Clinical Computing: Developing Trends of the World Wide Web

"The Internet is changing the world." We hear this message daily as advertisers, news programs, and journal articles refer to the World Wide Web with increasing frequency. The ease of using the Web has allowed it to capture the attention of both the business and the academic worlds, and this influence will extend to many aspects of psychiatric work as well (1).

This column describes how the process is currently proceeding and four general trends that are guiding it: the world's movement to the Web (the consolidation of information on the Web), the Web's movement to the world (increased access to the Web), managing the Web (the trend to facilitate management of Web information), and management by the Web (the trend toward use of Web-based information for management). We then explore implications of these trends for the practice of psychiatry and how the individual psychiatrist can address them.

The world's movement to the Web

The first trend guiding changes in the World Wide Web is the movement to place all types of electronic information on the Web. This broad movement can be divided into two general categories: adding newer forms of information and adding new information content from newer sources. Newer forms of information are the different formats for the presentation of information. Originally, the Web transferred text and perhaps occasional photographic images. Now Web pages contain more "multimedia," with images that are animated or interactive, responding directly to movements of a mouse or other indicator from the user (2). Sound and video are now appearing on the Web, with Web sites that allow one to hear news broadcasts from major television networks or see video clips advertising upcoming movies.

Although limited network speeds make it difficult to take advantage of these more complex possibilities, the leading edge of technology will continue to push forward to create even newer forms of information. Technologies such as Java or ActiveX permit the transmission of more than simple data, sending actual instructions for the computer (3). Current updates to the Microsoft Windows operating systems use the Web as an interface for all functions of the computer (4). Everything that is done electronically can eventually be accessed through a Web interface.

Besides additional forms of information, newer sources of information continue to be added to the Web. Organizations are rapidly moving on-line, representing themselves with Web sites even before they are really prepared for the implications. The pressure to be a part of this movement is tremendous. To save on costs, state and federal agencies are on the Web. Groups like the Internal Revenue Service provide downloadable forms that are available 24 hours a day, seven days a week, which obviates the need to hire office staff in every city (5). Peer-reviewed electronic journals and electronic versions of paper journals are appearing as publication companies and academicians attempt to carve out a niche in this information resource (6).

As people move more information sources to the Web, previously unavailable sources appear. Real-time traffic maps updated by remote sensors are available for major cities like Los Angeles, Seattle, Houston, and San Diego. Live video cameras connected to the Web document skiing conditions or provide views of the earth from the space shuttle. Many forms and sources of information are moving to the Web.

The Web's movement to the world

Complementing the movement of information to the Web is a movement toward broader access to the Web. We will see Web-based devices in more places, performing more functions. This trend is illustrated in the movement of the Web into the home television set. "WebTV" boxes, now marketed for less than $300, allow people to use their television set for Web browsing by connecting to the television and a telephone line. Several major television manufacturers offer special models of their television sets that contain such Web hardware.

The experience of television itself will likely change over the next year as new WebTV boxes link to live television programs. Cable companies and WebTV designers have created television programs that are "enhanced" with Web-based information so that a television viewer can jump to a Web page to obtain further information or complete an e-mail survey (7,8). Integrated systems using cable and newer transmission technologies will make the Web less of a specialized system accessed through slow modem-linked computers and more of an everyday enhancement of the technology we already take for granted.

In this mixing of technologies, other informational devices are interfacing with the Web. Fancy cellular telephones can now fax, e-mail, and access the Web. Computer interfaces connect Web information to telephones, fax machines, and pager services (9). Some adventurous researchers and companies have even created small wearable computers that connect to the Web. Although such gadgets are unlikely to have a wide appeal, technology will continue to push Web-connected devices and "Internet appliances" into all corners of our lives.

Managing the Web

The growth of Web-connected computing hardware is being followed by growth in systems design and software that attempt to make the use of that hardware easier and more intuitive. Currently, use of the Internet is difficult, requiring time to learn and practice obscure sequences of commands or rules of operation. Although the advent of the Web has somewhat simplified this process, the majority of adults still find the Internet intimidating, especially when they attempt to navigate through the large volumes of available information (10).

New technologies like that of "electronic agents" attempt to learn more about a user's preferences and then manage tasks or retrieve information. Experimental agents are currently being used to take a request for information, search though copyrighted databases, and then negotiate a payment for retrieved information (11). Even with such agents, a learning process is involved. The agent must learn the types of articles the user likes to read or must understand when a search through the New York Times might be preferable to one through Nature. Eventually, through a process of evolution, better systems will make it easier for everyone to effectively use the Web.

Management by the Web

Although systems remain difficult to use, more organizations are already immersing themselves in the Web because its ability to move information makes it useful in management. Traditional computer systems used proprietary methods of communication, making information sharing across different databases difficult. The simplicity and universality of the Web has made it a ubiquitous interface for current information systems.

Companies are quickly creating "intranet" networks, which use Web technology in private, non-Internet communication networks (12). These networks allow company managers to rapidly disseminate performance standards and retrieve performance data from the field. Wider use of the Web in this fashion is driving the development of tools to customize the Web for business tasks such as scheduling, communications, and process monitoring (13). Pressures for information management will synergize with further use of Web technology to make the Web a familiar tool for management in organizations.

Implications for psychiatry

In an age of managed care and public demands for concrete, simply defined solutions to illness, the four trends will work their way into the psychiatrist's office. The Web's movement to the world means that psychiatric information will be on the Web. Already we see Web sites for organizations like the American Psychiatric Association, the National Alliance for the Mentally Ill, and the National Institute of Mental Health. Free MEDLINE searches are available (14), and many publications are moving toward providing full text of articles on-line, including the Archives of General Psychiatry (15) and the Harvard Mental Health Letter (16). The American Psychiatric Association plans to have full-text editions of its journals—the American Journal of Psychiatry, Psychiatric Services, and Psychiatric News—available in 1999 through the HighWire Press of Stanford University (17).

The world's movement to the Web means that more and more of our patients will have access to such Web-based information and expect us to have similar access. That trend and expectation will grow as managing the Web becomes simpler and easier with academic and commercial improvement of Web technology. Managers will use these tools to communicate with us, disseminating standards and obtaining information about patient treatment (18). Standards from organizations like the National Committee for Quality Assurance are on-line (19).

The future we describe has both good and bad aspects. We will discuss some of the potential problems we anticipate in an upcoming companion column, suggesting more specific actions we need to take as individuals and as a profession. At this point, we simply emphasize that the processes described here are inevitable. Predictions about technology are always fraught with opportunities for error, and we will not presume to suggest that these trends present a precise definition of our future.

Yet the trends encapsulate the forces that are shaping what will be. We must prepare ourselves individually by educating ourselves and recognizing the ways in which we will have to alter our accustomed practice. We will also need to prepare as a profession, advocating for measures to protect our practice and encouraging the training of future psychiatrists in these areas (20) so that we can make informed and rational decisions about how we should react and adapt to an enclosing Web (21).

Dr. Huang is assistant director and Dr. Alessi is director of the psychiatric informatics program in the department of psychiatry at the University of Michigan, 1500 East Medical Center Drive, Box 0390, Ann Arbor, Michigan 48109-0390. Dr. Alessi is also director of the child and adolescent psychiatry program in the department. John H. Greist, M.D., is editor of this column.