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Notes

1. For an illustration of the role of health applications in motivating federal programs to develop national information infrastructure, see IITF (1994).

2. The Internet also has applications in support of clinical research (e.g., clinical trials), but these applications are not investigated in great detail in the report.

3. Others have also noted the importance of organizational and policy issues in influencing the rate of adoption of Internet technologies in health applications. For example, see Lindberg and Humphreys (1998).

4. For example, systems to transfer large medical image files between sites can be designed in different ways. Some systems demand high network bandwidth because there is little preprocessing of images and little attention to representative workflows; others rely more on preprocessing, which reduces network bandwidth requirements.

5. For a more detailed history of MEDLARS and MEDLINE, see Smith and Mehnert (1986).

6. These data are from the Bureau of Economic Analysis as presented in U.S. Department of Commerce (1999), the Appendix to Chapter III.

7. For an example of a Web site enabling communications with insurers, see AT&T (1999).

8. Managed care plans integrate insurance and delivery of care—functions otherwise provided by separate entities. Most managed care plans now pay care providers some form of discounted fee for services rendered, although some still pay a fixed fee based on the number of patients enrolled in their care.

9. Integrated delivery systems combine entities related to the provision of health care and may have relationships with health insurance plans. Such organizations typically include a range of different facilities, from major hospitals to local clinics, so they can provide a continuum of care.

10. For an example of Internet-based quality indicators and managed care data exchange, see Halamka and Hughes, 1998.

11. For example, researchers at Intermountain Health Care in Salt Lake City, Utah, have developed a system that provides clinical guidelines in real time to physicians who use the electronic medical record system. One study indicated that use of the system improved from 30 to 70 percent the percentage of diabetic patients with safe blood-sugar levels. It is estimated that the clinical guidelines have saved the organization $10 million, or $2,000 per patient, through improved clinical decision making (see Gillespie, 2000).

12. As noted by the Science Panel on Interactive Communications and Health (1999), self-care books provided to members of health maintenance organizations and Medicare beneficiaries have been shown to reduce office visits and specialty referrals (Vickery et al., 1988); systems to help patients prepare for office visits have been shown to improve treatment outcomes for chronic diseases (Greenfield et al., 1985); computer access to support groups and decision guidance has been shown to help women with breast cancer and patients with AIDS (Gufstafson et al., 1992, 1993, 1994); and shared decision-making tools have been shown to improve health outcomes while reducing the use of surgery and other high-cost medical procedures (Barry et al., 1995; Morgan et al., 1997).

13. These metrics are not independent of each other. For example, a high packet loss rate is likely to lead to low throughput because lost packets must be retransmitted, and the complete message cannot be reassembled until all packets are received.

14. Quality of service is distinct from reliability, which refers to the likelihood that a service remains available at all times. A network may be highly reliable in the sense that it is always possible to obtain connectivity to a given destination, but the same network may lack any assurance of performance (QOS, as defined here).

15. This level of isolation can be achieved even if there is some physical sharing at thecontinue



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