Intranets advance medical care

Physician Executive, June, 1996 by Marshall Ruffin

The Internet is coming to medical care in profoundly important ways, sooner than any of us would have predicted three years ago-in fact, sooner than most of us would have imagined even 12 months ago. These changes will not take place on the home pages of the Internet's World Wide Web. They will happen on Intranets-corporate networks of group practices, hospitals, health plans, and PHOs that use Web standards but are private.

And true community health information networks (CHINs) are coming soon. Community members will be linked-patients and potential patients, members of health plans and potential members-and will receive valuable services from access to CHINs spawned by providers and payers to make communication as convenient, efficient, and thorough as possible. There will be numerous networks offered in most metropolitan areas, each developed by an organization of providers or payers, to attract and retain customers.

There will be security provisions to keep the information of patients, health plan members, and providers private, while enabling the electronic exchange of data. Over the next five years, in many urban areas, the networks will evolve to support multimedia communication, permit telemedicine practice, and make consultations with physicians convenient for patients.

Our society will enjoy an increase in the velocity and accuracy of medical diagnosis and treatment with these networks, and more focused and effective interventions to prevent illness. Providers and health plans will discover that CHINs will be indispensable tools for managing their limited health care resources, and invaluable assets in their mission to wrest more customers from existing competitors. They will be as important as the networks supporting automated teller machines are to banks, and networks linking travel agents to their flight schedules are to the airlines.

Imagine you have to treat a boy named Christopher

Christopher is 10 years old, bright and inquisitive, and inclined to make his own decisions. He complains of a bilateral, frontal headache at 4:00 p.m. on a Monday afternoon, as his mother is driving him home from school. She instructs him to take three chewable childrens' Tylenol tablets. He has taken them before, and knows what they look like. In addition to the Tylenol tablets, his mother's purse also yields a sheet of Dimetapp Extentabs for adults, of which three are left. He reads the label, and recalls that he has taken Dimetapp pills (for children) before and they have made him feel better. Unbeknownst to his mother, he takes and ingests those three blue pills. They arrive home shortly afterward, and Christopher dives into his homework.

At 8:30 p.m., Christopher is lying in bed with a terrible headache, nauseated and vomiting. He has not eaten dinner and says he wants to rest. His mother attends to him, and asks him when his nausea started. He says shortly after he took those three blue pills. She gasps. She knows the Tylenol tablets are purple. She retrieves her purse. Christopher shows her the strip of Dimetapp tablets, from which he had taken the remaining three. His mother calls the pediatrician's office, and then the poison control center. She also summons her husband from his study. Her husband is a physician, and she is a nurse.

The poison control center suggests they check Christopher's blood pressure, because Dimetapp Extentabs contain 75 mg of phenylpropanolamine, a decongestant that in large quantities can raise blood pressure, and 12 mg of brompheniramine, an antihistamine. Christopher weighs 70 pounds. He has taken about six times the recommended dose of each medication. The phenylpropanolamine may cause the most trouble. His parents check his blood pressure, which is 140/100, with a regular heart rate of 70.

The pediatrician is appraised of the circumstances. He calls the emergency room and confers with poison control. Christopher's attendants choose to follow his blood pressure closely, but not to take him to the emergency room immediately. Because he took the medication four hours earlier and is already having dry heaves, they think the effects of ingested phenylpropanolamine may have peaked.

Every five minutes, Christopher's parents check his blood pressure, which rises to 160/120, with a regular heart rate of 65 over the next 10 minutes. His parents report this to the pediatrician, and decide to take him to the emergency room. As they are preparing to leave, Christopher's mental status changes; he becomes stuporous. His parents race him to the emergency room where, moments after arrival, he suffers a series of focal seizures involving his left leg, followed within a minute or two by a generalized grand mal seizure.

The seizure is brief, less than 30 seconds, followed by normal respirations. Christopher never appears hypoxic. His heart rate is 60 and regular, his blood pressure 170/125. The emergency room staff have an intravenous line in place, and give him Valium IV, which stops the seizure activity and reduces his blood pressure. He is unresponsive, and does not move his left side spontaneously Retinal examination is normal, without hemorrhages or papilledema. His pediatrician performs a literature search and learns that phenylpropanolamine in elevated doses may cause cardiac dysrhythmias and dystonic reactions, in addition to the hypertensive crisis Christopher has suffered.