Over the years, healthcare organizations have had to respond to many different changes – from advances in diagnostic and therapeutic procedures to the emergence of concepts such as managed care and telemedicine. Healthcare is fast becoming one of the most competitive and value added industries worldwide with many technology driven developments in diagnosis, treatment, care provision, patient monitoring and healthcare infrastructure.

One such technology is the Internet. The Internet has transformed various other industries by enabling the widespread sharing of information and allowing the creation of new business relationships. Public information increases on web sites, and consumers use the Internet to find information, communicate with friends and family, plan trips, and shop. It is expected that both the scope of applications and the number of Internet users will continue to grow as technologies improve and new online applications continue to emerge.

In healthcare, the Internet – with its powerful penetration and scalability – has the ability to empower patients, support information exchange, and consequently result in new operational strategies, business and care delivery models. To date, the use of the Internet in healthcare has been limited to e-commerce and e-mail communication between doctors. The Internet's potential, however, is increasingly being harnessed to transform healthcare delivery at the patient level. From growing email use by patients and consumer e-commerce in the drug market, to rising electronic procurement by hospitals, Internet diagnosis and eHealth, the use of the Internet in active healthcare delivery is rapidly gaining ground. Patients create online support communities, search for medical information, and share their experiences, while health care professionals get access to the latest information in their field, consult with their colleagues, and communicate with their patients. Indicative of the impact of Internet in healthcare is the fact that almost every healthcare business – from insurers to hospitals to pharmaceutical companies – has a dedicated Web site.

With the emergence of next generation rich web technologies, such as WEB 2.0 and Semantic web, the creation of a more dynamic and responsive online experience is within reach. This will, in turn, have an effect on how the web is used within the greater healthcare domain, presenting both new challenges and new opportunities.

Internet Penetration
There are currently more than 1.1 billion Internet users worldwide, following a usage growth of more than 200 per cent between 2000 and 2006. Almost a quarter of those users come from the EU-27 countries. With penetration levels high and steadily increasing, the Internet has become a major resource for many industries – from retail, and banking to tourism and manufacturing – and seems set to revolutionize healthcare. Healthcare is the second-most searched topic on the web. Surveys consistently show that 80 per cent of Internet users have used it to obtain online health information.

According to a 2006 survey by the European Commission, 98.0 per cent of the hospitals in Europe reported having Internet access. Among them, 78.0 per cent of hospitals claimed that their Internet access is broadband, while 41.0 per cent of hospital personnel had access to the Internet. Also, 34.0 per cent of the hospitals offered the opportunity of remote access to the hospital’s computer network. These indicators provide valuable insight into the penetration of Internet technologies in European healthcare services. Broadband is important to ensure adequate speed of Internet use, and remote access to the hospital’s computer network is important for access to patient data from outside the hospital's premises. Finally, the share of employees that are granted Internet access indicates the level of importance hospitals attribute to Internet use in everyday work.

What is driving this?
Compounded by the information overload that characterizes modern medicine, an experienced clinician needs close to 2 million pieces of information to practice medicine. Doctors subscribe to an average of 7 scientific journals, representing over 2500 new articles each year, making it literally impossible to keep fully up-to-date with the latest information about diagnosis, prognosis, therapy and related health issues. Furthermore, the interpretation of patient data is difficult and complicated, mainly because the required expert knowledge in each of many different medical fields is enormous and the information available for the individual patient is multi-disciplinary, imprecise and very often incomplete. As a result, there is an urgent need for tools that can aggregate information from multiple sources to improve health care decision making, enhance health management, and produce better patient outcomes. This is one of the main drivers for the use of the Internet in healthcare.

A growing number of patients are also becoming increasingly involved in the healthcare they receive. These 'power patients' are another important factor in driving the use of Internet in healthcare. ‘Power patients’ are a growing share of the population and healthcare organisations will have to meet the needs of such patients. Free choice of doctors, control over treatments they receive, access to quality information about their care and extremely high levels of customer service are some of the expectations of ‘power patients’.

These factors, amongst many others, are strongly driving the use of the Internet in the delivery and administration of healthcare services.

What is holding us back?
On the other hand, limitations do exist. A number of factors are slowing down the adoption of Web technologies, especially compared with other industries.

The main reason is that the care process is fundamentally more complex than in other industries like retail, manufacturing and financial services. Those can use the Internet to improve efficiency and by extension consolidate and modernize their marketplaces. Healthcare’s complexity, fragmentation and financial and regulatory disincentives, however, prevent it from becoming modelled after eBay or Amazon, for example.

The Internet may empower patients in new ways, but it does not replace face-to-face talks with physicians. It may extend the reach of physicians but it does not eliminate the need for office visits.

Using the Internet to exchange health information also raises serious security concerns. While various technologies and procedures are being developed to tackle these security problems, security breaches do not require just technical solutions, but also laws, detection of violations, enforcement and punishment. Despite recent activity at the EU level, many health organisations agree that security concerns prevent them from using the Internet to transfer medical records within organisations or from allowing providers to access such records remotely.

Rich Web Technologies
The technologies described by the term Rich Web Technologies have characteristics of both traditional Desktop Applications and of Web applications. They enable websites with more richness of user experience, more response and personalization facilities, for example, social networks like “facebook”, or map applications like “Google Maps”. They also allow the evolution of the Web, from an `information jungle' environment with largely narrative, human-understandable information, to a global knowledge repository, where much of the information is machine-readable and directly processable by computers. This enables the use of advanced knowledge management technologies.

WEB 2.0
The term “WEB 2.0” describes new characteristics of the Web. New types of services are made possible by the ability of sites to share or aggregate data, and for users to be part of the authoring process and able to influence what is presented to them. Often the content changes or is updated frequently, and in many ways there is a more desktop-like experience, in which Web applications converge with the features of ordinary applications. Although Web 2.0 applications behave increasingly like desktop applications, they continue to use Web technologies for content transmission, encoding, and presentation. Because Web 2.0 is an emergent phenomenon rather than a specific technology or set of technologies, there is no single designer or responsible authority that ensures development of WEB 2.0 technologies and practices.

The Semantic Web
The Semantic Web can be thought of as an extension of the present web: as an additional layer of machine-processable data beneath the visible layer of human-readable information. It is essentially an attempt to create a global, decentralized knowledge base, represented as a `semantic net' which is woven by a large heterogeneous community of `authors'. The Semantic Web is, from today's perspective, a vision of a future Web. It is based on technologies that dispose of a better artificial intelligence to analyze data. Most data on the Web is designed to be read by, not especially for, computers. Computers can parse headers, links and contents, but the real semantic is hard for them to identify. The Semantic Web is an extension of the current Web, where information is better accessible, and better understood from machines. In this space, the cooperation of people who produce content is much higher.

WEB 2.0 and the Semantic Web
The original web was characterised by connecting people to information. WEB 2.0 emphasizes the enhanced human communications on the Web, and the Semantic Web will allow humans to interact more meaningfully with computers. The relationship between WEB 2.0 and the Semantic Web is a very contentious issue for the future development of the Web. There is still some confusion over what precisely the Semantic Web and WEB 2.0 really are and where this is heading. It is in essence a debate about the shift from documents to data. However, to date, this vision is largely unrealized although technologies and applications are now beginning to appear, as opposed to just being researched. There is a potential split between the Web 2.0, social software enthusiasts, and supporters of the Semantic Web. There has been considerable, and at times heated, debate between those who favour the formality of controlled vocabularies and ontologies and those who prefer the more informal nature of social tagging. As part of this process, there are several areas where developments in Semantic Web and those within social software are beginning to be explored in consort:

• Semantic Wikis: This is a developing research area, but in essence, researchers are looking at ways to annotate wiki content with semantic information. A Semantic wiki allows users to make formal descriptions of things in a manner similar to Wikipedia, and also annotate these pages with semantic information using formal languages such as RDF.
• Semantic Blogging: Blogs can be more than an easy-to-use publishing tool. Their ability to also generate machine readable RSS feeds means that they can also be used to distribute machine-readable summaries of their content and thus facilitate the aggregation of similar information from a number of sources. Traditionally, these feeds are used for the headlines from blog postings, but by combining the ideas behind the Semantic Web with blogging software – Semantic Blogging – it may be possible to develop new information management systems. For example, RDF semantic data can be used to represent and export blog metadata, which can then be processed by another machine.
• Semantic Desktop: It is envisaged that combining the ideas of the Semantic Web and Web 2.0 services with traditional desktop applications and the data they hold (such as word processor files, emails and photos) on your local computing device will facilitate a more personalised way of working. In theory, this should create a more focussed information and knowledge management environment, helping to find a way through personal ‘data swamps’. Research work is at an early stage, but IBM is working on QEDWiki, a wiki-based application framework for collaboration working which enables the creation of enterprise mash-ups.

Future Healthcare Applications of Rich Web Technologies
Accessibility and quality issues of health information on the web are especially hot topics and the subject of hundreds of empirical studies. These mostly suggest that it is hard for consumers to find high-quality health information. Despite that, there is a surprising lack of debate in the medical world around the possibilities of technology to address these problems. If Rich Web Technologies become reality, this will have a profound impact on how people interact with the web and obtain information. The first and most obvious change will include the markedly improved abilities of search engines to conduct accurate and relevant searches on the web, and to guide users to trusted and relevant health information. In addition, results will be better `ranked' not only by relevance, but also by `quality', e.g. the degree of how trusted a health resource is in a community. Search engines will turn in little `expert systems', and may answer questions such as `what is the most common treatment for influenza' or `what is the best hospital for prostate cancer in London, UK?' answered from a global knowledge base. This possibility to guide consumers to trustworthy health information is perhaps the most pertinent application of Rich Web Technologies in healthcare.

The web, as it exists today, has played a significant role in fostering consumerism in healthcare through providing an abundance of information. However, giving `information' to a patient is certainly not enough. The ultimate goal is to enhance `knowledge': The information has to be put into context, the concepts have to be explained and defined, and their relationships to other concepts and to personal information (e.g. in the health record) have to be made explicit. The opportunities of Rich Web Technologies therefore go well beyond scheduling appointments with doctors. The vision is that people will use their web-based personal health record as a starting point, which may be enriched by all kinds of information gathered by intelligent agents from trusted sources on the web which are specifically relevant to the patient. For example, if the web-based health record contains a certain diagnosis, and on the same day the BMJ publishes new research results published about this disease, the agent (which would be a part of the electronic health record software) could automatically generate a link to that article. The web-based electronic health record would be a dynamic entry point and knowledge-management platform for patient and health professionals alike.

Perhaps most challenging for healthcare providers is the prospect that people will use the web to search for the best quality healthcare providers, taking into account their own preferences and decentralized data from different sources such as hospital performance statistics, specialised providers of healthcare performance data, and - perhaps most significantly - also based on ratings given by fellow patients with the same conditions and similar demographic background. Rich Web Technologies could be used to aggregate experiences of people with all kinds of health services and products, including for example their experience with over-the-counter or prescription drugs, hospital, or individual physicians. While patients today primarily use mailing lists, newsgroups and chat rooms to exchange anecdotal and narrative information and experiences about health products, services, and providers, in the future they could rate their treatments and services directly in the web-based electronic health record, and feed them into the Web, so that others can access them.

Conclusion
Health-related activities can benefit enormously from the Internet. The large number of stakeholders in healthcare – general practitioners, specialists, nurses, patients, administrators, researchers, and others - can take advantage of the Internet and its capability to support communication, and improve access to health information, thus forging new relationships among those stakeholders. Although a number of technical, organizational, and policy issues need to be addressed, especially in areas such as security, reliability, and timely transmission of information, the Internet has the potential to improve the quality of care, expand access to it, and reduce its cost.

Next generation healthcare information systems will not only allow the exchange of data between heterogeneous systems, but will also enable the representation of complex medical contents. Intelligent search engines, virtual agents and very specific data analysis tools will process semi-structured data and will help make the latest, quality assured information available for health care professionals, executives and patients. Health information generators will search for individual person-centred information in the web, using person-specific information from the EHR and will design health promotion programmes based on the latest evidence-based, quality-assured knowledge.

However, Rich Web Technologies should be seen as a double-edged sword. The main opportunities lie in the fact that consumers will have even better possibilities to find, aggregate and appraise health information than today. On the other hand, one might fear that this may lead to a further over reliance on external information, a process of disintermediation between patients and healthcare professionals and erosion of the patient-physician relationship.

Such concerns will however not stop the development of these technologies, as health information is still some of the most sought after on the web. People will not stop short of using these technologies for health products and services, researching the attributes and reputation of health products and services with a far greater sophistication than on today's web. The World Wide Web as it exists today might be just at the beginning of a health informatics revolution.