REULING: It's somewhere in between. I think there are probably a lot of people who think it's a novelty because they don't realize how much useful material is out there now. One of our jobs is to make it easy to find helpful resources worldwide and to put up local resources. We had an interesting experience with a department recently that illustrates the transition. Some of the physicians were wondering why we were taking their time to talk about the Web, but others were frustrated because we hadn't already come to them long ago to publish their information on the Web.

MERZ: Education will get us beyond the novelty. For example, I worked with a doctor the other day who asked to see a home site that had been prepared for him. He was astounded that it was only a page and a half. But when he clicked on the underlined items, he found 60 pages of relevant sites. I think he was hooked on the concept when we used a search engine, in this case Alta Vista, and he saw his name and information about his work pop up on sites from around the world. Sometimes physicians have to see that their competitors are gaining more patients because of how they present themselves in cyberspace.

FUCHS: If a physician spends just a few minutes to find that a world of information is available easily, then that person is sold. The number of pieces to be aware of is really quite small. Besides a computer, you need a key piece of software, a browser such as Netscape, which allows you to pull up pages. It also allows you to pull up on your screen one of many search engines, such as Alta Vista or Yahoo, which help you find one of the millions of pages available ‹ after just a few minutes, by simply pointing and clicking.

REULING: Even if the physician never directly uses the Web, other people will access his or her site. It's a useful medium for people who want to get the word out.

SHORTLIFFE: By now everyone has heard of the Web and realizes it can't be ignored. But there is a gap between knowing about it and overcoming the initial inertia to make that first connection. There is a lot of help out there. It's becoming standard practice for medical professional societies to meet their members' thirst for information by scheduling sessions on computing and on the Internet at their annual meetings. Once people learn the basics from a lecture, a short course, consultant or whatever about what software they'll need, how to connect to an Internet provider, that sort of thing, then it's usually clear sailing.

SHORTLIFFE: Lay news coverage, and the fact that you can't watch an ad on TV without seeing a URL [Web address]. People hear about it all the time, and they say, "Maybe I'd better get on this bandwagon. There is something happening in this culture that I'm missing."

SHORTLIFFE: I think the key to the Web is that you don't need to be a techie to use it, once somebody sets your machine up. I like to draw the analogy to automatic teller machines in banks. You can walk right up without any training and get money out.

REULING: Supplementary patient education, for example. The Health Library has a lot of this material on the Web. With less time to talk with patients, having credible resources available is a boon to everyone. By providing regular updates on chronic conditions, we have the opportunity to change physician visits from episodic to ongoing. And anyone considering referring a patient here would find the Stanford Physician Referral Guide a very useful resource. Also useful is the companion database on faculty research interests.

SHORTLIFFE: Physicians on the medical staff have access through their Stanford IDs to a large number of library resources such as high-quality Medline searching. And we're looking at ways to combine patient-specific information at hospital workstations ‹ such as results reporting and order entry ‹with general Web sources. We want physicians to have facile means to move between clinical data and such resources as information from professional associations or reference libraries to help us make decisions about patient care. Keep in mind that we must solve the remaining confidentiality issues before we can feel perfectly comfortable placing patient records on the Web. But we're very close now to ensuring that Web confidentiality is better protected than, say, the paper medical record.

MERZ: There are very active news groups and resources maintained by various health organizations, providing patients directly with information that in the past had been restricted to the professionals. When patients come in for their appointments, they can ask more informed questions. There is much high- quality information now available that patients can receive from their home computers.

SHORTLIFFE: It's the rare physician who hasn't had at least one patient come in with a laser-printed copy of some Web page related to his or her illness and start grilling the physician about it.

SHORTLIFFE: Some observers are concerned that people aren't going to get good advice and that they are going to take Internet advice over the advice from their doctors. How can people evaluate what is quality information vs. what is more faddish, outdated, or badly peer reviewed and would lead them to bad decisions? JAMA ran an editorial recently on this subject. There is an organization in Geneva, called Health on the Net, that set up a code of practices based on standards of peer review, accountability, quality and timeliness. It suggests a sort of Good Housekeeping Seal of Approval. The AMA isn't sure this is enough and is talking about professional society review of such materials. When I was asked about this issue, I tried to make the point that poor-quality health care information has always existed, mostly in print form. But it's remarkable how well most patients can assess whether or not they should believe what they read. They look to see what the source is. They have a good sense of what is authoritative and what is not. It's a rare Internet user who can't tell the difference between information they find on an AMA page and what they find on Aunt Martha's "What I do for Cystic Fibrosis" page, which you'll find out there when you do an Alta Vista search. I think consumers who get in trouble with the Net are the same people who get in trouble with poor quality printed information. Also there are some sites, such as Medical Matrix, that do carefully screen.

REULING: We've been working with the Health on the Net Foundation for more than a year now. We've displayed their logo on our pages. We're encouraging all the other Web developers, departments, and content providers within Stanford University Medical Center to read and follow those guidelines. It's not a perfect solution, but it's a good step.

FUCHS: It's easy. There are many ways. If there are obstacles to doing it at work, it's even easier at home. Call Pacific Bell, Sprint, MCI, America Online or similar places, and for $20 a month, sometimes less, you get software and dial-up capability. You might have to buy a modem to link your computer to the phone system. A modem costs about $200 right now and is available at virtually any electronics store. Most of the Internet Service Providers will, as part of their service, give you a Web Browser, which allows you to click onto the Web. You no longer have to go to the electronics store to buy one of these, but of course you can do that too. Working with a service at home is easy, but it might be easier to connect at work. Many offices have an information support team that can help install an Internet connection, and there are numerous consultants who can be hired by the job to come in and install your connection ‹ at the office or at home. Or, if you have a 12-year-old at home, you're all set.

FUCHS: Unfortunately, we're really not set up to be the support group for end users. We see ourselves as the publishers of information. The Information Systems Group based at the School of Medicine will help with installations for medical school departments, and they can be contacted through departmental administrators.

REULING: People have different expectations of information on the Web. Before, they might have been satisfied with a yearly printed directory and wouldn't be surprised if in June some information was out-of-date. Now, because it's on the Web, the assumption is that it's going to be up-to-the -minute. That's a challenge.

MERZ: We can often help or show users how to update existing printed material. With Web magic they can put it online, create vast new audiences for this information. We can give new life to printed material.

SHORTLIFFE: One pitfall is that many people believe that just because a document is on the Web, it's new. If you convert an old paper document, it may be new to the Web, but it's really old stuff.

REULING: There is no simple answer to that. Usually, we leave that to the content provider. For example, the Faculty Research Directory is going to be maintained, as the printed version was, centrally in the Dean's Office. However, we are going to give individual departments the ability to update their information. If the departments so choose, they may allow individual faculty members to update their own information. We won't be able to guarantee that the information is current. But we will remind departments if records appear to have gone out-of-date.

SHORTLIFFE: Individual faculty members will feel a different sense of urgency about updating information. We hope those who are reluctant will realize, "This isn't just some sidelight; this is the way the world is finding out about me. If I want the best grad students, I've got to care about my page."

REULING: Some incoming students are already using the faculty guide. We've heard numerous reports that this was a useful tool in their decision to come to Stanford and whom to contact. We've also had some good feedback on how to improve the database, and we'll be working on that this summer.

REULING: Yes. We've been able to make technical changes to the network to support the Web usage. Combining the two functions helps the engineering function stay in sync with users. We're evolving from laying pipes to making sure that pure water flows through those pipes.

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