DERM/INFONET: A concept becomes a reality

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DERM/INFONET: A concept becomes a reality Alfred W. Kopf, M.D.,* Darrell S. Rigel, M.D.,* Richard White, M.S., M.A., Lawrence Rosenthal, Ph.D.,** William P. Jordan, M.D., D. Martin Carter, M.D.,**** Mark Allen Everett, M.D.,***** and Jeanette Moore** New York, NY, Richmond, VA, Oklahoma City, OK, and Evanston, IL The DERMatology INFOrmation NETwork (DERM/INFONET) of the American Academy of Dermatology has become a reality. DERM/INFONET consists of a number of data bases providing information and educational programs for the dermatologist. Currently the components are: DERM/MLS (Medical Literature Search), DERM/RX (dermatologic therapy), DERM/ USP (United States Pharmacopeia data base), DERM/ALLERGENS (Food and Drug Administration and Environmental Protection Agency Listings of allergens); Melanoma Prognosis Model; Electronic Mail; Bulletin Board; Meetings Calendar; ICD/CPT (International Classification of Diseases/Current Procedural Terminology) codes; AAD Membership / Committee Directories; and Dermatology Quiz. Additional data bases are planned. As audiovisual and alphanumeric communication systems evolve, newer opportunities for enhancing the DERM/INFONET Biomedical Communication Network will undoubtedly provide even greater opportunities for aiding the dermatologist in delivering state-of-the art management for their patients. (J AM ACAD DERMATOL 1988;18:1150-7.)

On May 30, 1969, the Joint Committee on Planning for Dermatology chaired by Dr. Rudolf L. Baer presented to the National Institutes of Health a document entitled "National Program for Dermatology. ''t The National Program had previously received the official endorsement of the American Academy of Dermatology (AAD), the American Board of Dermatology, the American Dermatological Association, the Association of Professors of Dermatology, the Dermatology Foundation, and From The Departments of Dermatology, New York University School of Medicine, New York,* Medical College of Virginia,*** Rockefeller University and Cot'nell Medical College, New York, **** University of Oklahoma, Oklahoma City, ***** and the American Academy of Dermatology--National Headquarters Computer Center, Evanston.** Reprint requests to: Dr. Alfred W. Kopf, Skin & Cancer Unit, 562 First Ave., New York, NY 10016.

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the Society for Investigative Dermatology. This document represented a major impetus for improvements in the specialty of dermatology. The status of dermatology at that time concerning patient service, education, research, and administration was analyzed and the needs of the profession were identified. The National Program thus became a blueprint for reorganization and expansion of dermatology. Among the many recommendations made in this document was the following: "Effort would be expended for establishing a National Biomedical Communications Network for dermatology with a goal of providing up-to-date information and educational programs in an efficient, practical manner for all members of the specialty." Soon after the submission of the National Program for Dermatology, the American Academy of

Volume 18 Number 5, Part 1 May 1988

Dermatology created a Task Force on Biomedical Communications.2 The initial plan of the Task Force was to provide a central repository of audiovisual and alphanumeric computerized information that could be transmitted via telephone and television communication networks throughout the country. The primary restrictions in those days were the high cost of self-owned CRT television monitors and computers. Thus, the Task Force developed a plan using a central computer and began to assemble segments of information, including a data base on dermatologic literature (DERM/LIT) and treatment of dermatologic diseases (DERM/RX).2-7 The creation of these initial data bases was a major undertaking. Concomitant with the development of this information were rapid advancements in audiovisual and computer technologies. The improvements accelerated at such a pace that soon personal computers became a reality and now compact disks are in widespread use. In 1984 the Board of Directors of the American Academy of Dermatology created an Oversite Committee to review the current status and future potentials of the then current DERMatology INFOrmation NETwork (DERM/INFONET) system. A major reorganization resulted in rapid progress in the development of this concept. Currently there are almost 900 AAD members who have subscribed to this service. The purpose of this article is to review its current status.

DERM/INFONET The primary goal of DERM/INFONET is to provide an efficient communication network for the dermatologist in order to meet certain informational, communication, and educational needs. Currently the data bases are housed in the computer facilities of the AAD Education Center in our National Headquarters in Evanston, IL. These informational packages are available via telephonic communication as is illustrated in Fig. 1. The various components that are currently available via DERM/INFONET are shown in Appendix A. A brief description of each component follows:

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DERM/MLS This Medical Literature Search is a subset of the National Library of Medicine MEDLAR computerized data base of the medical literature. This online data base currently contains over 80,000 articles abstracted from all the 31 derrnatologic journals (national and international) and from 11 major nondermatologic journals in which articles of particular interest to the dermatologist are frequently published. Each entry includes computerretrievable information concerning the authors, title, journal, year published, and an abstract of the article.

DERM/RX This is a compendium of the management options for over 650 dermatologic diseases. 7 Essentially, DERM/RX is a guide to what has been published in the literature concerning the management of each dermatologic disease. It provides the following information for each entry: topical treatments, systemic treatments, physical modality treatments, other treatments, cautions, date revised, reviewer(s), and references. In addition, each therapeutic modality is rated according to the following system: (A) fully accepted and best therapy; (B) accepted and often used; (C) accepted, but not often used, or, adjunctive therapy; (D) experimental, very new; and (X) Unproved, unpublished, and / or controversial. Shown in Appendix B is a readout of the systemic treatment of dermatitis herpetiformis.

DERM/USP The United States Pharmacopeia has made its computerized data base available to the American Academy of Dermatology for inclusion in DERM/INFONET. All medications (not just dermatologic) are included. There are two portions to this data base. The first is the technical section written for physicians. The second portion is written in the vernacular for information to the patient. For each drug prescribed the patient can be handed a printout in laymen's terms that can be readily understood. Appendix C illustrates a portion of the data available on the drug, dapsone.

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How DERM/INFONET works

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Academy DERM/INFONET Data Base

Fig. 1. Hardware for DERM/INFONET including: personal computer, floppy disk, modem (computer-to-computer communication device), telephone, computer at the National Headquarters of the American Academy of Dermatology. FDA and EPA Allergens/Contact Dermatitis Data Base The Food and Drug Administration and the Environmental Protection Agency have made both of their extensive data bases available to the American Academy of Dermatology. In these data bases it is possible to identify those over-the-counter products (FDA) and those used in indust~ (EPA) that contain specific allergens. Also, it is possible to identify products that do not contain specific allergens. An example of this is shown in Appendix D.

Melanoma Prognosis Model Based on the New York University Clinical Cooperative Group Data Base, a prognostic model has been developed in which the predicted 2- and 5-year survival rates of patients can be calculated, based on information entered into the computer) An example is shown in Appendix E.

Electronic Mail This important aspect of DERM/INFONET allows the users to communicate electronic messages via the telephonic network. Messages can be sent to any one, all, or subgroups of users. Available software packages also allow "downloading" and "uploading" of information, which reduces the amount of "on-line" computer time.

Bulletin Board Important announcements providing information about our specialty are posted in the Bulletin Board.

Meetings Calendar A list of the local, regional, national, and international meetings is available to the DERM/ INFONET user. The dates, location, subject, title, sponsor, CME number, and responsible person to contact are provided. This calendar allows more precise planning for the dermatologist and avoids conflicts in scheduling meetings. I C D / C P T codes These represent an 8-digit expansion of the International Classification of Diseases (version 9) and a 7-digit Current Procedure Terminology (version 4) that make them more comprehensive for dermatology's needs and at the same time compatible with the lesser-digit ICD and CPT codes.

Dermatology Quiz The DERM/INFONET user has the option of taking the current quiz on relevant dermatologic topics. If the wrong answer is chosen, the computer provides remedial information to help the learner comprehend why that answer was incorrect and what the correct response should have been

Volume L8 Number 5, Part 1 May 1988

(Appendix F). The highest score achieved by any user is continuously updated so that the learner can compare his/her performance with the top score. A c a d e m y Membership and

Committee Directory This provides a current list of all members of the American Academy of Dermatology, including their addresses and phone numbers (see sample in Appendix G). Also, a constantly updated listing of all committees of the Academy is available to lnfonetters. TECHNICAL ASPECTS OF DERM/INFONET Within the past 2 years the hardware and software housed in the Academy's Computer Center have been substantially revised and upgraded. This has provided a "user friendly" system that is simple to understand and operate. No specific knowledge on the use of computers is required by the user. For those interested, the current hardware is as follows: I. An AT-compatible (ARC; American Research Corp.) file server operates a 290 Megabyte Priam disk drive on which major data bases reside. This can be expanded in the future to a I Gigabyte disk drive as the total amount of data increases. The Priam includes a 60 Megabyte cartridge tape for disk image backup of the disk drive. 2. Three PC-compatibles (PC Designs 1000) and one IBM PC each handle one incoming TYMNET line. These computers are referred to as line servers. Each line server has two 360K floppy disk drives, and 640K of memory. The PC Designs computers operate about 60% faster than conventional IBM PCs. If additional telephone lines are needed to accommodate more callers, additional PCs can be added-one for each line. As outlined below, this offers substantial performance improvements over a larger centralized system. 3. A Compaq 286 with 640K of main memory, a 30 Megabyte hard disk, and an Emerald 9-track tape drive. This is used for converting files from mainframe computer tapes and for file-by-file backup to tape. 4. A PC-compatible (PC Designs 1000) with a 48 Megabytc hard disk is used for network administration and for some file conversions.

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All of the computers listed above also have an Orchid PC Network card and communicate and share information by coaxial cable using Novell Advanced Netware 1.01 networking software. Each line server uses MS-DOS 3.1 as its operating system. Most of the programs that comprise DERM/ INFONET are written in dBASE III and compiled using the Nantucket Clipper compiler to increase their speed. Other programs are written in C to handle performance-critical and complicated communications tasks. The use of a network, with a PC assigned to handle each phone line, offers important advantages in cost and responsiveness compared to a centralized larger computer. It also makes it possible to tune the system for optimal performance while facilitating future system improvements. The use of a network results in less degradation in response as more callers use the system simultaneously since a computer is added for each new caller. The processing power of the line-serving PCs is closely matched to the computing needs of callers. As a dial-up telecommunications system, the TYMNET communications link is usually the ratelimiting step. A line server PC can easily fill a 1200 baud telecommunications line, with power to spare, and will in the future generally be able to process at 2400 baud as that becomes more widely used. While a caller utilizes a significant proportion of the computing power of his or her line server, comparatively minor demands are put on the shared central file server. Even at the peak demand of literature searching, a caller typically uses less than 1% of the file server's processing capacity, and even that is in short bursts. There are also cost advantages to the networked approach. Because the PC market is so highly competitive, components for PC-based systems are often dramatically less expensive than comparable components for bigger computers. A 9track tape drive for the PC, for example, costs about one-third the price of a comparable minicomputer tape drive.

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A final advantage of the network design approach is that it will make it easy to take advantage of new technologies that will bring DERM/ INFONET directly into the practitioner's office in a faster and more responsive way. Because the programs are written to run on a conventional PC, they will be able to run virtually without modification if the data base can be published on a CDROM or videodisk. 9 From the program's perspecfive, it doesn't matter much if it looks for the information on a network disk or a CD-ROM disk drive. However, significant performance improvements and an improved interface would be possible on such a system. TItE FUTURE A number of additional components to DERM/ INFONET are on the drawing board and should be available in the near future. These include: 1. An electronic textbook 2. Patient management problems 3. Placement service to identify opportunities for positions in dermatology nationwide 4. The National Cancer Institute's PDQ data base 5. Improved linkages between data bases (e.g., between treatments and literature) 6. Gating to other electronic data bases (e.g., "Grateful Med" system on the National Library of Medicine '~ 7. DERM DDX (DERMatology Differential Diagnosis) data base In the longer term, the developing technology of optical disks may enhance DERM/INFONET. Preliminary consideration is being given to the tremendous storage capacities of optical disks that could be used to bring the full contents of DERM/INFONET directly into practitioner's ofrices. Optical disk technology offers many advantages: (1) it can store incredible volumes of information; (2) it can store images and sound, as well as text; (3) it improves responsiveness since the rate-limiting telecommunications link is not essential; and (4) it costs less if sufficient numbers of disks are distributed. Thus, it is conceivable that the DERM/

Journal of the American Academyof Dermatology

INFONET system in the not too distant future will consist of an optical disk mailed to subscribers, just as this JOURNAL is now mailed to its readers. The disk would be used with the subscriber's personal computer running custom software to provide instantaneous access to the kinds of information now available through DERM/INFONET by phone. In addition, the optical disk permits access to visual images (including a pictorial atlas of dermatologic diseases, video sequences in motion [e.g., surgical procedures]), and audio explanations of the pictures, charts, and diagrams. The telephone link to the Academy's central computer would continue to be used (e.g., for changes in the data bases since the disk was published; for electronic mail). There are several competing optical disk technologies that could be used for a next generation DERM/INFONET. The principal contenders are: (1) CD-ROM (compact disk--read only memory); (2) CD-I (compact disk--interactive); and (3) videodisk. CD-ROM is based on the same compact disk technology used for high-quality musical recording. A typical CD-ROM can store an incredible 550 Megabyte of d a t a - - m o r e than twice as much as DERM/INFONET has on its central disks now. This is equivalent to the contents of a 120-volume encyclopedia, including the indices. CD-I is an extension of CD-ROM with greater visual capacity. It is expected to become widely available in the consumer electronics marketplace in the next decade. Videodisks are based on television video disk technology. Videodisks have less overall storage capacity than CD-ROM but offer better motion picture abilities. They are physically larger and more expensive. Thus, as audiovisual technology evolves, the Academy is ready to consider how each development might be utilized. This will provide for our profession the most efficient and economic means of retrieving the information required to remain at the cutting edge of the explosion of scientific and practical knowledge pertinent to our needs.

Volume 18 Number 5, Part 1 May 1988

REFERENCES 1. Baer RL. National Program for Dermatology. Prepared by the Joint Committee on Planning for Dermatology. Submitted to the National Institutes of Health, July 1, 1969. 2. Kopf AW. A decade of progress in education and communication in dermatology. J AM ACAD DERMATOL 1982;6:209-14. 3. Levit F, Chalice R, Kopf AW. DermLit: a year's experience with a computerized literature search service. Arch Dermatol 1975;111:1355-6. 4. Levit F, KopfAW, Huntley A, Stengel F, RabinovitzHS, Freeman MJ. DERM/RX: An experiment in computerizing information on dermatologic therapy. J AM ACAD DERMATOL1979;1:462-7. 5. Levit F, KopfAW. DermLit [editorial]. J AM ACADDERMATOL 1982;6:267-8. 6. Kopf AW, Rosenthal LE, Levit F. DERM/MIS update. J AM ACAD DERMATOL1983;8:732-6. 7. Kopf AW, Geronemus R, Sanchez M, Natow A, Grossman D, Goldberg D. DERM/RX: a computer aid to the management of diseases of the skin. Dermatol Clin 1986;4:589-98. 8. Rigel DS, Rogers GS, Friedman RJ. Prognosis of malignant melanoma. Dermatol Clin 1985;3:309-14. 9. Wertz RK. CD-ROM: a new advance in medical information retrieval. JAMA 1986;256:3376-8. 10. Haynes RB, McKibbon KA, Fitzgerald D, Guyatt GH, Walker CJ. Sackett DL. How to keep up with the medical literature: V. Access by personal computer to the medical literature. Ann Intern Med 1986;105:810-24.

Appendix A. DERM/INFONET Main Menu (showing available modules) Main Menu 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17

Literature Search (DERM/MLS) Therapy (DERM / RX) Melanoma Prognosis Model Electronic Mail Bulletin Board Meetings Calendar ICD/CPT Codes FDA Allergens/Contact Dermatitis EPA Allergens/Contact Dermatitis Pharmacology (DERM/USP) Physician Data Pharmacology (DERM/USP) Patient Data Change your help level Dermatology Exam--test yourself Picking the Office Computer That's Right for You Academy Membership Directory Academy Committees Directory DDX--Differential Diagnosis--Febrile Eruptions

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18 PDQ--National Cancer Institute Data Base Q Logoff ? Help

Appendix B. Search for Dermatitis Herpetiformis (systemic treatment in D E R M / RX ranked by efficacy (A, B, C, D, X) and with numbered references) Condition name? DERMATITIS HERPETIFORMIS Date revised: MARCH 1986 Revised by Dr. H. Rabinovitz, Dr. D. Goldberg, Dr. S. Katz DERMATITIS HERPETIFORMIS--systemic treatment Dapsone (diaminodiphenylsulfone) (1) 1,2.4,t7"2~ Diasone (sulfoxone) (B) 1'4'18-2~ Colchicine (C) j.~5 Sulfanilamide (C) 2,~7 Sulfasalazine (C) z Corticosteroids (C) ~,~7 Heparin (C) ~,17 Cholestyramine (D) TM Arsenic (X) ~,~7(may have been effective, but 25% of patients develop keratosis and other manifestations of arsenism') Ineffective medications (X) include disodium cromoglycateS"2~ tripelennamine+'; indomethacin~7'2~ nicotinic acid derivatives~7.2~ penicillin'7; tetracyclineXT; chloramphenicop7; isoniazid'7; PABAtT; and pyribenazamine. ~7.2o

Appendix C. Pharmacology (DERM/USP) Patient Data (patient data base o f pharmacology ( D E R M / U S P ) for dapsone concerning side effects o f this drug) Side effects of this medicine Along with its needed effects, a medicine may cause some unwanted effects. Although not all of these side effects appear very often, when they do occur they may require medical attention. Stop taking this medicine and check with your doctor immediately if any of the following side effects occur: More common Back, leg, or stomach pains Fever Loss of appetite

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Pale skin Skin rash Unusual tiredness or weakness Rare Bluish fingernails, lips, or skin Difficult breathing Itching, dryness, redness, scaling, or peeling of the skin, or loss of hair Mood or other mental changes Numbness, tingling, pain, burning, or weakness in hands or feet Sore throat Yellowing of eyes or skin Other side effects may occur that usually do not require medical attention. These side effects may go away during treatment as your doctor adjusts to the medicine. However, check with your doctor if any of the following side effects continue or are bothersome: Rare Dizziness Headache Lightheadedness Nausea or vomiting Other side effects not listed above may also occur in some patients. If you notice any other effects, check with your doctor.

Appendix D. FDA Allergens/Contact Dermatitis (Sample of FDA Allergens/Contact Dermatitis data base showing what is displayed when selecting list of baby products (lotions, oils, powders, and creams) not containing the allergen parabens mix; lists of this type can be given directly to the patient) Category: Baby products Lotions, oils, powders, creams not containing parabens Big B Discount Drags Big B baby oil Chesebrough-Pond's, Inc. Vaseline Intensive Care baby oil Glenn Marsh, M.D. ZBT baby powder Greer & Associates Inc. A & P baby oil Johnson & Johnson Products Inc. Johnson's baby oil Kayang Co. Ltd. Maiposa baby oil Merle Norman Cosmetics

Baby Magic lotion Baby Magic oil Neutrogena Corp. Beauty Skin baby oil Olde Colony Products Corp. Knight's baby oil Perfumes Juper SA Baby oil

Appendix E. Melanoma Prognosis Model (sample of prognosis calculation after data entered by the dermatologist on the patient) Patient profile Age 52 years Sex Male Site Supraclavicular area Ulcerated Ulcerated Thickness 3.2 mm Level Penetration into reticular dennis Stage Local Palpable No palpable regional nodes Dissected Dissected No. of nodes 29 nodes examined Hist Pos 0 histologically positive nodes found Two-year survival probability: 88.0% Five-year survival probability: 15.0%

Appendix F. CME Dermatology Examination (sample screen) 1. Approximately what proportion of individuals in high-risk groups for acquired immunodeficiency syndrome (AIDS) who become infected with the HTLV-III/LAV virus ultimately develop AIDS?

a. 0%-1% b. I%-10% c. 10%-25% d. 25%-60% e. 60%-85% Your answer: c That is not correct. The correct answer is b. Acquired immunodeficiency syndrome (AIDS) is a sexually transmittable infection caused by a retrovirus presently known as Human T cell lymphotrophic virus Type III/lymphadenopathy-associated vires (HTLV-III/LAV)/HIV (human immunodeficiency virus). Current data suggest that approximately I% to 10% of persons in high-risk groups infected with this virus ultimately develop AIDS and a larger proportion may develop AIDS-related complex. Reference: J AM ACAD DERMATOL1986; 14:707-26.

Volume 18 Number 5, Part 1 May 1988

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Appendix G. Academy Membership Directory

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(example o f looking f o r a dermatologist to refer a patient m o v i n g to Tulsa, O K (r,m: This example was arbitrarily c h o s e n b y the authors)

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Telephone/Address Directory 1 Look up by name 2 Look up by city 3 Look up by state 4 Look up by zip 5 Look up by country 6 Look up by ID number Q Main menu L Logoff

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918-492-4787 Tulsa, OK 918-582-1622 Tulsa, OK 918-749-2261 Tulsa, OK 918-492-3660 Tulsa, OK 918-749-2261 Tulsa, OK

Select item (1-5) or reposition (Beg/End/Next/Prev/Reenter/Quit/

+ x/--x): 3

Vincent Paul Barranco, M.D. 2121 East 21st St. P.O. Box 52588 Tulsa, OK 74152 918-749-2261 Membership category: Fellow

Your choice? 2 City, state: Tulsa, OK

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Jeff Alexander, M.D. Earl Udo Bachenberg, M.D. Vincent Paul Barranco, M.D. Clinton Maurice Coffey, M.D. Charles Kendrick Doran, M.D.

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BOUNDVOLUMESAVAILABLETO SUBSCRIBERS Bound volumes of the JOtJRN^LOFTHEAMERICANACADEMYOFDERMATOLOGYare available to subscribers (only) for the 1988 issues from the Publisher at a cost of $49.00 ($62.00 international) for volume 18 (January-June) and volume 19 (July-December). Shipping charges are included. Each bound volume contains a subject and author index and all advertising is removed. Copies are shipped within 60 days after publication of the last issue in the volume. The binding is durable buckram with the journal name, volume number, and year stamped in gold on the spine. Payment must accompany all orders. Contact The C. V. Mosby Company, Circulation Department, 1I830 Westline Industrial Drive, St. Louis, Missouri 63146, USA; phone (800) 325-4177, ext. 351. Subscriptions must be in force to qualify. Bound volumes are not available in place of a regular journal subscription.