Todd's paralysis

The Internet is coming to medical care in profoundly important ways, sooner than any of us would have predicted three years ago-in fact, sooner than most of us would have imagined even 12 months ago. These changes will not take place on the home pages of the Internet's World Wide Web. They will happen on Intranets-corporate networks of group practices, hospitals, health plans, and PHOs that use Web standards but are private.

And true community health information networks (CHINs) are coming soon. Community members will be linked-patients and potential patients, members of health plans and potential members-and will receive valuable services from access to CHINs spawned by providers and payers to make communication as convenient, efficient, and thorough as possible. There will be numerous networks offered in most metropolitan areas, each developed by an organization of providers or payers, to attract and retain customers.

There will be security provisions to keep the information of patients, health plan members, and providers private, while enabling the electronic exchange of data. Over the next five years, in many urban areas, the networks will evolve to support multimedia communication, permit telemedicine practice, and make consultations with physicians convenient for patients.

Our society will enjoy an increase in the velocity and accuracy of medical diagnosis and treatment with these networks, and more focused and effective interventions to prevent illness. Providers and health plans will discover that CHINs will be indispensable tools for managing their limited health care resources, and invaluable assets in their mission to wrest more customers from existing competitors. They will be as important as the networks supporting automated teller machines are to banks, and networks linking travel agents to their flight schedules are to the airlines.

Imagine you have to treat a boy named Christopher

Christopher is 10 years old, bright and inquisitive, and inclined to make his own decisions. He complains of a bilateral, frontal headache at 4:00 p.m. on a Monday afternoon, as his mother is driving him home from school. She instructs him to take three chewable childrens' Tylenol tablets. He has taken them before, and knows what they look like. In addition to the Tylenol tablets, his mother's purse also yields a sheet of Dimetapp Extentabs for adults, of which three are left. He reads the label, and recalls that he has taken Dimetapp pills (for children) before and they have made him feel better. Unbeknownst to his mother, he takes and ingests those three blue pills. They arrive home shortly afterward, and Christopher dives into his homework.

At 8:30 p.m., Christopher is lying in bed with a terrible headache, nauseated and vomiting. He has not eaten dinner and says he wants to rest. His mother attends to him, and asks him when his nausea started. He says shortly after he took those three blue pills. She gasps. She knows the Tylenol tablets are purple. She retrieves her purse. Christopher shows her the strip of Dimetapp tablets, from which he had taken the remaining three. His mother calls the pediatrician's office, and then the poison control center. She also summons her husband from his study. Her husband is a physician, and she is a nurse.

The poison control center suggests they check Christopher's blood pressure, because Dimetapp Extentabs contain 75 mg of phenylpropanolamine, a decongestant that in large quantities can raise blood pressure, and 12 mg of brompheniramine, an antihistamine. Christopher weighs 70 pounds. He has taken about six times the recommended dose of each medication. The phenylpropanolamine may cause the most trouble. His parents check his blood pressure, which is 140/100, with a regular heart rate of 70.

The pediatrician is appraised of the circumstances. He calls the emergency room and confers with poison control. Christopher's attendants choose to follow his blood pressure closely, but not to take him to the emergency room immediately. Because he took the medication four hours earlier and is already having dry heaves, they think the effects of ingested phenylpropanolamine may have peaked.

Every five minutes, Christopher's parents check his blood pressure, which rises to 160/120, with a regular heart rate of 65 over the next 10 minutes. His parents report this to the pediatrician, and decide to take him to the emergency room. As they are preparing to leave, Christopher's mental status changes; he becomes stuporous. His parents race him to the emergency room where, moments after arrival, he suffers a series of focal seizures involving his left leg, followed within a minute or two by a generalized grand mal seizure.

The seizure is brief, less than 30 seconds, followed by normal respirations. Christopher never appears hypoxic. His heart rate is 60 and regular, his blood pressure 170/125. The emergency room staff have an intravenous line in place, and give him Valium IV, which stops the seizure activity and reduces his blood pressure. He is unresponsive, and does not move his left side spontaneously Retinal examination is normal, without hemorrhages or papilledema. His pediatrician performs a literature search and learns that phenylpropanolamine in elevated doses may cause cardiac dysrhythmias and dystonic reactions, in addition to the hypertensive crisis Christopher has suffered.

Nevertheless, this is a story with a happy ending. Over the next 12 hours, Christopher recovers all of his neurological activity, and is discharged after a normal CT brain scan-about 16 hours after his initial change in mental status, and 20 hours after he ingested the wrong medication. His neurological deficits are considered to be transient, post-ictal paralyses (Todd's Paralysis). In two days, he returns to school with no apparent residual deficit.

He might not have been so lucky. His parents asked the right questions, determined his problem, measured his blood pressure, and got him to an emergency room before it was too late. Had his blood pressure continued to rise, had his parents not been able to check his blood pressure, had they told him to stay in bed and sleep his headache off, he could have sustained cerebral hemorrhages and permanent brain injury. He might have died.

Imagine that the year is 2000

Now imagine that the year is 2000, and Christopher is in bed with a headache, nauseated and vomiting. The community in which he lives has broadband telecommunication networks from competing, regional telephone and cable TV companies. His family does not include a father who is a physician or a mother who is a nurse. But, his family does subscribe to cable TV and uses a cable modem to obtain digital video signals for entertainment and video conferencing.

They use the video conferencing features of their entertainment and personal computer system, with a 36-inch monitor and 300 MHz Pentium Pro processor, to talk with family and friends. Their Gateway 2000 Destination system is three years old, but functions well. They have not used it to communicate with health care workers, but they will this evening.

Christopher's mother describes his severe bilateral headache and nausea to the pediatrician on call. The physician worries about a viral exanthem, perhaps a viral meningitis-she has seen several cases of it in the community recently. She asks to see and speak with Christopher. They walk to their living room to establish an encrypted video conference over the community Intranet.

Their pediatrician moves to her workstation and reviews Christonher's uneventful medical history in his electronic record-to which she connects in seconds on her computer via the WWW, while she waits for the call establishing the video conference, which occurs in a few minutes.

Christopher's mother has never participated in a home telemedicine session. She has never had to use the electronic blood pressure cuff and stethoscope their health plan sent them when they enrolled--these devices connect to a transducer that sends signals over the cable TV network. There is a small video camera on top of the large screen entertainment monitor, allowing the pediatrician to see Christopher in his living room.

The pediatrician talks his mother through the proper use of the instruments, which takes about two minutes, and speaks to and observes Christopher. A large image of the pediatrician is on their home monitor, captured by an unobtrusive video camera in the monitor of her workstation. She notices that Christopher obviously does not feel well, but seems to have normal mental status.

She asks him about his headache and when the nausea started. He says shortly after he took the medicine in his mother's purse for his headache. The pediatrician asks him to tell her what the pills looked like and he says they were blue and round. The pediatrician and Christopher's mother look at each other on their respective monitors. Chewable Tylenol are not blue, and they are not pills.

The physician asks Christopher's mother to retrieve her purse. She finds a sheet of Dimetapp Extentabs with three missing pills, and Christopher confirms he took them. He explains that he had taken Dimetapp before and they made him feel better, so he took them. His mother reminds him that he has taken children's Dimetapp before, but never Dimetapp for adults. The pediatrician says she wants to complete a brief physical examination of Christopher before she checks the poison control database.

His mother hooks up the blood pressure cuff, which also records heart rate, and the pediatrician sees on her screen a heart rate off 70 and regular and a blood pressure of 140/100. She is concerned. His parints (Christopher's father has joined them) hold the stethoscope where she instructs them to place it, as she watches Christopher. His lungs are normal. His heart is not. She hears a wide physiological splitting of the second heart sound, with a loud aortic component, but no third heart sound.

While that blood pressure, if transient, would probably not threaten Christopher, she knows, if it rises much further, he could be in serious trouble. She focuses the camera on his face and asks him a series of questions, all of which he answers well, though with tired and pained affect.

She asks his parents to stay in front of she entertainment center while she uses the community Intranet to revisit the poison control database and find information on the effects of a phenylpropanolamine overdose. The WWW site includes a spreadsheet, created as a Java apples, in which she enters the patient's age and weight, that he has normal renal and liver function, and that he took 225 mg of phenylpropanolamine four hours earlier.

The what-if analysis she performs indicates that the peak effect of the phenylpropanolamine is still probably more than one hour away and, if untreated, his blood pressure may rise to more than 180/130, with encephalopathy, seizures, and intracranial bleeding highly likely. She decides the best course of action is to ask Christopher's parents to take him to the closest emergency room to treat his hypertension if his blood pressure rises any further, or if there is a change in his mental status. The pediatrician maximizes the window on her workstation. She asks Christopher how he feels. She notices that he seems slightly less alert, and his answers are more monosyllabic. She asks for another blood pressure reading and heart rate. His heart rate is 65 and regular and his blood pressure is 150/110.

With his blood pressure rising and his affect flattening, she decides there is no time to waste. She urges them to take him to the emergency room where she will meet them. She signs off from the video conference and makes a quick video call to the emergency room, instructing the staff of Christopher's imminent arrival. Eight minutes later, Christopher and his parents arrive. He is walking, but tired and lethargic. His blood pressure is 160/120 and his HR is 60 and regular. Within five minutes, an intravenous line is in place, he is given sublingual nitrates and 1 mg of Valium IV. His blood pressure declines to 130/90, his heart rate increases to 75 beats per minute, he feels sleepy, and his headache diminishes. He stays for another four hours, then goes home with his parents, normotensive, with a normal neurological examination and minimum residual headache, for a well-deserved rest.

Christopher's real parents knew enough about medicine to ask the right questions and get him to an emergency room in time to prevent probable serious sequelae from his drug-induced hypertension and seizures. With the advent of video conferencing and home telemedicine sessions, we hope more situations like the one Christopher suffered can be avoided. Health care networks will offer parents the peace of mind of readily available video conferencing from home, on-line poison control databases, and electronic medical records with password and encryption protection.

Why develop Intranets?

An Intranet is a corporate asset, not a public service. It is a network connecting the stakeholders of an organization, allowing users to share data with browsers designed for the WWW. It uses hypertext mark-up language (HTML) and virtual reality mark-up language (VRML) to create the documents retrievable over the Intranet, and the JAVA application programming language to create small applications (applets) that make the intranet interactive. These networks adopt the browser and server software of the Web to bring multimedia information to corporate workstations using widely available technology.

Intranets are used to publish corporate newsletters and other periodicals, distribute policy manuals and instructions for operating equipment, maintain up-to-date directories of personnel and facilities, and give access to news and discussion groups. The Intranet can serve as a standard data entry device to allow employees to enter their ID numbers and passwords for inquiries about their retirement plan account balance, or for clinicians to enter patient ID numbers and their own passwords to check on laboratory results, and radiologists' interpretations of diagnostic studies. Corporations can take advantage of the enormously productive ferment in the communications industry and the improved software being designed for the Web. Corporations that use WWW standards on their private networks will not have to worry that they will only improve with the pace of a single vendor. Vendors may come and go, but the WWW standards will continue to mature at an astronomical rate.

In most developed countries, practically everyone will have an Internet address within the next few years. Each person will have at least one personal computer that can access the Web and know how to navigate it. The training costs for corporations that use those same standards for networking their computers will be far lower than those th-at use proprietary software unfamiliar to employees and other stakeholder with whom they want to share digital communication.

Designed as Intranets, community health information networks will link the homes and offices of people in a given geographic area with health care plans and providers. Software must be familiar to the staff in physicians' offices and the general public to induce them to use the network. No health care organization is going to spend the resources needed to install proprietary software for their network in the homes of patients, potential patients, health plan members, and potential members. But all those groups will have access to any CHIN designed with WWW standard browser software, as long as they have passwords to the network itself. Passwords are much less expensive to distribute to a large audience than copies of proprietary software, for which the health care organization must pay the developer, as well as for the additional costs of installation and training.

How health care stakeholders benefit

Patients, health plan members, physicians, nurses, allied health professionals (physical and respiratory therapists, dieticians, psychologists, occupational therapists, radiology and laboratory technologists, physicians' assistants, to name a few), administrators, family members of patients, pharmacists, regulators of the health care industry, suppliers to the industry, insurers and communities that depend on health care providers all are important stakeholders. And each could benefit from Intranet technology.

1. Members of health plans

Explanation of covered benefits: Members want to learn about their health care benefits before they need to use them. They want to know how to select a primary care physician for each member of their family if their plan requires that they declare one, and use him or her for guidance. Members know that many services will not be paid in full, or paid at all, unless they receive their primary care physician's approval to use them. Imagine if members could use the personal computer they use for balancing their checkbooks and calculating their taxes to check on their health care benefits electronically.

Clerical and administrative reporting: Most administrative offices of health plans are open from 9 a.m. to 5 p.m., Monday through Friday. When members are at home working on claims forms and family budgets, no one is available to answer their questions. Members could check on the status of claims they have submitted in the past three years, any time of the day or night, by entering their personal ID number and password. With that same computer, they could select a physician from a multimedia biography complete with a photograph, a brief videotape describing his or her training and beliefs about practice, and availability to take new patients.

Preventive Medical Services: Members want to know that their plan will alert them when screening procedures are due (PAP smears, sigmoidoscopies, tetanus boosters, flu shots, mammograms). They want to know if they are at risk for preventable diseases and stop them from occurring. A member can complete a health risk assessment on the home page of his or her health plan using a PC and see the answers immediately--what specific steps to take to reduce his or her risk of common chronic ailments. The answers could be copied to the electronic mail file of the primary care physician and added to the member's medical record.

If each member was asked to complete an annual health risk assessment from the convenience of home via the Web, a file of valuable patient history would grow. The health plan would be on top of the member's risks and could advise on habits to remain healthy, relying on the electronic medical record and health risk assessments that the patient helps to produce. Members prefer plans that emphasize preventive medicine and use modern information processing and knowledge bases to design specific health care regimens and help them avoid needing treatment.

2. Patients

Learning about what ails them: Each patient should learn as much about his or her ailment as possible, the life style effect it is likely to have, the alternative treatments available, the costs, the possible unintended side-effects, and what to do to expedite recovery. E-mail provides opportunities for the patient to check on the results of recent diagnostic studies, read a layman's interpretation of the illness, look up recommended recipes, check the schedule of health education classes and support group meetings, and invite a new friend in a support group to lunch.

Interactive learning engages patients and their families: Patients enjoy interactive learning online, such as completing health risk assessments and seeing the results immediately, interpreted in language they can understand. Today's fast Pentium computers with 31-inch monitors are available with the same capabilities as PCs. In addition, they have entertainment devices that attach to cable TV and modems to allow interactive electronic communication. The public will find themselves marveling at the merging of passive television viewing and computer gaming to produce interactive, educational, and entertaining video conferencing, with home entertainment equipment that doubles as a personal computer;

Evidence suggests that a patient with a chronic illness who has family members that understand the disease and can help provide care requires fewer medical resources, has fewer complications, and less acute exacerbation of the underlying condition. Just as telemedicine gives confidence to primary care physicians in rural locations who like to have a specialist confirm that they have made prudent choices for their patients, family members of patients with various cancers, neurological injury, acquired immune deficiency syndrome (AIDS), diabetes, and other chronic infections will benefit from periodic, brief electronic house calls by clinicians using telemedicine technologies.

3. Physicians

Telemedicine will facilitate acute care: Telemedicine consultations to physicians and allied health professionals will be common with teleconferencing equipment in the home. Many routine follow-up visits to physicians' offices and late evening visits to urgent care centers may be avoided with brief interactive video conferences.

The telemedicine program at the Medical College of Georgia has ample evidence that primary care physicians do well in their communities with occasional telemedicine consultation with sub-specialists: More than 80 percent of the patients who they attest they would have sent to the academic medical center for a face-to-face consultation were successfully handled with telemedicine. The patients do not need to travel, the primary care physicians learn how to manage unusual clinical situations, and the academic center builds a network of loyal community physicians who will transfer patients to it when the need arises.

The same digital networking technology that gives health plan members, patients, and their families access to multimedia documents about benefits and preventive health programs will permit video conferencing from home with clinicians.

Connect with all health plan members: Most providers don't know anything about the people they are not treating. Intranets offer them an opportunity to connect with the population of members they ought to get to know, and inform them about how to seek care when they want it and how to stay healthy. The network helps keep people in touch, so to speak. It is a powerful means for the health care organization to manage the health and the ailments of its health plan members and patients, and those members whom the plan helps to avoid becoming patients.

The era of electronic medical care is already here

Physicians have computers in their homes and offices and know how to use them. They have access to the Web, using commonly available browsers from either CompuServe (using Spry's Air Mosaic); America Online, Prodigy, Microsoft (Internet Explorer); Netscape (Netscape); and other derivatives of Mosaic from any one of a number of smaller firms.

AT&T is forcing down the price for access, giving their long-distance customers five free hours on the Internet per month, and everyone else a low fixed price for unlimited access. Cable TV companies are preparing their networks--that already reach into tens of millions of homes and offices, including those of many physicians--to offer Internet access through "cable modems" at data transfer rates much faster than those we can obtain with telephone modems.

While it may at first seem expensive to acquire the equipment and the knowledge to use the WWW, demographics of users show that every income group is well represented. Personal computers capable of accessing the Web outnumbered television sets sold in 1995, and the trend is estimated to continue. By the year 2000, most Americans will have PCs in their homes that resemble television sets.

Gateway 2000 has begun selling its Destination line of computers with fast Pentium processors, modems, and large hard disk and CD-ROM drives. Its monitor is 31 inches in diagonal size. It comes with a wireless, remote keyboard and controller, and, in fact, is ready for connections to standard coaxial cable TV. This device is a combination home computer and entertainment center. It is ready to attach to a camera to send video signals over a network, so it could be the sending and receiving station for teleconferencing.

This is the access point--physicians' own home pages on the WWW--for patients to learn how to care for themselves, about their health care benefits, the preventative, diagnostic, and therapeutic services available from local hospitals, and to participate in an electronic house call with a clinician at an urgent care center or emergency room. The advent of telemedicine into the home is nigh and the Internet and WWW, or a local cable TV firm, will probably be first to carry the data in your community.

The equipment to access Intranets for specific populations of patients and health plan members--with password protection to keep others out--is already in the homes and offices of most Americans, or will be shortly, at very affordable prices. The era of electronic medical care and home health is upon us. Innovative and telegenic physicians will be able to extend their preventive and therapeutic practice to more patients, in more locations.

Conclusion

We want data to help us address a specific set of circumstances in a timely fashion--but often cannot get the information when we want it, how we want it. Today, all information can be stored electronically on the World Wide Web or on a private Intranet, making data available to more people, more quickly. As a result of the efforts of literally tens of thousands of engineers, programmers, and systems analysts, we will not only make all documents available electronically, but we will make them interactive--an invaluable function that books and journals cannot offer.

With interactive multimedia information sources, our abilities to teach, learn, instruct, and inspire will grow considerably. Patients will learn more about what ails them and how to care for themselves from interactive Web sites than they could from health plan newsletters and brochures. Patients and physicians will confer over the Internet. Doctors will consult with other physicians interactively over the Internet or on the Intranets of their delivery networks. And children like Christopher will be less likely to suffer hypertension and seizures from misadventures with the wrong medication. Better care for our children is the most important reason for Intranets.

Marshall Ruffin, MD, MPH, MBA, FACPE, is President of The Informatics Institute, Falls Church. Virginia. He may be reached at 810 Gatehouse East, #401-East, Box 11, Falls Church, Virginia 22042, 703/205-3901, FAX 703/205-2301. Copyright 1996 by The Informatics Institute.

COPYRIGHT 1996 American College of Physician Executives
COPYRIGHT 2004 Gale Group