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Technology Review

Cruising the Information Highway: Online Services and Electronic Mail for Physicians and Families John G. Faughnan, MD; David J. Doukas, MD; Mark H. Ebell, MD; and Gary N. Fox, MD Minneapolis, Minnesota; Ann Arbor and Detroit, Michigan; and Toledo,

Commercial online service providers, bulletin board ser­ indirectly through America Online or directly through vices, and the make up the rapidly expanding specialized access providers. Today’s online services are “information highway.” Physicians and their families destined to evolve into a National Information Infra­ can use these services for professional and personal com­ structure that will change the way we work and play. munication, for recreation and commerce, and to obtain Key words. Computers; education; information services; reference information and computer . Com er­ communication; online systems; Internet. cial providers include America Online, CompuServe, GEnie, and MCIMail. Internet access can be obtained ( JFam Pract 1994; 39:365-371)

During past year, there has been a deluge of articles information), computer-based communications, and en­ about the “information highway.” Although they have tertainment. Visionaries imagine this collection becoming included a great deal of exaggeration, there are some the marketplace and the workplace of the nation. In this services of real interest to physicians and their families. article we focus on the latter interpretation of the infor­ This paper, which is based on the personal experience mation highway. of clinicians who have played and worked with com­ There are practical medical and nonmedical reasons puter communications for the past several years, pre­ to explore the online world. America Online (AOL) is one sents the services of current interest, indicates where of the services described in detail. Recently, one of the the problems lie, and speculates about the future of the authors used AOL’s Internet access to obtain the latest information highway. data on management of testicular cancer. W ith a few clicks The term information highway has acquired many of a computer mouse, an engaging graphical interface interpretations, and there is ample speculation about its allows navigation through a menu of over 165 medical potential. Cable companies imagine a large number of information sources. This menu includes the National channels and related entertainment services. Cancer Institute’s PDQ database, with a state-of-the-art Telephone companies focus on enhanced communica­ description of the management of testicular cancer. In the tion, including video images. Universities, government, same area, users can review Morbidity and Mortality and today’s online service providers advocate a collection Weekly Reports (MMWRs) from the Centers for Disease of computers that provide goods and sendees (particularly Control and Prevention, clinical alerts from the National Institutes of Health, and pressure sore clinical guidelines from the National Library of Medicine. All of this infor­ Submitted, revised, June 9, 1994. mation and much more is stored on computers around From the University of Minnesota, Health Computer Sciences, Minneapolis, Minne­ the world. AOL allows subscribers to view information sota (J.G.F., : [email protected]); the Departments of Family Practice, University of Michigan, Ann Arbor (D.J.D., email: David.Doukas® through their connection, or gateway, to the Internet, a nm.cc.mnich.edu), and Wayne State University, Detroit (M.H.E., email: network that links a huge number of separate resources. MarkEbell@.com), Michigan; and The Toledo Hospital Family Practice Residency Program (G.N.F., email: G.Fox6@.geis.com), Toledo, Ohio. Requests for re­ All the online services described in this paper have prints should be addressed to John G. Faughnan, MD, University of Minnesota Health their own private reference and discussion areas (medical Computer Sciences, UMHC 511 Mayo, Minneapolis, MN 55455 (email corre­ spondence preferred). and nonmedical), as well as access to thousands o f lnter-

© 1994 Appleton 8c Lange ISSN 0094-3509 365 Ihe Journal of Family Practice, Vol. 39, No. 4(Oct), 1994 Communicating via the Information Highway Faughnan, Doukas, Ebell, and Fox

net resources. There is something for everyone: family Good communications software allows the user to do as members who want to keep in touch through electronic much work as possible offline (before this connection is I mail (e-mail), physicians who want to participate in an established), which is economically advantageous, since electronic exchange of ideas on the social and behavioral online charges typically begin when the connection is aspects of family medicine, or an isolated rural physician made. Even though are less costly and more who wants to stay connected to a network of educators reliable than they used to be, using them can be a frus­ and other physicians—it is all possible through online trating experience. The quality of telephone connections sendees. varies, and poor quality telephone lines make high-speed We will begin with principles, followed by the communications difficult. Modems are an awk­ fundamentals and features of representative online ser­ ward bridge between the separate worlds of telephone vices. Our intent is to give readers a general understand­ and computer. Experienced computer users eagerly antic­ ing of the subject and to provide guidance for online ipate the day when true computer networks rather than exploration. voice lines are available for communications. Online services is a term applied both to the services that can be accessed by modem and also to the entities The that create, maintain, and provide those services (eg, CompuServe). These sendees include reference materials, ' Computer communications is simpler than renal physiol­ communications, information, entertainment, computet | ogy or VCR programming, but it involves a few novel services, and commerce ranging from airplane tickets to concepts with which users should become acquainted. To stock options. An access provider is an organization that that end, the process is described in terms of its compo­ provides access to online sendees, but does not create or nents: the user, the user’s and com­ maintain them (eg, Internet access providers). Although munications equipment, the connection between the us­ online service providers vary significantly, ranging from er’s computer and a distant online service, and some of tiny neighborhood electronic bulletin boards to large cor­ the services that are bundled together to produce an on­ porations, they have quite a bit in common. line service. Computer communications adds a new dimension to I The user, affectionately known as wetware, interacts our ability to exchange information. Text is the most with online services through reading and typing, and by common content of an electronic message, but sound, using menus and a mouse to send directions. Typically, images, and computer also can be exchanged. Com­ each user has one billing account, although some services munication can take place between two individuals or one allow many users to share an account. Subscribers to some message can be sent to many people. Messages may be online services can set up a family account in which each posted on public electronic bulletin boards, where they person has a private e-mail address. can reach many people. In most cases, communications A personal computer is the current gateway to online occurs across time, as with a letter, but it can also take services. Computers that run Apple , place immediately, as with a telephone conversation. Windows, IBM or Microsoft DOS, or IBM OS/2 soft­ E-mail functions in a manner similar to that of paper ware are easiest to use with these services. Communica­ mail. It most often consists of text sent from one person to tions software, which runs on these personal computers, another, but it is possible and easy to “ carbon copy” a manages communications hardware, and in cooperation single message to many recipients. The process of address­ with the computer, creates an interface, which enables the ing an e-mail message is usually automated by means of user to access online services. At one time, a terminal or software. Newer forms of e-mail allow audio and video teletype interface, which consisted of words that appeared attachments or computer files to be sent along with a one letter at time, was the only type of interface available. message. E-mail software can sort messages by date, sub­ Today, menus and pictures commonly help users navigate ject, or sender. E-mail is a useful alternative to telephone and work with online services. messages and paper mail. In theory, a person can retain A telephone line is usually the connection between one e-mail address throughout a lifetime regardless of the user’s personal computer and an online sendee. The residential changes, an obvious benefit in our mobile age. instrument that enables a phone to be used for computer Despite the potential of e-mail, the software provided by communications is a piece of hardware called a modem. many online services is disappointing, lacking sufficient This device translates computer signals into sounds, then addressing features and writing tools. translates the sounds back into computer signals at the Conferencing software allows many messages to be | other end. When the connection between a personal com­ typed and viewed simultaneously, although in practice, puter and a distant modem is achieved, the user is online. this is often less useful than a telephone conference call

366 The fournal of Family Practice, Vol. 39, No. 4(Oct), 1994 Communicating via the Information Highway Faughnan, Doukas, Ebell, and Fox i

Table 1. Comparison of Online Services Costs for Typical Table 2. Telephone Numbers and Addresses of Onljne Users in Urban and Rural Settings (Higher-Value Services Are Service Providers ft] Designated by a Greater Number of Stars; Lower-Value ------1 '- - - , Services by Fewer Stars) America Online (AOL): (800) 227-6364 America Online Inc, Vienna, VA i ’ Service Name Urban Rural AT&T Easy Link: (800) 242-600S i America Online1 ***** * * AT&T, , NY CompuServe * * * * Colorado SuperNet (Internet): (303) 273-3471 Golden, CO MCIMail2’3 * * * * * *

****** ***** Community' News Services (Internet): (800) 748-1200 Private BBS Colorado Springs, CO ***** * * * GEnie2 CompuServe: (800) 848-8199 CompuServe Inc, Columbus, OH CNS * * * * * * * * 1 America O nline costs u rb a n users about $ 1 0 .0 0 /m o fo r 5 hours o f use. Delphi: (800) 544-4005 2Provide toll- 8 00 service a t low or no a d d itio n a l cost. Delphi Internet Services Corp, Cambridge, MA 3 E-mail and fa x only. E stim ate is fo r a b o u t 2 0 - 3 0 messages a month; costs rise quickly as more messages are sent. GEnie: (800) 638-9636 Information Services, Rockville, MD

MCIMail: (800) 444-6245 unless there are text data to be exchanged. Public elec­ MCI Inc, Washington, DC tronic bulletin boards or newsgroups (with or without a : (800) 776-3449 moderator) resemble a radio write-in show. A user of a Prodigy Inc, White Plains, NY bulletin board or newsgroup may be called a subscriber. Subscribers post messages that can be viewed by other subscribers according to author, subject, or date. A col­ lection of such messages is a dialogue among subscribers Addresses and telephone numbers for tHfe services arc- across time and space. listed in Table 2. Now that we have reviewed the key concepts of on­ Because online services are not yet connected by a line services (user, equipment, connections, and services), true national information highway, they are reminiscent we are ready to examine samples of these concepts in of the train systems of the 19th century. To access spe­ action. cialized services, you may need to “ chainge tracks” to a different system. Fortunately, there is a growing network of bridges connecting various systems. Online Service Providers America Online Despite their diversity, online services share common el­ ements. We chose services to highlight based on their America Online (AOL) is a full- online service value, quality of service, unique characteristics, and special including e-mail, reference sources, public bulletin boards interest to rural users. The providers described here in (forums), computer file transfers, games; and entertain­ relative detail are America Online, MCIMail, private bul­ ment, online versions of news magazines and newspapers, letin board services, and the Internet. We will compare a variety of areas, and several Internet aeqess tools. CompuServe and GEnie with these sendees. The relative AOL emphasizes ease of use, creative services, support for value of service providers for urban and rural users is pocket computers (eg, Zoomer personal digital assistant, provided in Table 1. Costs of online sendee providers are , Fort Worth, Tex), bjnd integration difficult to compare because pricing schemes can be intri­ with the Internet. AOL is growing extremely quickly and cate, and specific services (e-mail, conferences) may be has a legion of loyal customers. * bundled differently. Rural users often cannot access ser­ Using AOL requires a Macintosh, IBM-compatible, vice providers through a local . Sendee pro­ or computer, or a Zoomer, with at leapt a 2400 viders with toll-free 800 number access are usually a better baud modem. The Windows, but not the DOS, software value for rural users. will run under OS/2 2.1. The AOL communications For each of the principal services, we have estimated software is free and easy to set up. AOL currently costs costs, described features and interface software, and iden­ $9.95 per month with 5 hours of free online time, and tified problems encountered in the use of these sendees. $3.50 per hour thereafter. Urban areas have access ______i.!.1______367 The Journal of Family Practice, Vol. 39, No. 4(Oct), 1994 Communicating via the Information Highway Faughnan, Doukas, Ebell, and Fox

numbers; users in rural areas generally are charged addi­ store all allow for a stroll through a computer-based mall, tional long distance fees (approximately $8/hour.). A classified advertisements area is provided for private Connecting with AOL requires their free software sales and purchases. package. Anyone familiar with a mouse and icon Learning and Reference is an immense area that in­ environment will enjoy using AOL. Clever design allows cludes Smithsonian Online (with information on exhibit responsive interactions, even with a relatively slow and and publications, and photographs you can download), antiquated 2400 bps modem. The icon-based “Depart­ CNN Newsroom Online, the Electronic University Net­ ments” menu presents multiple main heading options, work (with undergraduate and graduate courses), and each of which has numerous subsections, represented as Interactive Educational Seminars. The Medical Seminar nested folders. folder includes a patient education forum, medical infor­ E-mail offerings are extensive. Users can send mes­ mation files, and discussions on reform and sages to other AOL members and to any service with an office practice. Internet gateway, such as CompuServe, MCIMail, and Computing and Software has over 34,000 software GEnie. Messages can be composed and read offline (prior and text files that users can transfer to their individual to making and after terminating the online connection), computers. File areas for Clinical Care, Office Practice, which saves money. Only the Macintosh version of the and Patient Information are of particular interest to prac­ AOL access software allows mail to be automatically sent ticing physicians. Computing and Software also contains a and collected at any time of day without human interven­ vast collection of files in the areas of education, computer tion. The absence of this feature in the DOS/Windows applications and utilities, and games. The Macintosh Bi­ versions is a significant deficit. AOL allows a single house­ ble Online is a helpful resource for inexperienced Mac hold account to have several separate mailboxes. computer users. Especially helpful is the Industry Con­ The AOL communications software supports group nection, which allows for online connection to almost mailings, forwarding messages (within AOL only), and 100 computer software and hardware corporate forums, sending messages by or paper mail. A software address including Claris and Microsoft. Users can download soft­ book facilitates addressing, but the interface for adding ware updates and fixes and get help through public mes­ addresses is relatively weak. There is no way to transfer sage boards. AOL’s Download Manager, which allows address information into or out of the AOL format, which files to be downloaded as a group rather than individually, is a limitation for users with hundreds of e-mail addresses. is highly recommended. There is no added cost for e-mail use, including gateways People Connection allows for real-time conversation and Internet mail. in a variety of formats: “public lobbies” and “public The News and Finance area contains newspaper-like rooms” for common interests, and “private rooms” for departments, such as news, sports, features, and weather online private conversations. Entertainment includes On­ (including the ability to download satellite maps). “White line Gaming, which includes a variety of interactive com­ House Forum” provides press releases as well as tran­ puter games, and book and movie reviews. scripts of presidential briefs and impromptu remarks. Sev­ AOL is leading the way in providing easy access to eral magazines, such as New Republic, Tour Money, Omni, Internet services beyond e-mail, including bulletin board Time, PC World, MacWorld, and , are (newsgroup) and text retrieval () services. Inter­ available online. Time Online has several bulletin board net services are a major strategic focus for AOL, and its discussion areas on health care reform and Medicare, with providers clearly intend to be a major source of Internet contributions by Time magazine staff writers. There is a services for the public. To our knowledge, AOL is the also a financial folder with real estate and stock informa­ easiest way to access Internet services. tion, a brokerage service, and a report on the latest mort­ You can join AOL for free in several ways: through a gage refinancing rates. toll-free number (Table 2); by means of special offers Lifestyles and Interests includes bulletin boards on a included in computer magazines or accompanying com­ variety of topic areas ranging from astronomy to the Writ­ munications hardware and software; or through current er’s Club. To serve the health information needs of sub­ subscribers, who earn 5 hours access time credit. The scribers, there are bulletin boards, such as DisAbilities optional AOL manual makes exploring AOL easier. It (with topic areas from quadriplegia to Ehlers-Danlos syn­ costs about $20 and can be mailed to you within a couple drome), Senior Net, and the Better Health and Medical of days following your first sign-on. The customer sup­ Forum. port department has been increased several fold in re­ Travel and Shopping provides access to American sponse to the overwhelming influx of new subscribers. Airlines’ EAAsy for travel reservations and book­ Most urban centers now have higher speed (9600 bps! ings. AutoAdvantage, Online Bookstore, and Compu- local access to AOL, but smaller centers may still have

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slower speed access. Because there is no toll-free phone puters. This software is not as easy to use as AOL’s, but it line, rural users will incur the considerable expense of a is a big improvement on the older teletype-based inter­ long-distance phone call. face. America Online is a comprehensive online service A membership kit can be obtained for $39.95 by with good e-mail services (especially for Macintosh users), calling CompuSene. Each kit includes CIM software, a unsurpassed ease of use, innovation, good value, and an user’s guide, and a $25 usage credit. Less expensive pro­ enthusiastic customer base. Although it offers only a frac­ motional offers are often available. tion of CompuServe’s specialized forums, the addition of GEnie, which is a much smaller sen'ice than Com­ Internet newsgroups has dramatically increased its puServe, has been slow to develop graphical interface breadth of resources. For many new users, AOL is an software, and its teletype interface uses a menu system. excellent choice among available sendees. GEnie costs roughly the same as AOL and offers high­ speed toll-free sen-ice for rural users for an additional CompuServe and GEnie $6/hour. GEnie’s less demanding interface is suited to older computers of every make, including Is. CompuServe and GEnie are also full-spectrum online ser­ GEnie has an area dedicated to medical topics, in­ vice providers. Along with Delphi and Prodig)' (which are cluding public and physician-only categories. As with not reviewed here), these sendees differ somewhat in their AOL and CompuServe, GEnie provides an online ency­ market, depth of services, interface, and cost. Prodigy is clopedia, which may be a cost-effective alternative to CD- aimed at the same market as AOL and costs about the ROM or paper versions. GEnie is a good alternative to same, but includes intrusive advertising and has poor AOL for families with older computers, and for rural users Macintosh support. Delphi is oriented to a smaller spe­ who will appreciate the high-speed toll-free access. cialized market and emphasizes Internet services. CompuServe is the largest, most comprehensive, and Electronic Bulletin Board Services most complex of all the online service providers. It is also the most costly, with a Byzantine pricing structure that Private bulletin board services (BBSs) are home-grown often produces surprisingly large bills. Although Com­ versions of the national online services. A BBS can be set puServe is adjusting its pricing in the face of competition, up on a personal computer using inexpensive software. it generally costs twice as much as similar usage of AOL. One or more telephone lines and modems link the BBS to CompuServe has over 1.3 million members and acts the outside world. as both a private and public online sendee for a vast array A BBS may be established by a computer hobbyist, of organizations and corporations, ranging from the by a business, or by a governmental, educational, and American College of Physicians to the Ziff-Davis publish­ other organization for internal communications. Most ing empire. Many specialized technical support and cor­ localities have bulletin board services within a local calling porate services are available only through CompuSene. area. Access typically requires registration with the system CompuServe provides sophisticated e-mail services, al­ operator or sysop. Many BBSs are free or charge only a though their charge structure can make them costly for small annual fee, which makes them a superb way to learn extensive Internet use. about computer communications and a good online op­ Unique features of CompuServe include access to tion for computer and communication hobbyists and us­ the MEDLINE, AIDSLINE, and National Cancer Insti­ ers with limited budgets. tute databases. Accessing these services through Com­ A BBS reflects the interests of the sysop. Many bul­ puServe is much more expensive than through the Na­ letin boards have a special focus, such as religion or med­ tional Library of Medicine using the Grateful Med icine, but most include a generic set of services: discussion software. In CompuServe, a costly service called IQuest areas, file areas, games, and bulletins. Many BBSs sub­ Medical Infocenter provides access to 60 databases cov­ scribe to international discussion networks, such as the ering topics related to medicine, nursing, pharmacology, Fidonet and Internet discussion groups. These interna­ allied health professions, and more. tional networks may produce hundreds of messages a day There are many software packages from Com­ on topics ranging from pet care to computer equipment. puServe and other vendors that can be used to access Local discussion groups may focus on local issues, gossip, CompuServe. These packages vary widely in power and and political debate. Some BBSs allow subscribers to send complexity. Some save money by automating interactions and receive Internet mail, but connection to the Internet with CompuServe. Most users will choose the Com­ through a BBS may not be as reliable as connection puServe Information Manager (CIM) package created by through a major online service. CompuServe for Macintosh, DOS, and Windows com­ Using a BBS requires a modem and communications

The Journal of Family Practice, Vol. 39, No. 4(Oct), 1994 369 Communicating via the Information Highway Faughnan, Doukas, Ebell, and Fox

software. Any computer can connect with a BBS for mes­ names, e-mail address, and notes. It should be possible to sage services and many games, but the file areas will typ­ move information into and out of this file from another ically favor one computer system over others. A wide computer file and to automatically insert addresses from range of software supports offline message management, incoming mail. Software should support sorting and graphical interfaces, and other features. searching the address list, group mailings, secondary re­ Information can be obtained regarding which BBSs cipients (“cc” mail), and filtering incoming messages by are available in a given local dialing area through user author or subject. Most important, the sending and re­ groups and local computer vendors. Sign-up can be ceiving of e-mail should be fully automated, triggered achieved by calling the board and completing a registra­ either by a single keystroke or by a preset time. tion form online. If there are any associated charges, these Few e-mail packages support this list of features for will be displayed; if not, voluntary donations are usually any online service. We are not aware of any Macintosh appreciated. Local bulletin board services are a fun and software that meets minimum requirements for use with inexpensive way to explore the concepts of online com­ MCIMail. MCI publishes rather awkward M CI Express munications. software for DOS, and there are at least three different packages from various vendors for Windows. Norton E-mail (Electronic Mail) Commander/DOS 4.0 includes a simple MCIMail mod­ ule that meets most of these needs. E-mail is a simple tool of enormous value. The establish­ ment of connections between online services and the In­ The Internet ternet has transformed e-mail from a curiosity to a valu­ able tool that rivals paper mail, fax, and telephone. The Internet is different from the other online services Unfortunately, e-mail does not always get the attention it described in that it is not a service provider like Com­ deserves from full-spectrum service providers. puServe; it is the name given to computers around the MCIMail provides only communications services. world connected by wires or radio links. These computers AT&T Easy Link is a competing service oriented primarily can exchange information because they are intercon­ to corporations. MCIMail allows subscribers to commu­ nected, speak the same language, and have been regis­ nicate online with just about anyone anywhere and allows tered as Internet computers. The shared language, which fax messages, , and same-day delivery paper mail to is called TCP/IP, is necessary to establish a true direct be sent directly from your computer. Because MCIMail connection to the Internet. Configuring a direct connec­ uses an 800-number for all US subscribers, rural users are tion through a modem has been exceedingly difficult, but served as well as their urban peers. It is of special interest developments currently under way promise to simplify to rural users and to persons who travel frequently. this process. The Internet is not owned by anyone, and There are no connect-time charges and no charges although much of the US portion was developed by pub­ for receiving messages (an advantage for subscribers to lic money, it is not a public institution. The Internet is a Internet mailing lists). Typical e-mail messages cost $.50 cooperative entity analogous to a collection of private and to $.80 each to send. The most economical plan includes public roadways that permit traffic to pass for mutual a $ 10 monthly minimum. Charges for sending mail accu­ benefit. mulate quickly: a reasonably heavy user can spend over The computers that make up the Internet provide a $90 a month, even with MCIMail’s volume discount pro­ number of online services, such as communications. gram (which does not include the $35 yearly fee). This Many of these computers are available to everyone free of makes MCI a poor value for persons with local connec­ charge; others require billable accounts and special pass­ tions to AOL or other e-mail vendors. Some subscribers words. Access to the Internet is provided most often use MCIMail predominantly to receive messages and through an organization or business, such as an educa­ while traveling but otherwise use another service to send tional facility or commercial access provider. Some online messages. By subscribing to Internet mailing lists, users service providers, such as AOL, now provide a degree of can participate in worldwide dialogues in addition to stan­ Internet access. dard e-mail. The Internet is enormous, encompassing millions of Anyone with a modem and communications soft­ computers and most of the nations on earth. It serves as a ware can access MCIMail using standard communications connection between commercial online services and aca­ software (teletype interface). To actually benefit from any demic institutions; the standard e-mail address is an In­ e-mail service, however, a user needs special mail software ternet address even if the host is a commercial service. to support addressing and automated use. Ideally, this Major portions of the Internet were developed by public software should support at least one address file with funds that, in theory, are not to be used for commercial

370 The fournal of Family Practice, Vol. 39, No. 4(Oct), 1994 Communicating via the Information Highway Faughnan, Doukas, Ebell, and Fox

purposes, but in practice, the Internet is becoming much progress in only seconds from reading a document on a more commercial. It is an open standard for communica­ computer in Scotland to viewing clinical guidelines stored tions, so it has become a major channel through which in Bethesda, Maryland. government and academic institutions can provide infor­ There are many exciting software tools being devel­ mation resources to the general public. Once information oped for computers with full Internet access. One of these resources are on computer, it does not cost public insti­ tools, , can access and display multimedia content tutions much more to make them available on the Inter­ from computers around the world, although to the user, net. it may feel like a textbook. Unfortunately, Mosaic is There are disadvantages to the free-form evolution breathtakingly slow over a modem. As we develop direct and rapid growth of the Internet. Even expert users may (nonmodem) connections to the Internet, the true po­ have difficulty locating resources on the Internet, and tential of this new world will begin to unfold. obtaining a home or office connection may be quite chal­ lenging. Ironically, information resources on the Internet are often found through “word of mouth” or printed Beyond the Net: The National guide books. Although efforts to create electronic guides Information Infrastructure to the Internet are under way, paper guides remain essen­ tial for most users. In the near future, with or without government assis­ There has been a of books and articles that tance, some form of the National Information Infrastruc­ describe the Internet and its resources,1-6 some providing ture will evolve. Modems will become obsolete. Comput­ excellent general introductions to the Internet,4-6 and ers will continue to take on many new forms and become others offering both the directions and software an expert even more ubiquitous. In time, the network will be the needs to establish a full-fledged direct Internet connec­ place where labor contracts are posted and bid on, em­ tion.1-3 These computer-specific kits are currently avail­ ployment credentials certified, and transactions of every able for Macintosh, Windows, and DOS computers. sort negotiated and confirmed. New technologies will The easiest way for most physicians to access some evolve to manage one of the eentral challenges of the 21 st Internet resources is to subscribe to a commercial service century: storing, retrieving, and representing informa­ such as AOL, which handles the connection to the Inter­ tion. The “ networld” will reflect our material world: net. Expert users can get direct and complete access to the there will likely be more pornography than artwork, and Internet through commercial online service providers.1-3 more commerce than philosophy. Community News Sendees and Colorado SuperNet pro­ Today, any one of us can participate in the early vide toll-free direct access to the Internet. versions of this networld, and in doing so, gain many Internet users can exchange electronic mail and com­ practical benefits, only one of which is the potential to puter files, access vast software repositories, and navigate bore our descendants with tales of “Model T” explora­ multimedia hypertext documents that integrate the infor­ tions. mation resources of hundreds of institutions. Users can participate in an extraordinary variety of discussions, Acknowledgments which may have as many as 600 messages daily, or as few as two a month. The discussions come in two forms. One The authors gratefully acknowledge the assistance of Paul Kleeberg, MD, of St Peter Clinic, Ltd, in St Peter, Minnesota with sections form, called a list, can be joined by anyone with an Inter­ pertaining to the Internet. net e-mail address, which includes everyone using com­ mercial services described in this paper. Lists are conve­ nient but can overwhelm an e-mail account. The other References variety, called a newsgroup, is most like an electronic bul­ 1. Engst AC. Internet Starter Kit for Macintosh: everything you need letin board. It requires newsgroup software to use and to get on the Internet (with disk). 1st ed. Indianapolis, Ind: Hayden Books, 1993. some form of Internet access. There are more than 240 2. Fraase M. The Mac Internet tour guide: cruising the Internet the medical discussion groups and mailing lists, including easy way (with disk). 1st ed. Chapel Hill, NC: Ventana Press, 1993. computers in family medicine (Fam-Med) and behavioral 3. Fraase M. The Windows Internet tour guide: cruising the Internet the easy way (with disk). 1st ed. Chapel Hill, NC: Ventana Press, aspects of family medicine (Family-L). 1993. ' The National Institutes of Health and the National 4. Frisse ME, Kelly EA, Metcalfe ES. An Internet primer: resources Library of Medicine (NLM) are placing many of their and responsibilities. Acad Med 1994; 69:20-4. 5. Krol E. The whole Internet user’s guide and catalog. 1st ed. Sebas­ clinical and research resources on the Internet. The topol, Calif: O ’Reilly & Assoc, 1992. NLM’s Grateful Med software is increasingly oriented to 6. Levine JR, Baroudi C. The Internet for dummies. 1st ed. San use via the Internet. Using the Internet, it is possible to Mateo, Calif: IDG Books, 1993.

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