Networking Health Prescriptions for the Internet (2000) / Chapter Skim
Currently Skimming:
2. Health Applications of the Internet
2. Health Applications of the Internet
Pages 57-131
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From page 57... ...
By supporting financial and administrative transactions, public health surveillance, professional education, and biomedical research, the Internet can streamline the administrative overhead associated with health care, improve the health of the nation's population, better train health care providers, and lead to new insights into the nature of disease. The capability of the Internet to support these applications depends on whether the relevant technical needs are met and whether the operational aspects of the systems involved are understood and manageable.
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From page 58... ...
The confluence of so many factors confounds attempts to predict viable future applications of the Internet in the health sector. This chapter presents a broad overview of the types of applications that the Internet can support in consumer health, clinical care, financial and administrative transactions, public health, health professional education, and biomedical research.
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From page 59... ...
Consumer health initiatives that rely on the Internet reflect, and could even drive, significant changes in the structure of the health care industry. Concurrent with changes in the economics of the health care delivery system, the duration of a medical consultation is steadily declining, and the availability of practitioners for substantive discussions between visits is decreasing.
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From page 60... ...
For a fee, consumers can pose questions for a physician. Offers original, peer-reviewed reports and journal articles organized by specialty and intended for both health professionals and consumers.
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From page 61... ...
However, consumer health Web sites may drive the need for improved privacy-enhancing technologies. The information sought by consumers on the Internet, and the purchases they make, can reveal much about personal health concerns and problems.
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From page 62... ...
Other efforts focus on systems for classifying health Web sites according to metrics such as accuracy, timeliness, completeness, and clarity.2 With these evaluations, standard search engines could provide consumers with a measure of trust in the information they are retrieving at least to the degree that they trust the organization performing the content labeling. The World Wide Web Consortium, for example, has created a system called the Platform for Internet Content Selection (PICS)
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From page 63... ...
To avoid the risk of having messages discoverable at a place of work or other sensitive locations, individuals can store their e-mail files on the server of a trusted third party and/or encrypt messages for storage, but rules regarding disclosure still need to be developed. Health care organizations are also concerned that e-mail might overload care providers with yet another task in the context of increased clinical and administrative burdens.
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From page 64... ...
Consumers can use these records to help monitor and evaluate their health status, and they can grant access, if they wish, to different providers for purposes of care. Many sites provide some sort of override feature that enables care providers to gain access to a patient's records in an emergency situation something that is much more difficult to do if the records are not stored online.5 Like e-mail used for clinical purposes, Web-based medical records require considerable attention to security to minimize the risks of inappropriate disclosure.
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From page 65... ...
At present, most online medical records consist primarily of text and demand little bandwidth for fairly rapid downloading. If such records begin to include medical images (e.g., X rays, computed tomography (CT)
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From page 66... ...
deployed in the home. The goals of such activities are to assist in the early detection of potential health problems, ranging from heart attacks to congestive heart failure and diabetes, and to reduce the need for clinical intervention and costly hospital stays.7 Remote consultations to the home may be most useful for monitoring patients with ailments such as congestive heart failure and end-stage liver disease.
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From page 67... ...
The installations, connectivity, and subsequent support costs have accounted for a large portion of the cost of the monitoring efforts. Bandwidth is a more significant issue for provider organizations, which will need to ensure that their facilities can handle the aggregate load of monitoring numerous devices (e.g., if hundreds of thousands of patients with congestive heart failure are monitored at home)
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From page 68... ...
Even modest monitoring efforts will not be effective unless mechanisms are deployed to enable care providers to review the monitored data, identify worrisome outliers, and respond in a timely way. The need for oversight of such large numbers of patients at home could result in the emergence of a new category of ancillary health professionals.
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From page 69... ...
Access to patient health records could demand somewhat greater bandwidth than is typically available today or significantly greater if records include enhanced content, such as medical images or videotapes of telemedicine consultations. Latency ~ In general, applications that support consumer health do not require the instantaneous delivery of information, so the latency requirements of
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From page 70... ...
Policies will be needed to determine who can have access to consumer health information and under what conditions. Security requirements will grow as consumers use the Internet to store, retrieve, and update their personal health records.
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From page 71... ...
Ubiquity +~+ Key to the success of consumer health applications is widespread access to the Internet. As noted above, many consumer applications currently demand only moderate bandwidth and latency, meaning that standard modem access to the Internet, at 28.8 to 56 kilobits per second (kbps)
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From page 72... ...
Even where clinical expertise is available, but inconvenient for either the patient or the provider, remote medical consultations may be a cost-effective alternative to staffing multiple clinics with subspecialists. Remote consultations may also be useful to specialized service organizations that attempt to establish economies of scale for particular types of clinical service, such as the interpretation of radiological images (e.g., CT and magnetic resonance images)
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From page 73... ...
For remote analysis of a TABLE 2.3 Nominal Bandwidth Requirements for Different Telemedicine Applications Type of Telemedicine Needed Bandwidtha Examples High resolution, Store-and-forward Radiology, dermatology, pathology no motion Medium resolution, 128 kbps Stethoscope, visual exams, psychiatric low motion consultations, gastroenterology Medium resolution, 384 kbps Cardiology, neurology, and high motion emergency room consultations High resolution, 768 kbps Cineo-angiography and high motion echocardiograms Very high resolution, Up to 2.5 Mbps Gait analysis high motion akbps, kilobits per second; Mbps, megabits per second. SOURCE: David Batch, East Carolina University, personal communication, February 2, 1999.
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From page 74... ...
The ECU program and other experimental programs, such as the National Laboratory for the Study of Rural Telemedicine at the University of Iowa, also make use of statewide fiber-optic networks for connectivity between some sites.~3 Although costly, dedicated lines have been viewed as the most effective means of guaranteeing access to adequate bandwidth as needed. The Internet does not yet offer the quality of service needed for real-time video consultations.
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From page 75... ...
The most likely users of remote medical consultations would be primary care providers and patients living in rural or remote areas, many of whom have limited access to high-bandwidth Internet connections (see Chapter 3~. The future of remote consultations will be influenced by a number of factors beyond network technology.
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From page 76... ...
Profitability is currently constrained by the fact that many health plans, including Medicare, do not yet routinely pay for remote consultations, although experiments are under way to examine alternative repayment schemes (see Chapter 5~. Other issues, such as state-based licensure of health professionals, impede attempts to deliver remote consultations across state lines.
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From page 77... ...
The size of these studies is expected to grow as imaging technology advances; image resolution is expected to improve by a factor of 10 or more in cases such as cineo-angiography. As of early 1999 researchers at UCSF were working with digitized cineoangiograms that were 60 MB in size and with intravascular ultrasound images that were 50 MB.~4 High-resolution electron microscopes can produce individual images that are 2 MB in size, but such instruments are available only at a small number of research centers.~5 TABLE 2.4 Nominal File Sizes of Common Medical Images Images Size of One Exam Image Type Image Size (bits)
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From page 78... ...
This admittedly high-end application is within the average performance capabilities of the Internet backbones but not of all Internet service providers. A desire for faster turnaround in the interpretation of medical images could increase demands on networking resources, even if the volume of examinations transferred across the network is small.
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From page 79... ...
In some imaging applications, high-speed networks become less important if the data can be intelligently processed prior to transmission. For example, during the development of PACS for integrated health care delivery systems, users often specify that several care providers need to be able to simultaneously access uncompressed medical images from any location in the system within 2 seconds.
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From page 80... ...
Some health care organizations use a Web-based infrastructure for reporting laboratory results within an institution, but few integrate the laboratory data into the clini
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From page 81... ...
across the Internet, there is a significant opportunity to detect and prevent such errors.~7 Use of the Internet for transferring medical records would enable care providers to better treat patients who become ill or are injured while traveling or who have not previously been under their care. Despite the lack of effort in this arena to date, the Internet appears to provide a viable medium for use by hospitals to share patient health records for the purpose of improving care.
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From page 82... ...
The size of a medical record transmitted electronically between sites can vary considerably, from as little as 1 kB to as much as several gigabytes if the record contains several medical images. In general, older and sicker patients have the largest records.
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From page 83... ...
At issue are the confidentiality of clinical transactions which tend to contain personal information and
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From page 84... ...
System reliability is also an issue in clinical transactions. If health care organizations are to rely on Internet-based systems for access to patient records, then they must be assured that the systems will function properly 24 hours a day, 7 days a week.
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From page 85... ...
Unlike billing transactions or pharmaceutical transactions, clinical transactions have only an indirect effect, at best, on the profitability of health care organizations. The health care industry is much less consolidated than the pharmaceutical industry, which has been more successful in deploying an interoperability standard.
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From page 86... ...
clinician documentation, laboratory reporting, medication ordering) , there is a risk that important data relevant to patient care will become more dispersed and functionally unintegrated.
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From page 87... ...
Remote consultations, for example, would require sufficient bandwidth for realtime video at rates approaching 1 Mbps for some types of diagnostic procedures. The transmission of large medical images could also require high bandwidth in some instances, to support the transfer of large numbers of images between an imaging center and a remote interpretation center or rapid turnaround of diagnoses from a remote specialist.
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From page 88... ...
and the development of robust confidentiality policies to govern the disclosure of personal health information. Considerable technology is available for improving the security of many clinical transactions between established partners, but it is not widely deployed in health organizations (CSTB, 1997~.
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From page 89... ...
By one estimate, paper claims cost between $2 and $18 each to process, whereas electronic claims have costs measured in cents (McCormack, 2000) Health care organizations have filed claims electronically for some time.
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From page 90... ...
The Community Health Information Technology Alliance (CHITA) in Seattle, Washington, the Minnesota Health Data Institute, and the Affiliated Health Information Networks of New England, a project of the Massachusetts Health Data consortium, are three examples.20 Such programs attempt to facilitate information exchange among a variety of organizations, including care providers, insurers, pharmacies and pharmaceutical benefits managers, accrediting organizations, and state health organizations.
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From page 91... ...
CHITA and the Foundation for Health Care Quality worked with the Massachusetts Health Data Consortium and Minnesota Health Data Institute on a three-state project focusing on electronic security. The goals were to determine how electronic security could be implemented affordably and to develop a business case for a community-wide, secure infrastructure for electronic business.
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From page 92... ...
A number of obstacles may further delay the widespread use of the Internet for financial and administrative transactions. While many large health care organizations are moving toward electronic billing and have Internet connections, many private practitioners (almost half of all physicians practice independently)
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From page 93... ...
Granted, improvements in technology and processes could eventually allow for near-real-time review of claims and electronic payment for procedures, but response times and latency would not be a driving consideration in such systems. Availability +~+ The importance of availability in financial and administrative transactions is relatively high, depending on the specific use.
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From page 94... ...
A number of these activities could be enhanced by an Internet that is better attuned to public health needs, that provides sufficient security to protect sensitive medical records, that is accessible to all public health workers and the public at large, and that remains operational even in times of natural or man-made disasters. Public health surveillance, in particular, stands to benefit from Internet-based transactions to assist in collecting data about the health of individuals, personal risk factors, and medical treatments, as well as data about potential
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From page 95... ...
Several reports have reflected on the need for new relationships and better collaboration between public health officials and individual health care providers.22 The National Library of Medicine (NLM) , in conjunction with several other public health organizations, has initiated a program, Partners in Information Access, designed specifically to help public health officials gain access to the Internet and to relevant health information.23 Since October 1998, 20 awards totaling just under $1 million have been made for programs in 20 states.
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From page 96... ...
Such systems promise both to improve reporting of adverse events and to lower the costs of collecting and maintaining such data. Testing laboratories are required to report certain diagnoses to their local health offices so that public health officials may ensure that adequate treatment is delivered and that spread of disease is contained.
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From page 97... ...
It is intended to hasten the filing of reports, reduce the burden of reporting for laboratories and health agencies, improve the state's ability to track disease outbreaks that cross county lines, and ensure that reports are transmitted to the correct county health office. The system takes advantage of the broad reach of the Internet to establish connectivity among the health departments and private testing laboratories.
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From page 98... ...
Doing so would require that public health offices and their databases be connected to the Internet and that mechanisms be put in place for protecting the security and confidentiality of data that contains personally identifiable health information. Beyond integrating databases within the public health sector, the Internet offers the opportunity for public health officials to collect data from private sources that might be important in their surveillance efforts.
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From page 99... ...
Half lacked Internet access, 20 percent lacked suitable computer capacity, and 70 percent lacked training in the use of electronic information technologies for conventional health purposes (CDC, 1998~. To remedy this problem, CDC is developing a national Health Alert Network that will facilitate the collection of information from testing laboratories, the sharing of information among public health officials, and consultations among them regarding needed responses.27 A total of $28 million was allocated to this task in FY99.28 The network will use desktop personal computers and laptops connected to the Internet with sufficient bandwidth to handle the transfer of laboratory reports, interac
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From page 100... ...
Public health data rarely involve images or other large data objects, although videoconferencing among public health officials would require higher bandwidth from at least some computers and locations. Of course, there is also the potential for many data objects to be transmitted through the network, raising the bandwidth requirement by virtue of aggregated traffic levels rather than large individual files.
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From page 101... ...
Security +~+ The security of data on the Internet is of paramount importance to public health applications. Data reported by testing laboratories contain identifying information that is used by public health officials to map diseases and conduct interviews with affected patients.
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From page 102... ...
Public health organizations often run on tight budgets, so the cost of access to networking technologies must be reasonable. In any event, fewer distinct entities would probably need to be connected for public health applications than for consumer health, clinical care, or financial and administrative applications.
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From page 103... ...
Perhaps the best examples of such tools are those that allow students and clinicians to search and retrieve the latest medical literature over the Internet and use the evidence retrieved to guide clinical decisions. The process of incorporating knowledge from the medical literature into patient care decisions is referred to as evidencebased practice.
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From page 104... ...
Clinical students will increasingly be expected to support their patient care plans with evidence from the medical literature. To do this, they will become even heavier users of online literature retrieval systems such as MEDLINE and electronic journals.
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From page 105... ...
Such systems require extremely low latency, on the order of a few hundred milliseconds per round-trip, to prevent users from perceiving an unnatural lag between the time they take an action and sense a response (Table 2.5~. They also require the elimination of mismatches between different data sources: visual, audio, and haptic information need to be properly synchronized for a user to properly experience a virtual surgical system.
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From page 106... ...
As they use this upto-date knowledge at the point of need, clinicians will also be able to fulfill CE requirements, because the time they spend using the resources and the effect the knowledge has on the patient care process will be logged and reported automatically.31 Of course, such capabilities also raise issues of privacy. Will care providers be able to peruse outside information
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From page 107... ...
Technical Requirements for Health Professional Education Bandwidth +~+ The bandwidth requirements for health professional education are moderately high. Whether large numbers of people frequently use lowbandwidth applications, such as literature searching, or infrequently use high-bandwidth applications, such as teleconferencing or simulations, bandwidth will be important and sometimes a limiting factor.
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From page 108... ...
Ubiquity +~+ For health professional education, the ubiquity of the network is of great importance. Improvements in clinician knowledge and clinical outcomes will partially depend on the extensive deployment of new learning techniques and tools.
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From page 109... ...
For this reason, many users prefer to obtain a local copy of the databases so that they can subject them to high levels of use without TABLE 2.6 Examples of Online Databases of Interest to the Biomedical Research Community Database Content MEDLINE Index of the entire biomedical serial literature. Contains basic reference information since 1966 and limited full-text reference information from the National Library of Medicine.
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From page 110... ...
0 NETWORKING HEALTH: PRESCRIPTIONS FOR THE INTERNET monopolizing public resources.33 Doing so also allows companies to use the databases without fear that their searches will be watched by competitors. Knowing the kinds of information that companies are searching for can yield clues about the projects they are working on.
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From page 111... ...
High-resolution images containing millions of elements cannot be transferred rapidly enough to allow researchers to manipulate them in real time. Thus, accurate visualization requires that the image be rendered by a local computer with sufficient computational capabilities or by the efficient transfer of information from an image server to a display device on the Internet.
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From page 112... ...
These agents could scan newly published biomedical literature, the publicly accessible Web sites of other scientists, and other Internet information resources, bringing the most relevant sources to the attention of the researcher or abstracting and summarizing them in a manner that is most relevant. Some early examples of this technology have long been available through various journals and online services that notify users when items that match their personal profiles (based on keywords)
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From page 113... ...
Even though each individual software agent might not require very high bandwidth, a network experiencing multiple agents operating for millions of individuals will have a large aggregate requirement for bandwidth. Remote Control of Experimental Apparatus The Internet provides a means for remotely controlling some of the expensive experimental equipment used in biomedical research, including electron microscopes, DNA sequencing facilities, gene chips for analyzing the expression of nucleic acid or protein sequences, nuclear magnetic resonance spectrometers, and X-ray crystallographic radiation sources.35 In such systems, investigators send samples of interest to device operators, who load the samples and prepare the equipment.
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From page 114... ...
, intermediate-high-voltage electron microscope (IVEM) that can be used to create three-dimensional images from multiple two-dimensional images via a technique known as electron tomography.36 The slices required for three-dimensional reconstruction are 1,024 x 1,024 pixels, with 16 bits of precision per pixel, for an image size of 2 MB.
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From page 115... ...
For users with conventional network connections, video streams were compressed using IPEG algorithms to create grayscale images varying in size from 3 to 12 kB per frame. With these connections, the system performed at a maximum rate of 8 frames per second (96 kB/sec)
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From page 116... ...
Use of MPEG compression may also allow higher frame rates to be transmitted over more conventional network connections. Security, availability, and ubiquity of access are of less concern than bandwidth in the remote control of experimental apparatus but are still important.
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From page 117... ...
Latency and ubiquity are less important, since the retrieval of these data is often asynchronous with their collection and is done by specialized researchers. The success of online publishing of biomedical research findings (both primary data and the conclusions drawn from them)
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From page 118... ...
Collaboration Among Researchers The Internet could also prove to be a useful medium for enhancing collaboration among biomedical researchers in different locations. The remote control of experimental apparatus is one example of this capability, but others are also possible.
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From page 119... ...
In fact, any time multiple recipients are involved, multicast protocols may substantially reduce the impact computer applications have on the network. Another form of remote collaboration is virtual conferences.
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From page 120... ...
The Internet can contribute to a number of these activities, as manifest in clinical trials. As computer-based health records become more widely available, health services researchers will likely use them to explore dimensions such as effectiveness and patient satisfaction via the Internet.
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From page 121... ...
Technical Requirements for Biomedical Research Bandwidth +~+ The bandwidth requirements for many biomedical research applications are high. Teleconferencing and high-resolution, real-time transfer of images (during remote instrument manipulations, for example)
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From page 122... ...
Most importantly, only if they perceive an available Internet will reticent adopters of Internet technologies embrace these technologies fully. Security ++ For the most part, biomedical research deals with public domain information, so the security requirements for the network are not stressed.
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From page 123... ...
Bandwidth High bandwidth is important for a number of health applications, especially those relying on the transmission of real-time video or large medical or biomedical images. Beyond high bandwidth for specific dataintensive applications there is a need for high aggregate bandwidth to support a high volume of moderately data-intensive applications, such as transfers of large medical records.
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From page 124... ...
Although some health care applications might have lower requirements for network reliability, the most demanding applications still require a higher level of availability than most consumer applications. If health care organizations are to use the Internet for important patient care tasks whether retrieving medical records, accessing decision support tools, or conducting telemedicine sessions they need to know that the network will be available a large percentage of the time.
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From page 125... ...
Most importantly, TABLE 2.7 Relative Importance of Technical Needs of the Internet by Health-Related Applications Application Bandwidth Latency Availability Security Ubiquity Consumer health Clinical care ++++ +++ ++++ ++++ ++ + ++ Financial and administrative transactions Public health Professional education Biomedical research ++++ ++++ + + +++ ++++ + + +++ +++ +++ ++ ++ + +++ ++++ +++ ++ ++ ++ NOTE: Plus signs (+) denote the relative importance of the technical feature within the designated application area.
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From page 126... ...
Massachusetts Health Data Consortium, Waltham, Mass., April. American Medical Association (AMA)
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From page 127... ...
1999. "Internet Could Organize Medical Records," July 27.
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From page 128... ...
4. For example, a company named PersonalMD.com had stored the health records of 10,000 subscribers online free of charge as of July 1999.
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From page 129... ...
11. East Carolina University recently received a grant from the National Library of Medicine to investigate these requirements.
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From page 130... ...
23. Participating organizations include the National Network of Libraries of Medicine, the Centers for Disease Control and Prevention, the Health Resources and Services Administration, the Association of State and Territorial Health Officials, and the National Association of County and City Health Officials.
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From page 131... ...
41. Clinical research lies at the juncture of clinical care, biomedical research, and public health but is somewhat distinct from each of these topics.
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