It's a Wired Wired Wired Wired World

by Nancy Millichap

This article first appeared in the Spring 1994 issue of Dartmouth Medicine. The textual content of this article is copyright (c) 1994, Dartmouth College. The images are copyright (c) 1994, Dartmouth College and Columbia University.

The speed at which cutting-edge communications technologies are finding applications in medicine rivals the speed at which bits and bytes of data travel along the nation's electronic networks. And Dartmouth is right in the midst of the action. Some applications are already in the here and now, while some are intriguingly futuristic.

Topics Covered in this Article

Introduction

Everybody's talking these days about the "information highway," but a number of technologically-minded visionaries and visionary techno-wizards at Dartmouth Medical School are actually doing something about it. Pioneering efforts in areas as diverse as interactive video, virtual reality, and information systems design are both influencing present-day medical education and patient care and holding out promise for the future.

The information highway - that much-invoked metaphor for the electronic pathways along which, in the foreseeable future, information of all kinds will blast at lightning speed - has several prominent on-ramps at Dartmouth. One is virtual reality, with associate professor of surgery Joseph Rosen, M.D., as its most visible proponent. Another is interactive video technology, a medium that offers great potential for the education of health-care students, providers, and patients alike; Joseph Henderson, M.D., an associate professor of community and family medicine, eloquently propounds its theory and meticulously crafts its products in DMS's Interactive Media Lab. At the Foundation for Informed Medical Decision Making, professor of epidemiology John Wennberg, M.D., and his outcomes research colleagues have likewise settled upon the interactive videodisc as the best medium to support their effort to involve patients in choices about their care. And a vision being articulated within Dartmouth's Koop Institute promises to bring together numerous innovative efforts under the umbrella of a health information system to serve all of northern New England - and perhaps an even wider area. Ultimately, hopes the Institute's senior scholar, C. Everett Koop, M.D., this system will serve as a "national template," influencing the shape of the federal effort to integrate technology into health care nationwide.

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Virtual Reality

Without a doubt, the most futuristic of the electronic technologies currently under investigation at Dartmouth is virtual reality. As any teenager who has ever visited a video arcade can explain, the concept of virtual reality is that of a computer image raised from two to three dimensions and controlled in a way that simulates reality. In other words, users operate a virtual reality system not by typing a command or by manipulating a mouse but just by moving parts of their body. A person using virtual reality experiences the sensation of actually being within the world generated by the computer's software - however like or unlike the actual world that may be.

Current-generation virtual reality systems, pioneered by NASA in the 1980's, rely on apparatus of two kinds. First is a set of goggles or a helmet that gives the wearer the sensation of being surrounded by the environment created by the computer software; looking at the apparatus's screen, the user sees the created world as reality. And then there are sensor-embedded gloves, by means of which the user controls the simulated environment; a twist of the hand "turns" a doorknob, for example, and then a pulling back of the arm "opens" a door that only the user sees.

The environments into which users can enter via virtual reality can vary widely. Today's best-known virtual reality systems are for entertainment purposes; the teenager at the video arcade dons helmet and gloves to become a warrior against an opponent who exists only within the software. But educational and even practical applications of the technology are coming closer to realization. DMS's Joe Rosen talks enthusiastically about a virtual replication in France last year of an 11th-century church, through which a bishop and a museum curator were able to "walk."

The day when virtual reality moves from video arcades and research labs into the homes and workplaces of the average American is nearer than many people may think, according to Rosen. A nationally-prominent proponent of the possibilities of virtual reality, he came to Dartmouth from Stanford in 1991. In November 1993, his research group demonstrated for the Illinois health-care company Baxter International what Rosen calls an augmented reality system, in which reality and virtual reality meet. When a surgeon operates on a patient's leg in this system, he or she operates at the same time on a model of the leg and on a real leg - fused in a single view for the surgeon. The arthroscope through which the surgeon looks shows the video of the actual leg, texture-mapped onto the computer- graphics model of the leg; this enhances the surgeon's perception of what he or she is seeing and permits work of greater accuracy and precision.

Rosen describes another augmented reality system under development by Chris Wiley, M.D., an assistant professor of anesthesiology at DMS. Wiley's system is designed to train new anesthesiologists. "Let's say I want to learn how to do a lumbar puncture," Rosen explains. "You're not going to let me do it on you. It hurts." Working with Sunil Singh, Ph.D., of Dartmouth's Thayer School of Engineering, Wiley has created a box with an attached needle. When an anesthesiologist in training operates the needle, an apparatus within the box creates the sensations of the needle popping through the skin and hitting the bone, all by means of computer software. This allows the anesthesiologist to experience the sensations of doing the technique correctly and incorrectly without having to work on an actual patient.

But Dr. Rosen's visions for the future go far beyond such actual, present-day applications. In his long view, the 21st century will be a software century, in which the physical movements and processes of the present will be replaced by their virtual equivalents. He dreams of virtual-reality-based plastic surgery of the future, in which a surgeon approached by a patient unhappy by the look of her nose will sit down with a computer. "It'll adjust the nose to the way it should look to whoever looks at you," he says. "Whoever looks at you is wearing some kind of glasses. When they look at you, your nose looks perfect. And I haven't done anything physical to you. Then we'll face issues on constraint. Right now the constraints to change your nose are cost, risk, and lawsuits, whereas in the future the constraints are all going to be creativity."

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Multimedia

Joe Henderson, equally involved in designing and bringing forth technologically enhanced versions of the real world, takes a different tack on the effort. The productions of the Interactive Media Lab exist squarely in the here and now, with education rather than immersion as a central focus. Formerly with the Uniformed Services University of the Health Sciences, Dr. Henderson developed his earliest interactive videos for use in training military physicians. Since coming to Dartmouth in 1989, his focus has broadened; among other things, his group has produced a program on respiratory emergencies in children in rural areas, which has been used to train hundreds of pre-hospital providers in eight states.

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IML's HIV Program

Henderson's ambitious current project, designed for students in the health professions, aims to impart information about the diagnosis and treatment of patients who are HIV-positive. The videodisc blends interviews with HIV- positive patients, simulated interactions with a patient who is just learning of his or her diagnosis, and statistical data about the condition, its likely progression, and its treatment. The mix of material exemplifies an aspect of the interactive video medium that interests Henderson: the potential for involving students emotionally in the health-science concepts they are studying.

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The future nurses and other students who interact with the HIV videodisc will not don the apparatus of virtual reality. Nonetheless, letting people access a created environment by means of electronic technology is powerful stuff. "I do think there's a distinction between what people are calling virtual reality and multimedia, but it's not as distinct as people like to think. I think it's all pretty much part of the same stew, in that it gives us a way of affecting people at a deep level," Henderson observes. "With this HIV program, we want not only to stimulate people intellectually, but we also want to move them. We want them to come to a new understanding so that their attitudes about the world are changed."

The human stories that are part of the video are never less than affecting; it includes extensive interviews with four people, including a young mother - plus her deeply concerned husband - whom viewers encounter at several stages of her journey from HIV-positive status to full-blown AIDS. In other segments of the videodisc, the "patient" is a college student portrayed by an actress. The interactive quality of the presentation becomes apparent in the segments where she responds in different ways to news about her treatment, depending on which of several choices the student watching the videodisc makes in answering her questions.

Laurie ("Laurie Matthews," virtual patient)

Showing a visitor to his lab clips of the interview materials and of the animated graphics that clarify, among other things, the precise way in which the HIV virus invades a healthy cell, Henderson calls attention to the challenges he faces in melding the various parts of his presentations: "We're struggling at this point with just a mass of materials and trying to bring them to a form that flows well and is clear and looks good." However great the effort, Henderson does not feel that he is fighting or forcing the technology. "I really do feel like it's a Stradivarius," he says. "It's an instrument to play. You use the technology the best way you can. In fact, there's nothing better today than good, plain, old motion video. You get a camera, you crank it up, and you start taping. It's just amazing what people will say - and what they say makes learning memorable."

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Similarities & Differences

The differences between what Henderson does and what Rosen is aiming to do are as intriguing as the similarities. As a pioneer in the application of virtual reality to medical practice, Rosen dwells in the world of possibility, although he sees realization as being within reach. Henderson, a sometime kayaking companion as well as a faculty colleague of Rosen's, is also a proponent of virtual reality - but not of the sort that relies on goggle-and-glove apparatus.

From Rosen's point of view, the essential difference between their approaches is that Henderson's programs offer a discrete number of fixed choices, while his projects give the operator a more open-ended role within the created environments. Rosen exemplifies the difference by describing a project for the Department of Defense with which he is involved. He is currently working with a group in Chicago that is under contract to make a model of a virtual leg for the U.S. Special Forces. The leg will be able to be wounded with a virtual bullet in an infinite number of ways, creating any defect that a soldier who had been shot in the leg might have. "You can look at that as the paradigm," Rosen says. "Our concept would be to shoot it and create any deformity, whereas Joe Henderson's approach would call for shooting it and picking four possible scenarios."

Henderson's view, in turn, is that "it is true that the choices in our programs are limited in number by the design of the reality created." He goes on, however, to point out that Rosen's virtual reality programs have constraints of their own, such as limitations on the adequacy of the model to represent the actual limb. "Most of these types of programs focus on a very small portion of a reality of interest," he explains. Henderson calls this a "reductionist view of reality - a knee or hip" and asserts further that "even when the entire body is modeled according to [Rosen's] dreams of the future, I think there will still be something missing - call it spirit, animus, soul. Or call it history - a sense that this reality or person exists, that it has a past, present, and is on a journey somewhere. That's what's missing from most of the discussions of [virtual reality] that I've heard."

Rosen likewise acknowledges the limitation his colleague expresses and makes an effort to synthesize the two approaches. Henderson, he muses, "thinks the involvement's the most important and he emphasizes the story. We've not done that. We've emphasized the science. And I would argue that the real answer is a combination."

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Informed Decision Making

Another group that's deeply involved with the possibilities - and the problems - of interactive videodisc technology is the Foundation for Informed Medical Decision making (FIMDM). A non-profit organization with Dartmouth roots, the Foundation is devoted to realizing the potential of outcomes research, pioneered by DMS's Jack Wennberg, and maximizing its role in empowering patients to become participants in decisions about their care.

Joseph Kasper, Sc.D., former president of FIMDM and still a member of its board of directors, sees the Foundation as a user of the technology rather than as among those who, like Rosen and Henderson, are stretching the technology's capabilities to the limit. (The Interactive Media Lab that Henderson directs, however, produced many of the Foundation's early videos.) FIMDM's interests lie instead, Kasper says, in "breakthroughs with regard to the application of the technology."

He explains how the group does that: "We have a double-barreled challenge - taking both a new concept, which is the idea of patients sharing in the decision-making with their physicians, as well as a new medium, and attempting to cause both to become a part of the way that health care is provided. The incredible wisdom of Jack Wennberg, in terms of knowing in his gut that patients should be more involved, that's very, very real. The incredible capabilities of Joe Henderson and others to have a medium that's very good at conveying information - we're taking advantage of all this and, like everybody else, we're running up against this stone wall called American health care: where innovation is not necessarily prized; where, if anything, health-care organizations have hunkered down over the last year, waiting to find out what's going to be happening in Washington. That's our role, trying to knock down barriers to innovation, to bring in a new idea and a new concept where it's needed."

The Foundation's original interactive video was developed for patients who have benign prostatic hyperplasia - a non-malignant enlargement of the prostate - and who are facing a decision about whether to have a prostatectomy. The group has more recently produced a program on low-back pain, one on mild hypertension, plus two on early-stage breast cancer treatment, one that addresses a woman's surgical options and a second, intended to be viewed after surgery, that presents options regarding adjuvant therapy such as chemotherapy and hormonal therapy. These videodiscs have been commercially available since January of 1993 and more than a hundred copies are in use in clinics and doctor's offices in this country and Canada. Six additional programs are currently in production.

Many approaches might have been taken to increase patient participation in health-care decision-making. But the Foundation found several compelling reasons for utilizing the medium of interactive videodisc. One of the most important, according to Jasper, is the potential of computer and video technology to present patients with information geared specifically to their individual circumstances. Patients begin their interaction with each program by answering questions about their age, gender, symptom status, and test results. Using this information, the interactive technology provides information through the course of the program that is specific to that patient. The program takes material from its extensive databases of information about the outcomes of various surgical and other treatments and collates it with the details supplied by the patient to give tailored responses. A patient might hear the program's voice-over say, for example, "For a patient like you, the chances that surgery will improve your symptoms are 27%, the chances that your symptoms will stay the same are 44%, and the chances that your symptoms will get worse are 29%."

Kasper sees the videodisc medium as a powerful enabler of communications efficiency. Patients can control the presentation, seeing as much as the choose, in whatever order they choose, and repeating as many segments as they like - without feeling embarrassed or stupid. By touching one item on an on-screen list of choices known as a menu, a patient can direct the program to show information about blood transfusions or to replay a segment about diagnostic techniques. As Kasper says, "It's using the computer as a high- powered browsing tool." As a result, the videodiscs may give more balanced and more targeted presentations, in some cases, than physicians are consistently able to deliver. It's easy for a busy provider to err in either direction - explaining less or more than the patient wants or needs to know. Also, as Kasper observes, "Patients are very imperfect listeners, particularly in the presence of a physician. They may have a feeling that a doctor's time is so very valuable, and who are they to dare to ask a question." More basic communication problems, such as hearing impairments, can also be overcome with a videodisc, since a patient can turn up the volume, wear a headset, or replay a poorly-heard segment.

Further potential empowerment comes from the Foundation's commitment to have its videodiscs make sense to the average patient. "We're recognizing that if this is going to be geared at graduate students, it's useless," Kasper says. "We're targeting on 100% comprehension at the 10th-grade level, and absent purely technical words such as 'prostatectomy,' with all the rest of the language I think we're close to achieving the objective. And that takes some clever work on the part of the scriptwriters."

Patient response to the Foundation's productions has been very positive. When asked if other patients should have an opportunity to use this type of program, 90% or more of the videodisc users agree. "The idea of participation in knowledge, or participation in medical decision-making, is something that patients are responding to extraordinarily well," says Kasper. And they aren't intimidated by the technology. "Benign prostatic hyperplasia is a medical condition that affects largely men 60 and older, a set of people that you would argue are probably the most likely to be computerphobic - but they were delighted," Kasper observes. "They did tell us, 'No mouse - give us a touch screen,' but beyond that, computerphobia was not a part of what was going on." To illustrate just how powerful an effect the videodisc can have, he recalls a patient in Denver who came out in tears, saying, "This is fantastic. Do you have one on hysterectomy? My wife is about to face the decision."

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Technology in the Medical School

For a younger population - medical students at DMS - the future is now as well. Joseph O'Donnell, M.D., associate dean for student affairs, ticks off the array of technologically-based projects already integrated into the medical school curriculum. For the past three years, first-year students have spent time in Clinical Symposia viewing and registering their responses to Dax's Case, a documentary about a victim of severe burns and his struggle to be allowed to die rather than continue an excruciating series of treatments. Fourth- year students in Acute Cardiac Life Support see Henderson's trauma program in their Emergency Medicine block. The benign prostatic hyperplasia video has seen four years of use in the fourth-year course Health, Society, and the Physician, and the video on breast cancer has been used in the oncology section of Scientific Basis of Medicine for a year.

From O'Donnell's perspective, classes that employ such materials are particularly memorable for students. Putting together many elements - sound and video, patient's views in taped interviews, the professor's own views expressed in traditional lecture mode - helps get across the concept that there is no single right answer. "Student's get a sense of patients' perspectives and also of their own values," explains O'Donnell.

Some of the students now in their third year of medical school confirmed these views when they reported to officers of the Culpepper Foundation, which has underwritten some of these projects, during a site visit they made to DMS. The class in which they worked with Dax's Case, the students said, was the highlight of their first year. In that class, associate professor of psychiatry William Nelson, Ph.D., presents the documentary and associated computer-based material, which call on students to confront their own ethical attitudes about the patient's insistence on being allowed to die rather than undergo the treatment. Meanwhile, Henderson roams Kellogg Auditorium with a microphone, soliciting student's questions a' la Phil Donahue. Up front on Nelson's left, a video monitor projects interviews with the patient and his doctors; the question under discussion, or the names and titles of the speakers in the documentary, are displayed via computer projection on another screen to his right. Through a full range of media, the students explore and debate a particularly harrowing example of an ethical dilemma that every single one of them will face as a practicing physician: If you can treat a condition, is there an absolute obligation to do so?

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Telemedicine

How will projects like these, each presently a discrete entity, position themselves along the information superhighway of the future? The concept of interactive television, which Rosen says "is what the fuss is all about" today, was originally articulated in the late 1960s . As it's now understood, this interaction involves a centrally located supercomputer to receive and send information to multiple users, plus cameras to pass information over multiple telephone lines. But transferring the amount of information that would be generated if interactive television were implemented on a large scale would soon overwhelm the nation's video lines.

Dr. Rosen sees a new paradigm emerging, however, one that's in line with his own interests in creating an illusion that clarifies and expands upon reality. "In the old way, these lines are sending [information] to some big server in control of the system. In the virtual reality system you don't have a big server anymore. Instead, each of the nodes is a supercomputer. The old paradigm is a supercomputer at the center with multiple small nodes out there. " He and his colleagues envision a striking alternative: "Everyone that's on the system, let's say there are four people talking, they'd all think they were interacting with a central area, but in fact they're not. There is no central area. The center is virtual."

Henderson is already experimenting with making the materials he is developing accessible over the national network that will comprise the information superhighway. These efforts are taking place on a futuristic piece of equipment donated to his Interactive Media Lab by IBM; called a PowerServer, it is both a repository and a delivery system for multimedia materials. He plans to use his program on respiratory emergencies in children to develop ways of using interactive multimedia over networks - connecting the server and the materials it holds to people in different locations around the country. The extremely fast PowerServer, with 512 megabytes of internal memory and 53 gigabytes of hard disk storage (compared to about one megabyte on the standard floppy disk), represents a clear technological advance.

During the production of the interactive videodisc on HIV, graphic artist Scott Chesnut took advantage of the PowerServer's speed and memory to create the animations of the action of the AIDS virus. "Even on [the PowerServer], it takes about two minutes to do all the calculations needed to render one frame of the animation," Henderson notes, "so you can imagine how much computation is involved." But while his group depends on such cutting-edge technology, Henderson emphasizes practical utility in his lab: "Our philosophy is that we're not here to do esoteric engineering research, we're here to do practical things that are useful."

Large, powerful network servers will one day be way stations on the information highway, Henderson envisions, serving both as repositories of data and as telecommunications centers. They will make available programs like his interactive video presentations and will also enable real-time videoconferencing. Henderson, who routinely devotes his efforts to creating effective combinations of live video and computer programs, sees the potential for blends that incorporate both. "If you were a provider or a patient, you could access a virtual teacher or a virtual consultant from your home or office to get advice. That person would be there all the time, ready to interact with. But there could also be a combination, with virtual people who are there to serve, combined with real people in a teleconference mode. And those are all things that we're working on." The distinction between live videoconferencing and a stored presentation does not, in his view, always favor the live interaction: in some cases, a presentation may offer better information than an interaction. "The actual person may not be a good speaker, may not be organized, may be rushed or distracted, may have gotten up ill that morning, or may have had a fight with a close family member. Any number of factors can influence how the person will do, and if I am putting a lot of effort into crafting an interaction, the viewer can gain some advantages."

At FIMDM, the eventual goal of making materials available over the network would address several current impediments to the wide acceptance of these interactive presentations. "We're coming to find out the most precious commodity in all health care is space. There's gotta be a gizmo, it's gotta sit somewhere, and somebody's gotta take care of it," Kasper observes. He also notes that interactive video technology in its current state has an associated production and distribution time. "If for example, somebody came out today with a brand new instant pharmaceutical treatment for low-back pain that made all low-back pain go away, we couldn't get that information produced and disseminated immediately. It would probably take us three to five months. [Meanwhile], we all know that it'll be in USA Today in tomorrow's edition. That's going to get a lot better when some of the exciting things people are talking about with regard to telecommunications begin to be applied more seriously in health care. There's no reason why our programs should be on laserdiscs where there's a separate laserdisc in every office. This could all come out of some central pipe. The information superhighway and health care are going to come together."

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The Koop Institute

One force which may be instrumental in bringing them together is the momentum being generated by the Koop Institute to infuse medical education and medical practice in northern New England with a degree of innovation and excellence that can serve as a national model. "One of the Institute's goals is to provide telemedicine not only for the general population but also for the physician," says Dr. Koop. His vision for the Institute includes reforming health care through lifelong medical education, beginning before undergraduate school and continuing throughout a physician's entire career. Technology has a particular role to play, from his perspective, in the latter, lifelong stage of a physician's learning. "We need to take the medical center out to the physician and make that work," he says. Embracing Rosen's and Henderson's vision of tomorrow's ubiquitous network, he also envisions medical centers and physicians going out to patients via the high-speed networks of the future. "In a few years you could have a kid in Bridgewater, Vt., with a sore throat, and he could step up to a monitor And the physician could look at his throat and say, "Looks like strep - you'd better come in for a test."

The Koop Institute's board has already approved a proposal to create a health information system that will tap the resources and expertise that an academic medical center can provide and bring them, via network technology, to practicing physicians throughout Maine, New Hampshire, and Vermont. Since then, the telecommunications industry has shown an interest in a partnership that would expand the information system throughout all of New England and use it as a testbed for other large-scale medical information systems nationwide. "Our information system could serve as a template for the federal government's thinking on this issue," says Koop. And he's in a position to speak authoritatively on the subject, having recently co-chaired an advisory committee of the National Academy of Sciences on the interface of health-care reform with high-tech communication.

Back in his Interactive Media Lab, Joe Henderson sees this role - this shaping of the national adoption of technology in medicine - not only as important for the country but also vital to DHMC itself, as the American workplace increasingly becomes virtual rather than physical. "Soon, if not already, I could work for a top medical center in New York and live in New Hampshire," he says. "More and more, people are going to move out of the cities into rural America as they can choose their place to live instead of having it chosen for them. A doctor in Berlin, N.H., may have just as much access to an expert at the Mayo Clinic as to an expert at Dartmouth-Hitchcock Medical Center. And suddenly, our competitive edge on a geographic basis isn't there any more as much. Clearly, if the patient feels that specialty care is just as easy to get at the Mayo Clinic as at Lebanon, it's a different competitive climate for the medical center. It changes the model from the quality of care to the quality of the information you can deliver. That's fanciful, and I don't know if it will actually happen, but it's the trend."

In the future, Henderson goes on, "you're going to have a high end of virtual reality. Then you're going to have people who are just moving around and dealing with phones and wireless communications and computers. We're going to be working and being entertained a lot of the time in an electronic environment. There are real opportunities in that for health education. The more attuned we are to what people want, the better we're able to give them good information in the form that they can best use it, the better service we're going to deliver. The Koop Institute will be a catalyst," Henderson predicts, "pulling those energies together."

Indeed, the catalytic role is being recognized at the highest levels. When Vice President Al Gore spoke in January at an "Electronic Summit" at UCLA, he outlined the government's intention to eliminate barriers to competition in the telecommunications field. Efforts are already underway, he said, to put all hospitals, schools, government organizations, and industrial sites on the information superhighway within the next six years. And one example he gave of that far-reaching, forward looking effort was Dartmouth's own Koop Institute.

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About the Author

Nancy Millichap, a freelance writer whose previous contributions to Dartmouth Medicine include "People of Passion" in the Fall 1991 issue, is also Dartmouth's manager of humanities computing.

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