More advice and information
GERINET: A PROTOTYPE COMPUTERIZED MEDICAL TELECOMMUNICATION NETWORK
Robert Scott Stall, M.D.
April 22, 1987
Note: I wrote the following paper in 1987 shortly after I went on-line via my SUNY–Buffalo computer account and discovered the E-mail and Listserv functions as they existed at that time.
This article Copyright 1987 Robert S. Stall, M.D.
All Rights Reserved.
GERINET is a prototype medical telecommunication network (1)intended to facilitate and promote communication between members of the geriatric health care community, both domestic and worldwide. In addition, it could be used to aid in the flow of information between the medical world and the population served. The prototype system is structured so that it could easily be expanded to create a generalized MEDNET (2), servicing the entire medical community. Initial system implementation would occur over BITNET (3), an existing network of 1300 university-affiliated mainframe computers (4) currently in use as a telecommunications network.
The following is a description of the possible uses for such a system, methods of implementation, and consideration of several practical issues.
AREAS OF USE
The scope of use will be at various hierarchical levels:
At this level, GERINET may be used for several functions. On-line mailings to organization (e.g. AGS, AFAR) membership or between members could be greatly facilitated (5). Personal communications could occur between individuals or to the organization (6) (e.g. requests for information, suggestions/feedback). Special interest electronic “bulletin boards” could be established as a message clearinghouse (7) to service subgroups of the organization. Special priority communications (e.g. bulletins from the NIA Director or Surgeon General) would allow rapid dissemination of vital information (8).
Of particular interest to the geriatric community, GERINET can be utilized to facilitate communication in the development of a core curriculum for geriatric training by facilitating and coordinating input from fellowship training programs and organizational task forces (9). It would provide a forum for consensus development, with the likelihood of a greater diversity of input than from, for example, US mail polls or discussion at conventions and conferences (10). The basic nature of the system as a network would foster the interdisciplinary team approach often used in the care of the elderly (11). The ability to set standards through processes like those described above will facilitate quality assurance and uniformity of care for our patients (12). Likewise, this could be a method to ensure a high standard of care for patients living in rural areas by allowing access via computer telecommunication lines to the many resources available in urban areas (13).
Finally, such a network could minimize the delays inherent in publication of journal articles and could also help to speed and optimize the match between fellowship candidates and their intended programs (14).
Individual practitioners could contact each other quickly and easily to discuss problems (15) (e.g. on-line medical consultations). Access to existing informational databases could easily be incorporated (16) (e.g. access to MEDLINE information), as could access to expert systems (17)(e.g. INTERNIST), patient care documentation (18) (e.g. patient information pamphlets that may be distributed to a given practitioner’s patient population), and patient clinical databases (19) (e.g. current medications, problem lists, and progress notes).
In addition, linkages could be developed between individual practitioners and ancillary health care personnel (20) to facilitate the implementation of a comprehensive treatment plan for patients who require specific therapies or health education (21).
On-line informal communication between individual practitioners could eliminate the delays inherent in telephone communication (22) (e.g. busy signals, a practitioner being temporarily unavailable to come to the phone, etc.).
A question/answer bulletin board could be established to provide a forum for solving management dilemmas and other patient care issues (23). Home monitoring and emergency lines can be provided to high-risk patients by monitoring analog and alarm signals generated by the patient at home (24).
On-line communications between researchers could facilitate collaboratory efforts on specific research projects (25). In addition, it would establish a forum to discuss questions pertinent to research issues.
Laboratories could be linked to laboratory supply companies, instrumentation companies, and a variety of consultants to provide technical assistance when necessary during the course of research (26).
In house telecommunications, similar to that available at the NIH, could obviate the need for written memos, messages, and mailings. These functions would be similar to person-person interaction except performed on a departmental level.
The GERINET concept has a ready testing ground in the BITNET/ARPANET/DECNET (27) system available from 1300 mainframe computers throughout the United States and the world. User accounts are available at no cost (28) provided the user has an affiliation with the academic institution that owns the computer on that particular “node” of the system (29). User accounts are established within a few minutes by a computer systems operator (30). A user then need only dial-in via modem to access the computer (31). After stating the user ID and password (via keyboard input from the remote site) (32), the full capabilities of the system are available (33) (e.g. word processing (34), graphics (35), statistical analysis (36), as well as network telecommunications (37).
A directory of users would be published both on-line and in written form to provide the network “addresses” by which an organization, laboratory, or individual could be reached within the network (38).
Guidelines for usage must be established (39). System etiquette must be defined (40), confidentiality issues addressed (41), and communication priorities set. Maintaining professionalism, protecting user privacy and patient data, and determining a priority system for various levels of communication (e.g. official notices having transmission priority over informal communications) are all crucial implementation issues that must be addressed.
Specific initial applications are GECNET and FELLOWNET, networks to facilitate communication between Geriatric Education Centers and Geriatric Fellowship Programs, respectively.
Centralized Mail/Document Facility
To alleviate the burden of processing US mail, a central mail facility could be established. This will be essential to provide a link between users and nonusers (e.g. practitioners and patients) and may utilize all currently available mail systems (e.g. US Postal Service, UPS, Federal Express) in the actual delivery of mail and perhaps administration of the overall facility.
Users could transmit on-line lists of addressee(s) and a list of the on-line files to be sent. Hard copy of these files would be produced and written mail sent to the addressee(s). It is likely that this process could be largely automated to increase the efficiency of producing mailings and reduce the burden of manual handling of written documents. Off line documents/pamphlets would be available for mailing when the central facility is provided with the addressee list. Non users could have a catalog of documentation that is available for general use and could issue written or telephone requests for the information. Non -user addressee lists could be maintained on-line to facilitate future mailing requests.
The hardware required to implement the system is described below. All equipment is currently available and is in widespread use. Hardware considerations must also anticipate differences in software (e.g. file formatting, system commands) but systems in current use are in general highly compatible.
Peripheral User Sites
Minimum computer hardware requirements for peripheral sites would be a computer terminal with modem (<$1000). Addition of a personal computer (e.g. IBM PC or compatible) with printer would be the basic requirements for a truly useful system, allowing file storage and production of hard copy. Multiuser systems would be necessary for larger offices (e.g. group practices) and local mainframes necessary to coordinate communication from large organizations.
Central Computer Facility
For the prototype system, the existing BITNET mainframes could be used, at no cost currently to university-affiliated personnel or not-for-profit community organizations. In addition, for-profit agencies may get accounts for a nominal fee ($500-$1000/year) plus usage costs (at rates much less than those commercially available). These mainframes are IBM, VAX, and other brand multiuser machines capable of efficiently supporting approximately 100 users simultaneously.
Eventually a dedicated mainframe(s) would be desirable to provide a truly central focus for the network using a uniform dial-in number to ease access to the system. It will also allow for future system planning and alleviate the load an extensive system would place on the existing network. It would allow for greater syntax uniformity in specification of system commands and file designation.
State-of-the-art technology could be incorporated and developed through consultation with computer systems vendors (e.g. IBM) and electronic research laboratories (e.g. Bell Laboratories). Facsimile transmission and telephone conferencing are currently available and could be incorporated into the system. Remote medical consultations could be performed via videophone terminals. Laser disk technology could be utilized for Computer Aided Instruction (CAI) of medical students, practitioners, and patients.
Additional system linkages could be established with existing computer networks (e.g. Veterans Administration computer system) via system-system modem communication to allow direct in-hospital access to the network. The utility of a network such as this in crisis situations can be explored.
Real-time rate of data transfer should be the goal to maintain optimum user satisfaction and appropriate computer systems used to fulfill this goal and anticipate future system needs. Security and confidentiality issues must be addressed. Database backup is crucial as is hardware maintenance and repair. A network structure should be devised and tested (e.g. invisible or visible substructures, routing and priority of information transfer, and archiving). Development of a software package that would ease user access (i.e. user friendly) will be critical in order to gain general acceptance of the system. Manpower issues must be addressed as must cost analysis and funding sources. Legal, accounting, contracting, and publicity input will be necessary. Possible affiliations and parallel networks should be explored (e.g. linkage to the world-wide community). Finally, existing products that are used for networking (both hardware and software) should be investigated.
System Requirements (estimate)
Anticipating a throughput of 100,000 users @ 1000 transmissions/day/user (average length 1 kilobyte, 9600 baud), approximately 100,000 system seconds/day would be required at the input/output (I/O) ports. This translates to approximately 1000 systems days/day as the time spent transmitting at the I/O ports. Therefore, at least 1000 parallel I/O lines would be required to enter information into the processor, assuming 100% efficiency. A more realistic 25% efficiency would necessitate at least 4000 parallel lines. Depending on the existing technology, this would determine the number of mainframes required to support the system. However, within three months laser optic telecommunication lines will be operational throughout the network and will make internode communication virtually instantaneous (1.9 megabits/sec or about 1000 times faster than a 1200 baud modem).
Data storage requirements must also be determined. An average of 100-10,000 megabytes/user should be allocated. For 100,000 users this would translate to 10-1000 gigabytes (10-1000 trillion bytes) that would have to be maintained. Some of this burden may be alleviated at the peripheral sites (e.g. 100,000 users @ 20 Meg/user=2 Gb with current personal computer technology).
All hardware requirements appear to be currently available.
The system, once established, must recruit users. Person-to-person recruitment, journal advertising, and conferences (e.g. Geriatric Education Center National Conference, Buffalo, NY 4/27-4/28, International Symposium on Research and the Ageing Population, Bethesda, MD 5/1, American Geriatric Society Annual Meeting, New Orleans, LA 5/14-5/17, and The Gerontologic Society of America National Conference, 11/87) are all possible forums to promote the system. It is conceivable that in the future familiarity with the network would be a prerequisite to licensing and a means to assure continuing medical education. Training courses and usage manuals must be developed to explain how to use the system.
Overall, it seems that the potentials of a computerized medical telecommunication network (GERINET / MEDNET), as described above, warrants further investigation into its feasibility and implementation. However, using a widespread, existing network (BITNET), a workable prototype system could conceivably be in operation within the year.
For additional information please contact:
Robert Stall, M.D.
Division of Geriatrics/Gerontology
Veterans Administration Medical Center
3495 Bailey Avenue
Buffalo, New York 14215
UB VAX userid/node: DRSTALL@UBVMS
4/14/87 revisions: Home monitoring and emergency services added to “Personal” on p.2, “in general highly” instead of “remarkably” on p. 4, correction of calculation of “System requirements” from “1200 baud” to “9600 baud” on p. 5, and addition of “For additional information…” on p. 6.
4/15/87: “from” inserted after “diversity of input than…” on p. 1, paragraph 1 under the “Personal” section reworded p. 2, paragraph 1 under “Centralized Mail…” section reworded p. 3, paragraph 1 under “Central Computer…” section reworded p. 4, misspellings and condensation of paragraphs p. 4, “audiovisual” changed to “videophone” p. 4, thoughts about software and commercial products added to “Practical Considerations” section p. 5, 1.9 megabit/sec fiber optic lines described under “System Requirements” p. 5.
4/16/87: “correlates well” replaced by “would foster” p. 1, “for practitioners” removed p.2, “The other benefits of…” replaced by “These functions would be…” p. 2, “as well as private couriers” replaced by “in the actual delivery…” p. 3. Beginning of new paragraphs eliminated for “Non-users…” and “Non-user…” p. 4, “In addition, for-profit agencies…” inserted after “…not-for-profit community organizations.” p.4, “currently” changed to “current” near end of p. 5, “The Gerontologic Society of America, 11/87” inserted after “…5 14-5/17″ p. 6.
4/22/87: superscripts represent words and phrases to be annotated at a later date, name changed to GERINE11.DOC” as updated footnote, related document “PILOT1.DOC” describes nine pilot studies under way.