the next generation of Internet technologies. This chapter provides a broad overview of past and present uses of the Internet in health care; technical terms and considerations; and current R&D efforts that may advance the applications of the Internet and so improve health care.

A Systems Perspective

An example may help to demonstrate both the potential value of the Internet in health care and the close linkages between networking technology, other information technology, and nontechnical issues. Consider the following hypothetical scenario:

Alice and Bob are recovering from a particularly virulent flu that kept them both out of work for the past week. They awakencontinue

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