SPECIAL
ARTICLE
The
Pediatric
Internet
S. Andrew Spooner, MD <[email protected]>
ABSTRACT. The Internet is a set of rules for computer
communications that has created easy access to electronic
mail, electronic mailing lists, and the World Wide Web. The “pediatric Internet” consists of a growing collection of Internet resources that deal specifically with the health care of the young. Locating this information, judg-ing its quality, and determining its appropriate use pre-sents difficulties, but the ubiquity of the Internet makes it imperative for child health professionals to learn the skills necessary to access and provide information via this medium. The Internet will be used increasingly for scientific publishing, the original purpose of the World Wide Web. This article presents basic definitions for the Internet, some characteristics of the pediatric Internet,
guidance on how to locate information, and what the
future of the pediatric Internet holds. Pediatrics 199698:
1185-1192; Internet, computer networks, World Wide Web,
E-mail, medical informatics.
ABBREVIATIONS. US, United States; ISOC, Internet Society;
WWW, World Wide Web; URL, Uniform Resource Locators;
HTFP, Hypertext Transport Protocol; HTML, Hypertext Markup
Language; IP, Internet Protocol; DNS, Domain Name System; FTP, File Transfer Protocol; IRC, Internet Relay Chat; OMIM, Online Mendelian Inheritance in Man.
The medical content of the Internet is growing
apace with the rapidly changing on-line world.’
Par-ents, physicians, and others interested in child health
perceive a use for the pediatric Internet-the web
sites, electronic mailing (E-mail) lists, chat groups,
gopher sites, and file archives pertinent to health care
of the young. Although the usefulness and reliability
of information derived from the pediatric Internet is
unproven, professionals and the lay public are eager
to cite the Internet as a valuable source of
informa-tion that breaks down old barriers to information
access. This article joins others in the medical
litera-tur&4 in introducing the physician to the Internet’s
use in medical practice, with particular emphasis on
the pediatric Internet.
THE INTERNET, THE WORLD WIDE WEB,
AND E-MAIL
At its heart, the Internet is simply a set of rules that
dictates how computer signals on networks should
Received for publication Oct 16, 1996; accepted Oct 16, 1996.
Address correspondence to: S. Andrew Spooner, MD, Department of Pedi-atrics and Section of Medical Informatics, Division of General Internal
Medicine, Department of Medicine, University of Alabama at Birmingham School of Medicine, 1600 7th Ave 5, Suite 512, Birmingham, AL 35233.
PEDIATRICS (ISSN 0031 4005). Copyright © 1996 by the American
Acad-emy of Pediatrics.
be interpreted. These rules have become widely
ac-cepted, thanks to the early propagation of these rules
by
the United States (US) government. Since theInternet’s inception as a US Defense Department
project in the 1960s, the rules that make a computer
a participant in the Internet have spread to virtually
every network in the world. The diverse computers
and networks that use Internet rules behave as if they
are connected to one homogeneous, global network.
Its ability to effect communication between disparate
networks-to “internetwork”-is what gives the
In-ternet its name.
The rules that define the Internet are managed by
a professional organization known as the Internet
Society (ISOC, <http://www.isoc.org/>). Groups of
engineers from ISOC write and modify protocols
that computers use to communicate, but ISOC in no
way runs the Internet. No individual or group
dic-tates what information can be on the Internet. For
this reason, the Internet has become the focus of
efforts to regulate its content (The Communications
Decency Act,
US
Public Law No. 104-104, passed inFebruary 1996; currently, this is being contested).
Parents concerned about inappropriate content on
the Internet have created a market for software that
screens out words, images, and types of files that
might be inappropriate for children.
To many people, the Internet is synonymous with
the World Wide Web (WWW). Although the web is
certainly the most visible way people access the
In-ternet, the WWW is only one of many different ways
that information can be exchanged between
comput-ers on the Internet. E-mail, Gopher, Internet Relay
Chat, File Transfer Protocol, and Archie are several
other methods, each of which has its own set of rules
and computer programs.
The WWW is a good starting point in
understand-ing the Internet. The WWW consists of web pages
that one accesses via a web browser, like Netscape
Navigator (Netscape Communications Corporation,
Mountain View, CA) or Internet Explorer (Microsoft
Corporation, Redmond, WA). Fig I shows an
exam-ple of a web page that contains underlined words
that serve as hypertext links to other pages on the
WWW and to E-mail. Using a mouse, one clicks on
one of these links to go to the applicable web page.
Because pages are linked in this way, a richly
inter-connected “web” is formed; it is this web of
hyper-text links that gives the W%’VW its name. Another
important feature of the WWW is its multimedia
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Avoice for children for more theo 60 years, the Americen Acndemy of Pedintrics (AAP) is on
orgonizotion of 50,000 pediotricions dedicoted to the health, safety ond well-being of infonts, children, adolescents end young adults.
I Members IParents IQ.portments I I ti4 I Discl8i mer
!1I mailtG:k*[email protected] I ? li
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Fig 1. A World Wide Web browser window. The Netscape Navigator pro-gram is being used to view the home page of the American Academy of
Pe-diatrics, whose Uniform Resource
Lo-cator is <http://www.aap.org>. The
cursor is positioned over the “Mail”
hypertext link (underlined). The action this link will take-to send E-mail to [email protected] indicated at the bottom of the screen.
images, hear sounds, music, or heart sounds, and
read text in a variety of typographic styles on web
pages. This feature of the WWW can make web
content valuable for pediatric professionals; for
ex-ample, one may locate interesting radiographic
cases (eg, <http://www.uhrad.com/pedsarc.htm>)
or heart sounds (eg,
<http://synapse.uah.ualber-ta.calsynapse/OObl0000.htm>) on any Internet
com-puter, anywhere, without using special software.
This ability of the WWW-and the Internet as a
whole-to allow access to information regardless of
one’s type of computer or geographic location is
what makes the WWW revolutionary.
Each web page on the WWW has a name that
allows access of that document from anywhere on
the Internet. These names are called Uniform
Re-source Locators (URLs) and usually look like this:
<http://www.aap.org/news/news.html>
The first part of the URL specifies the protocol for
how the information is to be transmitted to the
re-questing computer; for web pages, the protocol is the
Hypertext Transport Protocol (HTI’P). The double
slash indicates that the next piece of text is the name
of a computer, in this case www.aap.org. The
remain-ing text specifies a subdirectory
(news)
and a
file namewithin that subdirectory (news.html). The html file
suffix in this example indicates that the file is a plain
text file that was prepared according to the
Hyper-text Markup Language (HTML) scheme. HTML is a
system of text tags that specifies features of the
doc-ument like typography, the layout of tables, the
lo-cation of graphics, and other aspects of the web page.
One does not need to know anything about HTML to
read web pages.
E-mail is the most frequently used method of
com-municating on the Internet. Because of Internet
pro-tocols, a person’s Internet E-mail address is the same
no matter where the person is or what kind of
corn-puter he or she uses. Generally, Internet E-mail
ad-dresses include a user name (eg, kidsdocs), followed
by the @ symbol, followed by the name of the
corn-puter (the mail server) which handles the person’s
E-mail (eg, aap.org). Because of a universal naming
scheme held in a distributed, worldwide database,
the name of this mail server cannot be confused with
the name of another computer on the Internet. All
computers on the Internet can have a name. For
example, the computer that hosts the American
Academy of Pediatrics WWW site (Fig 1) is called
www.aap.org. The org at the end of the machine
name implies that the name is registered to a
non-profit organization. Other machine names may end
in edu (educational institutions), corn (commercial
ventures), gov (governmental organizations), and so
forth. These machine names are translated into
Inter-net Protocol (IP) addresses by certain computers on
the Internet known as Domain Name System (DNS)
servers. For instance, www.aap.org’s IP address is
206.214.32.100. It is significant that one may use the
information located on the www.aap.org machine
without the slightest idea of what its IP address is.
This insulation of the user from bothersome details,
like HTML and IP addresses, is a major benefit of the
modern implementation of Internet protocols.
OTHER INTERNET PROTOCOLS
File Transfer Protocol (FTP) is a method of moving
files from computer to computer. A file in an archive
might have the URL
< file://ftp.aap.org/redbook94/pertussis.pdf>
which states that the file pertussis.pdf can be
ac-cessed through the FTP protocol, from the machine
ftp.aap.org,
in
the subdirectory redbook94. Onecould access this file through a web browser or
through a program that handles only file transfers.
in Adobe Acrobat (Adobe Systems mc, Seattle, WA)
form, which can be read by numerous types of
corn-puters using free reader software.
Gopher is a method of information access on the
Internet that has become less popular as the WWW
has gained popularity. Gopher-named for the
Golden Gophers of the University of Minnesota-is
similar to WWW in that one connects to a gopher
server (<gopher://gopher.nih.gov/> is one example
of a gopher URL) with gopher browser to view
in-formation stored on the server. Gopher is limited to
plain text information (ie, no graphics or fancy
ty-pography), so it is less appealing. In an era where top
modem speeds were less than a tenth of what they
are today, Gopher was useful because the amount of
data needed to fill a screen with plain text
informa-tion is far less than what is needed for today’s
graph-ics-laden web pages. Many sites that were once
go-pher sites have moved on to WWW servers.
There are other methods of accessing information
on the Internet. Usenet, a network created by
non-Internet protocols, may be accessed via the Internet.
Usenet consists of a set of newsgroups arranged in a
hierarchy by topic. There are some medical Usenet
newsgroups (rnisc.kids.health and sci.med are the
most applicable to pediatrics) but because Usenet
newsgroups are completely open to the public, they
have not been used much for serious medical
com-munications. Internet Relay Chat (IRC) is a method
of setting up a chat group in which people around
the world can participate in a conference at the same
time by typing messages that everyone else in the
group can read. Archie is a method of searching and
accessing file archives. Telnet is a protocol by which
people with an Internet connection can log-in
re-motely as a terminal to another computer. Wide Area
Information Service is yet another method of
provid-ing information on the Internet, in this case by means
of looking up information on-line databases. The
great majority of communication on the Internet is
achieved via WWW and E-mail.
MAILING LISTS
Although the WWW can support some two-way
communication, it is not usually used that way
to-day. The most popular method of two-way
commu-nication on the Internet is person-to-person E-mail,
but the true power of the Internet as a
communica-tion medium for health care professionals is in
mail-ing lists. An E-mail list works in much the same
fashion as a conventional, paper-based list: each
per-son on the list receives an identical copy of each piece
of mail sent to the list. Unlike the paper version, on
an E-mail list, one may reply to messages sent by the
mailing list. These replies are then re-mailed to the
entire list. In this manner, an electronic discussion
among all members of the list may take place.
Mail-ing lists are often called listservs, after the popular
listserv software package (L-Soft International, Inc.
Landover, MD), but not all mailing lists are run with
this software. Other popular packages do essentially
the same thing. Table 2 lists some current mailing
lists of relevance to pediatrics.
Membership to mailing lists may be restricted (eg,
CHILD-NEURO
in Table 2 is restricted to health careprofessionals, whereas CHILD-NEURO-PARENT is
not). Some mailing lists are moderated by one or
more list moderators, who must approve each
mes-sage before it is sent to the list. Most lists are not
moderated; unmoderated lists are easier to use but
tend to contain messages that may not be focused on
the intended topic. Mailing lists can also have
mes-sage archives in which old communications from the
list are stored for future review. These archives may
be accessed via E-mail, on a file server, or via a web
site, depending on the mailing list. Those who feel
inundated by large volumes of individual messages
may access mailing lists in digest mode, in which a
single piece of E-mail, containing all the day’s
mes-sages, is sent to those participants who choose to use
this mode. Most mailing lists automatically mail a set
of instructions for manipulating these and other
fea-tures of the mailing list when one first subscribes.
THE PEDIATRIC INTERNET
The pediatric Internet comprises those databases,
publications, pediatric practices, parent support
groups, and pediatric specialty interest groups that
focus on the health care of children. Hundreds of
web sites and dozens of mailing lists exist for
pedi-atricians and others interested in child health.
Databases and Interactivity on the Web
While most WWW sites give users access to
static web pages that change only when the web
author updates them, there are a growing number
of web sites that are connected to databases to
which users can pose queries to retrieve
informa-tion specific to a particular clinical problem. The
premier on-line database for pediatricians is
On-line Mendelian Inheritance in Man (OMIM, <http:
//www3.ncbi.nlrn.nih.gov/ornirn/>) a free service
of the National Center for Biotechnology
Informa-tion developed by Drs Moyra Smith, Victor A.
McKusick, and colleagues at Johns Hopkins
Uni-versity and elsewhere.5 Fig 3 shows an example
query of this database, which is accessed through
the WWW. OMIM contains articles on over 8000
genetic conditions, ranging from defined
syn-dromes to physical findings that appear to have a
genetic basis. OMIM is a good example of the basic
interactive functions of a web site, in which a user
enters search terms, selects check boxes, and
sub-mits queries. With the rise in popularity of the Java
programming language, which allows web sites to
load computer programs into the user’s web
browser, we are likely to see increased interactivity
on medical web sites. For an example of a Java
application in pediatrics, see the NICU IV
calcula-tor at <
http://www.csrnc.edu/neonatology/j
ava/
qiv.htrnl>
from
Cedars
Sinai
Medical
Center.
Publications
Publishers of journals have speculated that the
web can be a useful adjunct to the paper version of
their publications. The Nezv England Journal of
Medi-cine (‘<http://www.nejrn.org/>) publishes a freely
com-NICU-NET
PEDINFO
PEDTALK PICU
PREEMIE-L
PROS-NET
SCOTtie
SICKKIDS
Those who subscribe to mailing lists usually receive an initial message with instructions on how to post messages, subscribe, un-subscribe, switch to once-a-day mailings, and so forth. Users should take care to save these instructions. Like all Internet resources, there is no guarantee that these lists will be active indefinitely.
TABLE 1. Search Engines and Indexes of the Internet
Name URL Description
Alta Vista <http://www.digital.com/> General WWW and Usenet content
Excite <http://www.excite.com/> General WWW and Usenet content
WebCrawler <http://webcrawler.com/> General WWW content
Yahoo <http://www.yahoo.com/> General WWW content
Medical Matrix < http://www.slackinc.com/matrix/> General medicine
CliniWeb <http://www.ohsu.edu/cliniweb/> General medicine (clinical emphasis)
PEDINFO <http://www.uab.edu/pedinfo/> Pediatrics
Points of Pediatric Interest <http://www.med.jhu.edu/peds/neonatology/poi.html> Pediatrics
All indexes offer search capability of free text, keywords, or both. Some offer a hierarchy by which to browse indexed sites. The pediatric content of the general sites tends to be minimal. See <http://www.search.com> for a comprehensive listing of search sites.
plete text of some features but not the original
arti-des (the complete text is available by mail or fax for
a fee, payable on-line). Other publications in
medi-cine have used the web, but with subscription
in-come critical to the survival of many print
publica-tions, free access via the web has not become the
norm. Some publications that do not depend as
much on subscription income (like the Morbidity and
Mortality Weekly Report, <http://www.cdc.gov/epo/
rnrnwr/rnrnwr.htrnl>)
have
adapted
well
to on-line
form. Original publishing on the web (ie, without a
corresponding print publication) has not been as
popular, mainly due to uncertainty about how to
make such a venture financially self-sustaining.
Pe-diatrics News at Your Desktop
(czhttp://www.rned-connect.corn/finalhtrn/pedjc/pedclbabout.htrn>)
is
a feature of the MedConnect service (Medical
Net-work Inc, Princeton, NJ) which creates an free,
on-line pediatric journal club on the web. There are
many such on-line publications (see
<http://ww-w.uab.edu/pedinfo/Journals.html> for a partial list
TABLE 2. Mailing Lists Relevant to Pediatrics
of those relevant to pediatrics) but the value of these
on-line-only resources in practice has yet to be tested.
Practices On-line
There are a number of individual practitioners,
group practices, and clinics that have developed web
sites (see <http://www.uab.edu/Practices.htrnl/>).
At a minimum, these sites list personnel, policies,
hours, patient handouts, and other basic information
about the practice. More ambitious on-line practices
provide web-based forms by which one may ask a
question of a physician. Although no one at present
is requesting reimbursement for such service, these
web sites serve chiefly as good public relations for
the practice. Most of the pediatricians involved run
the web sites for fun, not for profit, and all include
the caveat that advice obtained via the WWW should
not be a substitute for routine care by one’s personal
physician. Since WWW communication crosses state
lines and even international borders, it may be soon
that on-line practices will face challenges from state
List Name Description
________
CHILD-NEURO Child neurology (restricted to professionals; moderated)
DOWN-SYN Down syndrome
EMSCNET-L Emergency medical services for children
IMMNET-L Immunization tracking systems
Neonatal intensive care (health care professionals)
Pediatric Medical Informatics
PEDSURG-L Pediatric surgery
General pediatric discussion
Professionals’ discussion of the care of critically ill children
For parents of premature infants
For participants in the AAP’s PROS research program
For members of the Section on Computers and Other Technologies of the AAP For kids who are ill
TSCTALK Tuberous sclerosis discussion for those affect by Tuberous sclerosis and their families and friends
Subscription Information Send a message describing your interest to
Send the message “SUBSCRIBE DOWN-SYN” to
Send a message with “Add Me to EMSCNETL” in the Subject line to [email protected]
Send the message “SUBSCRIBE IMMNET-L Iyour namel” to [email protected]
Send the message “SUBSCRIBE NICU-NET Iyour namel” to [email protected]
Send the message “subscribe PEDINFO [your namel” to [email protected]
Send the message “Subscribe PEDSURG-L [your namel” to [email protected]
Send the message “subscribe” to [email protected] Send the message “subscribe picu [your name]” to
Send the message “subscribe preemie-l [your e-mail address]” to [email protected]
Send the message “SUB PROS-NET [your name]” to [email protected]
Send the message “subscribe SCOTtie” to [email protected]
Send the message “sub SickKids [your name]” to [email protected]
_---
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licensure boards. Nonetheless, pediatric practice web
sites can be a good source for parents looking for
standard advice on common pediatric topics.
Parents On-line
Parents of children with uncommon conditions
were some of the first to place pediatric information
on the Internet. Because of the WWW’s ability to
bring information to geographically dispersed
indi-viduals, parents looking for support from parents in
similar situations have used the web and mailing
lists to supplement the activities of established
sup-port groups for Down syndrome, neurofibromatosis,
tuberous sclerosis, attention deficit hyperactivity
dis-order, and other conditions. The usefulness of these
parent-oriented resources for pediatricians and other
professionals is the opportunity to learn about the
day-to-day concerns of parents and patients and to
knowledgeably refer them to these on-line resources
when appropriate. Although only a minority of
par-ents may have the ability to take advantage of
sup-port web sites and mailing lists, the presence of a
support group on-line may be sufficient motivation
for many parents to obtain the hardware and
Inter-net service required.
Specialty Interest Groups
Another significant resource on the pediatric
In-ternet is a growing collection of subspecialty
orga-nizations that use the WWW and mailing lists to
bring professionals, parents, and patients together.
Table 2 includes several subspecialty related
mail-ing lists, which may be open to all comers or only
to board-certified subspecialists. Web sites related
to subspecialty area like the pedsccm: The Web Site
for Pediatric Critical Care Medicine
(<http://ped-sccrn.wustl.edu/>),
edited
by
Barry
Markovitz,
Carl Weigle, and Steve Pon is an example of a
collaborative effort among several subspecialists at
different centers. PedsCCM provides, among other
things, an on-line textbook, illustrative cases,
in-formation on professional meetings, and recent
ab-stracts. Subspecialty divisions at medical schools
often have web sites. At a minimum, these contain
referral information, but they can be more
elabo-rate, containing educational materials and even
on-line consultations (eg, various divisions at the
University of Virginia, <
http://glen.rned.virgini-a.edu/-srnb4v/ernailsrv.htrnl>). Professional
sub-specialty organizations, like the American
Acad-emy of Child and Adolescent Psychiatry (<http://
www.aacap.org/web/aacap/>)
have
web
sites
expressly designed to reach the public and
gener-alist practitioners.
MANAGING INTERNET INFORMATION
Problems with using the Internet as an information
source include finding the information and judging
its quality. Other areas that have posed special
prob-lems are the appropriate professional use of the
In-ternet and its role in academic publishing.
FINDING INFORMATION ON THE INTERNET
The Internet is large. No one can know how many
computers make up the Internet, but WWW pages
number in the tens of millions, according to the
databases behind the major Internet search engines
(Table 1). The great majority of these servers contain
nothing of particular use to health professionals, but
some contain indispensible clinical information.
5ev-eral techniques exist for finding useful information
on the Internet: search engines, indexes, and directed
browsing.
Search Engines
The WWW is like a large library without a card
catalog. The information is there, but there is no
official catalog of the content. The unregulated
na-ture of the Internet allows individuals and
To Search all fields, leave the 1 certain specific fields, check the, other ways to search.
Title: Ql Nuaber:
Tt.s:.’ Re.fejer-.,. . Cli..
Contr
Variants: ‘
_I Sjnopsts: J ,
,
JtOl$:. ‘: ‘
Fig 3. The Online Mendelian Inheri-tance in Man search page. The user has entered two search terms (which by default will be combined with the AND Boolean operator) and is about to search the database. In this case, II articles from the Online Mendelian In-heritance in Man matched the search. Check boxes on the web page allow the user to fine-tune the scope of the search.
approval process from a central agency. Numerous
entrepreneurs have taken advantage of difficulty in
finding Internet information by creating search
en-gines-web sites that allow users to enter search
terms to locate relevant web sites, Usenet news
post-ings, and other types of information on the Internet.
These search engines do not actually search the
In-ternet. Instead, they search a collection of web pages
that have been previously gathered, by automated
means, into a database. The larger search engines
have continuously-updated databases containing
millions of web pages. One example of a search
engine, shown in Fig 2, is Alta Vista (Digital
Equip-ment Corporation, Maynard, MA,
<http://ww-w.altavista.digital.corn>). To use Alta Vista, one
en-ters words that might appear on a web page or
Usenet posting of interest. One may enter partial
words, use Boolean logical operators, or restrict the
search to items that entered the database between
certain dates. WWW search engines usually index
items by the words that appear in them, instead of by
a carefully chosen controlled vocabulary like the
Na-tional Library of Medicine’s Medical Subject
Head-ings [MeSH] (but see Cliniweb at
<http://www.ohs-u.edu/cliniweb/> for an indexing project that does
use MeSH). Thus, one is usually at the mercy of
spelling variations and idiosyncrasies of phrasing
when searching. Table I shows a number of general
Internet search engines available as of October 1996.
Indexes
Indexes of the Internet exist, but no index can
claim to be comprehensive. An Internet index
at-tempts to classify Internet resources in a hierarchy of
topics. There are a few general Internet indexes and
several indexes relevant to medicine and pediatrics
(Table 1). No index, no matter how limited in scope,
can claim to be complete, because new resources are
added to the Internet every day. Indexes can,
how-ever, facilitate the information hunt by presenting a
selected collection of relevant resources. The medical
content of general indexes tends to be quite limited,
because those who compile the index do not have a
medical focus. For example, the Yahoo index at
<http://www.yahoo.com/> as of October
1996
listed85 links in its Health: Medicine: Pediatrics index,
whereas the two largest pediatric indexes have well
over 1000 links each. Although it is true that many of
the links found on a pediatric index may not be listed
in the pediatric section of a general index per se, it is
a considerable convenience to those searching the
Internet for pediatric information to have a source of
exclusively pediatric links.
An index prepared manually can be a useful
ad-junct for pediatric professionals searching for
infor-mation on the Internet, but the fluid nature of the
Internet makes all indexes perpetually out of date.
Another challenge to the comprehensiveness of any
index is the problem of resource burial. For example,
suppose a site on pediatric cardiology is listed in a
pediatric index under cardiology (as opposed to
con-genital heart disease, which is too specific). Those
who use the index looking for general references on
congenital heart disease may use this reference to
help their search. If the author of the cardiology web
site adds a new section to the site on, say, tetralogy of
Fallot, should the author of the index update the
index to reflect this as a distinct entity under another
classification such as congenital heart disease? The
resource on tetralogy of Fallot becomes buried-that
is, inaccessible from the index-if it is not expressly
listed. The problem of determining to what level of
detail a web site should be indexed is a problem
shared by the various pediatric Internet indexes.
Directed Browsing and Other Methods
The WWW takes its name from the richly
inter-connected web of hypertext links that carry one from
site to site around the world. Since most people who
construct web sites include links to related sites on
their pages, one may easily locate relevant
exactly what one is looking for, but may be three
links removed from just the right site. Other methods
of finding pediatric information on the Internet
in-dude using mailing lists to inquire of other users
where they have found useful resources. There are
also Usenet news groups devoted to medical areas
and also to announcements of new Internet
re-sources. Magazines and journals are increasingly
likely to list URLs of web sites.
THE QUALITY OF INTERNET INFORMATION
Once one has located information on the Internet,
how may one judge its quality? Publishing on the
Internet, via the WWW or E-mail, is very easy. There
need be no editorial board or peer review when
setting up a web site. This is a matter of concern to
pediatric health professionals because of the
“gar-bage in, gospel out” phenomenon,6 in which
infor-mation, no matter how unreliable, looks better when
presented in computerized form. Clearly, it is
rea-sonable to assume that information published on the
Internet under the auspices of a professional
organi-zation, medical school, or a licensed physician is
going to be more reliable because of the reputations
involved. But often it is unclear what the source of
the information is, and there is no mechanism for
endorsement by an organization like the American
Academy of Pediatrics. While the American
Acad-emy of Pediatrics will be participating in the
en-dorsement of durable technical products like
CD-ROMs and video games with pediatric content, it is
hard to see how such endorsements can be applied to
the fluid environment of the WWW. The Academy
continues to wrestle with such issues of “netiquette”
as it enters the world of on-line publishing itself
(<http://www.aap.org>).
ETHICAL AND LEGAL ISSUES IN INTERNET USE
As in any social interaction, questions of etiquette
and ethics arise. In this journal, commentaries have
discussed the legal implications of on-line
consulta-tions via Internet E-mail and mailing lists.7’8 The
general conclusion has been that because no
doctor-patient relationship is involved when one physician
asks another for an opinion by E-mail, these take on
the legal status of a curbstone consult. What is less
clear-and has yet to be tested in court-is under
what circumstances doctor-patient communications
on the Internet is proper professional conduct. Most
pediatric health professionals will use common sense
to restrict the content of such communications, but as
the Internet is used more and more as a part of
communication in our daily lives, this issue is bound
to come up. The Internet, and particularly the WWW,
has been proposed as an inexpensive method of
ex-changing medical records information.9 The cost
say-ings results from the ubiquitous,
platform-indepen-dent nature of the Internet, but privacy concerns
have hampered the development of this method of
information exchange as a standard. Physicians and
other health care professionals should acquire basic
knowledge of how the Internet works to take part in
discussions about its proper clinical use.
ON-LINE ACADEMIC PUBLISHING
The WWW was developed in the early part of this
decade at Centre Europ#{233}en Researche Nucleare
(CERN), the European Particle Physics Laboratory in
Geneva, Switzerland.1#{176} The original intent of the WWW
was to serve as a method of sharing research data
among research physicists. Although only a small
per-centage of WWW traffic concerns scientific
communi-cation, publishers have begun to use the WWW as an
inexpensive medium for quick publishing. Scientific
publishers have raised concerns about publishing in
these unconventional ways [Kassirer, 1995 #891. One
significant concern is the legitimacy of the electronic
medium-will an article published on-line be taken as
seriously as one in print? Pediatrics has entered the
electronic publishing as of January 1997 and has taken
steps to answer this concern (see accompanying
corn-mentary by Horbar on pages 1193-1194 of this issue).
Other printed scientific journals, like Science (<http://
science-mag.aaas.org/science/>), Nature
(<httpi/ww-w.nature.corn/>), The New England Journal of Medicine
(<httpi/www.nejrn.org>), and Archives of Pediatrics
and Adolescent Medicine (<http://www.ama-assn.org/
public/journals/ajdc/ajdchorne.htrn >), have created
on-line versions, and there have been some efforts
at scientific publications that exist only in on-line
form. Because on-line publications are not yet
in-dexed by the National Library of Medicine and are
still somewhat experimental, the prestige and
at-tractiveness to authors of these on-line
publica-tions remains in question. There is no reason to
believe, however, that on-line publications, as long
as they undergo the same peer-review process as
printed materials, should be held in any lower
regard.
THE FUTURE OF THE PEDIATRIC INTERNET
The Internet offers unprecedented ease of transfer
of information between computers, and physicians
and other health care professionals are using the
Internet. According to the recent surveys from the
Georgia Tech Research Corporation’s Graphics,
Vi-sualization, and Usability Center
(<http://www.c-c.gatech.edu/gvu/>), .74% to 1.15% of WWW users
are physicians (no data were available on other
health occupations). Physicians’ overrepresentation
among web users compared with the general
popu-lation implies that the Internet will be an accepted
method for health care communication in the near
future, but health care professionals have much to
learn before it can be safely assumed that all have
easy access to the Internet. Pediatricians and others
interested in child health care should view the
Inter-net as an information resource to be placed alongside
textbooks, phone consults, and print publications,
but they should understand the nature of Internet
publishing to ascribe a level of reliability to the
in-formation derived from the Internet. Medical
educa-tion in pediatrics should include computer
commu-nications as a basic skill, alongside laboratory test
interpretation, medical literature analysis, and
con-sultation skills. Getting connected to the Internet is
computers designed for home and office use is
tar-geted at consumers with a strong interest in Internet
access. With the advent of higher speed access
through cable companies and digital telephone lines,
the Internet will become only more popular.
Oppor-tunities to serve patients, support medical education,
and disseminate the results of research will grow
exponentially as the Internet continues to grow.
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WHO IS KIDDING WHOM ABOUT RESEARCH?
In the competition for funds, medical research has an advantage over many other
fields in claiming that its goal is. . .to prevent human suffering and premature
death from disease. We like to think this is our goal, but if this were the real
intention of researchers, they would be better advised to divert the funds to the
easily curable health care needs of the Third World, or even the inner cities of the
First. In fact, most researchers have no real goal beyond what may be termed an
unquenchable desire to understand. It is the need for money to reach the goals that
drives the rhetoric of “saving humankind.” The increasing commercialization of
research is responsible not only for making secrecy more common, but also for the
misleading inflation of the end results of medical research.
Goodman NW. Secrecy in research. N Engl
