The virtual naval hospital: A digital library for naval primary care providers and patients

Guarantor: Michael P. D'Alessandro, MD*

Contributors: Donna M. D'Alessandro, MDt; Mary J.C. Hendrix, PhD$; CAPT (Select) Richard S. Bakalar, MC USN

Objective: To deliver optimal patient care and promote wellness, naval providers and patients require convenient access to medical information from isolated duty stations. The Internet can lower barriers to accessing information. The goal of this study was to determine the technical feasibility of using the Internet to deliver medical information to isolated naval points of care. Methods: A digital library for naval primary care providers and patients with an integrated, problem-based interface was developed. The Virtual Naval Hospital (http:// www.vnh.org) was evaluated from sea, undersea, and shore. Results: The digital library was a popular resource. Access to it is currently limited because few ships have Internet access. Conclusions: The technical feasibility of delivering a digital library of medical information to the deckplates was proven. The digital library will realize its potential when satellitebased access to the Internet becomes available. In the interim, the digital library will also be distributed on CD-ROM.

Introduction he primary tasks of Navy medicine are to promote wellness in the service member and to treat illness and injury when they occur. These tasks are often made more challenging because of the isolated locations in which naval providers practice, coupled with naval medical force downsizing but increased missions such as participating in operations other than war. Naval leadership is reemphasizing that the center of Navy medicine is the corpsman, that medical care must be delivered to the deckplates where sailors and marines live and work, and that training sailors in preventive medicine is crucial to maintaining a healthy Navy. Additionally, it is being realized that "state-of-theshelf' computer and communications technologies can be used as force multipliers to help move information instead of people" and aid naval providers in the process of delivering health care to the deckplates.1

In educational circles, learning is regarded as an apprenticeship process. Learning should be situated in real-world activities rather than in contrived classroom situations, should be active rather than passive, and should be collaborative rather than isolated in nature. Learning should be regarded as a lifelong continuum, and the apprentice learner therefore requires a continuum of information support to allow him or her to pursue this course of lifelong learning.2-1

Medical apprentice learners' clinical skills are most closely related to their clinical experience. Patients seen by a health care provider are stored in the health care provider's memory as a story or "illness script." When a new patient is seen, the health care provider pattern-matches this new illness script to those stored in memory to arrive at a diagnosis.6 Once a diagnosis is made, the workup and treatment of the patient is driven by the health care provider's medical knowledge. This medical knowledge often has gaps, but studies have shown that although health care providers commonly generate questions about patients they are seeing, they rarely take the time to pursue ealth information to live a healthy life and prevent disease, to

Similarly, patient apprentice learn how to access require health care system when they are ill, and health information to live a healthy life and prevent disease, they may have.9 Studies have shown learn how to access the health care system when they at patient compliance increases with patient knowledge.'0-'2 The Internet and its vast amount diseases they medical information have.9 Studies have shown that potential of being able to meet compliance increases with patient knowledge. of

health care Internet and its vast amount of Unfortunately, tbis information holds the potential of being able to meet the information needs of variable quality and is not organized in any systemic fashion to facilitate its use at the point of care providers and patients. Unfortunately, this infore, finding tion is of variable quality and is not organized in any systemic fashion to facilitate its use at the point of care. Therefore, finding pertinent, quality information on the Internet in a reasonable period of time can be extremely difficult.

The mission of the Virtual Naval Hospital project (http:// www.vnh.org is to create a digital library of naval medical information that can serve as a personalized and integrated source of medical information on the Internet for naval primary care providers and patients. This digital library is intended to improve patient care by serving as an "apprentice's assistant" by linking authoritative medical information to clinical practice by delivering it to the naval primary care provider and patient at the point of care for reference use. The goal of this study was to create and distribute a prototype digital library of naval medical information and evaluate its use at sea and on shore to determine the technical feasibility of the concept.

Materials and Methods

Digital Library Design

The Virtual Naval Hospital is designed to meet users' needs. The first step in the design of the digital library was to determine the information needs of Navy health care providers and patients at sea. A literature-based needs assessment was performed, and the most common medical problems encountered at sea by general medical officers, independent duty corpsmen, and corpsmen (echelon 1 and echelon 2 providers) were identified, along with important health promotion topics that need to be taught to sailors and marines. An interview-based needs assessment was then performed with Navy medical personnel that corroborated the findings obtained from the literature.l3 Authoritative Internet medical information resources were identified, including: the Merck Manual, The University of Iowa Family Practice Handbook, and the U.S. Navy Healthwatch preventive medicine newsletter. In addition, authoritative, userfriendly medical World Wide Web (WWW) sites were also identified. Sites were considered authoritative if they were from a state, national, or international professional health organization, were up to date, and had already been internally peer reviewed. Sites were considered user-friendly if they were free to use, required no log-in password, and stored their information as simple Hypertext Markup Language (HTML) files that can be viewed in any WWW browser.

Two key Navy print medical references were identified, digitized, and placed on the Virtual Naval Hospital: the General Medical Officer (GMO) Manual (NAVMED P-5134), 3rd edition, and the Manual of the Medical Department ( NAVMED P- 117). This was done using a previously described technique.'4

The hardware and software architecture of the digital library is built on open Internet and WWW standards that allow for scalability, interoperability, and modifiability as the information in the Virtual Naval Hospital is expanded and new computer and communications hardware and software technologies become available. 4

To allow for redundancy in case of WWW server hardware or software failure, a backup, or mirror, copy of the Virtual Naval Hospital was kept at the University of Iowa on a separate server computer that was updated daily.

The information architecture of the digital library is usercentered and problem-based, allowing users to quickly and easfly find answers to their medical questions. A personalized view of the Internet was created for naval providers (http://www.vnh.org/Providers.html) by linking the most common medical problems seen at sea to the authoritative medical information in the resources previously cited. The naval provider's page also contains links to information on health promotion, occupational and environmental health, medical procedure descriptions, MEDLINE, continuing medical education courses, and Internet search engines.

A personalized view of the Internet was created for naval patients (http://www.vnh.org/Patients.html) by linking the most important health promotion topics to the authoritative medical information in the resources previously cited. The patient's page also contains links to information on first aid, consumer health information references, and Internet search engines.

User feedback is encouraged and is obtained via electronic mail and on-line comment forms. Users sending personal medical questions to the Virtual Naval Hospital are advised to contact their naval providers with the questions and are directed to other Internet sites where they may also find appropriate information.

The Virtual Naval Hospital digital library was opened for use on March 1, 1997. It was publicized by word of mouth, by listing the digital library in the most popular Internet search engines and indices, by an announcement in the weekly Navy and Marine Corps medical news bulletin, and by a lecture at the Navy Surgeon General's Leadership Conference. Digital Library Evaluation

The technical feasibility of distributing digital library content to users on shore, at sea, and under the sea was evaluated. Users on shore could access the Virtual Naval Hospital from any personal computer with a WWW browser connected to the Internet with either slow-speed modem or high-speed direct access.

To evaluate its usage from sea, the medical department of the U.S.S. George Washington (CVN-73) was trained in the use of and given access to the Virtual Naval Hospital for a 3-week period while at sea. This was done via the U.S.S. George Washington's Challenge Athena telecommunication link, which delivers T1 bandwidth to the aircraft carrier while at sea via a satellite link. Approximately 56K of this bandwidth is allocated to the medical department, which routinely uses it for telemedicine applications while at sea.'5 During the 3-week cruise, members of the medical department were asked to evaluate the feasibility of using the Virtual Naval Hospital from two personal computers located in the medical department for teleeducation and telereference while at sea. On-line support for the users was provided via electronic mail.

To evaluate its usage from under the sea, the Virtual Naval Hospital was deployed onboard the U.S.S. Atlanta (SSN-712) and made available to its corpsmen during the Joint Warrior Information Demonstration 97 exercise.'s The corpsmen had access to the digital library in their sickbay via a laptop computer with a CD-ROM drive that was connected to the Internet via a slow-speed Internet connection when on the surface or when submerged at a depth of up to 60 feet. In addition, to allow usage when the submarine was submerged at greater depths and Internet access was not available, the corpsman were supplied with a mirror, or duplicate, copy of part of the Virtual Naval Hospital. This mirror copy was developed using the WebWhacker (Blue Squirrel, Draper, Utah) WWW duplication software and placed onto a CD-ROM that could be placed in the laptop computer's CD-ROM drive.

Data for a descriptive quantitative usage study of the Virtual Naval Hospital was obtained in the following manner. A WWW server has a log file that records the following information each time an HTML file on the server is accessed: the name of the HTML file accessed, the time of day and day of the week it was accessed, and the Internet address of the computer accessing the file. The identity of the individual user accessing the HTML file cannot be recorded. These log file records were analyzed using the log file analysis programs Analog 1.2.3 (University of Cambridge Statistical Laboratory, Cambridge, England) and Wusage (Boutell.Com, Inc., Seattle, Washington).

WWW server log file analysis is developing rapidly; therefore, the definitions of a few terms that may be helpful in understanding the results are provided in the "Appendix."17

In addition to this quantitative information, qualitative information was obtained from users by an on-line comment form on the Virtual Naval Hospital and by postcruise interviews with members of the medical departments of the U.S.S George Washington and the U.S.S. Atlanta

Results

Evaluation of overall usage of the Virtual Naval Hospital from March 1 to September 30, 1997, showed that it received 50,391 qualified hits, or successful accesses. This translated to 39,502 page hits, or pages read, on the digital library. The total number of visitors during this period was 8,859 (Table I). Usage grew steadily during the study period, especially after the digital library was publicized. The visitors came from a variety of locations, with 44% coming from U.S. military and government sites representing users from military and government installations, 28% coming from Internet service providers and commercial and nonprofit organizations representing a mix of off-duty service personnel at home and civilians, 22% coming from universities, and 6% coming from foreign countries. The 5 most common foreign countries using the digital library were Australia, Germany, Japan, Italy, and Canada. The 25 most commonly accessed files of health care provider information covered a wide spectrum of topics (Table II), as did the 25 most commonly accessed files of patient information (Table III). Only 19 on-line comment forms were received. The primary topics of the comment forms included suggestions for additional content (6), medical questions, e.g., "ich immunizations can be safely received during pregnancy?" (5), technical questions, e.g., *Could you please link to our Navy medical WWW site?" (4), corrections of errors found on the digital library (3), and praise of the digital library (1).

The personal computers that can browse the Internet in the U.S.S. George Washington's medical department were not located at the point of care but in the senior medical officer's office and on top of the computed radiography system, and this somewhat limited their use in accessing the digital library. However, the Virtual Naval Hospital received 140 qualified hits (successful accesses), which translated to 67 page hits (pages read) from 21 visitors who were members of the US.S. George Washington's medical department during their 3-week cruise. Health care provider information accessed included information on dental emergencies, sexually transmitted diseases, urticaria, genital ulcers, aeromedical evacuation, asbestosis surveillance program, seizures, budgeting, and chain of command. Patient information accessed included information on cholesterol, sun safety, smoking cessation, back pain, and hearing loss. In postcruise interviews the naval providers indicated that the digital library was clinically effective, efficient to use, and valuable. Specifically, the Virtual Naval Hospital was felt to be a tremendous on-line reference tool that was well organized and easy to use, allowed access to more information than might usually be available onboard, and could be used to replace the print medical library on the ship. The providers felt that it was especially useful to corpsmen, who could use it as a reference to further their learning, and they felt that it would be even more valuable on ships with small medical departments that did not have a general medical officer onboard.

During the Joint Warrior Information Demonstration 97 exercise, the corpsmen on the submarine were given four telemedicine scenarios to handle: finger trauma, chest pain, iritis, and tooth fracture. For each scenario, relevant reference information was found on the Virtual Naval Hospital. In addition, relevant reference information was available for three emergency telemedicine consultations that occurred during the exercise. In the postcruise interviews, the providers indicated that the digital library had substantial value for patients as well as themselves. They praised the digital library's problem-based interface, the breadth and currency of the references on it, and its small footprint. They were impressed with how it could be used to deliver information to the point of care and with its usefulness in educating patients as well as providers. They felt that having a CD-ROM copy of the digital library was crucial for allowing continuous support of clinical locations without continuous Internet access, such as onboard a submarine.

Discussion

Lessons Learned

The technical and operational feasibility of using the Virtual Naval Hospital as a teleeducation tool at sea, under the sea, and on shore was proven. The digital library was easily accessed by users at sea, under the sea, and on shore, and they found that the digital library would work when it was needed and that the digital library could be integrated into their work flow. Furthermore, users felt that the digital library was efficient to use and that it was clinically effective and valuable. Thus, a new tool for naval providers was successfully introduced (1) by designing the digital library to be easy to use, (2) by providing a compelling reason for its use, and (3) by integrating it into the provider's work flow.

Ease of Use

To be viewable by its users, a digital library must be designed to meet the technical capabilities of its users. At this early point in the Internet's evolution, most users are novices and have slow-speed connections, particularly when at sea and in the field. The Virtual Naval Hospital's style, which is replicated across every page in the digital library, is designed to make navigation intuitive within the digital library.'8 The style clearly displays the name and affiliation of each content author and the content's creation date and date of last revision so that the user may have confidence in the content being viewed.l9 Media are stored in standard media file formats (HTML for text, GIF (graphics interchange format) and JPEG (joint photographics experts group) for images, and QuickTime for video) that are viewable from a WWW browser without the use of browser plugins or helper applications. Putting information in proprietary file formats, such as Adobe Acrobat, that require such plug-ins or helper applications for viewing presents a significant barrier to the user who is trying to view the information, because such plug-ins and helper applications are difficult to set up and configure. Because most digital library users are novices, putting information in proprietary file formats almost guarantees that most users will not be able to view it.20 To speed digital library response time to make it quick to use,21 aside from the home page, graphics were used only in the digital library when needed to convey an educational point. Compelling Reason for Use The principles of user-centered and learner-centered design were key to the success of this project.22 To be relevant to its users, a digital library must be designed to meet their information needs. This project was able to identify quality medical information on the Internet and then select relevant information from these sources, guided by the needs assessments. This Internet searching, performed by the authors, allowed us to function as intelligent agents, and thus eliminated in many cases the need for the users to search the Internet for the information themselves. This information was then assembled in an intuitive, integrated, problem-based user interface for the users, which allowed them to rapidly find answers to their questions, when they have them, at the point of care.

The digital library's ability to update information and to make the updated information instantly available to the fleet was well demonstrated in several ways during the project. Several months after the GMO Manual was digitized and placed on the Virtual Naval Hospital, 25 newly updated chapters were sent to the University of Iowa, and the GMO Manual on the Virtual Naval Hospital was updated within 1 week. During an international crisis, chemical and biological warfare information was placed on the Virtual Naval Hospital for use by the U.S.S. George Washington's medical department while the ship redeployed to the crisis theater. All of the digital library's links to external WWW sites were checked at regular intervals to ensure that they were operational, and if they were broken, they were updated. Finally, users contributed feedback that led to the identification of new WWW sites that should be linked to, and the appropriate links were easily and rapidly made. This ability of the digital library to be rapidly updated is of the utmost importance in times of unexpected military crisis or in operations other than war. In such operations, the medical forces diverted to the operation may not have all of the appropriate medical information needed. However, using digital library technology, mission-appropriate medical information can be loaded onto the digital library and made available to the medical forces quickly and easily via an Internet connection.

Medical departments at sea or in the field place a premium on the size and weight of their medical equipment. A departmental medical library of printed, often outdated textbooks is often sacrificed when a department is pressed for space or weight. A digital library stored in a laptop computer with a CD-ROM drive and an Internet connection has a small footprint and weight and is an efficient use of limited space. Now, an entire current digital medical library can be as accessible to forward-deployed forces as it is to forces in the continental United States. Integration into the Work FLow

Although the information in the Virtual Naval Hospital can be delivered to and used at the point of care, the ability to deliver the information to the point of care is far ahead of the naval provider's ability to access it at the point of care because there are currently very few naval points of care equipped to access the Internet. In the fleet, only two ships' medical departments can currently browse the Internet while at sea via the Challenge Athena satellite link, the U.S.S. Enterprise (CVN-65) and the U.S.S. George Washington (CVN-73). These satellite links are limited in that the satellite link is not always available, because the satellite dish must have a line of sight to the satellite. The medical departments in the other ships in the fleet can theoretically browse the Internet when in dock via dial-up modems, but most ships' medical departments currently have a limited computer and communications infrastructure. On shore, the majority of Navy hospitals and clinics have Internet connections, but again, most are currently limited, which prevents the delivery of the Virtual Naval Hospital to naval primary care providers at the point of care. In fact, naval providers and patients at home, with private Internet accounts with Internet service providers, have easier access to the Virtual Naval Hospital than most naval providers at work.

To compensate for this short-term, widespread lack of Internet access, the development of mirror, or duplicate, copies of the Virtual Naval Hospital on CD-ROM has assumed paramount importance. Personal computers with CD-ROM drives are more widespread at sea and on shore than personal computers with Internet connections. A CD-ROM mirror copy of the Virtual Naval Hospital is also useful when a personal computer with an Internet connection at sea or on shore has its Internet connection go down. The only disadvantage to the CD-ROM mirror copy of the digital library is that it is not as current as the live version on the WWW server. This can be partially overcome by a program of releases of updated CD-ROMs to the fleet at regular intervals, because it is better to have access to information that is several months old than to have no access at all. To allow for even wider distribution of selected Virtual Naval Hospital content, selected medical manuals on the Virtual Naval Hospital will also be included in the Navy Management System Support Office's Intranet Web Service, which is being created for use by ships at sea without connections to the Internet. The Future

In the long term, access to the Internet will be ubiquitous, both at sea and on shore. At sea, this will be achieved through constellations of low-earth-orbit satellite systems specifically designed to deliver telephone and high-speed Internet access to mobile users via small hand sets at low cost. The first telephone system, Iridium (Motorola, Schaumberg, Illinois) will become operational in 1998, and the first high-speed Internet system, Teledisc (Teledisc, Seattle, Washington) will become operational in 2002, with several other systems scheduled to become operational soon after.23

Access to the Internet for mobile professionals will therefore no longer be through large desktop computers and wired network connections, but instead through small hand-held computers with wireless network connections, so-called intimate computers. Intimate computers, carried in a naval provider's pocket, will be the ultimate means by which medical information may be quickly and easily accessed at the point of care.

Furthermore, the Internet will continue to expand in size, content, and disorganization. Using it in a productive manner in one's daily work will become even more difficult, and digital libraries with personalized, integrated views of the Internet, such as the Virtual Naval Hospital provides for naval providers and patients, will become even more essential.

Finally, digital libraries such as the Virtual Naval Hospital will become necessary and integral parts of telemedicine and electronic medical record systems, providing on-line reference information linked to the patient's telemedicine consultation or medical chart. The review of information from digital libraries at the point of care will ultimately form the basis of a new generation of continuing medical education systems that will award continuing medical education credit for medical education that is delivered in a clinical context.?

Conclusion

To deliver high-quality medical care, naval providers and their patients need to be equipped with convenient access to current, authoritative medical information. This study has demonstrated that a user-centered digital library such as the Virtual Naval Hospital can lower barriers to accessing authoritative information and help to overcome traditional information isolation, thus allowing medical education to be continued at the point of care and thereby enhancing the apprentice learning experience of the naval provider and his or her patient. The result, it is hoped, will be better-educated naval providers who will be able to deliver improved medical care and better-educated patients who can live healthier lives. Ultimately, this will help to maximize readiness and allow the Navy to more efficiently fulfill its missions. Acknowledgments The authors thank LT Thomas A. Craig, MC USN, and Laura E. Frantz at the U.S. Navy Bureau of Medicine for their assistance in obtaining Navy medical manuals for digitization; CDR Dean Bailey, MC USN, for allowing the at-sea evaluation to occur onboard the U.S.S. George Washington (CVN-73) while he was its senior medical officer; HMC Richard Hinesley for performing the undersea evaluation aboard the U.S.S. Atlanta (SSN-712); CAPT Vernon Schinsli, USN (Ret.), and Chester Pletzke, MS, from the Uniformed Services University of the Health Sciences for their help in establishing a mirror site; and the members of the Electric Differential Multimedia Laboratory, Department of Radiology, University of Iowa College of Medicine, for their assistance in creating, organizing, and distributing the Virtual Naval Hospital. Additionally, the authors thank RADM George F.A. Wagner, USN, Commander of the Space and Naval Warfare Systems Command (SPAWAR), for having the foresight and vision to put naval communications technology to use in support of medical applications; Marcia Rutledge of SPAWAR for exceptional work in coordinating the unique cooperative funding effort; and CAPT Michael T. Rader, USN, for providing the overall U.S. Navy/University of Iowa coordination and synergy that allowed this project to get under way.

This project was funded by a grant from the U.S. Navy Space and Naval Warfare Systems Command, agreement No. N00039-96-2-0001.

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[Author Affiliation]

Departments of *Radiology, +Pediatrics, and ;Anatomy and Cell Biology, The University of Iowa College of Medicine, Iowa City, IA 52242. Telemedicine Department, National Naval Medical Center, Bethesda, MD, 20889. This manuscript was received for review in January 1998 and was accepted for publication in March 1998.