Comments on:

The Next Generation Internet

Edward H. Shortliffe, MD, PhD

Professor of Medicine and of Computer Science

Associate Dean for Information Resources and Technology

Stanford University School of Medicine

Stanford, California 94305

Before

The House Committee on Science

Rayburn Building

September 10, 1997

I would like to thank Chairman Sensenbrenner and the other members of the Committee for this opportunity to address you regarding the Next Generation Internet proposals and, in particular, their relevance to the future of the nation’s health-care delivery system. I come to you both as a practicing internal medicine physician who serves on the faculty at Stanford Medical School and as a computer scientist who spends most of my nonclinical time devoted to teaching and research in the field of medical computing. Much of my recent work has explored the role of wide-area networking, and specifically the Internet, in support of health care, and I currently serve as a member of the Presidential Advisory Committee on High Performance Computing and Communications, Information Technology, and the Next Generation Internet. I also serve as the biomedical representative on the faculty advisory committee for the academic consortium known as Internet2. I therefore am familiar both with the NGI and Internet2 initiatives and with the relationships between them. Both are very concerned with anticipating and planning for the kinds of applications that will benefit our society but that cannot be supported effectively or reliably by the Internet of today. I will focus my remarks on such applications, with an emphasis on biomedicine.

I should perhaps mention that I am not a recent initiate to the world of the Internet. As a medical student at Stanford in the early 1970s, also studying computer science, I was fortunate to be exposed to advanced computing resources that were available on our campus. The machines I used were connected to the Arpanet, the predecessor to today’s Internet, and I soon realized that this marvelous, federally funded network was a boon to our research and allowed collaboration with scientists around the country in ways that would previously have been unthinkable. The world of electronic mail, file transfers, and distance collaboration became second nature to me, long before there was a World Wide Web. I therefore soon became frustrated as I realized that the world of medicine was slow to understand and adopt technologies that had great promise for enhancing the nation’s health care system as well as its basic biomedical research. Unlike many of the new technologies that have proliferated in health care, this one even had the chance of significantly reducing costs. Some 25 years later, despite remarkable advances and the transfer of the network to the private sector, we are only beginning to see our fragmented health care system understanding and adopting the Internet as a tool for health-care delivery and information access. With proper leadership, investment, and commitment, there are marvelous opportunities for innovative medical uses of the networking technology that is already available to us.

But my purpose today is to focus more on what the Internet of today cannot do for us, and how the research programs and testbed activities of the Next Generation Internet effort will help pave the way for what we envision for the future of our nation’s health.

I envision the day when today’s early telemedicine experiments, dependent upon specialized equipment and expensive communications lines, will have evolved so that the Internet becomes the standard vehicle for linking medical experts with other clinicians and patients at a distance. Clear video images will be transferred, high fidelity audio links will support listening to the heart and lungs, and common computing platforms at both ends of the link will at last make this kind of medical practice clearly cost-effective. Patients will avoid unnecessary travel from rural settings to major medical centers, primary-care clinicians will have expert consultation delivered to them in their offices in a highly personalized fashion, and patients will accomplish in single office visits what now often takes multiple visits and major inconvenience.

I envision the day when I can work with residents and medical students in a community clinic, discover an unusual skin lesion on an indigent patient, and obtain immediate teleconsultation from a dermatologist back at Stanford. Both the student and I will learn from the dermatologist, the expert will receive clear diagnostic-quality images of the lesion, and the patient will promptly receive an answer. All too often these kinds of patients, when referred to major centers, fail to keep their appointments due to travel problems or simple fear of the large institution. Instead of sending our patients to the experts, we will improve their care by using the Internet to bring the experts to them. The potential to reduce costs and improve efficiency and satisfaction is also clear.

I envision the day when citizens no longer have multiple medical records scattered around the country in the offices of various physicians and the medical record rooms of numerous hospitals. Instead, their records will be linked electronically over the Internet so that each person has a single "virtual health record", the distributed but unified summary of all the health care they have received in their lives. Furthermore, this record will be secure, treated with respect and confidentiality, and released to providers only with the patient’s permission or under strictly defined and enforced criteria at times of medical emergency.

I envision the day when a medical student on her orthopedics rotation, preparing to observe her first arthroscopic knee surgery, goes to the electronic learning center and uses the Internet to access and manipulate a 3-D "virtual reality" model of the knee on a computer at the National Institutes of Health. She uses new immersive technologies to "enter" the model knee, to look from side to side in order to learn the anatomic structures and their spatial relationships, and manipulates the model with a simulated arthroscope, giving her a surgeon’s-eye view of the procedure before she experiences the real thing.

I envision the day when a pharmaceutical researcher, working on problems related to drug discovery, uses the Internet to work with a 3-D molecular model on a supercomputer that is located hundreds of miles away. The researcher manipulates the model, visualizing it on a local display screen, and is able to examine the relationships among atoms, the shape of the active site of an agent or a receptor, and does all this without moving the data from the supercomputer to a local machine.

I envision the day when I can prescribe for my patient a specially-selected video educational program that will be delivered to his home television set by a direct Internet connection. Our hospitals and clinics will use video servers over the Internet not only to deliver such materials to patients, but also to provide continuing medical and nursing education to their staffs. Health-science schools will similarly provide distance-learning experiences via the Internet for postgraduate education, refresher courses, and home study by health-science students.

I envision the day when the video link into the home will be 2-way, so that the physician can move beyond the simple use of telephones for managing patient problems at a distance to using their visual senses as well. The infirm will have "home visits" via video links, avoiding unnecessary office or emergency room visits, and physicians will have important new tools for monitoring patients and putting new emphasis on prevention rather than on crisis management. Early experiments show remarkable enthusiasm by patients when familiar physicians and nurses provide such videoconferencing interactions in the home.

Although I could go on, the examples I have cited here have one thing in common in addition to their biomedical focus: they could not be effectively and reliably implemented on today’s Internet. Each requires bandwidth that is currently unavailable, of course, but the problems are more significant than that and point to the research agenda that motivates the NGI projects. We clearly need higher speeds, but many applications will fail to be effective or accepted if the quality of that bandwidth is also not adequate. How do certain kinds of applications obtain guaranteed, reliable transmission speeds, even if they are only needed for a short period of time? We don’t know. How can we best deal with the problems of latency, the inherent delays due to the time required for transmission of signals? We don’t know. A surgeon attempting so-called telepresence surgery over the Internet, bringing specialized expertise to an operating room possibly hundreds of miles away, will be unable to assist in the procedure if the movements he makes with hand devices at his end are not instantly reflected in what he sees happening with the actual instruments at the other end of the link. How do we assure interoperability across the many networks (some of which are provided by Federal agencies) that now criss-cross our country? We don’t know. How do we assure that the necessary bandwidth for the applications I have proposed is available not only on the major backbone networks, but also on the last segment of wire, cable, or wireless network that comes into our homes and offices? We don’t know.

There is a clear research agenda that must be tackled, and as was the case in the early days of the Arpanet, it will take an effective partnership between government and academia, informed by and coordinating with the changes that are occurring in industry. We would not have an Internet today if the Government had not created the Arpanet 30 years ago; industry would not have made the long-term investments necessary to create the technology and to gradually demonstrate its utility and practicality. It was 1995 before the national backbone network was finally fully handed off to the commercial sector. Similarly, as a member of the recently formed Presidential Advisory Committee on High Performance Computing and Communications, Information Technology, and the Next Generation Internet, I have already heard briefings from industry leaders that convince me that the innovations required for the NGI will not be undertaken if the investment is left to them. Only the Government and academia will take the long-range view necessary to move the agenda forward, but industry will provide important partnerships in the process, and will provide the mechanism for transforming prototypes and experimental models into industrial-strength implementations that the Next Generation Internet will require.

In conclusion, I am very excited by what is happening with the Internet today, but am eager to see developed the new technical and logistical capabilities that will enable the kinds of future applications that I have outlined this morning. The research agenda of the NGI is aimed at making these kinds of capabilities available, and I strongly support it. The biomedical computing community is also eager to participate in that research agenda. We look forward to creating the medical applications that will help to drive the development of advanced networking technologies while we also help to evaluate their capabilities. It is the health and medical care of our citizens that will ultimately benefit from these efforts.