Preface

The Committee and Its Charge

To obtain preliminary answers to these questions, the National Library of Medicine (NLM) asked the Computer Science and Telecommunications Board (CSTB) of the National Research Council (NRC) to conduct a study on the technical capabilities the Internet needs to support health applications and on ways of ensuring that these capabilities are implemented. The objectives were to (1) identify a range of health applications that could reasonably gain widespread, routine use over the Internet in the foreseeable future, (2) examine the technical capabilities these applications would demand, (3) define the characteristics of the Next Generation Internet and an associated infrastructure that would meet these requirements, and (4) recommend an appropriate strategy for achieving this infrastructure in light of other activities under way to enhance current Internet capabilities. The project was intended to address questions such as the following:

• What characteristics of the current Internet limit its utility for various types of routine health and biomedical research uses? For different types of telemedicine? For plausible future health-related uses that will require high bandwidth? What would be the likely future levels of various types of health traffic on the network if these limitations were overcome?
• What quality of service and security characteristics or tools will the Next Generation Internet require to be suitable for various types of health-related applications, given technical requirements and estimated traffic levels? Are the requirements of different health applications compatible with one another and with the requirements for other projected uses of the Internet? To what extent are they supported by technology available now or already in development?
• What specific strategies are likely to ensure that the United States attains a communications infrastructure to support the full potential range of routine health and biomedical research uses?

To conduct the study, CSTB assembled an expert committee consisting of 15 members drawn from the networking and health communities. The committee met five times between September 1998 and June 1999 to solicit testimony from outside experts, deliberate on its findings and recommendations, and draft its final report. It met again in September 1999 to discuss its plans for modifying the draft report in response to comments from many outside reviewers. The committee also conducted a series of site visits to gather information firsthand on the ways the Internet could be—and is being—used to support health and health care. Members of the committee visited with researchers and health practitioners at Stanford University, NASA Ames Research Center, the University of California at San Francisco, Kaiser-Permanente of Northern California, East Carolina University, the University of North Carolina at Chapel Hill, the University of Washington, Regence BlueShield, and the Washington State Department of Health. These visits provided an opportunity to directly observe Internet-based systems that had been developed for health care, biomedicine, and other health-related activities. It also provided an opportunity to learn more about the kinds of applications that cannot yet be implemented in an Internet-based system.

The committee used the information gathered during site visits and presentations by other briefers to synthesize a comprehensive view of the ways the Internet could transform health-related activities. It attempted to identify the technical and nontechnical challenges that need to be overcome in order to expand the use of the Internet in health and biomedicine and to devise a set of recommendations that will help make the Internet a more useful communications medium within the health sector. The site visits are summarized in Appendix A. Specific material from the visits has been incorporated into Chapter 2 of this report.

Acknowledgments

This report benefited from the combined talents of many people, including those who were directly associated with the project and many who were not. First, thanks are due to members of the committee itself, all of whom maintained a high level of enthusiasm, energy, and dedication over the course of the project. Committee members found time for project meetings, site visits, and drafting portions of the text despite their many other responsibilities and commitments. Approximately half of the committee members changed jobs and/or affiliations as the project unfolded—a living testament to the dynamic nature of the Internet in health applications—yet they remained committed to this project throughout.

Many other people volunteered their time and expertise to help the committee to better understand the ways in which the Internet might be used to support health objectives and the technical capabilities that health applications demand of the Internet. Special thanks are due to those who hosted, coordinated, and participated in its site visits and to those who met with the committee at its three open meetings (see Appendix D for a list of participants). The information gathered during these interactions proved invaluable to the committee's deliberations and forms the backbone of this report. Other people also provided useful information and advice to the committee. Mark Ellisman at the University of California at San Diego and Martin Hadida-Hassan at the San Diego Supercomputer Center helped to clarify the discussion of telemicroscopy in Chapter 2 of this report; Stewart Streimer, John Parmigiani, and Sandy Haydock from the Health Care Financing Administration provided updates on the agency's security policy, pilot programs for electronic submission of data, and information technology strategy, respectively. Grant Miller and Yolanda Comedy, from the National Coordination Office for Computing, Information, and Communications, supplied information and funding data on the federal government's NGI initiative. Kenneth Birman at Cornell University contributed valuable insight into security and reliability concerns associated with use of the Internet in health applications. Donald Simborg described early efforts to network computers in health care organizations.

The committee stands in awe of the remarkable, patient work of the CSTB and NRC staff in supporting its deliberations over the course of this study. Staff members kept the committee on track and helped its members to put their ideas and analyses into coherent prose. The committee is further indebted to the reviewers of an early draft of this report, whose thoughtful comments and criticisms challenged committee members to strengthen and refine their arguments—and to articulate them more clearly. This final report is considerably improved thanks to their input. It is a much more readable document thanks to Laura Ost, a free-lance editor who assisted the NRC's internal staff in editing the manuscript, and to James Igoe, from the National Research Council Library, who tracked down numerous references and helped to complete the citations in the reference lists.

Finally, thanks are due to Donald A.B. Lindberg, director of the NLM, Michael Ackerman, assistant director for High Performance Computing at the NLM, and Betsy Humphreys, associate director for Library Operations at the NLM. Their dedication to improving health, health care, and biomedical research through Internet technologies and their financial support made this project possible. The committee hopes that its findings and recommendations will assist them in leading the health and the networking communities to achieve their vision of a ''healthier" Internet.

EDWARD H. SHORTLIFFE, CHAIR

COMMITTEE ON ENHANCING THE INTERNET FOR HEALTH APPLICATIONS: TECHNICAL REQUIREMENTS AND IMPLEMENTATION STRATEGIES