Introduction
Access to the Net

Word Processing, Billing and Accounting

Patient Databases
Internet
Electronic Presentations
Future
Final Remarks






Introduction


We are currently living in interesting times. The information revolution is the third major revolution, after the agricultural and industrial revolutions. It is affecting everyone today, especially the physician. The computer provides him immediate access to educational resources through the world wide web and from free medline searches (available at http://www.medscape.com )


  • He has improved communication with his colleagues through email.

  • Computerizing billing and patient accounts enhances his office practice.

  • The patient benefits through improved educational information available on the world wide web.

The major use of computers in medicine still remains in the area of practice management, where a good computer system can improve the efficiency and cost-effectiveness of your practice.

Communication is the future of the Internet, and computers are the tools to connect to the internet.

For more detailed information on the Internet see - The Internet for Orthopaedists - available from Springer-Verlag

http://www.springer-ny.com/detail.tpl?cart=10433641223984561&isbn=038795483X



Remember, the computer is just a tool, it's not a religion!






What Hardware do you need?


1.   
The basic computer should be a Pentium pc, with a modem. You can improve the efficiency with a Pentium loaded with the latest  windows and a ISDN line, DSL or a cable modem. Many people have to be satisfied with the standard modem for home use.


2.   To image capture you need to have a  digital still image capture system on your arthroscopic camera.


3.   The Olympus, Nikon, Fugi digital cameras capture at high resolution, 2-4 megapixels  and are great for clinical pictures in the OR and clinic. I also take the x-rays from the view box with the Olympus camera.


4.   A good flatbed scanner is essential for larger images from textbooks, magazines, or photos.


I use both a inject color printer and a B&W laser printer for the document pinting to distribute.


5.   Another essential is to have at least a ZIP drive and preferably a JAZ drive to transfer and store images.


6. If you are going to make larger presentations you should have a CD writer. Both the writer and the blank CD's are quite inexpensive. The CD will store 650 Mb and allow you to take several presentations to the meeting.

7. The next step is to have a DVD writer that allows you to write 4 gig of information to one disc.






What Software do you need?


You need to have a TCP/IP connection with PPP. The connection to the net is made with a browser, either Netscape or the Internet Explorer from Microsoft. If you buy a new Pentium computer, with windows  loaded, and an internal modem, you will only have to get an internet service provider. Most computers will have the soft ware installed for AOL MSN and Prodigy, and all you need is your credit card to start surfing the Internet.

Even the process of connecting used to be difficult, but with windows  you use the built in TCP/IP found in the dial up networking, sign on with the Microsoft network or AOL and you will be up and running in a few minutes. When you buy a new computer from the 'big box stores', they will set up and configure MSN for free for the first year. 

Unlimited access time is $25.00 -30.00 per month. You should make sure that you have a local phone number for whatever service you sign on with. The long distance service charges are much more expensive than the service provider.

Microsoft Office  works very well to share the word documents with your PowerPoint presentation files. You can make up the presentation in word and share the images with PowerPoint.

You also need to have an image editing system such as Adobe Photoshop (www.adobe.com) . This will lighten, darken, or add text to the image. (plus many other functions) Lightview Pro (www.lview.com) is a less expensive choice that also works well to change image size and format quickly.

Ulead Photo Explorer (www.ulead.com)  is a simple program to archive photos. It sets up thumbnails of the images in the file folder where you have stored them. This makes it easy to open the file, review the thumbnails and find the image you need.






Access to the Net


The access to the net can be made with a local service provider, a national service provider, (like sympathico from Bell telephone), or by a commercial provider such as AOL or MSN.

The main commercial providers are:

  • AOL - American Online
  • CompuServe
  • The Microsoft Network - MSN
  • Prodigy.

The advantage of the commercial providers is that they are very easy for the novice. I initially started with a commercial provider and then switched to a local provider, to obtain unlimited connection at a fixed cost. It sometimes can be difficult to stop your service to some of the companies without actually cutting up your visa card!

Be sure that your phone connection is a local call, and not long distance, or you will quickly run up a large phone bill.






Word Processing, Billing and Accounting


Every country in the world has a different system of billing and accounting, but everyone can benefit from computerizing this aspect of practice.

Word processing is essential in orthopedics for patient documentation, and consultants' referrals. Most orthopedic surgeons still prefer to dictate their notes, and have their secretary transcribe the note on a word processor.


The Holy Grail of the paperless office is still unrealistic at present. In fact, I think that we have increased our paper use and not decreased it with our current state of computerization in our office. The next steps in arriving at the computerized medical chart are so far very expensive and difficult to justify in our cost containment atmosphere.

However, having said that, I spoke to Dr. Elliot Hershman about his electronic office on Long Island. He uses a tablet to enter all the patient information. This is transferred by infra-red to the main computer. After the patient has an x-ray in the adjacent office, he sits with the patient at a computer monitor and reviews the x-ray on the monitor. This office is effectively using the modern technology to the maximum.


Voice recognition software is available now, but is still more hassle than normal efficient typing, or dictating. The best program is Dragon Naturally Speaking (http://www.lhsl.com/naturallyspeaking/). The current speed is about 100 words per minute, at 95% accuracy. This needs to be 99.9% accurate before it becomes widely used in business, and that may take 5 years. The computer needs to be at least a Pentium 166 (mmx works best) and 48+ Mb of RAM. I have been trying the program on my laptop, pentium 3
with 256 Mb of RAM. It is slow, makes a few mistakes, but when you are keyboard challenged, it still beats typing long documents on the laptop.

Accounting and billing software greatly reduces the amount of time required for the secretary to process the data. In Ontario all our bills are submitted by codes on a floppy disc twice a month to one central billing office.

In our Sports Medicine Clinic, one secretary does all the billing for 5 Orthopods, and 5 family physicians in 8 hours per week! It is hard to beat that with a computerized system.

Soft ware is available for appointments and scheduling, but works only in low volume practice with appointments booked in advance.


Patient Databases


The more exciting area for future development is with patient databases. At the present time there are several available that allow the physician to record the history and physical examination on a hand held tablet, and have this data immediately entered on the main computer by infra red transfer. From this information the consultants note may be composed and printed. This is mailed to the appropriate source. ( emailed in the future)


Sports Medicine Applications



Documenting the examination and treatment at the time of injury is much more accurate than recording it after the fact. More practical is the use of a regular laptop with the documentation software loaded and ready to enter data in the training room. This is one area for concern in sports medicine, the documentation of injuries when traveling with sports teams. With the laptop and appropriate software this task is easy and accurate.






Internet


The use of the Internet to search for information is hampered at the present time by slow speed connections. With the cable modem and other faster connections, this may become a more important means of obtaining medical information during the working day.



Email


Communication has been revolutionized by email. This form of asynchronous communication is the best thing to happen since sliced bread. You can send a note to your colleague that he can answer on his own time. T his is similar to the fax, but with no ongoing expense.


List Serves and Mailing Lists


The use of email for list serves, or mailing lists, has also extended our communication of medical problems. The problem case is posted on a orthopedic or arthroscopy list; (a mailing list of interested members), the case appears when I open my email. I then can send a reply back to the individual who sent it, or to the list for everyone to read. The outcome is that this is a little like grand rounds, but with 800 members from around the world giving an opinion on the case.


Examples of these mailing lists are:


World Wide Web Sites


The best method of general searching is to use Google, found at www.google.com Yahoo at www.yahoo.com  has  all the web sites are categorized according to topics. You can search down through the categories or you can go to 'search' and enter the topic. Yahoo searches the titles of the web pages.

If you use excite or alta vista, then you can search into the pages of the sites. If you want to narrow the search further, enter quotes around the words. For example " anterior cruciate ligament" search for the 3 words used together.

The web sites of orthopedic organizations offer their members various services; members directories, abstract forms for the next meeting, educational books and materials, summaries from previous scientific meetings.

When faster connections become available, then it will be possible to view video of operative procedures, and the complete slide and audio digital capture of the previous scientific meeting. This will be especially important for the instructional courses.

The problem of how to charge for this service will be solved by secure credit card transactions or by a secure members password.


Examples

There are numerous web sites of orthopedic information. The best summary of the all the major sites (which lists all the sites that are related to orthopedics), may be found at:

http://owl.orthogate.com 


Examples of some sites of orthopedic and sports medicine interest are:

The Arthroscopy Association of North America - AANA at:

http:///www.aana.org


The America Academy of Orthopedic Surgeons at:

http://www.aaos.org

If you are a member of the academy, the Orthopedic Knowledge Online, OKO, is a new and potential leader in providing up to date orthopedic information. 

The American Association of Orthopedic Sports Medicine at:

http://www.sportsmed.org

ISAKOS - International Society of Arthroscopy, Knee Surgery and Orthopedic Sports Medicine www.isakos.com  



The Wheeless online orthopedic textbook is available to read online (note there is a sports medicine button to connect to sports medicine articles), you can find this site at:

www.orthogate.com 


If you want to do a
MEDLINE search then go to the address below for free online searches. Note, you have to pay to receive photocopies of the articles mailed out to you. There is a button on the home page of Medscape that connects to orthopedics and sports medicine.

http://www.medscape.com

You can also go directly to PubMed to search MEDLINE 

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi


A sports medicine newsletter (that just lists articles) is available at the address below. If you want to read the full article, you have to subscribe to the hard copy (and pay the subscription fee)

A sports medicine newsletter is online at:

http://cac.psu.edu/~hgk2/feature.html

This site just lists the articles, if you want to read the full article, you have to subscribe to the hard copy. ( and pay the subscription fee)

Patient information and CD-ROM information available from this site:

http://www.sechrest.com/mmg/

They also have a CD-ROM that has all their web site info, so that you do not have to spend time downloading the images. The images are extremely well done, and help to illustrate clinical problems. For example look up the anterior cruciate ligament and patellofemoral problems.



Another interactive sports medicine site is Sports Doc at:

http://www.medfacts.com

The Journal of Arthroscopy has abstracts of the latest journal at:

http://www.arthroscopyjournal.org

The sports science site is at:

http://www.sportsci.org/

The commercial newsletter Orthopedics Today is at:

http://www.slackline.com/bone/ortoday/othome.htm



The Hug
hston Orthopedic and Sports Medicine Clinic at:

http://www.hughston.com/


The home page of Dr Rick Hammesfahr:

http://www.arthroscopy.com/


Dr. Kevin Stone's web site is at:

http://www.stoneclinic.com/


Primary Care Sports Medicine

http://www.arcade.uiowa.edu/hardin-www/md-fam.html


A site that reviews and rates web sites for physicians is called Physician's choice at:

http://www.mdchoice.com


The virtual children's hospital in Iowa City has a good Intranet with lots of resource orthopedic information at:


http://vh.radiology.uiowa.edu/Providers/Textbooks/MuscleInjuries/MuscleInjuries.html


Another site in Canada that provides information is at:

http://www.cha.ab.ca


Intranets


A network designed for information processing within a company or organization.
Its uses include such services as document distribution, software distribution, access to databases, and training. An intranet is so called because it usually employs applications associated with the Internet, such as Web pages, Web browsers, FTP sites, e-mail, newsgroups, and mailing lists, but accessible only to those within the organization.

This is the medium to post the electronic presentations made by the hospital staff. We are currently setting up an Intranet for the "Ottawa Hospital". The most difficult aspect is to establish the policy of content, who publishes to the intranet, and who keeps the information up to date. Some companies have very extensive intranets, that enables them to cut down on paper work. If many people are to read a new policy, this can be posted on the intranet for everyone to read, instead of emailing it to everyone.






Electronic Presentations


PowerPoint has proven to be an excellent software package for presentations. Now the presentation can be projected from the laptop by a LCD projector to a large audience. There is no need to make slides. Images and video may also be incorporated into the project. The multi-media may be saved as html and put up on the web site for later viewing and downloading.


Electronic Publishing


Journals, newsletters and books are all available in multi-medial format on CD-ROM. The Journal of Bone and Joint Surgery is now available for the past years, and now even the current editions are on a CD-ROM. The Journal of Arthroscopy and Sports Medicine are also available on CD.

The Sports Medicine Digest is available in traditional paper format from Lippincott-Raven publishers. 

Practical Arthroscopy is available in paper format from:

Sports Medicine International,
P.O. Box 15043
Sarasota, FL.
34277.

Practical Arthroscopy is also available online at:

     http://www.newsltr.com/arthro/

Macromedia is a complex and powerful authoring tool for electronic publications. In many aspects this is far superior to books for learning. Think how much more vivid a video of the pivot shift examination is, rather than a textbook description of the same.

The textbook of Operative Arthroscopy
by McGinty 
is available on a CD-ROM with video of arthroscopic ACL reconstruction techniques. The newest revision will have operative procedures on a DVD.

Electronic publishing is certainly much easier and faster than the traditional methods. Instead of the text and prints having to be submitted separately, you can edit the layout on your own desktop publishing program such as Microsoft Publisher or Adobe PageMaker. This is then immediately available to print or to change to html and put on the web site.

Many of these programs are expensive, and beyond the reach of the busy practitioner to become proficient .








Future

Education and the Internet

Will the internet revolutionize the process of teaching, and replace the current methods?

I don't think so. I still believe that medical teaching will be done with a teacher, a student and a patient. Even in 10 years there will be no substitute for this one on one, live, real time, hands on experience.

So, where will the Internet fit in?

I think that it will add to our experience, especially in quickly searching for information, and discussion of interesting cases. The latter may be one of the greatest benefits. An interesting case, with images and even video, will be presented and hundreds of comments from around the world will be posted. This is much like a virtual grand rounds format.

The standard forms of communication by peer review articles and hard copy magazines will continue. The internet will only provide that information faster. However, there is no substitute for lounging around home in your favorite chair reading a journal.

'Just in Time' video will be available from Internet sites that will allow you to review the operative procedure just before you do the case. 


Voice Recognition


The voice recognition programs are still in the developmental phase. When they become faster and easier to use, this will open up the capabilities of the computer to many more people. There are many physicians who would use the computer more, but their typing skills are lacking enough to make the experience painful. When they are able to talk into a microphone and see the words appear at 100 words per minute, then it makes sense to dictate your letters and patient notes, avoiding the extra expense of a transcriptionist. See Dragon Naturally Speaking at http://www.lhsl.com/naturallyspeaking/.

Now with a software program we can use the computer for long distance phone calls without paying long distance rates. I think that the phone companies will probably not let this software develop too much farther!


Video Conferencing


With the addition of a inexpensive video camera ( $100 black and white ) you can send video and voice to another computer with the same software. Once we have higher speed modems and more bandwidth, this may become more popular. We keep hearing that next year everyone will be using this, but so far it is limited by the bandwidth of the services.

Cable modems are 100X faster than the 28.2 that we now use. Bill Gates seems to be banking on this, since he bought controlling shares in Comcast, one of the large US cable companies.

This technology would eliminate some of the traveling to meetings for information that we now have to do. There is no substitute for the one on one interaction that occurs during the meeting or over dinner.

At the Heart Institute in Ottawa there is a large screen television that is connected by satellite to a community hospital 100 km away. The view on the screen is of the patient in a bed. The local physician can place an electronic stethoscope on the patient, and the cardiologist in Ottawa can hear the sounds a clear as if he had the stethoscope on the patient in the same room. The chest x-ray can be scanned in 2 minutes, and visualized on the screen. The video is broadcast quality.

The next step in this process is to connect a remote hospital 1,500 Km away in Baffin island to the system. This hospital could relay the clinical examination, the scanned x-ray of the fracture, and decide with the orthopedic consultant in Ottawa if the patient required transfer to Ottawa, for further treatment.

We are starting with email and scanned x-rays as the first stage of this process.


Image and Video Integration in documents and Communication


The next logical step is the integration of the digital video of patients clinical examination, digital capture of arthroscopy images, x-rays, and video of operative procedures, into the patients chart. This is then stored in medical records and available on hospital intranets. This information is then accessed with a secure password, when the patient makes his post op visit to your office.

One of the leaders in this software is NoteMatic, at http://www.puremed.com 

Some parts of the record would be available to print, such as the operative record and the arthroscopy image to give to the patient or send to his referring physician.

In summary, in the medicine of the future, you are either going to driving the bus or waiting at the bus stop wondering if this is the right bus line. Or, it is going to be like the Middle Ages, you are either a peasant, or a landowner. In this digital age of information, you had had better know how to access and use the information available.






Final Remarks

So, what do I do with the computer?

      Communicate

    My major use of the computer is to communicate. I use email to communicate with colleagues, use the mailing list to discuss cases, refer to web sites to register for meetings such as www.aaos.org  and www.aana.org and the www.orthogate.com  site to search for a orthopedic information.

      Educational Communication.
    I use Word to make handout documents, and PowerPoint to make educational presentations. I use FrontPage to publish electronic documents such as this page and the CD on the anterior cruciate ligament.

    I collect and archive digital still arthroscopy images, digital clinical photos, and digital video. These are used in my PowerPoint and CD-ROM publications.